A Veterans Health Administration Imperative: Recommendations for Detecting Anxiety in Older Adults

D espite routine screening in the VHA for depression, posttraumatic stress disorder (PTSD), and substance abuse, anxiety (not due to PTSD) has received little attention, particularly for older veterans (defined as aged ≥ 65 years). In this review, the authors focus on the detection of late-life anxiety disorders, primarily generalized anxiety disorder (GAD), anxiety symptoms that don’t meet GAD criteria, and anxiety symptoms co-occurring in GAD. Fortyfive percent of veterans receiving care in VHA are ≥ aged 65 years; identification of mental health problems in this population is crucial. Depression affects 15% to 40% of older veteran primary care patients. Anxiety disorders are also prevalent among older veterans. Among VHA primary care patients aged 18 to 79 years, the prevalence of anxiety disorders was 10.6% for those without PTSD and 73.3% for patients with PTSD. Anxiety disorders are one of the most common classes of mental disorders in late life, occurring twice as often as depressive disorders in the general population and affecting about 7% of individuals aged > 65 years in a 12-month period. In comparison with young adults, older adults are more likely to experience impairment from clinically significant anxiety symptoms that do not meet the criteria for any anxiety disorder using current categorical diagnostic systems. Anxiety symptoms are highly prevalent in patients with chronic health problems such as congestive heart failure, chronic obstructive pulmonary disease, and diabetes. Both anxiety disorders and clinically significant levels of anxiety symptoms are associated with a poor quality of life (QOL), greater disability, and increased health care use among older adults. In addition, even mild anxiety is associated with reduced cognitive performance. The presence of one of the most common anxiety disorders, GAD, is associated with an increased risk of suicide among depressed older adults seen in primary care and psychiatric clinics. Detection of anxiety is a critical first step in connecting patients with treatments. Efficacious treatments for reducing late-life anxiety symptoms may minimize the negative effects of anxiety on patients’ QOL and help health care providers to address patients’ health problems. According to a recent meta-analysis, compared with placebo treatment, cognitive behavioral therapy (CBT) and relaxation therapy are efficacious treatments for late-life anxiety. In one study of older nonveteran primary care patients with GAD, CBT led to greater improvements in worry severity, depressive symptoms, and general mental health compared with enhanced usual care. Currently, a CBT treatment manual Dr. Gould is a postdoctoral fellow in advanced geriatrics at the VA Palo Alto Health Care System Geriatric Research Education and Clinical Center (GRECC) in Palo Alto, California, and a postdoctoral scholar (affiliated) in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in Stanford, California. Dr. Beaudreau is the National Associate Director of a VA Advanced Fellowship Program and an investigator at the VA Palo Alto Health Care System and the Sierra Pacific Mental Illness, Research Education and Clinical Center, both in Palo Alto, California. Dr. Beaudreau is also a clinical associate professor (affiliated) in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in Stanford, California. Dr. Huh is the associate director of education and evaluation at the VA Palo Alto Health Care System GRECC in Palo Alto, California, and a clinical assistant professor (affiliated) in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in Stanford, California.