Most effective, least worrisome therapies for late-life anxiety

Six months of group CBT or nondirective supportive psychotherapy have shown similar efficacy in reducing worry, anxiety, and depression scores in older adults with GAD.³² In a randomized trial,³³ group CBT produced slightly greater improvements in anxiety, depression, and pathologic worry among 75 older adults with GAD, compared with a worry discussion group (DG). CBT’s only statistically significant advantage, however, was that patients spent less time worrying immediately after treatment, compared with DG patients. This difference disappeared at 6 months.

For PD. Evidence supports using CBT for older adults with PD. CBT for PD typically includes interventions used for GAD but also integrates interoceptive exposure and tailored psychoeducation regarding panic symptom onset and maintenance. Older adults with PD who received 10 sessions of CBT over 12 weeks improved significantly on all symptoms measured—cognitive, behavioral, physiologic, and depression—in a study by Swales et al.³⁴ These improvements were seen immediately after treatment and at 3-month follow-up. In a separate study, a sample of 43 older adults—most of whom were diagnosed with PD—were randomly assigned to receive CBT or individual, in-home supportive therapy.³⁵ The CBT group reported greater reductions in anxiety and depression.

For mixed anxiety disorders. Several investigations have assessed the efficacy of CBT for older adults with mixed anxiety diagnoses and symptoms.

In one randomized trial, 84 older adults with a principal anxiety disorder diagnosis—GAD, PD, agoraphobia, or social phobia—were assigned to CBT, sertraline (maximum dosage 150 mg/d), or a wait-list.¹⁷ Compared with patients assigned to the waitlist, those in the CBT and sertraline groups improved on measures of anxiety and worry immediately after treatment and at 3-month follow-up. Patients receiving sertraline worried slightly less than those who received CBT. The sertraline and CBT groups did not differ in percentage of subjects who responded to treatment or end-state functioning.

For withdrawal support. Gorenstein et al³⁶ assessed withdrawal from anxiolytic medications among 42 patients age >60 with GAD, PD, comorbid GAD and PD, or anxiety disorder, not otherwise specified. Patients were randomly assigned to CBT plus medical management for medication taper or to medical management alone. Because of a high attrition rate, researchers used data only from subjects who completed the study. Compared with patients receiving medical management only, those who underwent CBT plus medical management had greater declines in anxiety and depressive symptoms from baseline. Many treatment gains were maintained at 6-month follow-up.

CASE CONTINUED: Combination pharmacotherapy CBT

You explain to Ms. W that depressed and anxious older adults frequently perceive memory difficulties. You further relate that it is possible that anxious older adults may experience memory changes because of medication side effects (particularly benzodiazepines) or interference of cognitive functioning by negative mood states. You prescribe sertraline, which is titrated to and maintained at 50 mg/d. Ms. W also participates in 10 psychotherapy sessions, which focus on psychoeducation about symptoms of GAD, relaxation strategies, sleep hygiene, grieving, and cognitive restructuring regarding her worries.

Modifying CBT for older adults. The quality of older adults’ cognitive functioning may affect their response to CBT,³⁷ particularly if they exhibit impaired executive functioning.³⁸ Modifying CBT to meet the needs of older adults has not been systematically investigated.

Mohlman et al³⁹ evaluated the use of modified CBT in 8 older adults with GAD who were randomly assigned to enhanced individual CBT or a waiting list. Strategies used to enhance adherence with cognitive-behavioral procedures included:

• weekly readings of psychoeducational materials that emphasized the relationship between cognitions, behaviors, physiological functioning, and emotions
  
• graphing symptom changes
  
• reminder/troubleshooting phone calls.
  

Using these strategies was associated with lower anxiety and worry symptoms as well as fewer symptoms of GAD or comorbid disorders. The enhanced CBT resulted in improvement on more measures and produced large effect sizes than standard CBT when each intervention was compared with a control group assigned to a waiting list.

CASE CONTINUED: Follow-up evaluation

You refer Ms. W to her primary care physician for follow-up. After 12 weeks of treatment, she reports declining anxiety symptoms. A repeat BAI indicates mild anxiousness, which she describes as minimally affecting her day-to-day activities. She continues sertraline and participation in individual psychotherapy with a particular focus on recent losses in her life.