Anxiety Disorders in Older Adults

Course #96690 - $18-

3

Study Points

  1. Describe the history and neuroanatomy of anxiety and anxiety disorder.
  2. Discuss the assessment and classification of anxiety disorders in older adults.
  3. Analyze the epidemiology of anxiety disorders in elderly patients.
  4. Describe the clinical implications of late-life anxiety disorders and their treatment.
    1 . António Egas Moniz was awarded the 1949 Nobel Prize for treating mental disorders with leukotomy.
    A) True
    B) False

    NEUROANATOMY

    In 1949, the Nobel Prize in Medicine was awarded to António Egas Moniz for his discovery of "a simple operation, always safe, [and] which may prove to be an effective surgical treatment in certain cases of mental disorder" [11]. Specifically, Moniz discovered the prefrontal leukotomy as a treatment for mental disorders, including anxiety disorders [12]. Since then, studies have found that damage to the ventromedial prefrontal cortex produces resistance against anxiety and depression [13; 14; 15; 16]. Despite the effective reduction of anxiety in these patients, it took many decades until research began to address the harms imposed by damage to the prefrontal cortex. For example, in addition to reducing anxiety, damage to the ventromedial prefrontal cortex also impairs self-regulation and decision-making and can induce sociopathic behaviors [17; 18; 19; 20; 21]. Similar patterns of anxiety reduction were also observed in one patient with focal bilateral lesions to the amygdalae who showed a similar pattern of impairment in her daily life as those with damage to the prefrontal cortex [22]. Although the prefrontal cortex and amygdala are critical structures in a neural network that is necessary for anxiety, these findings highlight the fact that damage to these structures comes with unintended consequences. These findings also highlight the more general point that, in treating anxiety disorders, it is also important to not abolish otherwise useful traits as it is to reduce the anxiety to a manageable level.

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    2 . Two neural structures that are necessary for anxiety responses are the temporal pole and amygdala.
    A) True
    B) False

    NEUROANATOMY

    In 1949, the Nobel Prize in Medicine was awarded to António Egas Moniz for his discovery of "a simple operation, always safe, [and] which may prove to be an effective surgical treatment in certain cases of mental disorder" [11]. Specifically, Moniz discovered the prefrontal leukotomy as a treatment for mental disorders, including anxiety disorders [12]. Since then, studies have found that damage to the ventromedial prefrontal cortex produces resistance against anxiety and depression [13; 14; 15; 16]. Despite the effective reduction of anxiety in these patients, it took many decades until research began to address the harms imposed by damage to the prefrontal cortex. For example, in addition to reducing anxiety, damage to the ventromedial prefrontal cortex also impairs self-regulation and decision-making and can induce sociopathic behaviors [17; 18; 19; 20; 21]. Similar patterns of anxiety reduction were also observed in one patient with focal bilateral lesions to the amygdalae who showed a similar pattern of impairment in her daily life as those with damage to the prefrontal cortex [22]. Although the prefrontal cortex and amygdala are critical structures in a neural network that is necessary for anxiety, these findings highlight the fact that damage to these structures comes with unintended consequences. These findings also highlight the more general point that, in treating anxiety disorders, it is also important to not abolish otherwise useful traits as it is to reduce the anxiety to a manageable level.

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    3 . The standard for anxiety disorder assessment is the structured interview.
    A) True
    B) False

    ASSESSMENT

    The standard procedure for anxiety disorder assessment is the structured diagnostic interview, which is administered by a trained professional. The structured interview consists of pre-determined questions that assess for relevant symptoms based on diagnostic criteria. For example, an interview for GAD would start by asking the individual questions about the presence of worry symptoms over the past six months. If the interviewee answers this question affirmatively, the interviewer would then ask the individual about the presence of secondary symptoms associated with the worry (e.g., sleep, irritability). If the individual responds affirmatively to the minimum number of secondary symptoms required for a diagnosis of GAD, the individual would then be queried about the presence of distress or impairment due to the worry. The key advantage of the structured interview is its standardized administration, procedure, and scoring, which minimize bias and error in assessment. Two commonly used structured interviews for the assessment of mental disorders are the Diagnostic Interview Schedule (DIS) and the Composite International Diagnostic Interview (CIDI) [56,57]. In addition, the Anxiety Disorders Interview Schedule (ADIS) is a structured diagnostic interview that was developed specifically for anxiety disorder assessment [58]. These interviews are regularly updated along with diagnostic criteria, as for example with new editions of the DSM. Structured interviews rely essentially on self-report; in addition to being administered by clinicians, they may also be conducted by trained lay persons and/or computer-assisted technology (as in epidemiologic surveys).

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    4 . The Overall Anxiety Severity and Impairment Scale (OASIS) consists of two items.
    A) True
    B) False

    ASSESSMENT

    The Overall Anxiety Severity and Impairment Scale (OASIS) is a brief, transdiagnostic screening tool designed to assess for the severity of anxiety in the past week of the individual's life [69]. There are five items, each rated on a five-point scale (0 to 4), yielding a total possible score of 20. A raw score of 8 or greater indicates the presence of anxiety disorder based on validation against anxiety disorder diagnosis using the psychiatrist-administered SCID [70]. Raw scores of 10 and 12 indicate the presence of marked and severe anxiety, respectively, based on validation against the clinician-rated Clinical Global Impression-Severity (CGI-S) scale in a sample of individuals with any anxiety disorder ascertained using the Mini International Neuropsychiatric Interview (MINI) [71].

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    5 . The most prevalent anxiety disorder subtype in older adults is specific phobia.
    A) True
    B) False

    EPIDEMIOLOGY

    Anxiety disorders are the most prevalent mental disorders in older adults [54,84]. The most prevalent subtypes are, in descending order, specific phobia, GAD, social anxiety disorder, and panic disorder. Table 5 displays the one-year prevalence of anxiety disorders, both overall and by subtype, in the NESARC and the Collaborative Psychiatric Epidemiology Surveys (CPES) of the United States. The prevalence of anxiety disorders is higher among women relative to men, and the prevalence of all anxiety subtypes decreases among persons 75 years of age or older. Previous studies have also reported ethnic differences in prevalence, such that Native and White Americans have the highest prevalence, and Hispanic and Asian Americans have the lowest prevalence of anxiety disorders [85]. Black Americans have a higher or lower prevalence of anxiety disorders depending on subtype; specific phobias and GAD are more prevalent, comparable to Native and White Americans, whereas panic disorder and social anxiety disorder are less prevalent, closer to levels observed in Hispanic and Asian Americans. The prevalence of anxiety disorders does not vary substantially by educational attainment or marital status.

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    6 . Women 55 years of age or older have the highest prevalence of any anxiety disorder according to data from the NESARC.
    A) True
    B) False

    EPIDEMIOLOGY

    ONE-YEAR PREVALENCE OF ANXIETY DISORDER AMONG ADULTS 55 YEARS OF AGE AND OLDER IN TWO NATIONAL SAMPLES

    PopulationSpecific PhobiaSocial Anxiety DisorderGeneralized Anxiety DisorderPanic DisorderAny Anxiety Disorder
    NESARCCPESaNESARCCPESNESARCCPESNESARCCPESNESARCCPESb
    Total5%6%2%3%1%3%1%2%9%6%
    Age (years)
    55–64
    65–74
    75+
    6%
    5%
    3%
    8%
    5%
    4%
    3%
    2%
    1%
    5%
    3%
    1%
    2%
    1%
    1%
    4%
    2%
    15%
    2%
    1%
    1%
    2%
    1%
    2%
    11%
    8%
    6%
    9%
    4%
    4%
    Sex
    Male
    Female
    4%
    7%
    4%
    7%
    2%
    2%
    2%
    4%
    1%
    2%
    2%
    3%
    1%
    2%
    1%
    2%
    6%
    11%
    5%
    7%
    Education
    Less than high school
    Completed high school
    Some college
    Bachelor's degree
    6%
    6%
    6%
    4%
    10%
    5%
    6%
    4%
    3%
    2%
    2%
    1%
    4%
    3%
    3%
    2%
    2%
    1%
    2%
    1%
    3%
    2%
    4%
    2%
    2%
    1%
    1%
    1%
    2%
    1%
    2%
    1%
    9%
    9%
    9%
    7%
    7%
    5%
    9%
    5%
    Marital status
    Married or cohabiting
    Widowed, divorced or separated
    Never married
    5%
    6%
    5%
    5%
    8%
    7%
    2%
    2%
    2%
    2%
    5%
    6%
    1%
    2%
    2%
    2%
    4%
    2%
    1%
    2%
    1%
    1%
    2%
    2%
    8%
    10%
    9%
    4%
    9%
    7%
    aSpecific phobia was assessed in a sub-sample of 9,282 respondents from the NCS-R.
    bSpecific phobia was not included in the overall anxiety disorder estimate for the CPES.
    Table 5
    Source: [31,84]
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    7 . The most persistent anxiety disorder subtype in older adults is generalized anxiety disorder.
    A) True
    B) False

    EPIDEMIOLOGY

    The chronicity of a disease refers to its persistence. Persistence is defined here as the percentage of respondents who meet diagnostic criteria for an anxiety disorder at baseline and who then meet criteria again at follow-up. Data from the NESARC indicate that approximately 30% of older adults (55 years of age and older) have persistent cases of anxiety disorder, or chronicity, assessed over a three-year follow-up period. The most persistent subtypes were specific phobia (25%) and GAD (20%), followed by social anxiety disorder (16%) and panic disorder (10%) [31].

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    8 . The most significant modifiable risk factor for anxiety disorder is cigarette smoking.
    A) True
    B) False

    EPIDEMIOLOGY

    The two strongest risk factors for anxiety disorders among older adults are female sex and younger age [84,108,109]. However, other risk factors have also been identified. Cigarette smoking is shown to be a major risk factor of anxiety disorder onset, while smoking cessation is associated with reduced anxiety, suggesting that smoking interventions would have a significant effect on anxiety disorder onset [110,111]. Another important risk factor of anxiety disorder onset in longitudinal studies is the occurrence of adverse life events, such as the ending of a relationship or the injury, illness, or death of a loved one [112,113,114].

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    9 . SSRIs and SNRIs are the most effective in the treatment of social anxiety disorder.
    A) True
    B) False

    TREATMENT

    Individual CBT was found to be effective for acute treatment compared with waitlist control groups. Pharmacologic interventions included anticonvulsants, benzodiazepines, monoamine oxidase inhibitors (MAOIs), noradrenergic and serotonergic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and selective norepinephrine reuptake inhibitors (SNRIs). SSRIs and SNRIs were found to be the most effective class of pharmacological treatment compared with placebo control groups [133].

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    10 . The treatment of choice for specific phobias is exposure therapy.
    A) True
    B) False

    TREATMENT

    Exposure therapy is the treatment of choice for specific phobias [139,140]. This includes in vivo (real-life) and virtual reality exposure to phobic stimuli or situations. Virtual reality exposure therapy was introduced in the 1990s, and although it may have some treatment benefit, it has not been found to have strong efficacy [141]. A one-session exposure therapy treatment for specific phobias was pioneered more than 30 years ago with a suggested duration of two hours and was subsequently used to treat various specific phobia subtypes [142,143,144,145]. More recent studies suggest that one session does not always turn out to be adequate and that multiple sessions are generally more efficacious [140,146]. However, there may be some cases where the single-session approach is viable.

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