Raymond Pary, M.D., Simrat Kaur Sarai, M.D., Steven Lippmann, M.D.

CLINICAL

Generalized anxiety disorder (GAD) is characterized by persistent, excessive worry. To confirm a GAD diagnosis, it must persist for over half a year, be present much of the time, and on most days. Those affected frequently express concern about apprehensiveness and/or irritability. Anxious elderly people commonly suffer distress, functional impairment, and somatic complaints, like fatigue or muscular tension. Serious medical pathologies often coexist, complicating lives with disabilities, and making clinical interventions complicated. Patients and physicians often find anxiety difficult to cope with or control.

Generalized anxiety disorder is the most common anxiety disorder among people over age 65 years (1). Phobic and/or panic disorders are occasional co-occurrences (2). Depression, substance abuse, and posttraumatic stress disorder are other co-morbidities.

Chronic diseases and persistence pain bother many such older persons. Comorbid depression worsens clinical presentations and outcome (3). Addressing these issues improves the prognosis.

Fear of falling down is a major concern among some of older individuals (4). Half of those who fell in the previous year exhibit persistent fear of reoccurrence (5).  Women, people with impaired mobility, or those needing gait assistance devices are particularly prone to such concerns. In this population, falling is commonly associated with significant injury, even death. Because of osteoporosis, women are particularly at risk for bone fractures and associated trauma-induced pathologies (e.g., pulmonary emboli). That can result in protracted fear of falling, further immobility, and isolation.  Gait precautions become paramount among infirm elderly people (6).

Social phobia is characterized by those who feel excessively watched in social situations. Fear of public speaking is one example.

Specific phobias are magnified fear responses to a specific object or situation; apprehension about falling can become a phobia. Since impaired balance and falls are so problematic, this might also be protective (4). Nevertheless, about half of all older residents in long-term care facilities are unstable while walking (7).

Panic disorders are noted by surges of intense anxiety, distress, and/or concern about potential misfortune. Since panic disorders emerge in older persons particularly during times of stress or health crises, medical illnesses and/or substance abuse remain in the differential diagnosis (8).

INTERVENTIONS

Newly diagnosed patients with mild anxiety sometimes undergo psychotherapy, such as with cognitive-behavior therapy (CBT). If symptoms are more profound, talk therapy is often combined with pharmacotherapies.

The selective serotonin reuptake inhibitor (SSRI) drugs or non-selective serotonin-norepinephrine reuptake inhibitor (SNRI) medications are the most frequently selected choices. Prescribing them offers easy, safe administration and effectiveness at diminishing anxiety.

Benzodiazepine medicines can be prescribed to quickly diminish emotional and somatic anxiety symptoms. If urgently needed, they are especially indicated only early in treatment, before other initial therapies achieve efficacy. Because these drugs induce tolerance, addiction, and potential misuse, they are not indicated for patients with substance abuse risk factors nor whenever misuse occurs. The development of pharmaceutical tolerance is a big concern; others include impairment in memory, gait, or dexterity. Benzodiazepines, thus, are often recommended only for short-term applications, aiming to avoid dependence, rebound insomnia, cognitive decline, and/or gait instability (9).

Pharmacotherapies in general, polypharmacy in particular, and high medicinal dosages are associated with more risk of falling. This is especially true for patients with dementia and/or with other infirmities (10). Yet, psychotherapy and/or medications can deliver greater personal comfort.

Physical therapy provides an underappreciated significant clinical benefit. The emphasis on balance-training, muscle strengthening, and safer gait techniques are helpful. Patient confidence and emotional comfort often also improve.

Maintaining interpersonal contacts and fostering social engagement are important for well-being. The best outcome follows multidisciplinary interventions, close monitoring, and socialization.

REFERENCES

1. Wittchen HU, Jacobi F, Rehm J, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 2011; 21(9): 655-679.
2. Brawman-Mintzer O, Lydiard RB, Emmanuel N, et al. Psychiatric comorbidity in patients with generalized anxiety disorder. Am J Psychiatry 1993; 150 (8): 1216-1218.
3. Tyrer P, Selvewright H, Johnson T. The Nottingham Study of Neurotic Disorder: predictors of 12 year outcome of dysthymic, panic and generalized anxiety disorder. Psychol Med 2004; 34: 1385-1394.
4. Scheffer AC, Schuurmans MJ, van Dijk N, et al: Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age and Aging 2008; 37:19–24.
5. Gagnon N, Flint AJ, Naglie G, et al. Affective correlates of fear of falling in elderly persons. Am J Geriatr Psychiatry 2005; 13: 7-14.
6. Denkinger MD, Lukas A, Nikolaus T, et al. Factors associated with the fear of falling and associated activity restriction in community-dwelling adults: a systematic review. Am J Geriatr Psychiatry 2015; 23(1): 72-86.
7. Lach HW, Parsons JL. Impact of fear of falling in long term care: an integrative review. J Am Med Assc 2013; 14:573-577.
8. Krasucki C, Howard R, Mann A. The relationship between anxiety disorders and age.  Int J Geriatr Psychiatry 1998; 13: 79-99.
9. Rickels K, Lucki I, Schweizer E, et al. Psychomotor performance of long-term benzodiazepine users before, during, and after benzodiazepine discontinuation. J Clin Psychopharmacology 1999; 19: 107-113.
10. Sterke CS, Verhagen AP, van Beeck EF, et al. The influence of drug use on fall incidents among nursing home residents: a systematic review. International Psychogeriatric 2008; 20(5): 890-910.