Anxiety Disorders in Late Life Research Paper

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Abstract

Recent   epidemiological    studies    have   underscored the   ubiquitous    nature   of   anxiety   disorders,   with approximately  25% of adults  being  affected over  the course  of their  lifetimes.  Furthermore,   the  economic burden  of these disorders  has been estimated at $42.3 billion, comprising 31% of psychiatric treatment  costs. Given   the   prevalence   of   anxiety   disorders,   it   is not  surprising  that  an increasing  amount  of attention has been given to investigating the prevalence and treatment  of these conditions. What is surprising, however,  is  how  little  attention   has  been  given  to anxiety   disorders   in   what   is   the   fastest   growing segment  of the  population,  namely  the  elderly.  This research paper summarizes how the existing research literature informs us with respect to the epidemiology of anxiety disorders in the elderly and then examines the treatment outcome literature with regard to the individual anxiety disorders.

Outline

1. Epidemiology of Anxiety Disorders in Older Adults
2. Assessment and Treatment of Anxiety Disorders
3. Conclusions

1. Epidemiology Of Anxiety Disorders In Older Adults

The United  States is aging. The U.S. Census  Bureau predicts that more than 72 million adults will be age 65 years or over by the year 2030. Recent epidemiological studies underscore  that anxiety disorders are the most prominent  of the psychiatric conditions,  with lifetime estimates nearing 25%. Despite the widespread prevalence and extensive cost to society of anxiety disorders, there is currently  little data on the rate and phenomenology of anxiety disorders in the elderly population.

1.1.  General Prevalence Data

It is generally believed that anxiety disorders occur less frequently  in the elderly population  than  in younger adults. However, there have been only a small number of epidemiological studies that have tested this contention  directly.  A recent  epidemiological  study  in  the United  States  that  included   persons  over  65  years of age is the  Epidemiological  Catchment  Area (ECA) study, which included more than 18,000 noninstitutionalized adults. The ECA study systematically examined the  rate  of anxiety  disorders  at  five sites across  the country.  Fully 30% of the ECA subjects were age 65 years or over. It was ascertained that the 1-month prevalence rate of anxiety disorders in the elderly was approximately 5.5%, lower than the 7.3% estimate for all adults surveyed. Furthermore, elderly women were nearly twice as likely to have anxiety disorders as were elderly  men.  The  percentage  of elderly  adults  with anxiety disorders was higher than that with any other psychiatric illness, including cognitive impairment, underscoring  the  need  for appropriate  identification and  treatment  in this population.  Furthermore, rates of anxiety disorders  were much higher than the 2.5% prevalence  rate  of affective disorders  in this  population.  Other  reviews of smaller  scale epidemiological studies  found  that  rates  of anxiety  disorders  ranged between  0.7 and  19.0%. Similar 6-month  prevalence rates of 3.5% have been found in Europe.

1.2.  Epidemiology of Individual Anxiety Disorders

Rates for  specific anxiety  disorders  also  vary across studies and differ between elderly males and females. Data from the ECA study suggest that phobias are the most frequently experienced anxiety disorder in the elderly,  affecting an  estimated  4.8% of older  adults. Panic disorder  (PD) and obsessive–compulsive disorder (OCD)  in the elderly population  are expected  to occur only infrequently. Rates for PD are estimated to not exceed 0.3%, and when panic does occur in elderly adults, it tends to be in women. Similarly, rates of OCD among the elderly are low, with prevalence estimates being  3.5% at  a  maximum  and  with  elderly  adults residing  in  institutional   settings  accounting  for  the upper end of these prevalence estimates.

Data regarding the prevalence of generalized anxiety disorder (GAD) suggest that it has a much more variable occurrence in the elderly population,  ranging between 0.7 and 7.1%. It is important to note that data on the  prevalence  of GAD are not  included  in the  ECA data and that other studies that find higher prevalence rates of GAD may be due to differences in their respective methodologies, for example, the decision rules applied in rendering a diagnosis.

1.3.  Reliability of Epidemiological Studies

There are several potential  explanations  for the wide variability of estimates of anxiety disorder  prevalence in the elderly. The existing epidemiological studies use different methodologies,  and this often makes it difficult to compare prevalence rates across individual studies.  Some of the studies  include  institutionalized elderly adults, whereas others survey community dwelling residents only. In addition, measures of anxiety symptoms validated on younger adults might not be applicable to older adults given that the experience and expression of anxiety may change with age. Likewise, the  instruments   used  to  assess anxiety  in older  adults  might  not  have norms  or other  psychometric  data  that  are  established  for older  adults,  let alone for very old adults. Further  research  is needed to delineate factors that contribute  to the difference in prevalence estimates and to clarify the nature of anxiety in the elderly. Until then,  estimates of prevalence rates of anxiety disorders in the elderly should be considered preliminary.

1.4.  Comorbidity

It is well known in the literature that anxiety disorders often co-occur with other diagnoses, including depression and other anxiety disorders. However, it is important to examine whether this is true for elderly persons as well. Research  is beginning  to  shed  light  on  the co-occurrence  of anxiety and other  psychiatric  disorders in older adults. As with younger adults, depression most frequently co-occurs with anxiety disorders among elderly patients. In addition, when depression is the primary diagnosis in elderly adults, anxiety frequently co-occurs. In general, the delineation between depression  and anxiety is not clear, and research suggests that it might be even less clear for older adults.

Unlike anxiety or depression,  the incidence of cognitive impairment  increases with age. Research examining the relationship between anxiety and dementia in older adults typically finds that these syndromes often coexist.   Symptoms  of  anxiety  often  occur   in  the context  of dementia  as well as in nondemented  older adults.

In summary, although the frequency with which anxiety disorders are present in older adults is lower than that in younger adults, these data may be confounded by methodological  problems  such  as differences in diagnostic  classification,  commonalities   between  anxiety and depression in this population, and the frequent occurrence of anxiety symptoms accompanying medical conditions.

2. Assessment And Treatment Of Anxiety Disorders

2.1.  Generalized Anxiety Disorder

2.1.1. Assessment

Diagnostic criteria for GAD have undergone  considerable revision over the past 20 years or so. The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) emphasizes chronic uncontrollable  worry that  causes significant  distress  or impairment  as the hallmark symptom of the disorder. In adults of all ages, GAD is most often comorbid with other affective and anxiety disorders and is sometimes viewed as a vulnerability factor for the development of additional psychiatric problems. GAD is often secondary to depressive disorders in older adults.

As noted by Carmin and colleagues in 1999, the only clinician-rated   diagnostic  interviews  that  have  been found to yield reliable diagnoses with elderly patients are the Structured Clinical Interview Diagnostic (SCID) and the Anxiety Disorders  Interview Schedule (ADISIV). Low interrater  reliability estimates were reported during  the  1980s for GAD; however, better  estimates have been found using DSM-IV criteria. A recent investigation using the SCID and the ADIS yielded substantial diagnostic agreement for all of the anxiety disorders in an older treatment-seeking  sample. Interrater  reliability for  GAD with  the  ADIS was  similarly  found  to  be excellent.

Two additional  clinician-rated  measures  have been used to determine  anxiety severity in the elderly. The Hamilton  Anxiety Rating Scale (HARS) is a 14-item scale tapping  anxiety  symptoms  in somatic,  psychic, and affective domains. In 1997, Beck and Stanley found that  the  HARS distinguished  older  adults  with  GAD from normal controls, providing some preliminary support   for  the  measure.  The  FEAR is  a  relatively new instrument  developed to measure  GAD in older adults in the primary care setting. The FEAR, a 4-item version of the 11-item Anxiety Disorder Scale, is meant to  be  administered  verbally  during  routine  medical exams or in the waiting room. The FEAR demonstrated very good sensitivity and  specificity in an initial  administration   to  88  older  medical  patients,  27%  of whom were diagnosed with GAD. Additional psychometric properties of the measure await investigation.

There  are  only  a few self-report  measures  that  are recommended  for use with late-life GAD patients. The Worry Scale (WS) is a 35-item, self-report questionnaire tapping three subscales of worry domains of importance to older adults—finances, health, social issues—using a 5-point Likert scale. The primary utility of the measure is the  assessment  of GAD. However,  the  use  of the measure with a sample of older adults with GAD yielded poor  convergent  validity,  with  low  correlations  with other measures of anxiety. The internal  reliability estimate was .93, but test–retest reliability was not reported. In a second  study  by Beck and  Stanley in  1997,  the measure showed adequate internal  reliability and convergent validity. Currently,  the properties  of this measure seem to be better  established  in healthy controls than in patient samples.

The Penn State Worry  Questionnaire  (PSWQ) consists of 16 items on a 4-point Likert scale designed to tap the generality, intensity, and uncontrollability  of worry. The measure has demonstrated good psychometric properties  (e.g., internal consistency, convergent validity)  in  several  studies   of  older   adults   with  GAD. However,  the  PSWQ failed  to  discriminate   between older adults with GAD and PD and has shown inadequate test–retest reliability in older GAD patients over a variable period  with  a mean  of 70 days. Stanley and colleagues found that the PSWQ showed good divergent validity with measures of depression.  Because late-life GAD is also comorbid with depressive disorders, this is one appealing feature of the measure.

The trait scale of the State–Trait Anxiety Inventory (STAI) assesses the  tendency  to  experience  frequent anxiety  and  nervousness.  The measure  has 20 items on a 4-point Likert scale and is one of the most frequently  used  self-report  questionnaires  in  studies of anxiety. In heterogeneous  older adult samples, the trait  scale  has  shown  adequate  psychometric  properties, and  there  are ample normative  data. In 1996, Stanley, Beck, and Zebb found low to moderate correlations between the STAI and other anxiety and worry measures in older GAD patients but found good internal consistency  of .88 for the  trait  scale. Test–retest reliability estimates were not given for the GAD sample but were good in a sample of healthy older adults. A more recent  investigation  showed good internal  consistency but low test–retest reliability (.58) in a sample of 57 older adults with GAD. Mohlman, deJesus, and colleagues found that scores on the measure were very similar in older adults  with GAD and PD, suggesting that it taps a nonspecific construct  in older samples.

2.1.2. Psychosocial Treatment  of Late-Life Generalized  Anxiety Disorder

Two early studies by Stanley and colleagues indicated that supportive  group therapy was beneficial for late life GAD treatment. The 14-week intervention  focused on the  discussion  of symptoms  and  experiences  and providing support  for group members.

Investigations of individual format cognitive behavior therapy (CBT) have suggested that this treatment is effective in older adults with GAD. However, it is notable that most of these studies have included nonstandard augmentations  to the therapy such as concurrent medication and weekly meetings with a physician, treatment  conducted  in  primary  care  or  in  patients’ own  homes,  and  the  use  of learning  aids.  The  only investigation of standard  individual  CBT delivered in a mental health clinic indicated very modest efficacy as compared  with  a wait  list  condition.  Currently,  the efficacy of individual CBT is not well supported.

Several studies assessing the efficacy of group CBT for late-life GAD indicate that the treatment is typically more effective than wait list control  conditions;  however, it is not  significantly better  than  other  control conditions.  Thus,  it is possible  that  nonspecific  elements of the group format (e.g., increased social interaction, mitigation of loneliness), rather  than elements specific to CBT, led to improvement.  Studies comparing  group  format  CBT with  individual  format  CBT should help to clarify this issue.

2.2.  Panic Disorder and Agoraphobia

2.2.1. Assessment

Notably, very few studies  have addressed  the psychometric properties of measures of panic and related symptoms in older patient samples. Two studies, one using a nonclinical community sample and the other using patients drawn from a medical clinic, studied the properties of the Beck Anxiety Inventory (BAI), a well-known measure of anxiety and panic symptoms and found that the  scale had  good discriminant  validity and  internal consistency.  The  latter  study  also  demonstrated   the BAI four-factor solution  with autonomic,  neuromotor, cognitive, and panic subscales, suggesting that anxiety symptom clusters are slightly different from those found among younger adults.

The Anxiety Sensitivity Index (ASI) is a 16-item measure  tapping  the  fear of anxiety  sensations,  which  is known to be a risk factor for the development of panic. In 2000, Mohlman and Zinbarg tested the structure and validity of the ASI in 322 healthy older adults (mean age 75 years). The ASI showed strong internal  consistency and moderate correlations with measures of related constructs. Confirmatory factor analysis indicated a hierarchical  structure  with three group factors—physical concerns, mental incapacitation concerns, and social concerns—as  well as a general factor, consistent  with previous investigations of the ASI in younger adults. In 1998, Deer and Calamari found that 49% of their older sample (mean age 81 years) reported  panic symptoms and that  27% reported  a panic attack during  the past year. Anxiety sensations  predicted  unique  variance in panic symptomatology and may function as a risk factor for the development of late-life panic.

2.2.2. Psychosocial Treatment  of Late-Life Panic  Disorder

Trials of psychosocial treatments in older samples with PD, panic disorder  with agoraphobia  (PDA), or agoraphobia without history of panic disorder (AWOHPD) are limited to case studies and three small pilot studies. One  study  found  that  principles  of reality  therapy, which focuses on an individual’s situation  and worldview, were effective when used by a neighbor to mitigate an older adult’s paranoia and agoraphobia.

Early investigations  of behavioral  treatments  conducted during the 1970s included relaxation, imagery, and  exposure.  In  1996,  Rathus  and  Sanderson  used CBT with  two  older  panic  patients:  one  70-year-old male and one 69-year-old  female. Treatment  components  were education,  cognitive restructuring, interoceptive and situational exposure, and diaphragmatic breathing. Both participants  achieved panic-free status and decreased depression  following 4 to 5 months  of therapy.

In  1991,  King and  Barrowclough  tested  CBT for panic and anxiety in a small sample of adults ages 66 to  78  years.  Of the  10  participants,   8  had  primary diagnoses  of  PDA. After  treatment,   7  were  free  of panic and 2 showed decreased symptom severity. Six months  later, 8 of the remaining  9 participants  were panic free and 6 showed improvement  on depression.

In 1996, Swales and colleagues tested 10 90-minute sessions  of CBT in  15  adults  ages 55  to  80  years. Participants experienced decreased severity and frequency  of panic  attacks,  depression,  avoidance,  and role impairment,  and this was apparent  at both post treatment  and 3-month  follow-up. A reanalysis of Gorenstein and colleagues by Mohlman indicated that CBT plus medication  management  (n = 5) was somewhat  more   effective  than   medication   management alone  (n  = 5)  in  assisting  older  adults  with  PD to decrease anxiety while tapering off anxiolytic medication. The use of interoceptive exposure was believed to facilitate habituation  to sensations  related  to PD and medication withdrawal simultaneously.

2.3.  Social  Anxiety Disorder

Although the social anxiety literature has grown tremendously  during  the  past  several  years,  there  is still  a relative dearth of empirical research examining the assessment  and  treatment   of  social  anxiety  in  older adults.  This  may  be  due  in  part  to  the  fact that  in epidemiological  studies,  social  phobia  is  a  relatively rare disorder among the elderly population. In addition, social anxiety as a distinct diagnostic category did not appear until the third edition of the DSM was published.

2.3.1. Assessment

As noted previously, the SCID and the ADIS-IV are the only   two   clinician-administered  diagnostic   instruments  with published  data on older  adults.  In 1993, Segal and  colleagues  reported  interrater  reliabilities ranging from good to excellent across anxiety disorder diagnoses with use of the SCID.

The  ADIS-IV is considered  the  gold  standard  for diagnosing   anxiety   disorders   in   adults.   In   2001, Brown and  colleagues found  the  interrater reliability of the lifetime version of this instrument to be excellent for social anxiety on a population of younger adults. Its reliability for diagnosing social phobia in older adults has not yet been established.

There are currently a number of self-report measures available for assessing social anxiety in younger adults. Unfortunately,  none  of the  measures  that  has  been used with younger cohorts has norms or other psychometric data supporting  its use with older adults.

2.3.2. Treatment

In contrast to the abundant literature examining psychological and pharmacological treatment  of social anxiety  disorder  in  adults,  there  are  no  published studies examining the efficacy or effectiveness of treatments  for  socially  anxious   older   adults.   In  2001, Fedoroff and Taylor conducted  a meta-analysis of 108 studies. These researchers  compared  pharmacological treatments, including selective serotonin reuptake inhibitors (SSRIs), benzodiazepines (BZDs), and monoamine oxidase inhibitors  (MAOIs), with components of CBT, including  exposure  and cognitive restructuring. Studies were included  in the analysis if they consisted of at least four patients  diagnosed  with  social anxiety using clinical interviews and consisted of standard  treatments   of  social  anxiety.  The  ages  of  the patients included in the meta-analysis were not provided, although  all studies consisted of adults. Results of the analysis suggested that pharmacotherapies were superior  to CBT at post treatment  and that both were superior  to  controls.  BZDs were  significantly  more effective  than  both  CBT and  controls  but  did  not significantly differ from SSRIs. Long-term maintenance of gains was not as well established  because many of the studies  did not contain  sufficient information  for estimating  this  variable.  Although  these  results  may have applicability to older adults,  the use of BZDs is ventured  very cautiously given that this class of medication  can cause  difficulties  with  dizziness,  respiration, and cognitive functioning.

In   summary,   the   literature   is  scarce   regarding effective treatments  for social anxiety in older adults. Although both  CBT and pharmacotherapy  have been proven  to  be  effective  treatments,   extrapolation   to older adults is premature.  More research is needed in this area before conclusions  can be made concerning best practice treatments  of social anxiety treatment  in older adults.

2.4.  Assessment and Treatment of Obsessive–Compulsive Disorder

The observation made by McCarthy and colleagues more than  a decade ago, that  there  is a paucity of research evaluating  the  efficacy of treatments  for  older  adults diagnosed with OCD, still remains true today. The limited literature that exists has focused primarily either on a variation of CBT called exposure and response/ritual prevention (ERP) or on pharmacological treatment.

2.4.1. Assessment

The assessment literature,  with regard to OCD in older adults, offers few recommendations other than the Padua Inventory, which was used with older adults diagnosed with  GAD. Some authors  have suggested  that  certain presentations  of OCD, such as obsessions and compulsions related to fear of forgetting names and pronounced ego-syntonic scrupulosity, are more likely to occur in the elderly. Besides these case reports, there is little evidence that particular  constellations of obsessions and compulsions are unique to older adults. Typical presentations  of OCD, such as contamination  fears with washing rituals and fears of harming  others  accompanied  by checking compulsions,  are also commonly  found  in the elderly. DSM-IV criteria  appear  to be appropriate  for use with older adults,  but more research  is needed  using structured diagnostic instruments  such as the ADIS-IV to better characterize the presentation  of OCD in the elderly.

2.4.2. Treatment

Two early  uncontrolled   case studies  of elderly  OCD patients reported  significant reductions  in OCD symptoms following ERP, whereas one anecdotal report documented  unsuccessful  combined  ERP and medication treatments in a 74-year-old woman with OCD and a learning disability. Several controlled  outcome  studies of ERP using single-case designs yielded similarly successful results.  The one study  that  directly  compared treatment  responses of older patients with those of younger patients examined the effectiveness of inpatient ERP administered to 10 severely impaired OCD patients age 60  years or  over  and  10  younger  OCD patients matched for gender and clinical severity. No significant differences  in  response  to  treatment  were  found  between the older adults and their younger counterparts, with the majorities  of both  groups  being classified as treatment  responders  at post treatment.  This finding is particularly  noteworthy  given that  the  older  patients reported having been symptomatic for more than twice as long as the younger adult cohort.

In  a  recent  controlled   case  comparison,   Carmin and  Wiegartz  described  two  older  men  with  OCD. One experienced  a successful outcome  and the other experienced  an unsuccessful outcome  when intensive inpatient   ERP  was  the   treatment   modality.   These authors concluded that the duration  of the illness, comorbidity  of other  psychiatric  disorders  as well as medical conditions,  and the availability of social support can have an effect on treatment  outcome.

Cognitive decline can exacerbate or mimic symptoms of OCD, and medical difficulties, such as cerebrovascular accidents (e.g., basal ganglia infarcts), are more prevalent  in the  elderly and  have been  noted  to produce OCD symptoms  in  previously  healthy  patients.  Such observations  raise the question  of whether  individuals who have experienced neurological insults that result in OCD can benefit from psychological treatment. Of considerable importance  is that ERP and pharmacological treatment   were  found  to  be  effective  in  treating  a 65-year-old  man  whose  OCD  was  related  to  recent basal ganglia infarcts.

In  comparison  with  the  previously  noted  studies that  used  ERP, a follow-up  study  of medication  and supportive psychotherapy that was offered to residents of an old-age home suggested that these methods  can have a positive effect on treatment of anxiety disorders, including OCD and panic. One limitation of this study was that this was a diagnostically heterogeneous group, and no details were provided about what medications were used or what supportive psychotherapy entailed.

Studies focusing on CBT for late-life OCD have consisted  of relatively  small patient  samples,  thereby limiting generalizability. Preliminary findings, however, suggest that  late-life OCD is treatable.  Even if subsequent research finds lower success rates for the elderly than rates typically reported  for the general adult population, there is sufficient evidence to conclude that at least some, if not most, older adults respond to ERP.

2.5.  Assessment and Treatment of Posttraumatic Stress Disorder

Much  of  the  literature   pertaining   to  posttraumatic stress disorder (PTSD) in the elderly focuses on holocaust and natural disaster victims and combat veterans. Given the vulnerability of older adults to physical violence, there is limited research that examines symptom presentations  of elderly crime victims and treatment.

Typically, PTSD symptoms in older adults reflect a chronic waxing and waning of symptoms, with exacerbations  linked  to the expected stressors of advancing age. Despite early studies suggesting a level of resiliency in older adult  disaster victims, this resiliency may reflect an underreporting of symptoms by PTSD sufferers, an underdiagnosis  by clinicians, or an attribution   of  anxiety-related   somatic   symptoms   to   the normal  frailties associated with old age by clinicians, thereby making the accurate diagnosis of this disorder difficult.

2.5.1. Assessment

There  are  several  measures  that  have  been  used  to assess PTSD symptoms in the elderly. The Clinician Administered PTSD Scale (CAPS) is a clinician administered  semi structured   interview  that  has  been used extensively with older individuals who have typically been exposed to war-related trauma. In addition, the  CAPS has  been  used  as a process  and  outcome measure for those experiencing non-combat-related PTSD. These studies suggest that the CAPS is recommended for use with older PTSD sufferers.

Although a number of self-report measures have been used to assess PTSD in older adult samples, these studies typically provide  descriptive  rather  than  psychometric data. Although the Impact of Events Scale (IES) has provided psychometric data, the findings are equivocal with respect to its use with elders, suggesting that the type of traumatic event may be more important than symptomatology in older  samples than  in younger  samples. The combat and civilian forms of the Mississippi PTSD Scales (MISS) have been significantly correlated with diagnostic measures of PTSD; however, the combat version appears to be the most accurate measure of PTSD severity in a small sample of elderly former prisoners of war.

2.5.2. Treatment

There are two reports of PTSD treatment in older adults. In 1998, Bonwick described a 16-week group day hospital   treatment   for  veterans.   The   program   included elements  of psychoeducation,   symptom  management, relaxation, group therapy, and physical exercise. No outcome data were reported, but the author noted that those receiving treatment  reported a greater understanding  of PTSD, improved coping skills, and an enhanced quality of life. A recent  conceptual  review of PTSD in  older adults indicates that a better understanding  of the issues related to risk and vulnerability to trauma, such as the availability of social support networks, the use of coping strategies, and perceptions of the meaning related to the traumatic event, may allow for a better understanding  of how to construct better treatment interventions.

2.6.  Assessment and Treatment of Specific  Phobias

2.6.1. Assessment

There is surprisingly little information  with respect to the assessment and treatment  of specific fears in older adults given that specific phobias is the most prevalent anxiety  disorder  in this  age group.  Of the  measures available  that  assess  for  the  gamut  of  phobias,  the Fear Survey Schedules (FSS-II and FSS-III) have been used with older adults and are promising screening measures for identifying specific fears. Kogan and Edelstein  revised  this  measure  specifically  for  use with older adults (FSS-OA). Their preliminary  results are encouraging but not conclusive. One measure, the Falls Efficacy Scale (FES), appears to have good reliability and validity. However, additional psychometric evaluations (e.g., convergent and discriminatory  validity) still need to be done before this self-report measure can be used independently  of a comprehensive anxiety assessment battery in older persons with somatic symptoms of dizziness or balance disturbances.

2.6.2. Treatment

There is one randomized  controlled  study comparing CBT with an educational  control  group in more than 400 individuals (average age of 77 years) experiencing fears of falling. The CBT patients  demonstrated post treatment  gains in mobility control and increased activity,  but  these  gains  were  lost  over  a  6-month follow-up period. At 1 year follow-up, the CBT patients showed increased improvement in different areas (e.g., mobility range, social functioning). The authors of this study noted that only 63.4% of their patients attended more than five of the eight offered treatment  sessions, thereby highlighting problems with compliance and attrition.

2.7.  Issues Related to Anxiety Secondary to a Medical Condition

There is considerable overlap between many symptoms diagnostic of an anxiety disorder  and symptoms that can be attributed to a medical illness. Medical illnesses such  as  cardiovascular  disease,  pulmonary  dysfunction,  stroke,  hyperthyroidism,   sensory  impairments, and dementia can mimic, exacerbate, antedate, and/or accompany symptoms of anxiety. For example, symptoms  of  panic  may  overlap  with  certain  symptoms related to angina, congestive heart failure, or emphysema, causing the diagnosis of panic to be overlooked. Alternatively, the normal developmental changes associated with aging can be mistaken for an anxiety disorder. Individuals who have sensory or mobility impairments may repeatedly check for where a hearing aid or walker is located or ask for frequent reassurance, resulting in clinicians mistakenly suggesting a diagnosis of OCD.  Clearly,  differentiating  between  anxiety disorders and medical illness in older adults is a complicated task. There are no studies that address the treatment  of comorbid anxiety and medical illness.

3. Conclusions

Enormous  strides  have been made in the area of the psychopathology, assessment, and treatment of anxiety disorders in adults. Unfortunately,  in the area of geriatric  anxiety,  a tremendous  amount  of research  still needs to be done.

There  are  significant  questions  as to  whether  the fundamental  nature  of anxiety  disorders  in adults  is the  same  as that  during  their  later  years.  A further complication arises in that neurobiological changes across the life span were found to cause an age-related decreased  cortisol response  to an experimental  stressor. These findings suggest a decrease in reactivity to stress with advancing years. It has likewise been hypothesized that age-related changes in hypothalamic–pituitary–adrenal (HPA) activity, as indicated  by cortisol level, are markers  for central nervous  system dysfunction.  If this  is indeed  true,  anxiety may be a link between central nervous system instability and the increases in cognitive impairment  that are often found in aging and may explain the decreased prevalence of anxiety disorders in older adults.

As noted previously, epidemiological studies are confounded   by  their   method   of  sampling.  Cohort effects relevant to the stigma attached to mental illness have a greater influence on older adults. Thus, fewer elderly individuals  may be willing to endorse anxiety symptoms in the course of an epidemiological  study. Likewise, where  samples  are drawn  from may influence prevalence data.

Finally,  it  would  appear  that   both  psychosocial and  pharmacological  treatments  appear  to aid in the reduction of anxiety symptoms in elderly samples. The prevailing form of psychotherapy that has been studied has been CBT. However, there is not firmly conclusive data  that  would  allow one  to unequivocally  endorse CBT or a particular  medication  for use in treating  a given anxiety  disorder.  Clearly, far more  research  is needed. One optimistic note is that the participants  in existing  longitudinal   studies,  such  as  the  Harvard/ Brown Anxiety Research Program (HARP), are aging. Data such as those generated by this study will allow for  the  close  examination  of how  anxiety  disorders progress over adulthood  and into later life and, hopefully, will provide  answers to many of the  questions that remain regarding geriatric anxiety.

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