How to manage anxiety in older patients

Anxiety is not a normal part of ageing, and yet it is often dismissed and rarely treated with evidence-based care in older adults.

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Anxiety symptoms in older patients are often left untreated in primary care, and research suggests this is due to attitudes of clinicians and patients who dismiss symptoms as a normal part of ageing or a normal response to health conditions. 

In addition, inaccurate beliefs that anxiety cannot be treated in older patients hamper the application of evidence-based care. 

This article summarises the evidence on the prevalence of anxiety in later life and how the clinical presentation of anxiety might be different in older patients. It also reviews the evidence for which interventions have been shown to be effective. 

Prevalence

Perhaps unexpectedly, given the health challenges in later life, anxiety symptoms are less likely to meet Diagnostic and Statistical Manual (DSM-5) disorder thresholds for an anxiety disorder (only 4% in Australian samples) compared with younger adults.¹ 

From about the age of 55, the prevalence of anxiety disorders, such as mood disorders, decreases.²

New onset of anxiety disorders are uncommon, with most anxiety disorders being longstanding or a re-emergence of a previous anxiety condition or predisposition. Epidemiological surveys show, as with younger age groups, that the most prevalent anxiety disorders are specific phobia, social anxiety disorder and generalised anxiety disorder, although generalised anxiety disorder is the most often seen in clinical settings. 

Despite the lower overall prevalence of anxiety disorders in later life, subclinical symptoms are still frequent and interfering, and require evidence-based intervention.  

Clinical presentation of anxiety in later life (See table 1)

There are no specific age-related diagnostic criteria in the DSM-5 for anxiety disorders. Instead, differences in symptom presentation are subtle.

Signs and symptoms of anxiety in older adults

Reporting lots of “concerns” about their health and others, and family issues

Often reporting feelings of agitation, uneasiness, racing heart, panicky, shakiness, dizziness

Avoiding trying new things, going out and meeting new people

Overwhelmed easily by activities or tasks

Difficulty sleeping and/or fatigue

Difficulty making decisions & commitments

Avoiding objects or situations which cause anxiety

Repeated checking of health indicators

Not being assertive (i.e. avoiding eye contact), or being shy

There is some evidence that older adults are more inclined to dismiss their worries as “concerns”, and to downplay the excessiveness of worry or symptoms.³

Older adults often have somatic symptoms that overlap with anxiety symptoms – such as sleep difficulties, muscle tension, dry mouth and fatigue – that can make detection more complicated. However, anxiety is often longstanding and precedes health conditions, and so assessing the onset of symptoms can assist with differential diagnosis. 

It is important to be mindful that in older adults, anxious behaviours are often normalised inappropriately. For example, perceptions of being “nervy”, anxious behaviours such as excessively checking blood pressure, or seeking frequent reassurance from medical practitioners about health concerns, can be inappropriately tolerated in primary care. 

Older adults’ avoidance of anxiety-provoking situations is also often normalised. For instance, older adults who avoid walking on uneven surfaces because of fear of falling despite never having had a fall, avoid driving in new areas due to unfounded fears of having an accident or getting lost, avoid the use of hearing or walking aids due to embarrassment, or avoid trying new things or meeting new people are seen as likely to have an underlying anxiety disorder. These “avoidance” behaviours are often dismissed by practitioners and encouraged or facilitated by family and friends. Continued avoidance of these situations increases dependency on others, reduces social participation and maintains anxiety in the long term. 

Measurement of anxiety

Age-appropriate self-report tools should be used to measure anxiety accurately. Generic self-report measures that conflate somatic symptoms with anxiety or use reverse scored items are generally less reliable. Instead, validated measures include the GAD-7⁴ for the assessment of worry (available here), or the Geriatric Anxiety Scale⁵ for general anxiety symptoms (available here).

Careful questioning about how often anxious symptoms occur “compared to other people of your age” is useful for assessing likely excessiveness, as are questions to identify potential triggers for anxious symptoms such as current “concerns” or upcoming events. Questions to understand what types of situations they avoid and why they are avoided will also provide clues into the interference associated with avoidance.

Treatment of anxiety 

Research indicates that older adults receive less treatment for anxiety than other age groups. This appears to be partially because of older adults and practitioners dismissing symptoms as being normal, as well as beliefs that interventions are less effective in older adults despite clinical evidence to the contrary.

The National Institute for Health and Care Excellence (NICE) guidelines, as well as the Royal Australian and New Zealand College of Psychiatrists (RANZCP) guidelines for the management of anxiety, recommend cognitive behavioural therapy (CBT) as the first-line treatment, particularly graded exposure therapy, followed by, or in combination with, pharmacotherapy (antidepressants, notably SSRIs).⁶

Although benzodiazepines have been found to be effective⁷, their use is cautioned because of potential dependency, as well as due to long-term use being associated with increased risk of falls and the risk for cognitive decline in older adults. 

Several systematic reviews and meta-analyses have demonstrated good evidence for the effectiveness of CBT when applied in age-appropriate ways.^8,9

Progressive muscle relaxation has been demonstrated to be effective in reducing worry in clinical trials as well as in primary care.¹⁰ Although few studies have examined other CBT components in isolation, it is likely that graded exposure (facing fears in a systematic way) is particularly relevant for reducing anxiety, as it is in other age groups. There is no evidence to suggest that older people are unable to cope with exposure therapy.

Focusing efforts on reducing avoidance of situations that limit independence or engagement with social activities should be prioritised. A slowly applied graded approach is most likely to lead to patient success. 

Cognitive therapy that focuses on challenging the evidence for misattributions of threat appraisals are also common components of CBT packages in older adults. There is some evidence that older adults with cognitive rigidity or mild cognitive decline may benefit less from these approaches; however, the evidence suggests most older adults can learn this technique and can use this technique to successfully manage anxiety.¹¹

Depression is commonly comorbid with anxiety, with studies suggesting up to 47% of older adults with an anxiety disorder also have a mood disorder.¹²

Physical or health complications are also commonly comorbid with anxiety in later life. Chronic conditions can also increase the risk for anxiety; these include diabetes, chronic obstructive pulmonary disease, cardiovascular disease and people with chronic pain syndromes. In fact, physical or health challenges often trigger or exacerbate anxiety symptoms. However, a recent meta-analysis demonstrated that comorbid depression and anxiety can be treated with similar efficacy to younger age groups.⁹

Evidence also suggests that psychological interventions for anxiety are still highly effective despite health challenges. As in the case for medical populations, CBT has great benefit in assisting clients to manage illness-related distress and reduce catastrophic or unhelpful thinking.

Don’t leave anxiety untreated

There is evidence that when anxiety is untreated, it increases risk for depression, disability, health care costs, medication use, mortality and reduced independent functioning¹². Therefore, it is important that anxiety is aggressively managed in older patients, just as it is in younger patients. 

A range of options exist for accessing CBT beyond GP-led interventions. Some patients will be eligible for treatment through older adult mental health services, or referrals to psychologists and other allied health professionals through the primary health network or private practitioners. The Centre for Emotional Health Clinic at Macquarie University offers face-to-face as well as telehealth CBT interventions developed specifically for older adults (Ageing Wisely program), through NHMRC-funded clinical trials (02 9850 8711, www.mq.edu.au/ceh). Internet interventions are available free through MindSpot (www.mindspot.org.au).

Conclusion

Anxiety symptoms in older adults can be easily missed and dismissed by practitioners. Careful assessment is critical for identifying clinically interference anxiety and avoidance. Clinical guidelines recommend CBT as the first step followed by, or combined with, pharmacology if required. The evidence suggests that CBT is just as effective for older adults as younger adults, even in the later years of life.

Professor Viviana Wuthrich is a clinical psychologist and director of the Centre for Ageing, Cognition & Wellbeing. She is an international expert on the assessment and treatment of anxiety disorders in older adults. 

References

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9. Wuthrich VM, Meuldijk D, Jagiello T, et al. (2021). Efficacy and effectiveness of psychological interventions on co-occurring mood and anxiety disorders in older adults: A systematic review and meta-analysis, International Journal of Geriatric Psychiatry. 36(6), 858-872, http://dx.doi.org/10.1002/gps.5486
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