Generalised anxiety disorder in elderly patients : epidemiology, diagnosis and treatment options.
Generalised anxiety disorder (GAD) is characterised by at least 6 months of excessive uncontrollable worry accompanied by symptoms of motor tension and vigilance and scanning. As with other anxiety disorders, GAD is less prevalent in older adults than younger adults. GAD has a high level of comorbidity with other psychiatric disorders and this has a bearing on estimates of its prevalence. GAD that is comorbid with another psychiatric disorder has a period prevalence of approximately 4% in community-dwelling older people. On the other hand, 'pure' GAD is less common, with a period prevalence of approximately 1%. Pure GAD in late life is a fairly even mix of chronic cases that began earlier in life and cases starting for the first time in later life. The most frequent and consistent finding regarding late-life generalised anxiety is its high level of comorbidity with major depression. There are few longitudinal data pertaining to the temporal association of generalised anxiety and major depression in late life, but the data that do exist suggest that the anxiety is frequently symptomatic of the depression. If generalised anxiety occurs exclusively during episodes of major depression, a separate diagnosis of GAD is not warranted. Cognitive behaviour therapy (CBT) is the most frequently studied psychological treatment for GAD. Although CBT is more effective than a wait-list control condition, it is not more effective than nondirective therapies in late-life GAD. Furthermore, a standard course of CBT appears to be less efficacious for GAD in older adults than younger adults. Further research is needed to develop more efficacious and specific forms of psychotherapy for late-life GAD. The three classes of medications that are most commonly used for GAD are: (i) antidepressants; (ii) benzodiazepines; and (iii) buspirone. Antidepressant medication is the pharmacological treatment of choice for most older adults with generalised anxiety. When generalised anxiety is secondary to an episode of major depression, the selection of an antidepressant is guided by the same principles that apply to treatment of nonanxious depression. Antidepressant medication is also effective for GAD in the absence of an episode of major depression. In this situation, citalopram and venlafaxine have been found to be efficacious in older people. Data from studies of mixed-aged patients suggest that escitalopram, paroxetine and trazodone may also be beneficial in late-life GAD. Despite their widespread use in older persons with anxiety, benzodiazepines have a limited role in the treatment of GAD in the elderly. If a benzodiazepine is initiated, pharmacokinetic considerations favour the use of either lorazepam or oxazepam. Buspirone also has a more limited role than antidepressants in the treatment of late-life GAD.
Flint
Alastair J
AJ
Department of Psychiatry, University Health Network and University of Toronto, Toronto, Ontario, Canada. alastair.flint@uhn.on.ca
D000368:Aged; D014151:Anti-Anxiety Agents / Q000627:therapeutic use*; D000928:Antidepressive Agents / Q000627:therapeutic use*; D001008:Anxiety Disorders / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D001526:Behavioral Symptoms / Q000453:epidemiology / Q000628:therapy; D015928:Cognitive Behavioral Therapy; D015897:Comorbidity; D006801:Humans
D014151:Anti-Anxiety Agents; D000928:Antidepressive Agents
Psychopharmacology (Berl). 1991;105(3):428-32
1798836
Can J Psychiatry. 1989 Nov;34(8):766-71
2684380
Psychol Med. 2003 Apr;33(3):499-509
12701670
Biol Psychiatry. 1993 Oct 1;34(7):465-70
8268331
J Affect Disord. 1997 Dec;46(3):255-62
9547122
Med J Aust. 1987 Mar 16;146(6):305-7
3821636
Am J Psychiatry. 1990 Feb;147(2):217-20
2301664
J Consult Clin Psychol. 2003 Aug;71(4):821-5
12924687
J Clin Psychiatry. 2000 Feb;61(2):91-4
10732655
Stroke. 1996 Feb;27(2):270-5
8571422
J Neurol Neurosurg Psychiatry. 1997 Mar;62(3):294-5
9069497
J Clin Psychopharmacol. 1990 Jun;10(3 Suppl):47S-51S
2198301
Am J Psychiatry. 1991 Feb;148(2):274
1987832
Depress Anxiety. 2004;19(4):234-40
15274172
Psychosomatics. 1982 Jun;23(6):641-5
6750675
Am J Geriatr Psychiatry. 1993 Winter;1(1):46-58
28530946
Arch Gen Psychiatry. 1983 Nov;40(11):1167-73
6139099
Acta Psychiatr Scand. 1986 Nov;74(5):451-8
2880459
Int J Geriatr Psychiatry. 1998 Oct;13(10):717-26
9818308
J Affect Disord. 1996 Jul 29;39(3):165-73
8856420
Am J Geriatr Psychiatry. 1997 Spring;5(2):107-15
9106374
J Consult Clin Psychol. 2003 Apr;71(2):309-19
12699025
J Clin Psychiatry. 2002;63 Suppl 8:24-34
12044105
Biol Psychiatry. 1998 Sep 1;44(5):348-60
9755357
Depress Anxiety. 1997;5(2):103-7
9262941
J Clin Psychopharmacol. 2003 Jun;23(3):240-9
12826986
Behav Res Ther. 2003 Jun;41(6):633-46
12732372
Am J Psychiatry. 2003 Apr;160(4):749-56
12668365
J Affect Disord. 1997 Dec;46(3):273-7
9547124
J Consult Clin Psychol. 2003 Feb;71(1):31-40
12602423
Am J Geriatr Psychiatry. 1996 Summer;4(3):252-257
28531084
Arch Gen Psychiatry. 1993 Nov;50(11):884-95
8215814
Psychol Aging. 2003 Sep;18(3):622-7
14518822
Am J Psychiatry. 1999 Jun;156(6):943-5
10360137
Psychiatry Res. 1997 Jan 15;66(1):23-31
9061801
J Neuropsychiatry Clin Neurosci. 1998 Winter;10 (1):34-40
9547464
Depress Anxiety. 2001;14(4):219-25
11754129
Br J Psychiatry. 1989 Sep;155:317-29
2611541
Psychopharmacol Bull. 1993;29(2):303-8
7904761
Curr Med Res Opin. 1990;12(4):215-23
1981698
Arch Gen Psychiatry. 1988 May;45(5):444-50
2895993
Am J Psychiatry. 1986 Dec;143(12):1590-2
2878622
Acta Psychiatr Scand. 2000 Jan;101(1):37-45
10674949
J Clin Psychiatry. 1986 Apr;47(4):170-4
3514583
J Gerontol A Biol Sci Med Sci. 1999 Jul;54(7):M348-52
10462166
BMJ. 1999 Feb 27;318(7183):579-80
10037636
Am J Geriatr Psychiatry. 2003 Jan-Feb;11(1):24-32
12527537
Br J Psychiatry. 1996 Mar;168(3):308-13
8833684
Drugs Aging. 1994 Nov;5(5):335-45
7833587
N Engl J Med. 1986 Mar 13;314(11):719-20
2869408
Psychol Med. 2002 May;32(4):649-59
12102379
Br J Psychiatry. 1987 Oct;151:466-73
3328991
Am J Psychiatry. 1999 Dec;156(12):1915-23
10588405
Int J Psychiatry Med. 1990;20(4):349-64
2086522
Am J Geriatr Psychiatry. 2001 Summer;9(3):261-8
11481134
Br J Psychiatry. 1987 Jun;150:815-23
3307986
Arch Gen Psychiatry. 1994 May;51(5):355-64
8179459
Drugs Aging. 1998 Oct;13(4):269-80
9805208
Int Clin Psychopharmacol. 1995 Sep;10(3):181-95
8675972
J Clin Psychiatry. 2001 May;62(5):350-7
11411817
Psychopharmacology (Berl). 1998 Oct;139(4):402-6
9809861
Br J Psychiatry. 1997 Oct;171:369-72
9373428
J Clin Psychopharmacol. 2001 Feb;21(1):59-65
11199949
Am J Psychiatry. 1995 Aug;152(8):1174-9
7625466
Am J Psychiatry. 1994 May;151(5):640-9
8166303
Can J Psychiatry. 1997 Oct;42(8):817-25
9356769
Br J Psychiatry. 1995 Mar;166(3):328-32
7788124
J Am Geriatr Soc. 2002 Jan;50(1):18-25
12028242
Int J Geriatr Psychiatry. 2003 Nov;18(11):994-1001
14618550
Acta Psychiatr Scand Suppl. 1998;393:6-11
9777041
Br J Psychiatry. 1992 May;160:681-6
1591578
Br J Psychiatry. 1991 Jan;158:83-92
2015456
Expert Opin Investig Drugs. 2002 Oct;11(10):1477-86
12387707
Age Ageing. 1994 Nov;23(6):461-4
9231938