Evidence-Based Reviews

How anxiety presents differently in older adults

Current Psychiatry. 2011 March;10(3):65-72

References

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Generalized anxiety disorder

Although GAD is the most common anxiety disorder among geriatric patients, with a prevalence of 0. 7% to 9%,¹³ it remains underdiagnosed and undertreated.¹⁴ In a cross-sectional observational study of 439 adults age ≥55 with lifetime GAD, approximately one-half experienced onset after age 50.¹⁵ Late onset is associated with more frequent hypertension and a poorer health-related quality of life than early onset.¹⁵

Compared with younger individuals, older persons with GAD have a greater variety of worry topics, including memory loss, medical illnesses, and fear of falls,¹⁶ but worry less about the future and work than younger patients. This type of anxiety is largely situational and temporary, and often accompanies comorbid medical problems (Table 1) .

Obsessive-compulsive disorder

A study comparing older (age ≥60) and younger obsessive-compulsive disorder (OCD) patients found that the clinical presentation of the disorder does not substantially differ between age groups; however, geriatric patients had fewer concerns about symmetry, needing to know, and counting rituals. Handwashing and fear of having sinned were more common.¹⁷

OCD is fairly uncommon in geriatric patients. Prevalence rates decrease with age, ranging between 0% and 0. 8% among persons age ≥60.¹⁸ OCD seldom begins in late life; most geriatric patients with OCD have had symptoms for decades. By late life, most individuals with OCD improve, although they may continue to experience clinical or subclinical symptoms.¹⁹ However, 1 report found a second peak of incidence of OCD in women age ≥65.²⁰ Case reports of late-onset OCD have found evidence of cerebral lesions, often in the basal ganglia, which suggests a possible neurodegenerative pathophysiology.²¹

Table 1

DSM-IV-TR criteria for generalized anxiety disorder

A.	Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)
B.	The person finds it difficult to control the worry
C.	The anxiety and worry are associated with 3 or more of the following symptoms with at least some symptoms present for more days than not for the past 6 months: Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance
D.	The focus of the anxiety and worry is not confined to features of an axis I disorder
E.	The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
F.	The disturbance is not due to the direct physiological effects of a substance or a general medical condition and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder
Source: Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000

Posttraumatic stress disorder

Clinical Point

Life changes may precipitate so-called delayed PTSD, when symptoms relating to past traumatic experiences present for the first time

Untreated posttraumatic stress disorder (PTSD) often is assumed to be a chronic disorder. Recollections of past trauma may lead to new PTSD symptoms in older patients. Neurodegeneration of memory pathways and cognitive impairment associated with Alzheimer‘s disease or vascular or alcohol-related dementia may disinhibit PTSD symptoms in patients whose PTSD was fairly well controlled.²²

Life events associated with aging—death of a spouse, financial and physical decline, chronic pain, or diminished cognitive coping resources—may precipitate or revive PTSD symptoms associated with earlier exposure to severe psychological trauma.²³ These life changes also may precipitate socalled delayed PTSD, when symptoms relating to past traumatic experiences present for the first time. Geriatric patients may be more likely than younger persons to deny their PTSD symptoms if their cultural background emphasizes stoicism and fortitude.²⁴

Phobias

Specific phobias. The prevalence of specific phobias drops dramatically in late life, although older patients might underreport symptoms. Many older persons are afraid of falling. Approximately 60% of older adults with a history of falling—and 30% of older individuals with no such history— report this fear. Fear of falling is more prevalent in women and increases with age.^25,26 This fear may be a protective response to a real threat that prevents older persons from attempting high-risk activities, but it also can cause patients to restrict their activities, which can result in decreased social, physical, or cognitive functioning and loss of in-dependence.²⁵

Social phobias (social anxiety disorder).

Among older adults, common social phobias include eating food around strangers, and—especially in men—being unable to urinate in public bathrooms. In a cross-sectional observational study, social anxiety disorder (SAD) was more common among older persons who reported stressful life events, such as death of a spouse.²⁷ MDD, specific phobia, and personality disorder are associated with SAD in geriatric patients.²⁷ Prevalence rates of SAD appear to slightly decrease with age, although the condition remains common in geriatric patients—5% of older adults report lifetime prevalence—and its presentation is similar to that seen in younger adults.²⁷