PS
Psychiatry

Anxiety in Older Adults

June 07, 2013.
Eric J. Lenze, MD,

Educational Objectives

The goal of this program is to improve recognition and treatment of anxiety in older adults. After hearing and assimilating this program, the clinician will be better able to:

1. Describe unique causes and presentations of anxiety seen in older adults.

2. Prescribe medications capable of safely relieving anxiety in older adults.

3. Recognize and potentially reverse specific forms of cognitive impairment associated with aging and anxiety.

4. Combine cognitive behavioral, relaxation, and pharmacologic approaches to prevent relapse of anxiety.

Summary

Differentiating anxious states: at minimum, researchers attempt to distinguish anxious arousal (ie, fear; apprehension related to imminent threats) from anxious apprehension (ie, worry; related to more distant physical or psychologic threats); these states thought to have different adaptive purposes as well as shared and differential features of neurobiology

Studies on late-life anxiety disorder (AD): small structural neuroimaging study — found patients lacked gross pathology reflective of Alzheimer disease or cerebrovascular disease; AD in older adults not just dementia with presentation of anxiety; correlation found between cortical volume and severity of worrying (not seen with limbic [eg, amygdala] volume); conclusions about structural neuroanatomy of late-life AD difficult to make given lack of further data; upcoming research from University of Pittsburgh — suggests neuroanatomic basis to pathologic anxiety in older adults possibly due to decreased ability of prefrontal cortex to deactivate limbic areas (and thus stop worry); future neuroimaging studies may link late-life AD with disorder of neurocircuitry

Prevalence of ADs in older adults: underestimation may stem from naturalistic improvement of more fulminant ADs (eg, phobias, posttraumatic stress disorder [PTSD], panic disorder) as adults age; worry peaks during childhood and at ≈50 yr of age (less common in early adulthood); studies on exposure to trauma (conducted after, eg, disasters) found older adults have some protection from development of PTSD; fear of falling relatively unique to older adults (not recognized by Diagnostic and Statistical Manual of Mental Disorders [DSM], but extremely common and disabling)

ADs and aging: risk factors — chronic disabling medical conditions; cognitive decline; underlying brain changes (neurodegenerative and normative) related to aging; grief; social isolation; protective factors — accumulated life experience; improved emotional regulation; wisdom; optimism; mastery; higher levels of religious involvement; greater financial stability

Multimodal and preventive treatment: minimize risk factors; maximize protective factors; emphasize positive aspects of aging; comment on any acquired skills patients may find more accessible after acute treatment of AD

Identifying causes of late-onset ADs: avoid rush to suspect medical causes; in older patients who suddenly develop acute anxiety and lack history of ADs (as confirmed by family members), investigate all possible causes (including medical [most commonly cardiopulmonary, endocrine, or metabolic abnormalities], medications, and psychosocial risk factors); assess if any risk factors have been activated, or if any protective factors have been eliminated (eg, onset of disability or cognitive dysfunction may trigger late onset of AD); avoid treating AD as disorder of exclusion (ie, by ruling out every possible cause), and focus on diagnosis and treatment

Useful work-up for late-onset ADs: go beyond searching for brain lesions; reveal addressable problems related to medication (most commonly involving anxiogenic medications or sudden discontinuation of anxiolytics) or psychosocial factors (eg, grief, caregiver stress)

Studies: AD found to be risk factor for development of activity limitations, eg, confinement; another study showed presentation of anxiety symptoms (particularly when combined with depression or generalized anxiety disorder [GAD]) associated with excessive health care costs; findings may be due to increased somatic symptoms (and related worries and fears) seen with ADs

Generalized Anxiety Disorder

Background: DSM criteria focus on difficulty controlling worries as core symptom; speaker advises against using term “excessive worry” with older adults; GAD only applies to individuals who spend significant amounts of time worrying; somatic symptoms — include sleep disturbance, fatigue, irritability, being “keyed up,” muscle tension, and difficulty with concentration; often prompt psychiatric referrals from other physicians

Differentiation from “normal” worrying: most adults >50 yr of age frequently worry, but only small fraction have diagnosable GAD; cutoff for normal worrying unclear; speaker focuses on commonality and severity of worrying, and any distress or lack of control over worrying

Treatment: benzodiazepines (BZDs) commonly used; although BZDs show efficacy in late-onset AD, speaker does not encourage their use due to high prevalence of existing BZD prescriptions among older adults, and associations with falls and cognitive impairment (CI) or decline

Antidepressants: federally funded study of selective serotonin reuptake inhibitor (SSRI) escitalopram showed only minimal efficacy for GAD; compared to younger adults, older adults showed no differences in response rates to venlafaxine extended-release and duloxetine; newer serotonin-norepinephrine reuptake inhibitors may have similar efficacy

Second-line augmentation with atypical antipsychotics: quetiapine shows efficacy in late-life GAD; atypical antipsychotics act as major tranquilizers with known antidepressant and antianxiety effects

Other medications: pregabalin and mirtazapine also effective; contraindicated treatments include antihistamines, anticholinergics, and sedatives (eg, high-dose BZDs); speaker recommends limiting BZDs to short-term adjunctive use, and discourages use on as-needed basis

Guidelines for comprehensive treatment: use medications first, but avoid medication-only approach; although some patients may have ideal outcomes with medication alone (and many show responses), few enter remission; medications cannot change core constructs related to patients viewing themselves as pathologic worriers; many older adults may refuse or prematurely discontinue medication; phobias tend to require specific psychotherapies, and unlikely to respond to medications (some agents [eg, BZDs] may even impair responses to psychotherapy); relaxation training viewed as most effective component of cognitive behavioral therapy (CBT) for GAD

Cognitive Behavioral Therapy

Late-life ADs: CBT appears superior to wait-listing and usual care (typically ineffective), but shows little difference when compared with active controls (eg, supportive or discussion group therapies); monotherapy with BZDs or antidepressants shows limited efficacy

Combining SSRIs with CBT: start patients on SSRIs to reduce acute distress and somatization; after achieving best possible stabilization, add CBT to improve or bolster coping skills and address underlying pathologic worry; small pilot study (Wetherell, 2011) — all patients started escitalopram for 12 wk; limited to adults ≥60 yr of age with GAD as primary diagnosis; general anxiety and somatization symptoms showed significant improvements, but worry symptoms had only limited response; patients randomized to receive 16 sessions of CBT for late-life anxiety; CBT had minimal effects on general anxiety and somatization, but substantially reduced worry; in patients randomized to discontinue escitalopram, CBT appeared to help prevent relapse (although to lesser extent than if medication continued), and thus demonstrated long-term benefits of SSRIs and CBT

Treatment of Anxiety and Depression

Interaction of depression and anxiety: presence of anxiety results in slower and lower rates of remission from depression; in maintenance study of paroxetine for late-life depression, higher baseline levels of anxiety predicted recurrence of depression

Treatment: monoamine antidepressants and antipsychotics target anxiety symptoms and depressive symptoms; other studies (including meta-analysis) have not identified comorbid anxiety as factor in treatment resistance; speaker views anxiety as prognostic factor for more severe symptoms (eg, suicidal ideation); since depressed individuals with comorbid anxiety have higher rates of suicide, aggressive treatment and close follow-up should be pursued with greater priority; for geriatric depression with comorbid anxiety, psychotherapy problematic due to amotivation from depression, avoidance from anxiety, and CIs from both conditions

Cognitive Impairment

Types of impairment: memory impairment predominant, followed by impairment of executive function (consistent finding in longitudinal studies); anxiety appears to predict cognitive decline (similar to depression)

Pharmacologic treatment: SSRIs have few benefits; one study showed escitalopram superior to placebo in only one measure of executive function

Mechanisms of CI in late-life anxiety: many patients have underlying neurodegenerative pathologies due to advanced age and illness

Reversible changes in brain: caused by stress and anxiety; pathologic activation of hypothalamus-pituitary-adrenal axis leads to higher levels of cortisol in majority of older adults with ADs or depression; excess glucocorticoid signaling results in synaptic dysfunction and loss, decreased neurogenesis, and ultimately neurocircuitry dysfunction in regions necessary for healthy cognitive function (eg, hippocampus, prefrontal cortex); if these dysfunctions affect areas important for control and management of anxiety, then stress may lead to persistent anxiety

Speaker’s study: older adults with anxiety showed nonsubtle increases in cortisol levels (relative to healthy older adults); these levels seem to improve with relief from anxiety; high cortisol level potential target of treatment for CI in anxiety and stress disorders of aging

Mindfulness via meditation: behavioral treatment shown to lower cortisol levels in some populations; teaches patients to remain “in the present” (instead of focusing on past or future); meditation acts as exercise to develop skill of mindfulness, rather than rumination and worry; meditation and other mind-body techniques increasingly acceptable to older adults; mindfulness-based stress reduction structured technique and widely available; ongoing open-label pilot study — for older adults with anxiety or depression (particularly with CI); preliminary findings show increased mindfulness, reduced worry pathology (with effect size similar to CBT) and subjective cognitive symptoms, improved neuropsychologic functioning, and reduced cortisol levels

Questions and Answers

Patients with existing prescriptions for BZDs: safety primary concern; immediately taper BZD in patients at risk for delirium or falls; consider dosage and rate of elimination (complicated clinical assessment); weigh potential distress due to tapering against potential improvements or reductions in risk for, eg, CI, falls, motor vehicle accidents; if patients do not show acute risk, then SSRIs may be added before tapering BZDs (to reduce anxiety); guidelines typically recommend tapering 10% per week (or smallest amount possible to cut from pill every 2 wk)

Other medications: β-blockers in older adults — not used by speaker due to unfavorable risk-benefit ratio; prazosin for anxiety — viewed by speaker as experimental treatment; studies suggest prazosin may reduce sleep-related problems of PTSD; testing of prazosin under way as novel treatment approach for of anxiety; relatively unstudied in older adults

“Black box” warnings: citalopram — dosing limited to 40 mg daily (20 mg in older adults; limit does not apply to escitalopram); speaker’s studies used median dose of 30 mg; discontinuation not recommended in patients doing well on citalopram, but check electrocardiography for safety (QT prolongation may not be specific to citalopram); antipsychotics for elderly patients — study found low doses of quetiapine (?100 mg daily) effective and well-tolerated in elderly patients with ADs; antipsychotics increase mortality in patients with dementia (due to, eg, increased cerebrovascular and cardiovascular events), and this may or may not apply to other populations of older adults; speaker always advises patients and families about this warning

Gabapentin and pregabalin (Lyrica): no controlled studies of gabapentin in older adults with ADs; pregabalin surpassed placebo in study of older adults with GAD (at 150-300 mg divided doses), but mechanism of action remains unclear; used in speaker’s treatment algorithms

Readings

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Lenze receives research support from Hoffmann-La Roche, Johnson & Johnson, and H. Lundbeck A/S. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Lenze was recorded at the 18th Annual Psychopharmacology Update, held February 13-17, 2013, in Las Vegas, NV, and presented by Nevada Psychiatric Association.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PS421101

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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