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Cognitive and Behavioral Practice 29 (2022) 635–647

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Anxiety Disorders in Late Life: Considerations for Assessment

and Cognitive-Behavioral Treatment
Julie Erickson, Department of Applied Psychology & Human Development, University of Toronto., Forest
Hill Centre for Cognitive Behavioural Therapy
Neil A. Rector, Department of Psychiatry and Psychological Clinical Science, Univeristy of Toronto, Forest
Hill Centre for Cognitive Behavioural Therapy

Anxiety disorders are among the most frequently diagnosed mental disorders in late life. As older adults comprise a growing
segment of the population, evidence-based treatments for anxiety disorders in late life have come into sharper focus.
Cognitive-behavioral therapy (CBT) for anxiety disorders in late life has received less empirical attention and widespread
dissemination relative to other age groups. Increasing older adults’ access to timely assessment and effective treatment can
help reduce the personal and societal costs of anxiety disorders. The purpose of this review paper is to discuss important
considerations for the assessment of anxiety disorders in older adults and offer adaptations to CBT treatment for this pop-
ulation. As part of assessment considerations, we discuss how physical health conditions, cognitive impairment, and func-
tional limitations can impact anxiety disorder diagnoses with older adults. We also outline validated self-report measures
of anxiety disorder symptoms for older adults and highlight the importance of assessing older adults’ suitability for CBT.
Several recommendations for adapting CBT protocols for older adults with anxiety disorders are described, such as extend-
ing psychoeducation, altered treatment pacing, use of content aids, and medical contraindications for interoceptive expo-
sure. A case study is included that illustrates helpful assessment and treatment adaptions for an older woman with panic
disorder. We highlight the pressing need to increase research and dissemination of CBT for anxiety disorders for older
adults to meet the needs of an increasing segment of the population worldwide.

A NXIETY DISORDERS are among the most common

mental disorders affecting older adults. An esti-
mated 3.2–14.2% of adults in later life have been diag-
pharmacological treatment (Wetherell et al., 2005).
An additional challenge to treating late-life anxiety
disorders is the drastic shortage of geriatric mental
nosed with an anxiety disorder and a majority of these health care specialists relative to the projected demand
individuals do not receive the treatment they need for psychological treatment in later life (Institute of
(Wolitzky-Taylor et al., 2010). The public health pres- Medicine, 2012). The gap in geriatric mental health
sures of geriatric mental health will mount as 22.0% care has been labeled a growing crisis requiring urgent
of the world’s population will be over the age of 60 action (Moye et al., 2019). There is a strong need to
by 2050 (World Health Organization, 2017). Older disseminate evidence-based psychological treatments
adults have limited access to effective psychological for anxiety disorders in late life in order to address
treatment for anxiety disorders due, in part, to the fact these disabling conditions and improve the quality of
that many existing treatment protocols and guidelines life for a growing segment of the population.
being for adults ages 18–65 and are potentially less Cognitive-behavioral therapy (CBT) is a leading
relevant. Treatment guidelines specific to older adults evidence-based psychological treatment for most anxi-
with anxiety disorders are limited in scope and tend ety disorders (Butler et al., 2006; Hofmann & Smits,
to focus on generalized anxiety disorder (GAD) and 2008; Stewart & Chambless, 2009). CBT protocols for
GAD (Craske et al., 1992), social anxiety disorder
(Clark et al., 2003; Heimberg & Becker, 2002), panic
Keywords: older adults; geriatric; anxiety; cognitive-behavioral
therapy; assessment
disorder (Craske & Barlow, 2007), and illness anxiety
(Taylor & Asmundson, 2004) have all received strong
1077-7229/20/! 2022 Association for Behavioral and Cognitive empirical support for treatment with general
Therapies. Published by Elsevier Ltd. All rights reserved.
636 Erickson & Rector

adult populations. CBT may be preferred over anxiety disorders in late life. Second, cognitive decline
pharmacological approaches for anxiety disorders in can interfere with an accurate assessment of symptoms
late life due to older adults being on a larger volume and limit CBT effectiveness. Third, distinguishing age-
of medications and at higher risk for potentially inap- related versus anxiety-related avoidance behavior is
propriate prescribing and adverse drug interactions important for anxiety disorder diagnosis and case con-
(Cassidy & Rector, 2008; Fried et al., 2014). There is ceptualization. We further elaborate on these diagnos-
a smaller body of research that has examined the effec- tic challenges and provide suggestions for clinicians
tiveness of CBT for anxiety disorders among older who are routinely faced with these issues. We also dis-
adults relative to other age groups. CBT for GAD has cuss empirically validated measurement tools for late-
received the most empirical attention compared to life anxiety disorders, as well as assessing older adults’
other anxiety disorders in late life, and it has been suitability for CBT.
demonstrably effective relative to usual care and no-
treatment control groups (Hall et al., 2016; Hendriks Physical Health
et al., 2008; Wolitzky-Taylor et al., 2010). There is far
less evidence that has specifically examined the effec- Older adults experience a greater number of
tiveness of CBT protocols for treating panic disorder, chronic and acute physical health conditions and are
specific phobias, and social anxiety in late life, and on higher volumes of medication relative to younger
existing research is difficult to interpret due to small age groups (Morin et al., 2018). Older adults are also
sample sizes (Hendriks et al., 2008). more likely to report somatic symptoms as part of their
As existing evidence-based protocols have limited experience of anxiety disorders than younger age
empirical support in older adult populations, there groups (Balsamo et al., 2018; Palmer et al., 1997). This
are a number of overlooked yet important adaptations can result in diagnostic confusion, misdiagnosis, and
to assessment and CBT treatment that would be help- misguided treatment. There are several diagnostic pos-
ful for this age group. Based on our work as practition- sibilities for clinicians to consider when assessing anxi-
ers in a specialty community CBT anxiety disorder ety disorders among older adults: medical or
clinic that aims to assess and treat anxiety across the life pharmacological explanation for symptoms, co-
span, including older adults, we highlight some of the occurring anxiety disorder and a medical condition,
unique physical, cognitive, and behavioral factors that or an anxiety disorder in the absence of medical
can complicate a diagnosis of an anxiety disorder, high- comorbidity.
light helpful adaptations to the delivery of CBT with There are a multitude of physical health conditions
older adults, and provide practical suggestions for and substances that may produce symptoms resem-
adapting assessment and treatment. Finally, we present bling symptoms of an anxiety disorder. Table 1 depicts
a case example that illustrates the unique challenges of
assessing and treating panic disorder in this age group
and highlights strategies for effective intervention. This Table 1
review focuses primarily on community-dwelling older Physical Conditions and Substances Producing Symptoms of
adults, as the needs of older adults in long-term care Anxiety
facilities may be more unique due to the context of Physical conditions Substances producing
care delivery, and severity of cognitive and/or func- producing anxiety anxiety
tional impairment. Studies examining the efficacy ! Cardiovascular: ! Caffeine
and implementation of CBT with institutionalized arrhythmias, angina, ! Corticosteroids
older adults have been published elsewhere (e.g., myocardial infarction, ! Nicotine
Braun et al., 2016; Garcia-Alberca, 2017; Hyer et al., heart failure ! Psychotropic: antide-
2009; Konnert et al., 2009; Stanley et al., 2013). ! Endocrine: hyperthy- pressant, antipsy-
roidism, hypoglycemia, chotics, stimulants
Assessment Considerations pheochromocytoma ! Sympathomimetics:
! Respiratory: chronic pseudoephedrine,
Previous published research has discussed a number obstructive pulmonary beta-agonists
of unique physical, cognitive, and behavioral factors to disease, asthma, pul- ! Thyroid horomones:
consider when conducting a thorough assessment of monary embolism overreplacement
anxiety disorders in late life due to their possible ! Neurologic: Alzhei-
impact on diagnosis and treatment suitability mer’s disease, move-
(Balsamo et al., 2018; Hyer et al., 2004; Kogan et al., ment disorders,
2000). First, changes in physical health status and pre- temporal lobe epilepsy,
scribed medications can pose difficulties to diagnosing stroke
 Anxiety Disorders in Late Life 637

Reuben et al. (2016) a summary of the possible (but Cognitive Functioning

not exhaustive) physical health conditions and medica-
tions to consider in the differential diagnosis of anxiety Any comprehensive psychological assessment of
disorders in late life. Clinicians should work closely older adults should include, at minimum, a screening
with their clients’ medical practitioners to help deter- for cognitive functioning. Cognitive decline is universal
mine any medical or substance-induced symptoms during late life (Park et al., 2003)—however, only a
prior to diagnosing anxiety disorders in late life. subset of older adults will develop clinically significant
It is not uncommon to have co-occurring anxiety dis- cognitive impairment. An estimated 5–7% of adults
orders and physical health conditions in late life. New- over age 60 have diagnosed dementia and incidence
onset anxiety disorders in late life are often secondary rates increase sharply with age (Prince et al., 2013).
to physical illness and poorer health-related quality of Helmer et al. (2006) document that 17% of adults over
life (Reuben et al., 2016). A number of medical condi- age 75 have moderate to severe cognitive impairment.
tions can be a risk factor for the onset or worsening of There is a paucity of research examining comorbid
anxiety disorders—for example, asthma, chronic dementia and anxiety disorders. As such, it is unclear
obstructive pulmonary disease (COPD), vestibular dys- if and how the symptom presentation or treatment of
function, thyroid disorders, and cardiac disease all anxiety disorders might be different for this subpopula-
demonstrate elevated rates of comorbid panic disorder tion. There is some discussion of how observable anxi-
(Simon & Fischmann, 2005). Anxiety disorders are also ety in older adults with cognitive impairment may in
associated with new-onset medical conditions. In a fact be agitation, a behavioral manifestation of demen-
population-representative sample of adults over age tia (Kogan et al., 2000), reflecting the diagnostic chal-
55, anxiety disorders collectively and posttraumatic lenges associated with these conditions. The co-
stress disorder were associated with increased odds of occurrence of moderate to severe dementia and anxi-
developing gastrointestinal disease (El-Gabalawy ety disorders could make it difficult for these individu-
et al., 2014). The sheer number of physical health dif- als to engage in CBT treatment, suggesting that other
ficulties also appears to be associated with increased treatment options may be better suited for these indi-
odds of having an anxiety disorder, even after control- viduals. Some evidence suggests that older adults with
ling for the presence of comorbid mood and substance executive functioning difficulties are less likely to ben-
use disorders and sociodemographic variables (El- efit from CBT (Mohlman & Gorman, 2005). Assessing
Gabalawy et al., 2011). cognitive functioning could be an important factor in
The co-occurrence of an anxiety disorder and phys- treatment planning for older adults, and more specifi-
ical health problems may be attributed to shared cally, determining suitability for CBT. Common screen-
pathophysiology or increased anxiety in response to ing measures for cognitive functioning in late life
the physical symptoms of a medical condition (Simon include the Montreal Cognitive Assessment (MoCA)
& Fischmann, 2005). Clinicians should gather thor- and the Folstein Mini-Mental State Examination
ough symptoms histories and the age of onset of symp- (MMSE). The MoCA has generally shown better sensi-
toms to help distinguish whether anxiety disorder tivity and specificity in detecting mild cognitive impair-
symptomatology predated, is co-occurring, or is sec- ment (MCI) relative to the MMSE (Nasreddine et al.,
ondary to physical health conditions. Comorbid physi- 2005). A cutoff score of 23 on the MoCA is recom-
cal health problems are important considerations for mended to differentiate healthy aging from mild cog-
conceptualizing client concerns and making any mod- nitive impairment and suggest more in-depth
ifications to CBT treatment. Clinicians may benefit neuropsychological assessment is needed (Carson
from obtaining information from their client’s general et al., 2018).
medical practitioner concerning any medical diag-
noses, past and current medications, and the physi- Behavioral Considerations
cian’s opinion on whether symptoms of anxiety
overlap or are distinct from his or her health problems. Individuals with anxiety disorders commonly avoid
It may also be prudent to involve other allied health situations, activities, or substances associated with the
professionals (e.g., social workers, physiotherapists) nature of their worry (e.g., social situations, doctors
and family members who are well situated to provide appointments, physical sensations associated with
collateral clinical material and offer comment on the panic attacks). Older adults can experience a reduc-
broader context of the client’s symptoms. tion in their daily activities due to functional changes,
638 Erickson & Rector

mobility limitations, or physical health concerns. As Table 2

such, when assessing older adults with a suspected anx- Self-Report Inventories for Anxiety With Older Adults
iety disorder, it is imperative to determine the function Name Measures
of any avoidance behaviors identified. For example,
Beck Anxiety Inventory General anxiety
visual impairments may preclude an older adult from (Beck et al., 1988)
driving, or mobility issues might limit participation in State–Trait Anxiety General anxiety
certain forms of physical exercise. Some older adults Inventory (Spielberger,
may also have a fear of fainting or falling due to respi- 1983)
ratory or musculoskeletal issues as opposed to a panic Anxiety Sensitivity Index Fear of anxiety, panic
attack. Identifying whether avoidance is primarily dri- (Peterson & Reiss, symptoms
ven by fear versus practical or physical limitations is 1992)
critical to diagnosing and conceptualizing anxiety dis- Penn State Worry Pathological worry
orders in late life. Clinicians are encouraged to consult Questionnaire (Meyer
et al., 1990)
with family members and/or other allied health profes-
Geriatric Anxiety Scale Cognitive, affective, and
sionals involved in the older adult’s care (e.g., occupa-
(Segal et al., 2010) somatic symptoms of
tional therapist, physiotherapist, social worker) to help anxiety
distinguish the cause of avoidance behaviors. Older Adult Social- Social anxiety
Evaluative Situations
Age-Appropriate Assessment Measures Questionnaire (Gould,
Gerolimatos, et al.,
2012)
Self-report symptom measures are commonly used
Geriatric Anxiety Fearfulness, worry,
to assess symptom severity and responsivity to treat- Inventory (Pachana metaworry, cognitions
ment. There are a number of empirically validated et al., 2007) about anxiety, somatic
self-report measures that are routinely used to assess symptoms, anxious mood,
anxiety disorder symptomatology with adults. There is and anxiety sensitivity
some concern over the applicability of these measures Adult Manifest Anxiety Fear of aging,
to older adults due to changes accompanying normal Scale-E (Reynolds physiological anxiety, and
aging (Edelstein et al., 2007; McNeilly & Anderson, et al., 2003) worry/oversensitivity
1996), medical problems (Kogan et al., 2000), and dif-
ficulties correctly identifying symptoms of anxiety rela-
tive to younger cohorts (Wetherell et al., 2009). There (Balsamo et al., 2018). Additionally, there are no
has been relatively less research devoted to developing norms or established cutoff scores for older adults
self-report measures specific to late-life anxiety and (Dennis et al., 2007). The State–Trait Anxiety Inven-
examining the psychometric properties of commonly tory (STAI; Spielberger, 1983) has been shown to dis-
used measures with older adult populations. Compre- tinguish older adults with an anxiety disorder from
hensive reviews of self-report measures of anxiety for individuals without this diagnosis. Test–retest reliability
older adults have been published elsewhere (Balsamo is variable—however, there is a lack of normative data
et al., 2018; Dennis et al., 2007) and we present a brief for older adults (Dennis et al., 2007; Stanley et al.,
overview of this literature. Table 2 summarizes self- 1996). The Penn State Worry Questionnaire (Meyer
report measures used frequently in the assessment of et al., 1990) assesses pathological worry and has shown
late-life anxiety. good internal consistency and convergent validity in a
There are several self-report measures developed for sample of older adults (Beck et al., 2000). The Anxiety
younger adults that have also been examined with Sensitivity Index (ASI; Peterson & Reiss, 1992) assesses
older adults. The Beck Anxiety Inventory (Beck et al., fear of anxiety and panic symptoms, and there is some
1988) is used to assess symptoms of general anxiety evidence supporting a similar factor structure of the
and within samples of older adults demonstrates strong ASI with older adults (Mohlman & Zinbarg, 2000).
internal validity and evidence of convergent validity There are several self-report measures that have
(Wetherell & Gatz, 2005). Evidence of divergent valid- specifically been developed for use with older adults
ity with measures of depression is weaker (Wetherell & with anxiety disorders. The Geriatric Anxiety Scale
Gatz, 2005). Given the preponderance of items assess- (Segal et al., 2010) assesses the cognitive, affective,
ing somatic symptoms of anxiety, there is some con- and somatic symptoms of anxiety, and generally
cern over its use with older adults with medical demonstrates good internal consistency and evidence
problems who may have inflated scores related to their of convergent and construct validity. The Geriatric
physical health concerns as opposed to anxiety per se Anxiety Inventory (Pachana et al., 2007) is also strong
 Anxiety Disorders in Late Life 639

psychometrically and demonstrates excellent internal that may be of use to clinicians as they assess to what
and concurrent reliability. It assesses fearfulness, worry, extent an older client is a good candidate for CBT. It
metaworry, cognitions about anxiety, somatic symp- is important to acknowledge that the absence of one
toms, anxious mood, and anxiety sensitivity. The Older or more of the psychological dimensions of CBT treat-
Adult Social-Evaluative Situations Questionnaire ment suitability identified above does not preclude an
(Gould, Gerolimatos, et al., 2012) is one of the few older adult from benefiting from CBT treatment but
self-report measures to specifically focus on social anx- rather, the presence of one or more of the treatment
iety in older adults. Initial psychometric evaluation pro- suitability criteria would likely increase the chance of
vides support for convergent and discriminant validity treatment success. It could also be said that aspects
of the measure (Gould, Gerolimatos, et al., 2012). of the psychological dimensions of CBT treatment
The Adult Manifest Anxiety Scale (Reynolds et al., suitability (e.g., ability to identify and differentiate
2003) was developed for three different age demo- emotions, willingness to overcome avoidance and
graphics, one of which is for individuals older than experience anxiety-producing content) may be a focus
age 60. Items assess fear of aging, physiological anxiety, of intervention during treatment leading to skill devel-
and worry/oversensitivity. Internal reliability is in the opment and enhancement of ability along these
adequate to excellent range and test–retest reliability dimensions.
is in the adequate to good range (Lowe & Reynolds, With respect to older adults’ ability to identify and
2006; Reynolds et al., 2003). Moderate validity coeffi- differentiate emotions, there is some research suggest-
cients have been documented with the STAI and other ing that older adults are more reluctant to discuss neg-
validated measures of anxiety, lending some support to ative emotions and more likely to minimize their
its construct validity (Lowe & Reynolds, 2006). symptoms (Pachana et al., 2007). Others have specu-
There are several validated measurement tools to lated that older adults are less psychologically minded
select from when assessing anxiety disorder symptoma- (Burgmer & Heuft, 2004)—however, this has not been
tology and treatment response with older adults. The demonstrated empirically and systematic research is
measures developed specifically for older adults may needed to determine whether there are age differences
be of greater utility for clinicians due to stronger evi- in the ability to recognize and articulate thoughts and
dence of their validity and reliability. Additional psy- feelings. Clinicians are advised to assess to what extent
chometric evaluation of measures nonspecific to their older adult client can articulate his or her own
older adults is required in order for clinicians to con- thoughts and label his or her emotions; if this proves
tinue to employ these measures with confidence. to be an area of difficulty, consider making this more
of a focus of early treatment.
Seeing oneself an active agent in treatment, or pos-
Assessing Suitability for CBT
sessing high self-efficacy, is considered a mechanism of
change in CBT treatment for anxiety disorders
In addition to completing a diagnostic assessment,
(Gallagher et al., 2013). There is some evidence sug-
providing appropriate treatment recommendations
gesting that older adults with GAD report lower levels
and assessing suitability for CBT is an important
of self-efficacy relative to older adults without this diag-
aspect of client care. Older adult clients who are ill
nosis and younger adults (Stanley et al., 2002), which
suited for CBT may risk having suboptimal treatment
could conceivably influence decisions to engage in
experiences and experience a delay in receiving more
treatment and benefit from CBT. As such, assessing
appropriate treatment. With respect to predictors of
to what extent clients believe in their ability to execute
CBT treatment response in older adults, lower symp-
actions necessary for good treatment outcomes is
tom severity, ability to attend sessions regularly, length
important prior to recommending CBT treatment.
of treatment, and perceived credibility of therapy have
Clinicians would also be advised to provide psychoedu-
been identified as predictors of response to treatment
cation to prospective older adult clients about the
for GAD (Hundt et al., 2014). There have been several
active role that clients play in CBT, in hopes of also
other psychological dimensions of CBT treatment suit-
countering any preexisting beliefs about the treatment
ability identified, such as ability to identify and differ-
provider being the “solver” of problems. They may also
entiate emotions, awareness of automatic thoughts,
want to highlight “evidence” from other domains of
seeing oneself as an active agent in treatment, belief
the client’s life (e.g., career, parenting) suggesting
in the effectiveness of CBT, and willingness to over-
self-efficacy and capability to solve problems.
come avoidance and experience anxiety- producing
In addition to feeling capable of participating in the
content (Safran et al., 1990). There has been relatively
components of CBT, it is important that clients feel
less research on how older adults may vary in their
optimistic that CBT will be helpful to them. Older
suitability for CBT but there is some adjacent research
640 Erickson & Rector

adults report having equally as positive attitudes toward (1990) Suitability for Short-Term Cognitive Behavioral
seeking help for mental health difficulties relative to Therapy Rating Scale (SRS) can be used by clinicians to
younger cohorts and in some samples have more posi- assess 10 dimensions related to the tasks and goals of
tive attitudes toward help seeking (Mackenzie et al., CBT—namely, accessibility of automatic thoughts,
2008). Although there is a limited body of research awareness and differentiation of emotion, acceptance
examining older adults’ beliefs about CBT treatment of personal responsibility for change, compatibility
more specifically, there is some evidence suggesting with cognitive therapy rationale, therapeutic alliance
that older adults tend to rate CBT as being a more potential from both in-session and outside of session
acceptable form of treatment relative to selective sero- evidence, chronicity of the client’s problems, focality
tonin reuptake inhibitors (SSRIs; Gaudreau et al., of the client’s attention on a specific problem, and gen-
2015). In assessing suitability for CBT, it is important eral optimism regarding therapy. McLellan et al.
for clinicians to gauge their older adult clients by (2016) have also developed a self-report measure of
espousing positive beliefs about the helpfulness of suitability for CBT that could also be completed by cli-
CBT and then seeing to what extent they are optimistic ents to assist in making treatment recommendations.
that it could be of assistance to them. For clients who There is scant research about how this instrument per-
feel less than optimistic, clinicians may wish to share forms with older adults; thus, further exploration into
the abundance of outcome data on the effectiveness the use of this instrument with geriatric populations
of CBT, situating it as the “gold standard” of psycholog- is warranted.
ical treatment for a number of mental disorders. A In sum, in assessing older adults with suspected anx-
final consideration to assess in determining older iety disorders it is important for clinicians to take into
adults’ suitability for CBT involves how willing clients consideration how their client’s physical health, cogni-
are to face anxiety-producing stimuli instead of resort- tive functioning, and behavioral limitations may inter-
ing to avoidance. This can often be a challenge for sect with anxiety symptomatology and the
individuals who have a high degree of anxiety sensitiv- implications, if any, for their participation in CBT treat-
ity, defined as “the tendency to fear body sensations ment. Using age-appropriate symptom measures is
associated with anxious arousal because of their per- encouraged for valid and reliable assessment of anxiety
ceived physical, psychological, or social consequences” disorder symptomatology. Additionally, assessing psy-
(Wheaton et al., 2012, p. 891). chological factors implicated in the tasks and goals of
Anxiety sensitivity is often a significant issue across CBT is critical to help determine to what extent older
many diagnostic groups, such as panic disorder, GAD, adults are likely to benefit from CBT, targets of early
and social anxiety (Rector et al., 2007). The literature intervention (e.g., identifying thoughts and feelings),
on anxiety sensitivity within older adults is sparse— or whether other treatment approaches may be more
however, there is some evidence that it tends to be helpful. We next turn to discuss how CBT can be tai-
lower overall compared to samples of college-age lored to fit the needs of older adult clients with anxiety
adults (Mahoney et al., 2015). Although anxiety sensi- disorders.
tivity may be less pronounced in older adults, it is still
incumbent on clinicians to assess to what extent their Treatment Considerations
older adult clients fear anxious arousal and to what
CBT treatment protocols for many anxiety disorders
extent they are willing to expose themselves to these
typically consist of 10–12 sessions in which individuals
feelings. Some literature has suggested that older
obtain psychoeducation about the CBT model of the
adults may prioritize positive affect and certainty more
anxiety disorder, engage in self-monitoring of the fre-
so than younger cohorts, and as such, may be less will-
quency and intensity of symptoms, identify and chal-
ing to tolerate the uncertainty and discomfort that
lenge problematic misappraisals of thoughts, engage
accompanies exposures (Löckenhoff et al., 2012).
in problem solving of realistic worries, conduct regular
Determining to what extent older adults are open to
exposures targeting the foci of their worry (e.g., physi-
confronting both discomfort and uncertainty is an
cal sensations, social situations, uncertainty, enclosed
important precursor to CBT treatment for anxiety dis-
spaces) in order to reduce fear over time, and examine
orders. As part of this, older adults may benefit from
negative core beliefs associated with anxiety (Anthony
brief psychoeducation about anxiety to help correct
& Swinson, 2017; Craske & Barlow, 2007; Heimberg
maladaptive beliefs about facing discomfort during
& Becker, 2002; Robichaud & Dugas, 2015). There is
CBT treatment (e.g., allowing any anxiety will cause
considerable evidence for the efficacy of CBT for treat-
serious physical health problems). Clinicians may wish
ing anxiety disorders in adults and adolescents
to employ more structured measures to assess their
(Hofmann et al., 2012; Sanchez-Meca et al., 2010).
older adult client’s suitability for CBT. Safran et al.
There is relatively less research examining CBT
 Anxiety Disorders in Late Life 641

treatment outcomes for anxiety disorders in older initial assessment process. We have highlighted the
adults, especially for panic disorder, social anxiety dis- importance of spending ample time socializing older
order, and illness anxiety disorder. Existing literature clients to the CBT process, especially for those who
suggests that CBT treatment for anxiety disorders in are unfamiliar with psychotherapy. Whereas many first
late life are efficacious (Gould, Coulson, et al., 2012; sessions of CBT involve gathering a symptom history,
Hofmann et al., 2012)—however, effect sizes are gener- educating the client about a disorder, outlining the
ally smaller relative to younger adults (Wetherell et al., CBT model, and articulating client goals, this agenda
2013; Wolitzky-Taylor et al., 2010). It has been sug- may be too ambitious for older adult clients (Secker
gested that CBT protocols should be adapted to fit et al., 2004). Attempting to cover this information
the specific needs of older adults so as to maximize too quickly may run the risk of leaving clients demoral-
treatment effectiveness (Ayers et al., 2007). Other pub- ized and unsure about CBT treatment. Secker and col-
lished research has discussed helpful strategies for con- leagues recommend that when working with older
ducting CBT with older adults (Secker et al., 2004). We adults, spend Session 1 on assessment and diagnosis,
incorporate these suggestions with other treatment and discussion of the therapeutic process, and devote
strategies specific to anxiety disorders to enhance the Sessions 2 and 3 to reviewing the CBT model, goal set-
provision of CBT with older adults. ting, introducing self-monitoring tools (e.g., tracking
panic attack frequency and severity), and assigning
Extended Psychoeducation homework. This outline may be further protracted
for older clients with dementia. This revised pace
A number of studies have highlighted lower rates of allows clinicians and their clients ample time to reiter-
mental health literacy among older adults relative to ate, clarify, and summarize important points.
other age groups (Farrer et al., 2008; Fisher & In addition to pacing the content of treatment, clin-
Goldney, 2003; Wetherell et al., 2009). Jorm (2000) icians should consider the length and frequency of
defined mental health literacy as “knowledge and treatment sessions. For clients with mild cognitive
beliefs about mental disorders which aid their recogni- impairment or difficulties with attention span, schedul-
tion, management or prevention” (p. 396). Further- ing two 30-minute sessions weekly may be more realis-
more, older adults tend to have lower rates of mental tic and effective given their cognitive capacity. For
health treatment seeking relative to younger age more advanced dementia, Kraus et al. (2008) recom-
groups (Mackenzie et al., 2010). Older adults present- mend one 30-minute session per week with a focus
ing for treatment of anxiety disorder may possess less on one or two skills per session. For older clients with
knowledge of CBT and be less aware that their con- mobility concerns, alternating in-person sessions with
cerns are highly treatable within this framework. As telepsychology sessions may be helpful. Ensuring that
such, it is prudent for clinicians to devote extra time offices are wheelchair or walker accessible is also
to educating older adult clients about their anxiety dis- important to consider. Scheduling breaks within ses-
order, the structure of CBT treatment, and the CBT sions for older adult clients may be needed, especially
model so individuals are aware of the role of cognitive for those with arthritis, low blood-sugar levels, or blad-
distortions, misappraisals, and hypervigilance to symp- der concerns. Clinicians should use their judgment
toms, and the maladaptive function of safety behaviors and client input to match the rate, frequency, dura-
and avoidance in maintaining anxiety disorders. tion, and location of treatment with the client’s cogni-
Directly explaining the effectiveness of CBT for treat- tive and physical capacity.
ing anxiety disorders can help instill client optimism.
Devoting sufficient time to providing comprehen- Content Aids
sive psychoeducation can also help inform client
expectations for treatment, strengthen the therapeutic Manualized protocols of CBT, irrespective of age
alliance, and enhance willingness to engage in home- group, employ a number of visual and written aids to
work outside of treatment sessions. help clients remember and retain key information
from sessions and track homework in between meet-
Treatment Pacing ings. Using content aids are especially important when
working with older adults given that most have some
Clinicians may need to modify the pacing of session degree of memory decline unrelated to dementia
content, duration, and frequency when working with (Park et al., 2003). The use of retrieval and reminder
older adults with anxiety disorders. Older adults tend cues are further emphasized in CBT protocols devel-
to have more lengthy personal and medical histories oped specifically for older adults with dementia
to gather, which could add additional time to the (Kraus et al., 2008). It is integral for clinicians to
642 Erickson & Rector

structure each session with a clearly written agenda that increase the extent to which older clients practice
is visible to both client and therapist. This ensures that CBT skills (Robinson et al., 2011). Health care provi-
both client and therapist make the most of each session ders can also be collaborators in treatment. For exam-
and revert back to priority areas in the event that con- ple, an older adult’s visit to his or her health care
tent has strayed from the agenda. It is also important provider could be a form of exposure for some anxiety
for older adults to be taking notes in session and to disorder presentations. Where it seems helpful, and
have copies of handouts pertinent to treatment. Hand- with the client’s permission, allied health care profes-
outs could be tailored so as to be most helpful to older sionals could be more directly involved as treatment
adults—for example, having larger fonts and more collaborators (e.g., informing the older adult’s physio-
streamlined instructions. McQuaid et al. (2000) CBT therapist that he or she will use the treatment session as
intervention for older adults with schizophrenia a form of in vivo exposure). If family members play a
employed a short mnemonic for cognitive restructur- more central role in the older adult’s life, the client
ing called the “three Cs”: catch the thought (identify and therapist could discuss what role they might have
cognitions), check it (assess whether the thought con- in their treatment. For example, the client could dis-
tains any distortions and/or interferes with function- cuss the role of reassurance seeking in anxiety with
ing), and change it (develop alternative thoughts). his or her family members and identify better forms
This could also be useful to include in handouts for of support. Evidently, there are many opportunities
older adult clients with anxiety disorders. and advantages to collaterals being involved in older
Other CBT protocols developed specifically for adults’ CBT treatment. It is incumbent on the treating
older adults with dementia and anxiety offer recom- clinician to have a discussion with the older adult client
mendations for simplified cognitive restructuring to determine whether and how he or she would like
(Paukert et al., 2010). Clinicians should inquire other health care professionals or significant others
whether their older adult client has any visual, audi- to be involved in his or her treatment.
tory, or writing impairments that would impact the for-
mat of content aids in session and make alterations as
Medical Contraindications and Adaptations
necessary. In addition to the above, it is highly benefi-
to Interoceptive Exposure
cial to bridge each session with a review of the previous
meeting and end treatment sessions with a summary of
Interoceptive exposure (IE) is a highly effective and
the content covered. Asking older adults to summarize
integral component of CBT for panic disorder. There
their “take-home” points in their own words and writ-
has been increasing interest in expanding it to the
ing it down can be a helpful way to maximize retention
treatment of illness anxiety, social anxiety disorder,
of information and probability of following through on
posttraumatic stress disorder, and some phobias
homework.
(Boettcher et al., 2016; Wald et al., 2010; Walker &
Furer, 2008). There is very little research that has
Involvement of Others in Treatment specifically focused on the efficacy of IE for older
adults with anxiety disorders, and the existing litera-
In contrast to working with other age groups where ture has focused primarily on the use of IE for panic
the focus of CBT interventions is generally on a single disorder (Hendriks et al., 2010, 2014; Swales et al.,
individual, CBT treatment with older adults may, by 1996). This literature suggests that IE is generally as
necessity or preference, involve other people. Older effective for older adults as it is for younger adults—
adults may be concurrently seeking treatment from a however, the heterogeneity in study design and small
variety of other health care professionals, such as phys- sample sizes limits the strength of these conclusions.
iotherapists, occupational therapists, medical special- Further research is needed to confirm the efficacy of
ists, social workers, and others. Depending on the IE with older adults with panic disorder and explore
older adult’s living circumstances and cultural back- the use of this intervention with a broader range of
ground, family members may be involved to varying anxiety disorders.
degrees with their activities of daily living (e.g., ambu- IE involves repeatedly generating sensations that
lating, dressing, bathing) or instrumental acts of daily activate autonomic nervous system arousal while avoid-
living (e.g., transportation, shopping, managing ing the use of safety behaviors or otherwise escaping
finances). the discomfort. This is thought to aid in reducing fear
Involving the wider network of persons in the older responses, as well as disconfirming misappraisals of
adult’s life can be a significant advantage in delivering physical sensations. IEs can take many forms and are
CBT treatment. For older adult clients with dementia, tailored to the sensations that clients experience as
involvement of family members has been shown to part of their panic attacks or acute episodes of anxiety.
 Anxiety Disorders in Late Life 643

Hyperventilating, breathing through a straw, spinning ment and treatment outlined above were applied
in a circle, sitting in a warm environment, and engag- successfully.
ing in intense cardiovascular exercise are all examples
of common IEs. The intensity of these exercises can be Case Study
modulated by length, combining different symptom Mrs. A is a 78-year-old widowed female who lives
induction techniques (e.g., running on the spot while independently in a large urban city. She attended the
breathing through a straw), or setting (e.g., in a con- session with her adult daughter. She reports having dif-
fined vs. open space). ficulties with chronic nausea for the past year with no
Although exposure-based treatments in general are identifiable cause. She indicated that typically once a
regarded as safe and highly effective therapeutic inter- day she experiences acute episodes of racing heart,
ventions for older adults (Clapp & Beck, 2012), there trembling, dizziness, tingling, feelings of depersonal-
may be cases in which interoceptive exposures are con- ization, and a strong fear of losing control. Mrs. A’s
traindicated due to the presence of specific medical nausea worsens during these episodes. These sensa-
conditions. Individuals with cardiopulmonary condi- tions tend to last for 5 minutes at a time and seem to
tions are discouraged from engaging in IE that elicit occur “out of the blue.” When these sensations first
cardiorespiratory conditions (Forsyth & Fuse, 2003). started occurring, she visited the emergency room on
Individuals with asthma, chronic obstructive lung dis- several occasions due to fear she was having a heart
ease, renal disease, seizure disorders, and certain blood attack or stroke. Mrs. A reports that she has stopped
disorders, such as anemia, are advised not to engage in driving, become less socially active, and avoids going
IEs that involve breathing through a straw, rebreathing to her cottage alone on weekends. She indicated that
expired air, or inhaling enhanced concentrations of car- she typically brings a plastic bag with her when she goes
bon dioxide-enriched air (Forsyth & Fuse, 2003). There out in public in the event that she does vomit. She had
is a paucity of research examining what medical condi- asked her daughter to bring a plastic bag to the first
tions might limit older adults to safely participate in IE. session. She also avoids using the elevator in her apart-
Existing clinical trials of CBT for panic disorder in late ment building due to triggering feelings of nausea.
life have excluded older adults with severe cardiovascular Mrs. A indicates that she is “very healthy and active”
conditions (Hendriks et al., 2010, 2014) but have not for her age aside from a diagnosis of tachycardia 2 years
elaborated on other conditions that might impact the ago. She expressed a concern that due to her tachycar-
safety and format of IE. Given that older adults are more dia, her anxiety might induce a heart attack.
likely to experience a number of chronic and acute med-
ical conditions, clinicians are advised to consult with
Assessment and Diagnosis
their client’s general medical practitioner to ensure that
the client is medically stable so as to participate in IE.
Mrs. A was given a structured clinical interview dur-
Getting written permission from the client’s general
ing which she endorsed experiencing unexpected
medical practitioner is advisable and preferably as early
panic attacks on a daily basis. She also reports engaging
as possible in the assessment phase.
in maladaptive behaviors due to the presence and pos-
The presence of chronic medical conditions does not
sible recurrence of panic attacks, such as going to the
universally preclude older adults from participating in
hospital, avoiding using the elevator, and carrying a
IE. IE has been adapted for a number of different med-
plastic bag. It was clarified that Mrs. A’s avoidance of
ical concerns, such as COPD (Barrera et al., 2014), atrial
driving, going to her cottage, and socializing was due
fibrillation (Särnholm et al., 2017), and heart disease
to a fear of having a panic attack and not being able
(Tully et al., 2017). IE intensity can be modified via the
to escape in the event she had a panic attack. Based
duration of the exposure (e.g., 30 seconds instead of 1
on the above, she would meet full DSM-5 criteria for
minute), setting (e.g., alone vs. in the presence of
panic disorder with agoraphobia. Mrs. A completed
another person), and nature of the exposure (e.g., run-
the ASI during the initial assessment and scored in
ning on the spot vs. up a flight of stairs). There is a lack
the severe range. Mrs. A reported that she recently vis-
of research and specific clinical guidelines around adapt-
ited her general practitioner, who referred her for a
ing IE for different medical conditions, especially those
number of diagnostic tests to rule out physical explana-
that might affect older adults. Clinicians should consult
tions for her nausea. With Mrs. A’s written permission,
with their client’s general practitioner when adapting
her general medication practitioner was contacted to
IE such that it is within reasonable limits of what the cli-
confirm the absence of medical explanations for her
ent can reasonably do physically.
symptoms and her physical capacity to engage in
The case study below illustrates an older adult with
treatment, especially considering her diagnosis of
an anxiety disorder and how the procedures for assess-
tachycardia. Her practitioner denied the presence of
644 Erickson & Rector

any medical conditions that would explain her nausea, to help reframe Mrs. A’s catastrophic appraisals of vom-
and that her tachycardia did not present any impedi- iting. There was a discussion of active coping strategies
ment to participating in IE. Mrs. A was administered to employ if an adverse physical health event were to
a MoCA and found to be intact cognitively. Finally, occur. Mrs. A’s age was pointed out as a marker of suc-
Mrs. A was administered the SRS (Safran et al., 1990) cessful adaption and she reflected on how she has man-
and found to be a suitable candidate for CBT, which aged to cope with physical or emotional discomfort in
was also demonstrated, in part, by her ability to recog- the past. Attention redirection and pleasant activity
nize and articulate her thoughts and feelings, expres- engagement can be introduced as an adaptive coping
sion of her desire to be an active participant in strategy for chronic nausea.
therapy, perceived value and helpfulness of CBT, and Mid/late treatment (i.e., Sessions 7–11) focused on
self-reported willingness to confront anxiety- IEs. IE exercises for Mrs. A aimed to increase her heart
provoking situations. rate, induce dizziness, and feelings of depersonaliza-
tion. IE began with in-session symptom induction test-
ing to determine which IE procedures generate
Treatment
symptoms most similar to Mrs. A’s experience of panic
attacks (Craske & Barlow, 2007). These procedures
Early phases of treatment (i.e., Sessions 1–3) with Mrs.
were moderated to be more conservative in intensity
A focused on psychoeducation of panic disorder, intro-
initially so as to ensure Mrs. A did not feel over-
duced the CBT model of panic, outlined the course
whelmed or incapable of repeating IEs repeatedly on
and scope of treatment and its effectiveness, and
her own. We worked collaboratively to create an expo-
addressed Mrs. A’s concerns about this process. In addi-
sure hierarchy to guide her regular engagement in IE.
tion to outlining the content of treatment, we discussed
We discussed the option of completing situational
the pacing of treatment and determined optimal fre-
exposures to avoided circumstances first (e.g., using
quency and length of sessions in light of logistical barri-
the elevator, socializing, short car rides) if those were
ers she experienced (e.g., transportation to the clinic).
deemed to be lower in subjective anxiety for Mrs. A.
Given Mrs. A’s belief that increased anxiety will poten-
She expressed a willingness to engage in IE first and
tially cause a heart attack due to her preexisting diagnosis
then combine IE with situational exposures. Her use
of tachycardia, it was reiterated that treatment will involve
of safety behaviors (e.g., carrying a plastic bag in the
increasing autonomic nervous system arousal but that
elevator) was discouraged during exposures. Following
exposures are a safe and effective means of reducing fear
the first few weeks of Mrs. A engaging in exposures,
over time. Finally, we discussed the role of Mrs. A’s
unexpected challenges were addressed in session
daughter in treatment and she decided that it would
(e.g., encountering other people in the elevator during
be helpful to give her daughter a summary of each ses-
an exposure), and we attempted to consolidate what
sion to facilitate her understanding and memory for con-
she learned (e.g., allowing physical discomfort tended
tent covered. She also mentioned that she would stop
to result in dissipation of these feelings over time)
asking her daughter to bring a plastic bag to appoint-
and reinforce gains made.
ments, as she recognized this as a safety behavior.
Late treatment sessions (i.e., Sessions 12–14) with
In keeping with Craske and Barlow’s (2007) treatment
Mrs. A focused on assessing treatment gains, identify-
protocol, Mrs. A started recording panic attack fre-
ing any remaining areas of concern, creating a relapse
quency, symptoms experienced, and their intensity. Writ-
prevention plan, and discussing therapy termination.
ten and visual aids outlining the CBT model of panic
We created a written summary of Mrs. A’s treatment
disorder were provided and Mrs. A was encouraged to
in which she identified progress made, helpful CBT
bring a notebook or electronic device to record her
interventions, and early warning signs of a lapse. She
own notes of each session. A large visible agenda was cre-
completed the ASI for the second time and her score
ated for each session and key points from the sessions
decreased by 60% and moved from the severe to the
were reiterated at the beginning and end of each session.
mild range. The frequency of her panic attacks
Early/mid treatment (i.e., Sessions 4–6) focused on
decreased from once daily to once a month.
helping Mrs. A identify any catastrophic misappraisals
of physical sensations and to start to use cognitive inter-
ventions to develop more realistic appraisals. Mrs. A’s Conclusion
fear of having a heart attack, stroke, or vomiting as a Anxiety disorders can be debilitating for older
result of a panic attack was challenged via evidence adults and as an increasing proportion of the world’s
gathering and considering realistic probabilities. population is aging, they are of heightened concern
Thought records were demonstrated in session to help for mental health providers. Improving access to
assist with this process. Socratic dialogue was employed evidence-based psychological treatment for older
 Anxiety Disorders in Late Life 645

adults with anxiety disorders is imperative given the Burgmer, M., & Heuft, G. (2004). Occurrence and treatment of
comparatively low rates of help seeking within this post-traumatic stress disorder in an elderly patient after a traffic
accident. International Journal of Geriatric Psychiatry, 19, 185–188.
age group and disabling nature of these disorders. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006).
We have highlighted a number of ways in which clini- The empirical status of cognitive-behavioral therapy: A review of
cians can alter their assessment and CBT treatment meta-analyses. Clinical Psychology Review, 26, 17–31.
procedures so as to be optimally effective for older Carson, N., Leach, L., & Murphy, K. L. (2018). A re-examination of
Montreal Cognitive Assessment cutoff scores. International
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Additional research is required on how existing CBT Clapp, J., & Beck, J. G. (2012). Treatment of PTSD in older adults:
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protocols perform with older adults and whether fur-
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Stanley, M. A., Calleo, J., Bush, A. L., Wilson, N., Snow, A. L., Kraus- Received: August 16, 2020
Schuman, C., Paukert, A. L., Petersen, N. J., Brenes, G. A., Accepted: April 29, 2021
Schulz, P. E., Williams, S. P., & Kunik, M. E. (2013). The Available online 5 June 2021
peaceful mind program: A pilot test of a cognitive-behavioral