Treating Late-Life Anxiety
Treating Late-Life Anxiety
Despite high prevalence and negative consequences of anxiety disorders in later life, this area has received little research attention. A relatively small number of outcome investigations on late-life anxiety have focused on the impact of pharmacological and psychotherapeutic treatments.
Community prevalence rates for anxiety disorders in older adults range from 3.5% to 10.2%, suggesting a higher prevalence than for late-life depression (Beekman et al., 1998; Bland et al., 1988). Anxiety disorders are even more common among older adults with medical illness and in senior housing facilities (Junginger et al., 1993; Tolin et al., 2005). Generalized anxiety disorder (GAD) is one of the most common anxiety disorders, with community prevalence rates ranging from 1.9% to 7.3% (Beekman et al., 1998; Blazer et al., 1991). Anxiety symptoms that do not meet DSM criteria are even more prevalent, with rates from 15% to 20% in community samples and even higher in medically ill populations (Himmelfarb and Murrell, 1984; Mehta et al., 2003; Wittchen et al., 2002). For example, panic attacks, but not necessarily DSM-diagnosable panic disorder, are common in chronic obstructive pulmonary disease (COPD). Anxiety symptoms and disorders are associated with many negative consequences such as decreased physical activity and functional status, poorer self-perceptions of health, decreased life satisfaction, increased loneliness, increased physical disability, decreased quality of life, and increased service utilization (Brenes et al., 2005a, 2005b; Lenze et al., 2001; Stanley et al., 2001; van Balkom et al., 2000).
The first line of treatment for anxiety in later life is typically pharmacological. Benzodiazepines are the most commonly used anxiety management medication, followed by serotonergic antidepressants, buspirone (BuSpar), and venlafaxine (Effexor) (Mamdani et al., 2005). Recent research has also examined the impact of psychotherapy, typically cognitive-behavioral therapy (CBT), for late-life anxiety.
Approximately half of older patients diagnosed with an anxiety disorder in primary care are prescribed an anxiolytic or antidepressant medication (Stanley et al., 2001). All pharmacological interventions reviewed are approved treatment options for anxiety disorders. Benzodiazepines are the most frequently prescribed medications for anxiety in later life, with usage rates of 10% to as high as 43% for individuals with persistent anxiety (Gleason et al., 1998; Gray et al., 2003; Mamdani et al., 2005; Schuurmans et al., 2005). However, benzodiazepines can lead to an increased risk of falls, and possibly increased cognitive decline, in older people (Paterniti et al., 2002).
Benzodiazepines. Only three randomized controlled trials have investigated the efficacy of benzodiazepines for anxiety disorders in later life. Two of these focused on GAD (Bresolin et al., 1988; Frattola et al., 1992) and one on an earlier, comparable category of anxiety neurosis (Koepke et al., 1982). The data from these trials suggest the utility of benzodiazepines for anxiety disorders in older adults. Despite the results demonstrating efficacy, limited and short-term use of benzodiazepines is recommended given the possible negative consequences (Sheikh and Cassidy, 2000).
Antidepressants. Five pharmacotherapy studies of late-life anxiety disorders have tested antidepressant medications. Two of these studies included patients with panic disorder (PD), one included a mixed group of patients with GAD, PD or obsessive-compulsive disorder (OCD), and two included patients with GAD. Sheikh and Swales (1999) found promising results when comparing the efficacy of imipramine (Janimine, Tofranil), alprazolam (Xanax) and placebo in patients with PD. A follow-up investigation demonstrated improvement in anxiety symptoms in patients with PD using sertraline (Zoloft) (Sheikh et al., 2004). A sample with mixed anxiety disorders showed high response rates to fluvoxamine (Luvox) (Wylie et al., 2000). Interestingly, none of the three patients with PD responded to treatment. Katz and colleagues (2002) conducted a secondary analysis of data from patients age 60 years and older who participated in five randomized clinical trials of venlafaxine for GAD. Venlafaxine demonstrated superiority to placebo in this investigation. In the only prospective, randomized trial to date of a serotonergic antidepressant, Lenze and colleagues (2005), found citalopram (Celexa) superior to placebo, and these gains were maintained at 32-week follow-up for patients who continued taking the medication (Blank et al., in press).