Introduction

Geriatric Essentials

• Anxiety in the elderly occurs most commonly in a wide range of physical disorders and in mental disorders other than primary anxiety disorders.

Everyone periodically experiences fear and anxiety. Fear is an emotional, physical, and behavioral response to an immediately recognizable external threat (eg, an intruder, a car bearing down on a pedestrian). Anxiety is a distressing, unpleasant state of nervousness and uneasiness; its causes are less clear. Anxiety is less tied to the exact timing of a threat; it can be anticipatory before a threat occurs, persist after a threat has passed, or occur without an identifiable threat. Anxiety is often accompanied by physical changes and behaviors similar to those caused by fear.

Some degree of anxiety is adaptive; it can help people prepare, practice, and rehearse so that their functioning is improved, and it can help them be appropriately cautious in potentially dangerous situations. However, beyond a certain level, anxiety is maladaptive, causing undue distress and dysfunction. At such a level, anxiety can be considered a symptom of a disorder.

Anxiety in the elderly most often is secondary to a wide range of physical and mental disorders other than anxiety disorders. Less often, the elderly have a primary anxiety disorder; anxiety is the predominant symptom of primary anxiety disorders.

Primary anxiety disorders are classified as generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobic disorders, and stress disorder (eg, acute stress disorder, posttraumatic stress disorder). All occur in the elderly. Prevalence and sometimes symptoms and outcomes in the elderly differ from those in younger people.

Etiology

In the elderly, physical and mental disorders (see Table 34-1) and drugs (see Table 34-2) are the most frequent causes of anxiety or similar symptoms that are easily mistaken for an anxiety disorder. Delirium is often accompanied by moderately severe anxiety and agitation, especially if the patient is in unfamiliar surroundings. Dementia is a common cause of anxiety in the elderly. Early signs of cognitive impairment, including memory loss, in socially active people often progress to generalized anxiety, with periodic panic attacks; the panic attacks, in turn, contribute to social withdrawal and isolation. The anxiety may cause severe and traumatic behavioral changes, which can mask the underlying dementia. Major depression frequently produces symptoms of anxiety.

The causes of primary anxiety disorders are not fully known. Many people develop primary anxiety disorders without any identifiable triggers. Acute stress and posttraumatic stress disorders are the easiest to trace to a specific event; most cases of these disorders are caused by trauma such as accidents, although sexual abuse can also be a cause.

Symptoms

Severity of anxiety ranges from barely noticeable qualms to complete panic. Anxiety can arise suddenly, as in panic, or gradually over many minutes, hours, or even days. Anxiety may last from a few seconds to years; longer duration is characteristic of most primary anxiety disorders; however, the most severe--panic--usually lasts for only a brief period. The ability to tolerate a given level of anxiety varies from person to person. Primary anxiety disorders can be so distressing and disruptive that depression may result. Alternatively, a primary anxiety disorder and a depressive disorder may coexist, or depression may develop first, with symptoms of an anxiety disorder occurring later.

Diagnosis

When evaluating a patient for a possible primary anxiety disorder, physicians must first determine, by history, physical examination, and appropriate laboratory tests, whether anxiety is secondary to a physical disorder or drug. Physicians must also determine whether anxiety is better accounted for by another mental disorder such as depression. If other causes are not found and if anxiety is distressing, interferes with functioning, and does not stop spontaneously within a few days, then a primary anxiety disorder is present and merits treatment.

Diagnosis of a specific primary anxiety disorder is based on its characteristic symptoms and signs. A family history of anxiety disorders (except acute stress and posttraumatic stress disorders) helps in making the diagnosis, because some patients seem to inherit a predisposition to the same anxiety disorders that their relatives have as well as a general susceptibility to other anxiety disorders. However, some patients may seem to acquire the same disorders as their relatives through learned behavior.

Agitation (the physical manifestation of hyperactivity) is important to differentiate from anxiety. Agitation without true anxiety often occurs in people with dementia. Elderly people who are agitated do not always experience the sense of impending doom and dread that characterizes anxiety. Some agitated elderly people report early-morning anxiety that borders on panic, especially if they awaken in the dark and other people in the house remain asleep. These symptoms tend to remit as the day progresses.

Neuropsychologic testing is rarely beneficial for diagnosing primary anxiety disorders in the elderly, although such testing is frequently used for diagnosing dementing and mood disorders.

This topic was last updated September 2005.