Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by excessive, almost daily, anxiety and worry for >= 6 mo about many activities or events. The cause is unknown, but GAD commonly coexists in people who have major depression or panic disorder or who have abused alcohol. Diagnosis is based on history. Treatment is psychotherapy, drug therapy, or both.

Geriatric Essentials

• Symptoms of generalized anxiety disorder in the elderly are similar to those in younger people.

Generalized anxiety disorder (GAD) is common, affecting up to 3% of community-dwelling elderly people within a 1-yr period. Women are twice as likely as men to experience GAD.

Symptoms

Symptoms of GAD in elderly patients are similar to those in younger people. The patient has multiple worries, which often shift over time. Common worries in the elderly include money, health (their own and that of their family members), and safety.

Diagnosis

Diagnosis of GAD is based on criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR). To meet the criteria, a patient must experience excessive anxiety and worrying about several events or activities on most days for >= 6 mo. The patient must also experience >= 3 of the following: restlessness, unusual fatigability, difficulty concentrating, irritability, muscle tension, or disturbed sleep. The anxiety and worrying cause significant distress or dysfunction. The course is usually fluctuating and chronic and worsens during stress. Most people with GAD have one or more comorbid physical and mental disorders, including major depression, specific phobia, social phobia, and panic disorder.

Treatment

Drugs that may contribute to the anxiety (see Table 34-2) should be stopped if possible. All coexisting physical and mental disorders that are potentially contributing to anxiety should be treated. Treatment of mild symptoms may begin with one-on-one counseling and family support provided by a physician, mental health nurse, mental health social worker, or psychologist. If symptoms are moderate and if the patient is motivated, psychotherapy alone or in combination with drug therapy is recommended first. If symptoms are severe or if the patient is not motivated for psychotherapy, drug therapy is the treatment of choice.

Drug therapy: The drugs of choice for anxiety in the elderly are antidepressants and benzodiazepines. An antianxiety drug such as an antidepressant or a benzodiazepine can be prescribed based on the suitability of the drug and, for a patient who is taking other drugs, on the possibility of drug-drug interactions. In general, elderly patients respond satisfactorily but not exceptionally to antianxiety drugs. Most patients experience relief but not elimination of tension and agitation, and many symptoms persist.

Antidepressants, especially SSRIs (eg, paroxetine, starting dose of 5 mg po once/day, increasing every 1 to 2 wk to 20 mg po once/day) and serotonin-norepinephrine reuptake inhibitors (SNRIs; eg, venlafaxine extended-release, starting dose of 37.5 mg po once/day, increasing every 1 to 2 wk to 150 mg po once/day), are effective but typically only after being taken for at least a few weeks. Recent concerns about a potential relationship between use of SSRIs or SNRIs and suicidal behavior in adolescents have not been raised about use in elderly patients; whether use of SSRIs and SNRIs increases suicide behavior in the elderly is not known. Abruptly stopping SSRIs and SNRIs may increase the risk of suicidal behavior. When SSRIs and SNRIs are to be stopped, the dosage should be tapered gradually over 2 to 3 wk to avoid increasing the risk of suicidal behavior and other adverse effects.

All benzodiazepines work well in treating anxiety. However, elderly people usually respond better to and experience fewer adverse effects from short- or intermediate-acting benzodiazepines (eg, lorazepam, oxazepam) than long-acting benzodiazepines (eg, diazepam, clonazepam). The dosage of benzodiazepines for elderly patients is usually lower (eg, lorazepam, starting dose of 0.25 mg po tid, increasing gradually to a maximum of 1 mg po tid; oxazepam, starting dose of 7.5 mg po tid, increasing gradually to a maximum of 15 mg po tid) than that for younger patients. Benzodiazepines are usually best prescribed on a fixed dosage schedule rather than as needed, although patients with occasional anxiety may use the drugs intermittently.

Benzodiazepines are likely to cause sedation and may impair the ability to drive or safely perform other demanding tasks. Ataxia, slurred speech, impaired coordination, confusion, poor concentration, memory loss, sleep disturbances, and depressive symptoms may occur. Benzodiazepines with long half-lives can greatly increase the risk of falls and hip fractures in the elderly. Patients should be monitored closely for adverse effects. If adverse effects occur, the dose must be reduced or the drug stopped, even if a patient must be hospitalized so that withdrawal symptoms can be monitored and treated appropriately. Rarely, an elderly patient has a paradoxical reaction to benzodiazepines and becomes more agitated and anxious. Occasionally, short-acting benzodiazepines produce a rebound anxiety effect before the next dose is given. In such cases, a longer-acting drug may be preferred.

Often benzodiazepines are needed for only a limited time (eg, up to 4 to 6 wk). In such cases, stopping the drug is easier if prescribers clarify from the outset that treatment is for only a brief period.

After continuous use for an extended time, benzodiazepine use may be difficult to stop for psychologic and physical reasons. Nevertheless, periodic efforts should be made to stop the drug or at least to reduce the dose. Results are best if the drug is stopped over the course of 3 to 4 wk, during which the dose is gradually reduced every few days.

A useful strategy for reducing the potential for adverse effects or withdrawal symptoms that can occur with benzodiazepines involves starting with concomitant use of a benzodiazepine and an antidepressant. Once the antidepressant becomes effective, the benzodiazepine is tapered.

Buspirone, an alternative to antidepressants and benzodiazepines with fewer adverse effects, is also effective. The initial dose of 5 mg bid is increased weekly to a maximum of 10 mg tid. Patients are less likely to become dependent on buspirone than on benzodiazepines, and, perhaps because of the sedative effect, buspirone may be tolerated by elderly people who cannot tolerate benzodiazepines. However, buspirone does not effect subjective improvement as quickly as the benzodiazepines do; its anxiolytic effect usually occurs after 2 to 4 wk of continuous therapy. People who have responded to benzodiazepines in the past often do not respond to buspirone.

Psychotherapy: Psychotherapy, usually cognitive-behavioral therapy, is effective and can be both supportive and problem-focused. Progressive relaxation and biofeedback may be of some help, although few studies have documented their efficacy.

Interdisciplinary care issues: Elderly people with GAD, which commonly occurs with comorbid physical and mental disorders, are most likely to present to nonphysician health care practitioners in the managed-care environment and in long-term care facilities than to physicians. Thus, professionals from multiple disciplines should be aware of the symptoms of GAD.

Nurses frequently encounter elderly patients with GAD in long-term care facilities. Patients initially transferred from the hospital or from home are at increased risk for anxiety, especially mild to moderate symptoms, which may not be reported to a physician. In these cases, brief supportive psychotherapy, which is informative and nondirective, can be beneficial.

Social workers frequently encounter elderly patients with GAD in long-term care facilities. They also see such patients in mental health centers, although the elderly are less likely than younger people to use these centers. Social workers can provide supportive therapy to the patient and to family members.

Social workers or psychologists are most likely to provide psychotherapy to elderly people with anxiety disorders. They usually collaborate with physicians, who can prescribe drugs. Such interdisciplinary care is most effective if it is well coordinated; active ongoing communication between the social worker or psychologist and the physician is essential.

This topic was last updated September 2005.