How Do You Treat Anxiety in the Elderly?

In the elderly, anxiety medication and therapy combinations must also consider a patient’s home environment, existing support systems or lack thereof, mobility, level of isolation, level of independence, ability to manage daily tasks, health history, and existing illnesses.

Anxiety disorders are a common type of psychiatric disorder characterized by anxiety or fear that does not diminish over time. 

Types of anxiety disorders include:

• Generalized anxiety disorder
• Social anxiety disorder (social phobia)
• Panic disorder
• Separation anxiety disorder
• Phobias
• Agoraphobia
• Selective mutism
• Substance/medication-induced anxiety disorder
• Anxiety disorders due to other medical conditions

Symptoms of anxiety disorders in the elderly vary depending on the type of anxiety disorder present and may include: 

• Excessive anxiety and worry 
• Restlessness or feeling on edge
• Being easily fatigued
• Shakiness
• Irritability
• Difficulty concentrating 
• Sleep problems
• Muscle tension
• Difficulty breathing
• Dizziness
• Lightheadedness
• Sweating
• Nausea
• Digestion problems
• Headaches
• Eye and vision problems
• Confusion
• Forgetfulness
• Sleep problems/nightmares
• Scary thoughts
• Fear of social situations and exposure to possible judgment by others, that can hinder the ability to function 
• Fear of humiliation or embarrassment
• Chest pain
• Shortness of breath
• Obsessive thoughts
• Compulsive behavior
• Feeling as if a heart attack is occurring (panic attack)
• Sudden onset of fear, usually peaking within 10 minutes 
• Changes in personality, such as becoming more passive, dependent, or withdrawn
• Intense anxiety when exposed to specific situations such as heights, small spaces, animals, or storms
• Fear of being trapped with no escape 
• Irrational and out-of-proportion fear attached to specific situations (such as flying, heights, animals, insects, blood, needles)
• Avoiding people, places, activities, and thoughts that trigger anxiety
• Changes in weight, appetite, or eating habits
• Resistance to leaving home
• Substance abuse 

Anxiety disorders may have a number of possible causes, including:

• Genetic factors
• Environmental factors such as early childhood trauma
• Known or undiagnosed medical condition 
• Substance-induced

In the elderly, there may be triggers that can cause or worsen anxiety, such as:

• Health problems
• Loss of independence
• Immobility
• Chronic pain
• End-of-life planning
• Grief and loss
• Financial insecurity
• Dementia
• Role reversal
• Changes in sensory perception, including vision or hearing loss and diminishing taste and smell
• Isolation

Anxiety disorders are usually diagnosed with a psychological evaluation. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association provides diagnostic criteria for an anxiety disorder. 

Lab studies to diagnose or exclude medical conditions that may cause anxiety disorders include:

• Complete blood cell (CBC) count
• Chemistry profile
• Thyroid function tests
• Urinalysis
• Urine drug screen

Tests to rule out central nervous system (CNS) disorders that can cause anxiety include:

• Electroencephalography (EEG)
• Lumbar puncture
• Brain computed tomography (CT) scan
• Magnetic resonance imaging (MRI) of the brain 
• Neurologic consultation 
• Positron emission tomography (PET) scan

Tests to rule out heart conditions that can cause anxiety include:

• Electrocardiography (ECG) 
• Treadmill ECG

Tests to rule out infectious causes of anxiety include:

• Rapid plasma reagent test
• Lumbar puncture (CNS infections)
• HIV testing

Other tests to rule out other physical causes of anxiety include:

• Arterial blood gas analysis 
• Chest X-ray

Treatment for anxiety disorders usually consists of a combination of medication and/or psychotherapy.  In the elderly, treatment must also consider a patient’s home environment, existing support systems or lack thereof, mobility, level of isolation, level of independence, ability to manage daily tasks, health history, and existing illnesses. There are professional care managers who can help assess all these elements and develop a treatment plan. 

For the elderly, social day programs provide support and care that may help manage symptoms. 

Types of therapy used to treat anxiety disorders include:

• Behavioral therapy and cognitive behavioral therapy (CBT) 
• Computerized CBT (FearFighter) 
• Psychodynamic therapy (or insight-oriented therapy) is rarely used on its own for phobias but may be used for phobic disorders that overlap personality disorders
• Interpersonal psychotherapy 
• Relaxation therapy
• Supportive psychotherapy
• Mindfulness therapy

Medications that may be used to treat anxiety disorders include: 

• Antidepressants
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs) 
  • Atypical antidepressants 
  • Tricyclic antidepressants
• Monoamine oxidase inhibitors (MAOIs) 
• Benzodiazepines, especially in emergency situations 
• Anti-anxiety drugs 
• Anticonvulsants 
• Antihypertensive drugs 

Other treatments used for anxiety disorders include: 

• Cranial electrotherapy stimulator (CES) for treatment of anxiety, depression, and insomnia

Hospitalization may be indicated to treat anxiety disorders in severe cases such as: 

• Severe functional impairment (cannot meet own daily needs)
• Suicide or homicide risk
• Deficits in social skills