Treating Late-Life Anxiety

March 1, 2006
Catherine Ayers, PhD

,
Julie Loebach Wetherell, PhD

,
Eric J. Lenze, MD

,
Melinda A. Stanley, PhD

Volume 23, Issue 3

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.

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.

Pharmacological Interventions

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).

Psychotherapy Interventions

Most psychotherapy studies of late-life anxiety have used CBT with patients with GAD. We found evidence for the efficacy of CBT for GAD in seven studies. The CBT protocols in these investigations typically consisted of education about anxiety, relaxation training, cognitive therapy and systematic desensitization to worry-provoking thoughts and situations, most commonly administered in a group format. Control conditions included waiting list, minimal contact control, usual care, supportive therapy and a discussion group attention placebo. Data suggest that at follow-up, gains are maintained, particularly when booster sessions are given.

One study found that supportive therapy (which emphasized empathic listening) and CBT were equally effective in reducing anxiety and depressive symptoms (Stanley et al., 1996). Another investigation compared CBT to a minimal contact control condition and demonstrated superiority of CBT, even at 12-month follow-up (Stanley et al., 2003a). Wetherell and colleagues (2003), compared active (CBT and discussion group attention placebo ) and inactive (waiting list) conditions and demonstrated roughly equal efficacy in active conditions compared to waiting list. Interestingly, CBT was only superior to discussion group placebo on one measure of anxiety, and this finding was no longer significant at six-month follow-up. A small study of primary care patients demonstrated the effectiveness of individually administered CBT compared to usual care (Stanley et al., 2003b). This investigation was an important initial effort to disseminate anxiety treatment options into a primary care setting, where the majority of older adults with GAD present for treatment.

Other approaches to the treatment of late-life anxiety have added techniques to the standard CBT protocol. One approach used an enhanced form of individually administered CBT (Mohlman et al., 2003). Enhanced CBT included the standard CBT elements as well as additional memory aids (e.g., reminder phone calls, weekly review of concepts and techniques). Overall, results suggest that CBT enhancements improved treatment outcome compared to waiting list. A follow-up investigation compared enhanced CBT to a waiting list among patients with varying levels of executive functioning (Mohlman and Gorman, 2005). Results suggested that individuals with impaired executive functioning did not respond to CBT whereas those with intact and improved executive functioning were more likely to respond. Another approach used a CBT protocol based on the concept of intolerance of uncertainty as the key feature of GAD (Ladouceur et al., 2004). The majority of patients in this study no longer met criteria for GAD upon completion of treatment.

Much less research has been conducted in older adult populations with anxiety disorders other than GAD. Some research suggests the effectiveness of CBT for PD, agoraphobia, OCD, specific phobia and social phobia. There have been no randomized, controlled psychosocial interventions conducted exclusively with older adults with PD. However, a non-controlled study produced promising results demonstrating the effectiveness of CBT in older PD patients (Swales et al., 1996). A retrospective chart review of older inpatients treated for OCD using exposure and response prevention, along with other elements (e.g., pharmacotherapy, milieu therapy) showed that staff and self-report improvement ratings were high (Carmin et al., 1998).

Several studies have demonstrated the effectiveness of CBT in samples with mixed anxiety disorder diagnoses. Radley and colleagues (1997), found efficacy for CBT in a multiple baseline design in a small sample of patients with a variety of anxiety disorders.

A small case series of patients with various anxiety disorder diagnoses also found improvement in anxiety symptoms following CBT (King and Barrowclough, 1991). Another study used a home-based individual format, which demonstrated significant effects for CBT relative to supportive therapy (Barrowclough et al., 2001). Gains were maintained at 12-month follow-up. Gorenstein and colleagues (2005) found equivalent effects for CBT plus medication management relative to medication management alone.

Conclusion

Overall, available data suggest the potential utility of both pharmacological and psychotherapeutic treatments for late-life anxiety disorders, especially GAD. The CBT literature has demonstrated the effectiveness of CBT compared to no treatment, but evidence does not consistently support the benefits of CBT relative to other psychosocial treatment options (e.g., supportive therapy). Pharmacological treatment is more effective than placebo in the treatment of late-life anxiety, and some evidence suggests that it is more effective than CBT (Wetherell et al., 2005).

Limitations of this literature include homogeneous and unrepresentative samples in terms of age, functional status, ethnicity, education, or medical health; neglect of anxiety disorders other than GAD; and a relative dearth of research on treatment in settings more typically used by anxious older adults (e.g., primary care). Another concern is the failure to investigate long-term maintenance. In most CBT studies, follow-up is limited to 12 months or less. Pharmacological trials have typically not examined the nature and efficacy of various maintenance options.

Psychotherapy attrition rates are higher among older adults (21% to 39%) than among younger adults (approximately 10%) (Gould et al., 2004). Attrition from pharmacotherapy trials is somewhat lower (15% to 23%) and is consistent with attrition rates in younger adults with anxiety disorders (Katz et al., 2002; Lenze et al., 2005). Psychotherapy trials typically analyze data only from completers, whereas pharmacological trials more often analyze on an intent-to-treat basis. Furthermore, psychotherapy studies typically use multiple outcome measures, which complicate the interpretation of inconsistent results across measures. Finally, there is no psychotherapy comparison condition equivalent to a pill placebo.

Although initial results point to the efficacy of pharmacological and psychotherapeutic treatment for geriatric anxiety disorders, more research is needed on other intervention techniques, patient samples, and anxiety disorder diagnoses. More research is also needed to determine whether medication is an acceptable and effective long-term management tool for these chronic disorders. Long-term follow-up of patients and creative methods for the dissemination of these treatments remain important goals for future research, as do combinations of pharmacological and psychotherapeutic treatment and stepped care approaches.

References:

REFERENCES1.Barrowclough C, King P, Colville J et al. (2001), A randomized trial of the effectiveness of cognitive-behavioral therapy and supportive counseling for anxiety symptoms in older adults. J Consult Clin Psychol 69(5):756-762.
2.Beekman AT, Bremmer MA, Deeg DJ et al. (1998), Anxiety disorders in later life: a report from the Longitudinal Aging Study Amsterdam. Int J Geriatr Psychiatry 13(10):717-726.
3.Bland RC, Newman SC, Orn H (1988), Prevalence of psychiatric disorders in the elderly in Edmonton. Acta Psychiatr Scand Suppl 338:57-63.
4.Blank S, Lenze EJ, Mulsant BH et al. (in press), Outcomes of late-life anxiety disorders during 32 weeks of citalopram treatment. J Clin Psychiatry.
5.Blazer D, George LK, Hughes D (1991), The epidemiology of anxiety disorders: an age comparison. In: Anxiety in the Elderly: Treatment and Research, Salzman C, Lebowitz BD, eds. New York: Springer Pub. Co., pp17-30.
6.Brenes GA, Guralnik JM, Williamson J et al. (2005a), Correlates of anxiety symptoms in physically disabled older women. Am J Geriatr Psychiatry 13(1):15-22.
7.Brenes GA, Guralnik JM, Williamson JD et al. (2005b), The influence of anxiety on the progression of disability. J Am Geriatr Soc 53(1):34-39.
8.Bresolin N, Monza G, Scarpini E et al. (1988), Treatment of anxiety with ketazolam in elderly patients. Clin Ther 10(5):536-542.
9.Carmin CN, Pollard CA, Ownby RL (1998), Obsessive-compulsive disorder: cognitive behavioral treatment of older versus younger adults. Clinical Gerontologist 19(2):77-81.
10.Frattola L, Piolti R, Bassi S et al. (1992), Effects of alpidem in anxious elderly outpatients: a double-blind, placebo-controlled trial. Clin Neuropharmacol 15(6):477-487.
11.Gleason PP, Schulz R, Smith NL et al. (1998), Correlates and prevalence of benzodiazepine use in community-dwelling elderly. J Gen Intern Med 13(4):243-250.
12.Gorenstein EE, Kleber MS, Mohlman J et al. (2005), Cognitive-behavioral therapy for management of anxiety and medication taper in older adults. Am J Ger Psychiatry 13(10):901-909.
13.Gould RA, Safren SA, Washington DO, Otto MW (2004), A meta-analytic review of cognitive-behavioral treatments. In: Generalized Anxiety disorder: Advances in Research and Practice, Heimberg RG, Turk CL, Mennin DS, eds. New York: Guilford Press, pp248-264.
14.Gray SL, Eggen AE, Blough D et al. (2003), Benzodiazepine use in older adults enrolled in a health maintenance organization. Am J Geriatr Psychiatry 11(5):568-576.
15.Himmelfarb S, Murrell SA (1984), The prevalence and correlates of anxiety symptoms in older adults. J Psychol 116(2d Half):159-167.
16.Junginger J, Phelan E, Cherry K, Levy J (1993), Prevalence of psychopathology in elderly persons in nursing homes and in the community. Hosp Community Psychiatry 44(4):381-383.
17.Katz IR, Reynolds CF 3rd, Alexopoulos GS, Hackett D (2002), Venlafaxine ER as a treatment for generalized anxiety disorder in older adults: pooled analysis of five randomized placebo-controlled clinical trials. J Am Geriatr Soc 50(1):18-25.
18.King P, Barrowclough CA (1991), Clinical pilot-study of cognitive-behavioral therapy for anxiety disorders in the elderly. Behavioural Psychotherapy 19(4):337-345.
19.Koepke HH, Gold RL, Linden ME et al. (1982), Multicenter controlled study of oxazepam in anxious elderly outpatients. Psychosomatics 23(6):641-645.
20.Ladouceur R, Leger E, Dugas M, Freeston MH (2004), Cognitive-behavioral treatment of generalized anxiety disorder (GAD) for older adults. Int Psychogeriatr 16(2):195-207.
21.Lenze EJ, Mulsant BH, Shear MK et al. (2005), Efficacy and tolerability of citalopram in the treatment of late-life anxiety disorders: results from an 8-week randomized, placebo-controlled trial. Am J Psychiatry 162(1):146-150 [see comment].
22.Lenze EJ, Rogers JC, Martire LM et al. (2001), The association of late-life depression and anxiety with physical disability: a review of the literature and prospectus for future research. Am J Geriatr Psychiatry 9(2):113-135.
23.Mamdani M, Rapoport M, Shulman KI et al. (2005), Mental health-related drug utilization among older adults: prevalence, trends, and costs. Am J Geriatr Psychiatry 13(10):892-900.
24.Mehta KM, Simonsick EM, Penninx BW et al. (2003), Prevalence and correlates of anxiety symptoms in well-functioning older adults: findings from the health aging and body composition study. J Am Geriatr Soc 51(4):499-504.
25.Mohlman J, Gorenstein EE, Kleber M et al. (2003), Standard and enhanced cognitive-behavior therapy for late-life generalized anxiety disorder: two pilot investigations. Am J Geriatr Psychiatry 11(1):24-32.
26.Mohlman J, Gorman JM (2005), The role of executive functioning in CBT: a pilot study with anxious older adults. Behav Res Ther 43(4):447-465.
27.Paterniti S, DuFouil C, Alperovitch A (2002), Long-term benzodiazepine use and cognitive decline in the elderly: the Epidemiology of Vascular Aging Study. J Clin Psychopharmacol 22(3):285-293.
28.Radley M, Redston C, Bates F, Pontefract M (1997), Effectiveness of group anxiety management with elderly clients of a community psychogeriatric team. Int J Geriatr Psychiatry 12(1):79-84.
29.Schuurmans J, Comijs HC, Beekman AT et al. (2005), The outcome of anxiety disorders in older people at 6-year follow-up: results from the Longitudinal Aging Study Amsterdam. Acta Psychiatr Scand 111(6):420-428 [see comment].
30.Sheikh JI, Cassidy EL (2000), Treatment of anxiety disorders in the elderly: issues and strategies. J Anxiety Disord 14(2):173-190.
31.Sheikh JI, Lauderdale SA, Cassidy EL (2004), Efficacy of sertraline for panic disorder in older adults: a preliminary open-label trial. Am J Geriatr Psychiatry 12(2):230.
32.Sheikh JI, Swales PJ (1999), Treatment of panic disorder in older adults: a pilot study comparison of alprazolam, imipramine, and placebo. Int J Psychiatry Med 29(1):107-117 [see comment].
33.Stanley MA, Beck JG, Glassco JD (1996), Treatment of generalized anxiety in older adults: a preliminary comparison of cognitive-behavioral and supportive approaches. Behavior Therapy 27(4):565-581.
34.Stanley MA, Beck JG, Novy DM et al. (2003a), Cognitive-behavioral treatment of late-life generalized anxiety disorder. J Consult Clin Psychol 71(2):309-319.
35.Stanley MA, Hopko DR, Diefenbach GJ et al. (2003b), Cognitive-behavior therapy for late-life generalized anxiety disorder in primary care: preliminary findings. Am J Geriatr Psychiatry 11(1):92-96.
36.Stanley MA, Roberts RE, Bourland SL, Novy DM (2001), Anxiety disorders among older primary care patients. Journal of Clinical Geropsychology 7(2):105-116(12).
37.Swales P J Solfvin J F, Sheikh J I (1996), Cognitive-behavioral therapy in older panic disorder patients. Am J Ger Psych 4(1):46-60.
38.Tolin DF, Robison JT, Gaztambide S, Blank K (2005), Anxiety disorders in older Puerto Rican primary care patients. Am J Geriatr Psychiatry 13(2): 150-156.
39.van Balkom AJ, Beekman AT, de Beurs Eet al. (2000), Comorbidity of the anxiety disorders in a community-based older population in The Netherlands. Acta Psychiatr Scand 101(1):37-4 [see comment].
40.Wetherell JL, Gatz M, Craske MG (2003), Treatment of generalized anxiety disorder in older adults. J Consult Clin Psychol 71(1):31-40.
41.Wetherell JL, Sorrel JT, Stanley MA, Lenze EJ (2005), Comparison of cognitive-behavioral therapy and citalopram for late-life generalized anxiety disorder. Presented at the 26th Annual Conference of the, Anxiety Disorder Association of America, Seattle: March.
42.Wittchen HU, Kessler RC, Beesdo K et al. (2002), Generalized anxiety and depression in primary care: prevalence, recognition, and management. J Clin Psychiatry 63(Suppl 8):24-34.
43.Wylie ME, Miller MD, Shear MK et al. (2000), Fluvoxamine pharmacotherapy of anxiety disorders in later life: preliminary open-trial data. J Geriatr Psychiatry Neurol 13(1):43-48.