In this last section, we provide a blueprint for managing older (and equally so, younger) adults with anxiety disorders, based on empirical findings and our own clinical experience.
1. Assessment should measure severity and provide objective criteria for assessing response, and should assess comorbidity, prior treatment, cognitive status, and need for a medical workup
Assessment of anxiety is often overlooked by mental health providers. A helpful introduction to the topic is to ask about stress; eg, “older adults often deal with stress; how do you feel in times of stress?“ Patients who describe symptoms suggestive of anxiety or worry can then be further queried. Use nondirective questioning to determine the severity of anxiety symptoms, by: (i) level of distress (asking how much the anxiety symptoms bother the patient, what strategies they are trying in order to control or avoid it, and what somatic symptoms they are having); (ii) how much of their time it takes; and (iii) avoidance. Avoidance is a key component of all anxiety disorders yet often is not recognized. For example, older adults may rationalize changes in behavior patterns to perceived poor health or environmental limitations. Inquire about behavioral changes including activities given up or, conversely, intrusive overinvolvement with family members. Talk to the family for corroboration.
We are often asked about differentiating anxiety from depression. In our experience, some patients (and some neurobiologists!) fail to appreciate the importance we place on this diagnostic distinction. Clinically, the clinician will often have to deal with anxiety as well as depression in a patient.
The medical differentiation of late-onset anxiety is long but should chiefly consider: (i) depression; (ii) cognitive impairment (dementia, delirium); (iii) anxiety-inducing medications (or recent discontinuation or inconsistent use of sedatives); and (iv) common and rare medical conditions that could masquerade as an anxiety disorder. Regarding the latter, consider thyroid disease, B12 deficiency, hypoxia, ischemia, or metabolic changes (eg, hypercalcemia or hypoglycemia).
2. Think twice about a benzodiazepine prescription
As previously noted, benzodiazepines, like any sedatives, have a poorer risk:benefit ratio in elderly persons than in young adults. Therefore, long-term use of benzodiazepines appears unfavorable in this age group. Patients should be warned about the potential risks associated with these medications.
Benzodiazepines provide a fast anxiolytic action, so a common recommendation is to use these medications at low dose as a short-term adjunct, in which case they may provide some early relief and improve adherence to the treatment regimen. Even this adjunctive use of benzodiazepines is typically unnecessary and can reinforce an inappropriate message to patients that anxiety must be immediately relieved, which is akin to an avoidance response.
3. Psychoeducation about anxiety and treatment, including potential health benefits
Psychoeducation may be the most important management step. Providers should inform patients that they have a treatable condition and should address stigma, misinformation, and other common and surmountable barriers to treatment. Emphasize the importance of treating anxiety for improving quality of life, health, and brain health. Include the family in these discussions.
4 First-line treatment according to patient's preference, provider preference and competence, and treatment availability
First-line options include one or more of the following: SSRI, SNRI, relaxation training, and CBT. Bibliotherapy can and should be recommended alongside any of these options. Often these options will need to be started along with, or after, discontinuation of harmful or inappropriate confusogenic medications such as sedatives, anticholinergics, and antihistaminergics.
Features of anxiety disorders across the lifespan.
5. Frequent follow-up, particularly within the first month of treatment or dose change, to encourage adherence and monitor treatment response
Most anxious adults will receive a pharmacological trial as first-line treatment. Older adults vary from young adults in terms of increased comorbid medical conditions, pharmacokinetic changes, frailty, and drug interactions. Yet, anxious older adults' reports that they are sensitive or intolerant of antidepressant medications appears to result less from actual side effects than from their anticipatory concern, vigilance towards interoceptive stimuli, and tendency to catastrophize about any interoceptive sensations they detect.
Overcoming such fears related to the medication's potentially negative effects is not an easy task. This task is made more difficult by the standard list of potential side effects with any medication, many of which sound frightening or are symptoms that the patient already has (eg, fatigue, insomnia). To combat these fears proactively, describe how such antidepressant medications have established efficacy and high tolerability. Also, a health care provider should describe their experience in prescribing this medication and state that, while side effects are possible, no particular side effect is inevitable: most patients taking the medication will either have no side effects or will have brief, self-limited side effects which subside in a few weeks. Emphasize that the medication is unlikely to be incapacitating. When patients mention that “I already have that symptom,” they are not more likely to have that as a side effect as a result; in contrast, physical symptoms tend to decrease with pharmacological treatment.225
Family involvement can help with adherence. Nevertheless, most patients will have additional concerns after the medication is prescribed, especially before and just after they take the first dose. Address this in several ways, stating to patients/families that it is natural to have questions, and encouraging them to call, providing 24-hour contact information (typically patients do not, but benefit from the knowledge that they can). Ideally, as in clinical trials, we would provide weekly visits, or biweekly visits with interim telephone contacts, for the first month of treatment and the month subsequent to a dose increase, since this is when patients are most likely to develop concerns about side effects.
Follow-up includes interviewing patients closely for any concerns about perceived side effects. Patients often seem to perceive as side effects symptoms that predate the start of medication and are clearly a component of the disorder. In anxiety, adherence issues stem from vigilance to perceived side effects and subsequent catastrophizing. If such an issue is noted, an immediate contact will reassure the patient that they are being monitored closely by experts and that the medication is not causing some sort of severe or worsening problem. This brief but timely intervention reduces premature discontinuation of pharmacotherapy.
Geriatric anxiety disorder patients usually get better, but given the fluctuating nature of the disorders and the issues with insight, they often do not realize they are improving. Repeated assessment of frequency and severity of anxiety is important not just for assessing success of treatment but also demonstrating improvement to the patient.
6. With medications, start low, go slow, but go - as aggressively as required to treat symptoms to remission
After psychoeducation and clean-up of inappropriate medications, the proximal goal of acute care is to get the patient a treatment trial of sufficient intensity and duration to improve symptoms. This requires dose optimization, often at high doses that do not vary across the lifespan in the case of SSRIs/SNRIs.
Key points from a lifespan view of anxiety disorders.
7. Consider augmentation treatment and refer to experts if necessary
Monotherapy is usually inadequate, and if a good trial is only partially effective, add another. Providers should not “run out of options” but then should refer a patient to someone with additional expertise in (eg, a geriatric psychiatrist or a psychotherapist skilled at treating anxiety disorders).
8. Provide maintenance treatment; evaluate the need for such if treatment is discontinued
Since anxiety is chronic, treatment will usually need to be long-term, ie, maintenance medication and/or booster psychotherapy sessions. As the patient has already overcome any fears or initial side effects, maintenance pharmacotherapy requires less frequent oversight though continued monitoring of clinical changes, side effects, and changes in coprescribed medications is necessary. If a patient chooses to taper off a medication, they should be informed that they may need to resume treatment in the event of relapse. A taper should be very gradual (ie, over several weeks) to avoid rebound anxiety symptoms. Management does not have an end point, even when the patient is no longer receiving active pharmacotherapy. In the case of psychotherapy benefits, booster sessions provide important reminders to continue to use effective new coping skills.