Anxiety Disorders

Across the Lifecycle:

A Closer look at the Geriatric Population
 Program Faculty
Kiran Rabheru, MD, CCFP, FRCP Lilian Thorpe, MD, FRCPC
Associate Professor & Chair, Division Professor of Psychiatry (Clinical)
of Geriatric Psychiatry University of Saskatchewan
University of Western Ontario Geriatric Special Programs
London, Ontario Saskatoon City Hospital,
Saskatoon, Sask.
Peter K.Y. Chan, MD, FRCPC Dr. Jacques Bradwejn, FRCP
Geriatric and Consult-Liaison Professor and Chair
Psychiatrist, Vancouver General Department of Psychiatry
Hospital. University of Ottawa
Clinical Associate Professor of
Psychiatry,
University of British Columbia.
 Agenda
Time Topic Faculty

11:00 a.m. Welcome and Introduction Dr. Kiran Rabheru

11:05 a.m. Epidemiology and Prevalence of Anxiety Dr. Lilian Thorpe

Disorders in the Older Adult

11:20 a.m. Detection and Diagnosis of Anxiety Disorders in Dr. P.E. Chan
the Older Adult

11:40 a.m. The Psychobiology of Anxiety Disorders in the Dr. J. Bradwejn

Older Adult

11:55 a.m. Treatment Options for the Older Adult with Dr. Kiran Rhaberu
Chronic Anxiety

12:15 p.m. Faculty Question Period All faculty members

Anxiety in the Elderly: Epidemiology
and Impact on Patients and Society

Lilian Thorpe BSc MSc MD FRCP

Professor of Psychiatry (Clinical)
University of Saskatchewan
 Disclosure
Dr. Thorpe has no financial interests in, and no grants
from industry sources, but has received support for ad
hoc advisory boards and/or presentations from the
following:

Astra Zeneca Lundbeck

Bristol Myers Squibb Novartis
Eli Lilly Organon
GlaxoSmithKline Pfizer
Janssen-Ortho Wyeth
Goals and Objectives

To review the prevalence

of anxiety disorders in the
elderly

To review the individual

and societal impact of
anxiety disorders in the
elderly
Types of Anxiety Disorders
Generalized anxiety disorder (GAD)
Specific phobia
Post traumatic stress disorder
Social phobia (social anxiety disorder)
Obsessive-compulsive disorder
Panic disorder (with or without agoraphobia)
Agoraphobia without panic disorder
Anxiety due to general medical condition
Substance induced anxiety disorder (specify)
Prevalence Studies of
Anxiety in the Elderly
 Epidemiology and comorbidity of
anxiety disorders in the elderly: Review
Anxiety disorders are less common in the elderly than in
younger adults.
Generalized anxiety disorder and phobias account for most
anxiety in late life; Panic disorder is rare.
Agoraphobia, and possibly obsessive-compulsive disorder
in females, may occur as a primary disorder for the first time
in old age,
Simple phobia, obsessive-compulsive disorder in males,
and panic disorder either persist from younger years or
arise in the context of another psychiatric or medical
disorder.
Flint AJ. Am J Psychiatry. 1994 May;151(5):640-9.
 Epidemiology and comorbidity of
anxiety disorders in the elderly.
There is considerable comorbidity of geriatric depression
and generalized anxiety disorder and phobias, although
the depression usually goes untreated or is
inappropriately treated with benzodiazepines.

The rate of comorbidity of anxiety and medical illness and

alcoholism is lower in the elderly than in younger persons.

Flint AJ. Am J Psychiatry. 1994 May;151(5):640-9.

 ECA One Month Prevalence (%) of Mental
Disorders 65+ (Regier et al, 1988)
8 All 18+
7 All-65+
6 Men 65+
5 Women 65+

4
3
2
1
0
Anx Severe Mood Alcohol Schiz Antisoc
Cog
Regier DA et al. One-month prevalence of mental disorders in the United States.
Based on five Epidemiologic Catchment Area sites. Arch Gen Psychiatry. 1988
Nov;45(11):977-86.
 Anxiety disorders in later life: a report from
the Longitudinal Aging Study Amsterdam.
12

10

8
Age: 55-85 6
DX: DIS 6 mo.
4

0
All anxiety GAD Phobic PD OCD
disorders

Beekman AT, et al. Anxiety disorders in later life: a report from the Longitudinal
Aging Study Amsterdam. Int J Geriatr Psychiatry. 1998 Oct;13(10):717-26.
At least one Anxiety Disorder (65+)
40
35.8
35
30 29.4

25
20.4
20 18.1 Current
14.2 Lifetime
15
10 8.7
5
0
Men Women All

Ritchie K et al. Prevalence of DSM-IV psychiatric disorder in the

French elderly population. British J Psychiatry 2004; 184: 147-152
Current Prevalence of DSM-IV
Anxiety Disorders
14

12

10

8 Men
Women
6 All
4

0
All phobias

Agoraphobia

SP

GAD

OCD

Panic
/ specific
phobi

Ritchie K et al. Prevalence of DSM-IV psychiatric disorder in the

French elderly population. British J Psychiatry 2004; 184: 147-152
Age at first episode (years), mean (SD)
Men
Men ((n
n=773)
=773) Women
Women ((n
n=1090)
=1090) Total
Total ((n
n=1863)
=1863)

Agoraphobia
Agoraphobia and
and
specific 29.5
29.5 (21.6)
(21.6) 31.1
31.1 (23.5)
(23.5)
specific phobia
phobia 31.6
31.6 (24.1)
(24.1)

Social
Social phobia
phobia 24.8
24.8 (19.9)
(19.9) 12.9
12.9 (12.7)
(12.7) 16.3
16.3 (16.0)
(16.0)

GAD
GAD 34.6
34.6 (20.6)
(20.6) 31.3
31.3 (20.2)
(20.2) 32.2
32.2 (20.4)
(20.4)

OCD
OCD 25.1
25.1 (22.1)
(22.1) 35.1
35.1 (30.4)
(30.4) 30.8
30.8 (26.8)
(26.8)

Panic
Panic disorder
disorder 46.7
46.7 (19.8)
(19.8) 40.5
40.5 (20.9)
(20.9) 42.2
42.2 (20.5)
(20.5)
 Comorbid Anxiety Disorders in Elderly
Patients With Major Depressive Disorder
45
40
35
30 Lifetime
25 Current
20
15
10
5
0
1+ 2+ GAD PD Social Spec phob Agoraphob OCD PTSD
Phob

Lenze EJ et al. Am J Psychiatry 157:722-728, May 2000

 Comorbid Anxiety Disorders in
Depressed Elderly Patients (Lenze)
Symptoms that met inclusion criteria for generalized
anxiety disorder, measured separately, were present in
27.5% of depressed subjects.

Presence of a comorbid anxiety disorder was associated

with poorer social function and a higher level of somatic
symptoms.

Symptoms of generalized anxiety disorder were associated

with a higher level of suicidality.
Anxiety Disorders in Canada
Anxiety disorders affect 12% of the population,
causing mild to severe impairment.

The highest rates of hospitalization for anxiety

disorders in general hospitals are among
those aged 65 years and over.

Hospitalization rates for anxiety disorders in

general hospitals are twice as high among
women as men.

Health Canada. A Report on Mental Illnesses in Canada. Ottawa, Canada 2002

Cat. No. 0-662-32817-5
http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/miic-mmac/chap_4_e.html
Impact on patients and society:
Quality of Life
 Quality of Life
The value assigned to the duration of life as
modified by the social opportunities,
perceptions, functional states and impairments
that are influenced by disease, injuries,
treatment or policy.
Domains of assessment:
Physical functional status.
Disease and treatment related physical symptoms.
Psychological functioning.
Social functioning.

Mendlowicz MV & Stein MB. Quality of life in individuals with

anxiety disorders. Am J Psychiatry 2000;157(5):669-682
 Quality of Life
Anxiety disorders are illnesses that markedly
compromise QOL and psychosocial functioning.

Effective pharmacological or psychotherapeutic

treatment has been shown to improve the QOL
for patients with panic disorder, social phobia
and PTSD.

Mendlowicz MV & Stein MB. Quality of life in individuals with

anxiety disorders. Am J Psychiatry 2000;157(5):669-682
Impact on patients
and society:

Health care
utilization and costs
 1990 US costs of anxiety
disorders (Total cost $42.3 billion)
60
Percentage of total costs

50

40

30

20

10

0
Mortality Workplace Meds Psych Rx Non-psych Rx

Greenberg PE et al. The economic burden of anxiety disorders in the 1990s.

J Clin Psychiatry. 1999 Jul;60(7):427-35.
 The social costs of anxiety
disorders
Data from the (NIMH) ECA program were analyzed.
Nearly 30% of those with panic disorder had used
the general medical system for emotional, alcohol
or drug-related problems in the six months prior to
the interview.
Those with anxiety disorders were also more likely
to seek help from emergency rooms and from the
specialized mental health system.

Leon AC, Portera L, Weissman MM.

Br J Psychiatry Suppl. 1995 Apr;(27):19-22.
Percentage of Saskatchewan Seniors
With a Prescription in 1998
25
20
Percentage

15
Anxiolytic/hypnotic
10 Antidepressant
Antipsychotic
5
0
65- 70- 75- 80- 85- 90- 95+
89 74 79 84 89 94
HRSURC June 1999
Age Group
 Hospitalizations for Anxiety Disorders
in General Hospitals per 100,000 by
Age Group in Canada (1999 / 2000)
70
70 Females
Females
60
60
Males
Males

50
50

40
40

30
30

20
20

10
10

00
<1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Age Group (Years)

Using
Using most
most responsible
responsible diagnosis
diagnosis only
only
Source:
Source: Centre
Centre for
for Chronic
Chronic Disease
Disease Prevention
Prevention and
and Control,
Control, Health
Health Canada.
Canada.
Using
Using data
data from
from Hospital
Hospital Morbidity
Morbidity File,
File, Canadian
Canadian Institute
Institute for
for Health
Health Information
Information
 Hospitalizations for Anxiety Disorders in General Hospitals
per 100,000 by Contribution to Length of Stay
and Age Group (1999 / 2000)
600
600
Anxiety
Anxiety disorder
disorder as
as an
an associated
associated condition
condition
Anxiety
Anxiety disorder
disorder as
as the
the most
most responsible
responsible
diagnosis
diagnosis for
for length
length of
of stay
stay
400
400

200
200

00
<1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+

Age Group (Years)

Source:
Source: Centre
Centre for
for Chronic
Chronic Disease
Disease Prevention
Prevention and
and Control,
Control, Health
Health Canada.
Canada.
Using
Using data
data from
from Hospital
Hospital Morbidity
Morbidity File,
File, Canadian
Canadian Institute
Institute for
for Health
Health Information
Information
Impact on patients and society:

Depression treatment
outcome

Mortality

Suicide
References

Sheikh JI, Cassidy EL. Treatment of

anxiety disorders in the elderly: Issues
and strategies. J Anxiety Disord 2000;
14(2):173-90.

Sheikh. JI. Anxiety in older adults:

assessment and management of three
common presentations. Geriatrics
2003;58(5):44
 Anxiety in Geriatric
Populations: Diagnostic
Considerations

Dr. Peter K.Y. Chan, MD, FRCPC

Geriatric and Consult-Liaison Psychiatrist,
Vancouver General Hospital.
Clinical Associate Professor of Psychiatry,
University of British Columbia.
 Disclosure
No financial interests invested in, and no
grants from, industry sources
Received honoraria for presentations or ad
hoc advisory boards for:
Astra-Zeneca
Eli-Lilly
Janssen-Ortho
Lundbeck
Organon
 Objectives
Know the prevalence of anxiety disorders in
1 geriatric populations

2 Name 3 comorbid conditions and how they may

influence the manifestations of anxiety in the
elderly

3 Describe why anxiety disorders can adversely

affect seniors
 Anxiety Disorders
Generalized
Panic Disorder Anxiety
Disorder
Anxiety
Disorders

Obsessive Phobic
Compulsive Post Disorders
Disorders Traumatic
Stress
Disorder
 Evolution of Anxiety
Disorders in DSM
From: Rickels and Rynn. Psych Clin NA 2001; 24(1)

DSM -I Anxiety Reaction

DSM-II Phobic Obs-Compul

Anxiety Neurosis Neurosis
Neurosis

GAD Panic Agoraphobia

DSM-III Simple and OCD PTSD
(1 mo.) Disorder Social Phobia
DSM-III R
GAD Anxiety
DSM-IV
(6 mo.) Dis. NOS
 Prevalence of Anxiety
Disorders in the Elderly:
ECA study

ECA community prevalence (1 month)

Total Anxiety Disorders: 5.5%

Phobias 4.8%
OCD 0.8%
Panic Disorder 0.2%
Prevalence of Anxiety Disorders in
the Elderly: AMSTEL study
Community prevalence
(age 55-85; DIS; 6 mo):

MDD 2%
Any Anxiety Disorder 10%
GAD 7.3%
Social Phobia 3.1%
Panic Disorder 1.0%
OCD 0.6%
From: Beekman et al. Am J Psych
2000; 157
 Prevalence of Anxiety Disorders in Clinical
Populations with Geriatric Populations
N=182 with MDD; Psych and Primary Care Settings

23% had concurrent diagnosis of Anxiety Disorder

Panic Diorder 9.3%
Specific Phobia 8.8%
Social Phobia 6.6%

27.5 % had concurrent GAD (exclusion rule

modified)
From: Lenze et al. Am J Psych 2000;
157
 Prevalence of Anxiety
Disorders and Age or Gender
Krasucki et al. Int J. Geri Psych 1998; 13:
GAD: No change with age
PD, OCD, Phobia: Decrease with age
Higher rates in women over lifespan, with differences
diminishing in the elderly

Schoevers et al. Int. J. Geri Psych 2003; 18

n=4051 AMSTEL study, 62% female
Women with higher odds ratio risk for:
Anxiety 3.73x (1.65-8.46)
Mixed anxiety-depression 5.53x (2.36-13.00)
Psychopathology of Anxiety
Disorders in the Elderly
Similar phenomenology compared to
younger adults in:
Social phobia
(Gretar
(Gretar et
et al.
al. Behav
Behav Res
Res and
and Ther
Ther 2004;
2004; 42)
42)

GAD
(Beck
(Beck et
et al.
al. Behav
Behav Res
Res and
and Ther
Ther 1996;
1996; 34)
34)

Panic Disorder
(Raj
(Raj et
et al.
al. J.
J. Clin
Clin Psych
Psych 1993;
1993; 54)
54)
 Social Phobia in the Elderly
Prevalence lower than younger adults, but
20% screened positive in elders

Symptoms similar, but triggers may differ:

Talking business
Writing or typing in front of others
Speaking at small informal meeting
Interacting longer than a few minutes
Avoiding social situations when others present

from: Gretar et al. Behav Res Ther

2004; 42
 Comorbidities and Causes

Psychosocial
Depression Issues

Anxiety

Dementia
Physical Illness And
Cognitive
Decline
 Comorbidity of Depression
and Anxiety
High rates of MDD in elderly with Anxiety
Disorder
Beekman et al. (AMSTEL)11: 26%

High prevalence of Anxiety Disorder in those

with geriatric MDD
Beekman et al (AMSTEL)11: 48%
Lenze et al. (US)22: 34-50%

1=Am J Psych 2000;157

2=J Affect Dis 2003;77
Anxiety and Geriatric
Depression
Low incident rates of de novo
anxiety disorders in the elderly:

9 Beware of Depression in those

presenting with anxiety!

9 Rule out organic causes (eg:

hyperthyroidism, cardiac causes)
Consequences of Comorbid Depression
and Anxiety in Elders

Increased suicidal ideation (AMSTEL)

Poorer response to treatment
Increased dropout rates in treatment studies

More likely agitated depression?

More somatization and use of services?
Higher level of physical disability?
Poorer quality of life?
 Anxiety and Cognition
Prevalence of Anxiety in Dementia: 23-66%
(Levy
(Levy and
and Cummings,
Cummings, Gerontology
Gerontology 1999;
1999; 45.
45. Ballard
Ballard et
et al.,
al., Int
Int JJ Geri
Geri Psych
Psych 1996;
1996;
11.)
11.)

Prevalence of Anxiety in MCI: 10-45%

(Sinoff,
(Sinoff, Int.
Int. JJ Geri
Geri Psych
Psych 2003:
2003: 18;
18; Forsell
Forsell et
et al.,
al., Acta
Acta Neurol
Neurol Scand
Scand 2003:
2003:
107,
107, suppl
suppl 179)
179)
Risk
Risk for
for further
further cognitive
cognitive decline
decline is
is 4x
4x over
over 33 years?
years?

Prevalence of Anxiety Decreases with Dementia

Progression due to transition to Agitation or
Aggression?
(( Mintzer
Mintzer and
and Brawman-Mintzer,
Brawman-Mintzer, JJ Clin
Clin Psych
Psych 1996:
1996: 57,
57, suppl
suppl 7)
7)
Anxiety and Physical Disease

COPD

Cardiac Disease
(Davies
(Davies et
et al,
al, BMJ
BMJ 2004:
2004: 328)
328)

Parkinsons Disease
(Stein
(Stein et
et al,
al, Am
Am JJ Psych
Psych 1990:
1990:
147)
147)

Falls in the Elderly

 Anxiety and COPD
Average prevalence is approx 20%
Higher than in other common medical conditions?
Prevalence 10-16% for GAD, 8-37% for Panic disorder

More ER visits

Difficult to distinguish panic attack from COPD

exacerbation
Sequence of symptoms
Situation (eg: exertion)

CO22 retainers vs. Non-CO22 retainers

From: Brenes, Psychosom Med 2003;

65
 Anxiety, Fears, and Falls
Prevalence of fear of falling in 30-77% of
seniors

Falling may lead to or worsen Depression,

impeding recovery

Less known about rates of Anxiety Disorders

developing after a fall

From: Kressig et al, JAGS 2001: 49;

Scaf-Klomp et al, Age and Aging 2003:
32
Anxiety and Psychosocial
Issues

Losses or helplessness

Caregiver stress

Fear of future disability or death

Future Directions in Diagnosis

At what threshold of anxiety

is there disability, and
therefore should be
addressed?

Does late-onset GAD

duration and course differ in
the elderly?
 Review of Objective 1

Know the prevalence of anxiety disorders in

geriatric populations

10% in community surveys

Higher in clinical populations, especially if
comorbid depression
 Review of Objective 1

Name 3 comorbid conditions and how they

may influence the manifestations of anxiety in
the elderly
 Comorbidities and Causes
Depression:
Difficult
Psychosocial
to distinguish Issues
from GAD

Anxiety

Physical Illness: Dementia/MCI:

Physiologic and Common to be
Psychosocial Anxious and
overlaps Agitated
 Review of Objective 2
Describe why anxiety disorders can adversely
affect seniors

Impact of future development of physical and

other mental disorders (eg: depression)
Impact on level of disability, quality of life, and
recovery from acute illness
The Psychobiology of Anxiety
Disorders in the Older Adult

Jacques Bradwejn MD
Professor and Chair
Department of Psychiatry
University of Ottawa
 The Neurobiology of Anxiety
Disorders
Multichemical/multitransmitter Network, transmitter systems
identified so far: Noradrenergic, GABAergic, Serotonergic,
dopaminergic, CCKergic, others (adenosine, CRF, NPY)

Possible specificity:
Panic Noradrenergic, Serotonergic, GABAergic,CCKergic, others
disorder
Social Noradrenergic, Serotonergic, dopaminergic, others
Anxiety
GAD Noradrenergic, GABAergic, Serotonergic, others

OCD Serotonergic, others

 Multidimensional
Multidimensional Etiological
Etiological
Concept
Concept of
of Anxiety
Anxiety Disorders
Disorders
Predispositions

Temperament Life events

Psychology
Anxiety
Anxiety disorder
disorder (s)
(s)
Co -morbidities
Co-morbidities
Psycho -neurobiology
Psycho-neurobiology
 Increased
Increased Frequency
Frequency Of
Of A
A CCK-2
CCK-2
Receptor
Receptor Gene
Gene Polymorphism
Polymorphism In
In PD
PD
(Kennedy,
(Kennedy, Bradwejn,
Bradwejn, Koszycki
Koszycki et
et al,
al, 1999)
1999)
70 Frequency
60 (%)

50
Control (n=99)
40
Panic Disorder (n=99)
30
20
10
0
6 7

2 (6 + 7)=12.38, df=2, P=0.002

 SP
GAD, OCD
PD

Depression

Time of Onset
Substance Abuse

Lifespan Physical illnesses

Anxiety Disorders
Across The Lifespan

Functional impacts
 Social Phobia: Age of Onset
Schneier et al92
25
20
15
10
5
0
0-15 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75

Age (years)
Does the Neurobiology of
Anxiety Disorders Change
with Aging?

Questions:
Are there quantitative changes?
Are there qualitative changes?
Are changes clinically relevant?
 Impact of Aging on
Anxiety Disorders
Changes in brain biology?
Changes observed in human brain function: change in the multichemical
networking profile of the in vivo human brain (Grachev ID et al. J
Neurochem. 2001; 77:292-303.

Evidence of reorganization of the chemical network of the living human

brain. (Grachev ID et al. Brain Res Cogn Brain Res. 2001;2:185-97).

Changes observed in human brain neurotransmitter function: GABA-A,

Dopamine, Serotonin (5HT1a, 5HT2, transporter)

Changes observed in human brain G-protein function (Gonzalez-Maeso

J. Neuropsychopharmacology. 2002;26:468-478)
Impact of Aging on Anxiety
Disorders
The changes are complex:
Regional differences observed
Simultaneous changes in function of several
neurotransmitter systems
Changes within a neurotransmitter system can
result in a zero net effect
Net effect can be minimal when several systems
are studied simultaneously
Net effect can be a decreased sensitivity e.g.
CCK (Flint et al. Am J Psychiatry. 1998;
155:283-285).
 Response
Response to
to CCK-4
CCK-4 and
and Age
Age
(Flint
(Flint et
et al.
al. Am
Am JJ Psychiatry.
Psychiatry. 1998;
1998; 155:283-285).
155:283-285).

30 * P<.001
25

20
Young
15
Elderly
10
*
5
*
0
SIS NS
 Impact of Aging on
Anxiety Disorders

Changes in brain biology? Yes and no

Changes in incidences and prevalences?
Changes in clinical presentations?
Changes in vulnerability to an anxiety disorder?
Changes in impact from an anxiety disorder?
Changes in treatment responses?
 Impact of Aging on
Anxiety Disorders

Changes in incidences and prevalences?

Late onset anxiety disorders rarer than early onset ones.
Some evidence that ageing is associated with an intrinsic
reduction in susceptibility to anxiety (Schaub RT et al,
Compr Psychiatry. 2000;41:48-54. Jorm AF, Psychol Med.
2000:11-22)
Clearest for panic disorder, GAD or worry might be an
exception (Alwahhabi F, Harv Rev Psychiatry. 2003:180-93)
Methodological issues still exists, such as ageing versus
cohort effects (Jorm AF, Psychol Med. 2000:11-22)
 Impact of Aging on
Anxiety Disorders

Changes in clinical presentations?

Very little studies but it seems that decreases in symptom
severity and associated distress, not type of symptoms,
characterize late-onset panic disorders (Sheikh JI et al,
Am J Geriatr Psychiatry. 2004:12, 102-109).
Similar findings for OCD (Kohn R et al. Am J Geriatr
Psychiatry. 1997; 5:211-215).
Similar findings for PTSD (Wintrier D, Ruskin PE. Harv
Rev Psychiatry. 1999; 7:144-152)
 Impact of Aging on
Anxiety Disorders
Changes in vulnerability to an anxiety disorder?
Decreased vulnerability according to epidemiological
studies, as said earlier.
PTSD response to trauma seems similar across age
groups: following exposure to technological disasters,
young, middle-aged and elderly community residents
displayed similar post-traumatic responses and employ
similar coping strategies. Chung MC et al. Int J Geriatr
Psychiatry. 2004;19:333-343.
 Impact of Aging on
Anxiety Disorders
Changes in impact from an anxiety disorder?
Negative impact of anxiety seen on psychosocial functioning,
personal mastery and need for more emotional support in the
functioning of healthy aged. Same impact on chronic urinary
incontinence, hearing impairment and hypertension (ibid.)(Mehta KM
et al. J Am Geriatr Soc. 2003; 51:499-504).

Impact of anxiety on cardiac function and heart disease: e.g.. the

association of abnormal QT-interval variability with anxiety in the
elderly (Piccirillo G et al. Clin Sci. 2001;101:429-438), and of worry
on cardiac heart disease (Kubzansky LD. Circulation. 1997;95:818-
24).
 Impact of Aging on
Anxiety Disorders
Changes in treatment responses?
Impact
Impact of
of benzodiazepines
benzodiazepines on
on weakened
weakened cognitive
cognitive capacities
capacities (Lucki
(Lucki II and
and
Rickels
Rickels K.
K. Psychopharmacol
Psychopharmacol Ser.
Ser. 1988;6:128-39;
1988;6:128-39; HoganHogan DB.
DB. Can
Can JJ Clin
Clin
Pharmacol.
Pharmacol. 2003;10:72-77;
2003;10:72-77; Paterniti
Paterniti S
S et
et al,
al, JJ Clin
Clin Psychopharmacol.
Psychopharmacol.
2002;22:285-293.)
2002;22:285-293.)

When
When pharmacokinetics,
pharmacokinetics, pharmacodynamics,
pharmacodynamics, physical
physical illness
illness and
and chronicity
chronicity are
are
set
set aside,
aside, itit is
is not
not clear
clear whether
whether aging
aging alters
alters response
response to
to pharmacological
pharmacological
treatment
treatment

There
There is
is evidence
evidence that
that neurobiological
neurobiological plasticity
plasticity is
is maintained
maintained in
in response
response to
to
pharmacotherapy
pharmacotherapy

There
There is
is evidence
evidence that
that neurobiological
neurobiological plasticity
plasticity is
is maintained
maintained in
in response
response to
to
psychotherapy
psychotherapy
Does the Neurobiology of Anxiety
Disorders Change with Aging?
Questions:
Are there quantitative changes?: yes, some
Are there qualitative changes?: no, very little
identified specifically
Are changes clinically relevant?
Somewhat in terms of decreased
susceptibility
More in terms of managing the impact of
the disorder than the primary disorder
itself: physical health, cognition, function?
 Brain-Diet Interactions

Koda H et al. J Agric Food Chem.

2003;51:5238-44. Aging of whiskey increases
the potentiation of GABA(A) receptor response.
Treatment Options for the Older
Adult with Chronic Anxiety

Kiran Rabheru
MD,
MD, CCFP,
CCFP, FRCP
FRCP
Associate
Associate Professor
Professor &
& Chair,
Chair, Division
Division of
of Geriatric
Geriatric Psychiatry
Psychiatry
University
University of
of Western
Western Ontario
Ontario
London,
London, Ontario
Ontario
 Placebo Trials:

The response to placebo in published trials of antidepressant medication for MDD is highly variable and often
substantial and has increased significantly in recent years, as has the response to medication.

DRUGS:
NECESSARY
BUT NEVER
SUFFICIENT
ALONE!!

JAMA 2002 Apr 10;287(14):1840-7

Placebo response in studies of major depression: variable, substantial, and growing.
Walsh BT, Seidman SN, Sysko R, Gould M.
 Anxiety in the Elderly:
Treatment Program
Strong doctor-patient relationship
Environmental, Social, Recreational,
Supportive & Spiritual Interventions
Psychoeducation
include Family
Medication
Drugs
Dosage
Duration
ECT for severe cases
 The Geriatric
Psychiatry Giants
Comorbidity:
The Rule
DELIRIUM
BEHAVIOUR DISTURBANCE ANXIETY / DEPRESSION
PSYCHOSIS DEMENTIA
AGGRESSION GENETICS,
PERSONALITY,
PARENTING
PSYCHO-SOCIAL
& ENVIRONMENT
 Geriatric Depression
symptoms: Same as adults

Except:
Fewer mood symptoms
Somatic preoccupation
Agitation & Anxiety
Psychotic symptoms common

Complex cases: Reimbursement issues are a problem

 Complicated by:
Attitude:Depression / Anxiety is normal in old
people
Pain, sleep, medications.
Poor energy due to medical illness.
Bereavement / Grief
Dementia like presentation
superimposed on it

Leads to under-detection and under-treatment

Primary vs. Secondary Anxiety
Primary Anxiety Disorder: Worry / Early
Secondary to MDD: s/s of MDD
Secondary to dementia: late onset /
cognitive loss
Secondary to medical cause: acute / cause
Secondary to medications:
sympathomimetics, benzodiazepine withdrawal,
amphetamines, anticholinergics, caffeine,
antidepressants, antipsychotics
 Majority of Depressions have
comorbid Anxiety
Impact
Poor Recovery
Increased severity and chronicity
Greater functional impairment
Decreased response to antidepressants
Higher incidence of suicide

Feighner et al. J Clin Psych 1999;60 (Suppl 22):18-22. Enns et al. Can J Psych 2001:46 (Suppl 1):77S-90S.
 General Points
Anxiety: not well characterized in elderly

Benzodiazepines: first-line elderly are

largest consumers BUT

Problematic: Falls, Fractures, Cognitive

disturbances

Treatment literature: not abundant; expert

opinion & extrapolation for younger adults

Comorbidity is the rule

 Development of Antidepressant
Treatment
Escitalopram
Escitalopram
MAOI NaSSA Duloxetine
Duloxetine

1950 1960 1970 1980 1990 2000

TCA SSRI SNRI

 Geriatrics and Depression
Selecting an antidepressant

Severity of depression & Previous response

Comorbid conditions / other medication
Half-life / kinetics / dynamics
Risk of overdose & drug interactions

Tips:
- Compliance
- Avoid anticholinergic drugs
- Avoid cardiotoxic drugs
 Newer Antidepressants and
CYP 450 System
1
0.9 Citalopram
0.8 Mirtazapine
0.7 Venlafaxine
0.6 Wellbutrin
0.5
Sertraline
0.4
Nefazodone
0.3
Fluvoxamine
0.2
0.1
Paroxetine
0 Fluoxetine
1A2 2C19 2D6 3A3/4
CYP 450
 GAD, PTSD, Panic Disorder
GAD, PTSD, Panic Disorder has some geriatric
literature

Specific phobia, social phobia, OCD: has very little

GAD: Until recently: little known >60 yrs

Point prevalence 3.7%-7.4% increases with agehigh

in >80 yrs.

Early-onset continues but many develop in late life.

 Controlled Trials of GAD
in older adults
Agent Author Duration N Age Efficacy
weeks
Oxazepam Koepke et al 4 220 >60 >PBO
1982
Individual CBT Stanley 14 48 >55 CBT
1996 = supportive
Enhanced Mohlman et 13 15 >60 N too small
al 2003
CBT
Primary care Stanley et al 8 12 >62 CBT > usual care
CBT 2003
CBT Stanley et al 15 85 >60 CBT > wait list
2003
Group CBT Wetherell & 12 75 >55 CBT=supportive Rx >
Gatz 2003 W/L
 Venlafaxine XR in the
elderly with GAD

Pooled efficacy analyzed: 5 PC studies GAD in

>age 60

N=136 Effexor XR ; N=47 Placebo

HAM-Anxiety Score weeks 8, 24

Results strongly suggestive of effective

treatment for GAD in older adults
 PTSD
PTSD: likely to develop in elderly and young
Seen in cardiac pts., stroke, organ transplant.
Rx extrapolated from young (SSRIs).
CBT & Group therapy recommended
 Panic Disorder
Panic Disorder: Possibly rare in elderly 0%-
1% due to ? biological factors
Atypical panic syndromes
Somatic presentations medical causes
Most common in MDD poor compliance
No RCTs in elderly. No psychotherapy
studies.
 Other Anxiety Disorders
Other mixed disorders: Several treatments
Two studies with SSRIs without MDD, mostly
GAD.
Open-label fluvoxamine 2/3 remitted
Placebo-controlled trial of citalopram 10-40
mg/day efficacious
Buspirone in placebo-controlled trials
efficacious
CBT helpful.
 Other Studies in
Anxiety in Elderly
Sample Agent Author Duration N Age Results
weeks

Mostly Fluvoxami Wylie et al 21 19 >50 Effective

GAD ne 2000 in 66% of
completer
s
Mostly Citalopram Lenze et 8-16 34 >60 >PBO
GAD al 2003

Secondary Buspirone Bohm et al 4 40 >65 >PBO

to neurotic 1990
depression
Mostly Individual Barrowclo 16 43 >55 CBT>
Panic CBT ugh et al Supportive
2001
 Anxious Depression
Anxious Depression: mixed symptoms
Subsyndromal anxiety common in MDD
Increased suicidality
Possibly delayed / diminished response
SSRIs, venlafaxine, mirtazapine recommended
May need benzo in acute phase
 Anxious Dementia
Anxiety in Dementia: Unstable day-to-day
Increased in executive impairment &
dementia difficulty in problem-solving
May be more common in vascular vs. AD
Loss of function may lead to s/s
Pace, agitation, screaming, worries (repetitive
questions), expression.
May be secondary to psychosis
Rx: Search for underlying cause medical
 Neuropsychiatric Clusters in Dementia
Also helpful when assessing BPSD..
Aggression Agitation
Walking aimlessly
Pacing
Aggressive resistance Trailing
Physical aggression Restlessness
Apathy Verbal aggression Repetitive actions
Dressing/undressing
Withdrawn Sleep disturbance
Lack of interest
Amotivation Sad
Tearful
Hallucinations
Hopeless
Delusions
Low self-esteem
Misidentifications Psychosis
Depression Anxiety
Guilt

Adapted from McShane R. Int Psychogeriatr 2000; 12(Suppl 1): 14754

 Citalopram vs Placebo
SSRIs in Depression plus Dementia
Change in GBS Rating11 (Baseline to Week 4)
Improvement in GBS Rating (%)

90
80 * Citalopram
70 Placebo
60 n = 98
**
50 **
**
**
40 *
30 *
20
10
0
Emotional Confusion Irritability Anxiety Fear-Panic Depressed Restless- Motor Intellectual
Bluntness Mood ness Impairment Impairment

* P < 0.005 ** P < 0.01 (within groups)

P < 0.05 P < 0.01 (between groups)
1
GBS = Gottfries-Brane-Steen Dementia Rating Scale
Nyth and Gottfries, Br. J. Psychiatry 1990; 157: 894-901
 Anxious Dementias

Environment, agoraphobia-like, left alone.

Rx: atypicals, SSRIs, venlafaxine,
mirtazapine, cholinergics.
Reduced use of benzos; no anticholinergcs
 Bezodiazepine Use in Elderly:
The
The prevalence
prevalence of
of benzodiazepine
benzodiazepine therapy
therapy for
for older
older people
people in
in Ontario
Ontario has
has
steadily
steadily declined
declined between
between 1993
1993 and
and 1998.
1998. There
There is
is aa trend
trend of
of dispensing
dispensing
relatively
relatively more
more short-acting
short-acting than
than long-acting
long-acting benzodiazepines
benzodiazepines and and ofof
replacing
replacing benzodiazepines
benzodiazepines with
with antidepressants
antidepressants in in older
older people
people without
without aa
remarkable
remarkable increase
increase in
in barbiturate
barbiturate consumption.
consumption. These
These findings
findings suggest
suggest
that,
that, without
without undue
undue regulation,
regulation, physicians
physicians areare making
making progress
progress inin the
the
prescribing
prescribing of
of benzodiazepine
benzodiazepine therapy
therapy onon the
the basis
basis ofof current
current knowledge
knowledge
available.
available.

CONCLUSION:
Benzodiazepine use in Ontario
for the elderly is decreasing.

J Am Geriatr Soc 2001 Oct;49(10):1341-5 Progressive trends in the prevalence of

benzodiazepine prescribing in older people in Ontario, Canada.
Tu K, Mamdani MM, Hux JE, Tu JB
 Mirtazapine &
anxiolytic/hypnotic use
Benzodiazepines and other sedative /hypnotics are the most frequently
used drugs for attempted suicide, followed by analgesics and tricyclic
antidepressants, the majority of which are prescribed by physicians [1]

[1] Schwarz UI, Ruder S, Krappweis J, Israel M, Kirch W.

[Epidemiology of attempted suicide using drugs. An inquiry from the
Dresden University Clinic]
Dtsch Med Wochenschr. 2004 Jul 30;129(31-32):1669-73
[Article in German]

A recent study suggests that patients receiving mirtazapine are less

likely to be on anxiolytic/hypnotic agents.[2]

[2] Gardner ME, Malone DC, Sey M, Babington MA.

Mirtazapine is associated with less anxiolytic use among elderly
depressed patients in long-term care facilities.
J Am Med Dir Assoc. 2004 Mar-Apr;5(2):101-6.
Summary of Treatments

First-line: SSRIs, venlafaxine, mirtazapine

Second-line: TCAs, MAOIs
Atypicals are promising
CBT helpful but limited in GAD.
Need a lot more research.
 Treatment Summary
CBT has limited evidence of efficacy
More effective if memory is factored for.
Comorbity is big problem.
Pharmacological evidence is essentially
absent for non-benzodiazepines
SSRIs, venlafaxine, mirtazapine, buspirone
proven in younger pts. but no large RCTs in
older patients
Importance of Mental Health

Mental
health is
fundamental
to health
Faculty Question Period