Evidence-Based Reviews

How anxiety presents differently in older adults

Author and Disclosure Information

Age-related changes, medical comorbidities alter presentation and treatment



Discuss this article at http://currentpsychiatry.blogspot.com/2011/03/how-anxiety-presents-differently-in.html#comments

Although anxiety disorders are common at all ages, there is a misconception that their prevalence drastically declines with age. For this reason anxiety disorders often are underdiagnosed and undertreated in geriatric patients, especially when the clinical presentation of these disorders in older patients differs from that seen in younger adults.

In older persons, anxiety symptoms often overlap with medical conditions such as hyperthyroidism and geriatric patients tend to express anxiety symptoms as medical or somatic problems such as pain rather than as psychological distress.1 As a result, older adults often seek treatment for depressive or anxiety symptoms from their primary care physician instead of a psychiatrist. Unfortunately, primary care physicians often miss psychiatric illness, including anxiety disorders, in geriatric patients.

Anxiety may be a symptom of an underlying psychiatric disturbance, secondary to a general medical condition, or induced by dietary substances, substances of abuse, or medications. Late-life anxiety often is comorbid with major depressive disorder (MDD) ( Box ) and other psychological stressors as older adults recognize declining cognitive and physical functioning.2 Anxiety disorders commonly begin in early adulthood, tend to be chronic and interspersed with remissions and relapses, and usually continue into old age.3 In generalized anxiety disorder (GAD), there is a bimodal distribution of onset; approximately two-thirds of patients experience onset between the late teens and late 20s and one-third develop the disorder for the first time after age 50.3

Prevalence rates for anxiety disorders among older adults (age ≥55) range from 3. 5% to 10. 2%.4 These rates are slightly lower than those for younger adults.5 Among older adults, presence of a 12-month anxiety disorder was associated with female sex, lower education, being unmarried, and having ≥3 or more chronic conditions.6


Comorbid anxiety and depression: Highly prevalent, poorer outcomes

The Longitudinal Aging Study Amsterdam study—one of the largest epidemiologic studies to examine comorbidity of anxiety disorders and depression in patients age 55 to 85—found that 48% of older persons with primary major depressive disorder (MDD) also had a comorbid anxiety disorder, whereas approximately one-fourth of those with anxiety disorders also had MDD.a Pre-existing anxiety disorders, such as social phobia, obsessive-compulsive disorder, specific phobia, agoraphobia, and panic disorder, increase the risk of developing depression.b Rates of comorbid anxiety and depression increase with age.c

Late-life MDD comorbid with generalized anxiety disorder or panic disorder is associated with greater memory decline than MDD alone.d In addition, comorbid anxiety and depression is associated with greater symptom severity and persistence, greater functional impairment, substance dependence, poorer compliance and response to treatment, worse overall prognosis and outcome than patients with either disorder alone,e and greater likelihood of suicidal ideation in older men.f


a. Beekman AT, de Beurs E, van Balkom AJ, et al. Anxiety and depression in later life: co-occurrence and communality of risk factors. Am J Psychiatry. 2000; 157(1): 89-95.

b. Goodwin RD. Anxiety disorders and the onset of depression among adults in the community. Psychol Med. 2002; 32: 1121-1124.

c. Merikangas KR, Zhang H, Avenevoli S, et al. Longitudinal trajectories of depression and anxiety in a prospective community study: the Zurich Cohort Study. Arch Gen Psychiatry. 2003; 60: 993-1000.

d. DeLuca AK, Lenze EJ, Mulsant BH, et al. Comorbid anxiety disorder in late life depression: association with memory decline over four years. Int J Geriatr Psychiatry. 2005; 20(9): 848-854.

e. Merikangas KR, Kalaydjian A. Magnitude and impact of comorbidity of mental disorders from epidemiologic surveys. Curr Opin Psychiatry. 2007; 20: 353-358.

f. Lenze E, Mulsant BH, Shear MK, et al. Comorbid anxiety disorders in depressed elderly patients. Am J Psychiatry. 2000; 157: 722-728.

Anxiety and disability risk

Anxiety disorders affect geriatric patients more profoundly than their younger counterparts. Persons age ≥65 who have an anxiety disorder are 3 to 10 times more likely to be hospitalized than younger individuals.1 Anxiety is associated with high rates of medically unexplained symptoms, increased use of health care resources, chronic medical illness, low levels of physical health-related quality of life, and physical disability.7,8

Anxiety symptoms may predict progressing physical disability among older women and reduced ability to perform activities of daily living over 1 year.9 Anxious geriatric patients are less independent and increase the burden on family and caregivers.10 Anxiety disorders are associated with lower compliance with medical treatment, which could worsen chronic medical conditions and increase the risk for nursing home admission.11 Anxious older adults report decreased life satisfaction, memory impairment, poorer self perception of health, and increased loneliness.12


Next Article: