How Anxiety Presents Differently in Older Adults: Age-Related Changes, Medical Comorbidities Alter Presentation and Treatment

Although anxiety disorders are common at all ages, there is a misconception that their prevalence drastically declines with age. For this reason anxiety disorders often are underdiagnosed and undertreated in geriatric patients, especially when the clinical presentation of these disorders in older patients differs from that seen in younger adults. In older persons, anxiety symptoms often overlap with medical conditions such as hyperthyroidism and geriatric patients tend to express anxiety symptoms as medical or somatic problems such as pain rather than as psychological distress. 1 As a result, older adults often seek treatment for depressive or anxiety symptoms from their primary care physician instead of a psychiatrist. Unfortunately, primary care physicians often miss psychiatric illness, including anxiety disorders, in geriatric patients. Anxiety may be a symptom of an underlying psychiatric disturbance, secondary to a general medical condition, or induced by dietary substances, substances of abuse, or medications. Late-life anxiety often is comorbid with major depressive disorder (MDD) (Box, page 66) and other psychological stressors as older adults recognize declining cognitive and physical functioning. (2) BOX Comorbid anxiety and depression: Highly prevalent, poorer outcomes The Longitudinal Aging Study Amsterdam study--one of the largest epidemiologic studies to examine comorbidity of anxiety disorders and depression in patients age 55 to 85--found that 48% of older persons with primary major depressive disorder (MDD) also had a comorbid anxiety disorder, whereas approximately one-fourth of those with anxiety disorders also had MDD. (a) Pre-existing anxiety disorders, such as social phobia, obsessive-compulsive disorder, specific phobia, agoraphobia, and panic disorder, increase the risk of developing depression. " Rates of comorbid anxiety and depression increase with age. (c) [ILLUSTRATION OMITTED] Late-life MDD comorbid with generalized anxiety disorder or panic disorder is associated with greater memory decline than MDD alone. (d) In addition, comorbid anxiety and depression is associated with greater symptom severity and persistence, greater functional impairment, substance dependence, poorer compliance and response to treatment, worse overall prognosis and outcome than patients with either disorder alone, (e) and greater likelihood of suicidal ideation in older men. (f) Source: For reference citations, see this article at CurrentPsychiatry.com Anxiety disorders commonly begin in early adulthood, tend to be chronic and interspersed with remissions and relapses, and usually continue into old age. (3) In generalized anxiety disorder (GAD), there is a bimodal distribution of onset; approximately two-thirds of patients experience onset between the late teens and late 20s and one-third develop the disorder for the first time after age 50. (3) Prevalence rates for anxiety disorders among older adults (age >55) range from 3.5% to 10.2%. (4) These rates are slightly lower than those for younger adults. (5) Among older adults, presence of a 12-month anxiety disorder was associated with female sex, lower education, being unmarried, and having [grater than or equal to]3 or more chronic conditions. (6) Anxiety and disability risk Anxiety disorders affect geriatric patients more profoundly than their younger counterparts. Persons age >65 who have an anxiety disorder are 3 to 10 times more likely to be hospitalized than younger individuals. (1) Anxiety is associated with high rates of medically unexplained symptoms, increased use of health care resources, chronic medical illness, low levels of physical health-related quality of life, and physical disability. (7), (8) Anxiety symptoms may predict progressing physical disability among older women and reduced ability to perform activities of daily living over 1 year. …