Anxiety Disorders in Older Adults

Abstract

Anxiety disorders can have detrimental effects on the health of older adults. Generalized Anxiety Disorder (GAD) in particular is the most prevalent anxiety disorder among this growing population. Physical and mental decline in older adults are some of the factors that contribute to the development of a GAD diagnosis. It is important to assess additional environmental factors that may be contributing to anxiety in older adults. In addition, ensuring that older adults remain physically active by engaging in some form of exercise can reduce the symptoms of GAD. Identifying GAD or any other anxiety disorder within the older population can be challenging due to preexisting medical conditions that may mimic symptoms of an illness, so it is important for medical providers to engage with this population and conduct thorough assessments by listening and being patient with older clients instead of “pushing” them through the health care system. Fortunately, there are treatment options like self-help methods and cognitive behavioral therapy that can relieve GAD symptoms in older adults. Social workers and practitioners also play a crucial role in guiding this population towards a full recovery by obtaining additional training as well as creating educational programs for other professionals that work with older adults. Providing community awareness will also ensure additional support systems are initiated.

Introduction

Anxiety disorders affect countless people on a daily basis and in many cases can become debilitating. For older adults’ being diagnosed with an anxiety disorder can present a whole new set of challenges. Combined with the stressors of existing medical conditions anxiety disorders can have a negative impact on the quality of life for older adults. Due to advances in medicine people are living longer and the older adult population is increasing. It is estimated that by 2030 the older adult population will reach 70 million as the baby boomers reach older adulthood (Salaz, Gutierrez, & Dykeman, 2016). These numbers are pretty significant and highlight the importance of accommodating this population with medical services that include mental health and the treatment of anxiety disorders. It is the responsibility of social workers and medical practitioners to advocate and make services accessible for older adults and most importantly help them understand what anxiety disorders are and how they can be treated. As the older population increases, mental-health problems among older adults in the United States will also rise, affecting and estimated 15 million (Salaz et al., 2009). Generalized Anxiety Disorder (GAD) is the most common anxiety disorder among older adults and it is estimated that 7% to 20% of this population meet diagnostic criteria for GAD (Salaz et al., 2009). GAD is defined as a psychological disorder characterized by excessive or disproportionate anxiety about several aspects of life, such as work, social relationships, or financial matters.

Contributing Factors

Since the older population is living longer, they may encounter increased stress due to multiple medical diagnoses which in turn increase anxiety. This paper will focus on the most common anxiety disorder GAD and its impact on older adults. Kathy Rifaat, a social worker and former director of senior services for a non-profit organization called Interfaith was interviewed by email and provided valuable insight into the complexities of anxiety disorders and their ability to impair normal functioning for the senior population. The former director specialized in overseeing multiple senior living communities which included responsibilities of arranging transportation for medical appointments for seniors as well conducting routine home visits to assess overall wellness. The social worker was able to identify client’s that were diagnosed with GAD and detailed the debilitating qualities of the disorder along with a few other clients that suffered from anxiety.

There are a number of factors that can contribute to GAD in older adults. A family history of anxiety disorders or the experience of a stressful or traumatic event like the loss of a loved one can be contributing factors (“Anxiety and Older Adults,” nd). In addition, stresses and changes that sometimes go along with aging-poor health, memory problems, and losses-can cause an anxiety disorder (“Anxiety and Older Adults,” nd). Common fears about aging can lead to anxiety. Many older adults are afraid of falling, being unable to afford living expenses and medication, being victimized, being dependent on others, being left alone, and death (“Anxiety and Older Adults,” nd). Many of these concerns can be alleviated with the proper care a social worker can provide by connecting clients with resources to reduce and combat their worries and fears.

The social worker described a client that had lost her husband and naturally was devastated. Her grief had contributed to being diagnosed with GAD and it changed her life considerably. She refused to attend the bi-weekly activity group at the community center that her and her late husband would hardly miss unless they had a doctor’s appointment. She described how this client would refuse to do routine activities and withdrew from her friends and social groups. She was constantly worried that something may happen to her if she left her apartment and hardly felt safe. This client also began hoarding items that reminded her of her husband and refused to let anything go. Depression comorbid with an anxiety disorder prevented this client from resuming her normal life style. This client continued this pattern for over a year and refused to seek medical attention until her children encouraged her to seek help (K. Rifaat, personal communication, November 9, 2018). GAD is associated with significant functional limitations, use of health-related services, and impaired quality of life (Goncalves & Byrne, 2012).

The primary symptom of GAD is pathological worry (Wetherell, Le Roux, & Gatz, 2003).  Challenges specific to late life, such as a widowhood, caregiving, or cognitive or physical decline, may inspire realistic or adaptive worries that should not be interpreted as pathological (Wetherell et al., 2003). Physical decline stands out as a contributing factor to GAD that many senior citizens are confronted with more frequently. The inability to participate in regular activities as before can contribute to high levels of anxiety that if left undiagnosed can become worse with time. For example, the social worker described an elderly lady who slowly began to withdrawal from a group of ladies that played bingo once a week in the common area of her complex. This client had fallen a few times in the previous year but never sustained any serious injuries. She had developed anxiety that she may fall again and seriously hurt herself, so she began to isolate herself and refused to leave her apartment. Her constant worrying of falling robbed her of her normal routine but more significantly the companionship she valued most (K. Rifaat, personal communication, November 9, 2018). Moreover, GAD is capable of removing normalcy and crippling older adults by keeping them stagnant in a cycle of worry that is nonproductive.

Health Effects

Anxiety disorders can have detrimental effects on the health of older adults. The prevalence of clinically significant anxiety is as high as 20% among older adults (Wetherell et al., 2003). Anxiety symptoms in late life are associated with higher risk of fatal coronary heart disease, pain and analgesic use, disability, and inappropriate use of medical services (Wetherell et al., 2003). Not understanding the symptoms of GAD can increase doctor or hospital visits regularly due to the similar symptoms’ anxiety disorders can produce (Wetherell et al., 2003).  For example, a panic attack can mimic a heart attack and unnecessarily send a client to the emergency room (Wetherell et al., 2003). As social workers and practitioner’s education is crucial when diagnosing and developing a plan to successfully address a disorder. This can be a difficult task due to the various medical issue’s older adults encounter and the masking of GAD symptoms.

That is why screening for anxiety disorders is crucial for older adults now more than ever due to the rapidly increasing rate of this population. Home healthcare workers and social workers should be trained in identifying potential anxiety disorders in older adult clients. More specifically they must be able to successfully communicate this with their clients while reassuring them that symptoms can be treated with therapy or medication in some cases. If clients are able to gain an understanding as to why they are feeling or experiencing anxiety related symptoms, they will be more open to suggestions from social workers or medical professionals on how begin treatment. A skilled practitioner can help remove the stigma of a disorder and encourage an older client to take the necessary steps in identifying if there is or isn’t an anxiety disorder that is limiting the quality of life for the client. Once the client understands that it can improve their overall well-being, they will be more inclined to participate in an assessment.

Treatment

There are several ways to treat GAD and in more severe cases medication may be necessary but for the most part therapy and physical activity can relieve and reverse symptoms especially if they are identified at an early stage. As mentioned earlier depression and anxiety can be comorbid so it is important to distinguish the two and provide the correct treatment. Depression and anxiety are associated with an increased risk of morbidity; impairments in physical, cognitive, and social function; and declines in psychosocial health (Aguiñaga, Ehlers, Salerno, Fanning, Motl, & McAuley, 2018). 

Engaging in a physical activity even for small increments has shown to provide tremendous benefits for people suffering from many different disorders. Studies have demonstrated that after participation in physical activity intervention, psychosocial factors such as physical self-worth (PSW) man influence negative affect (e.g. depression, anxiety) (Aguiñaga et al., 2018). Thus, by participating in a physical activity intervention, older adults may improve perceptions of their physical condition, attractiveness, or strength, thereby reducing negative affect (Aguiñaga et al., 2018). The social worker contributed to these findings by mentioning that her senior clients always improved drastically when they engaged in a physical activity. In particular an 80-year-old client had been suffering from anxiety and staying home more frequently due to repeated hospital visits. The social worker invited him to a senior citizens dance that is held once a month at a community center. The client was reluctant at first but then agreed to attend. The social worker stated that he had an amazing time and his outlook completely changed. He danced with several ladies that night and being able to move about the dance floor came with therapeutic benefits. The social worker also recommended that he attend an aerobics/weight training class for seniors to keep him active (K. Rifaat, personal communication, November 9, 2018).

 In many cases a good exercise program alone can combat symptoms of anxiety. A study was done to observe the benefits of a home-based physical activity program and its effects on anxiety. The program developed a DVD that delivered flexibility, toning, and balance intervention, which improved physical function, strength, and flexibility at postintervention, 12 months, and 24 months, also improved physical activity and self-esteem levels (Aguiñaga et al., 2018). This is encouraging, in that a home-based physical activity intervention can reduce depression and anxiety in a nonclinical sample and is supportive of other work with older adults (Aguiñaga et al., 2018). The social worker emphasized the importance of keeping seniors or older adults active in any way possible. She has seen the benefits of exercise and socialization with others. The social worker also mentioned how she organized day drips where walking was involved and made sure to incorporate a fun site to visit so seniors wouldn’t pay much attention to the exercise aspect. The excitement of the trip usually limited the complaints of having to walk too far (K. Rifaat, personal communication, November 9, 2018). It is important to implement an exercise program for every senior regardless if they are suffering from GAD or any other mental disorder. If a senior is homebound or has physical limitations, home based programs can provide an individualized plan or workout specific to their needs.

Unfortunately, GAD and other anxiety disorders are often overlooked especially in older adults that many have several medical conditions that make it more difficult to diagnose. Late-life anxiety is highly comorbid with depression and is associated with disability, pain, sleep difficulties, cognitive problems including cardiovascular diseases (Landreville, Gosselin, Grenier, Hudon, & Lorrain, 2016).  The social worker also reinforced the notion that many of her clients experiencing anxiety also battled some form of depression whether it be the loss of a partner or declining mobility that limited self-sufficiency (K. Rifaat, personal communication, November 9, 2018).  Many factors impact the quality of life for older adults, so it is imperative for social workers to be patient and conduct a thorough assessment that focuses on all aspects of the client’s health as well as considering environmental factors that may be triggering symptoms of anxiety. It is the responsibility of social workers and practitioners to be a voice for older adults suffering from GAD by fully immersing themselves and being patient in understanding the complexity of onset as well as develop treatment plans that would benefit each client.

Moreover, social workers should ensure that older adults with anxiety disorders can obtain access to resources and treatment options to address their symptoms. GAD is one of the most widespread anxiety disorders in older adults (Landreville et al., 2016). That is why it is crucial for practitioners and social workers to work together to close the gap in undertreated adults suffering from GAD (Landreville et al., 2016). The undertreatment of disorders like GAD can also be explained by the inaccessibility of mental health treatments (Landreville et al., 2016).

In addition, specific factors that can complicate access to treatment include difficulties with mobility and lack of transportation (Landreville et al., 2016). The social worker touched on the importance of being involved with the community and tapping into resources that can help clients become self-sufficient and live quality lives. She touched on the importance of networking with other non-profit agencies and the importance of continual advocacy for senior needs especially those that are suffering from debilitating mental disorders like GAD (K. Rifaat, personal communication, November 9, 2018). Training programs should be implemented for mental health professionals to help identify this problem in the growing adult population. These programs should include identifying unique characteristics that clients display that point to GAD as well as incorporate skills in ascertaining comorbidity. Three types of comorbid conditions tend to complicate the diagnosis of anxiety disorders in late life-depressive disorders, cognitive deterioration, and physical illness (Sable & Jeste, 2001). This can be a challenging process for medical providers but of the utmost importance. They need to ensure the correct disorder is being treated and avoid the risk of it gradually becoming worse by misdiagnosing or overlooking symptoms that could have been identified by taking the time to speak with older clients and truly listen to their concerns. Due to the increasing size of the older population many medical practitioners including social workers may unintentionally keep patients moving through the healthcare system and miss things like GAD.

In less severe cases clients can gain access to self-help books that can help them learn how to cope with this disorder as well as learn specific techniques to reverse the symptoms. Self-help treatments using readings have been designated as a promising avenue for the treatment of anxiety in the elderly (Sable & Jeste, 2001). Guided self-help (GSH) is a psychological treatment that patients learn to use from home in a more or less autonomous way (Sable & Jeste, 2001). This method would reduce potential additional anxiety by remaining in the comfort of their home while they learn about the disorder and ways to relief the symptoms. The social worker mentioned how seniors can benefit from self-help techniques because it keeps them distracted and less focused on stressors in their lives (K. Rifaat, personal communication, November 9, 2018). These methods can be accompanied with the assistance of a therapist by either communicating by phone or email (Sable & Jeste, 2001). There are many benefits to this type of treatment for GAD. There are a number of advantages of GSH for GAD: (1) it offers a long-term treatment for individuals suffering from this chronic disorder, (2) it constitutes an alternative to psychotherapy for individuals who do not feel understood by health care professionals, and (3) it remains an option when access to psychological services is limited (Sable & Jeste, 2001). In addition, this can be advantageous to seniors who live on a fixed income and can’t afford co-pays for continual therapy (Sable & Jeste, 2001). 

There are several advantages to GSD that include less time with a therapist which also makes it less expensive (Sable & Jeste, 2001). From the description of the social worker seniors struggle with transportation especially in the community she was assigned. There was no form of public transportation, so several churches and non-profits had developed volunteer programs that provided limited transportation to seniors for their medical appointments (K. Rifaat, personal communication, November 9, 2018). However, it is quite challenging to secure appointments for transportation, so the method of GSD would definitely be more appealing for clients suffering from GAD. There are benefits to other types of treatments and therapy. Cognitive Behavior Therapy (CBT) techniques have also been found to be beneficial for older adults. CBT is considered effective for older patients with anxiety disorders (Palazzolo, 2015). Modifying CBT to focus on the meaning of losses and transition and accommodating cognitive decline is likely to improve efficacy (Palazzolo, 2015). As the social worker mentioned many of her clients have experienced the loss of a loved one or their physical abilities are declining rapidly which can increase anxiety levels (K. Rifaat, personal communication, November 9, 2018).  As previously noted, the older a client gets the more likely they will experience some form of depression comorbid with anxiety. Losses and transitions can trigger thoughts of missed opportunities or unresolved relationships and reflection on unachieved goals (Palazzolo, 2015). CBT for older adults should focus on the meaning the patient gives to these losses and transitions (Palazzolo, 2015). This approach helps older clients handle their difficulties more efficiently by changing their way of thinking. Treating GAD with CBT consists of relaxation training, cognitive restructuring, and worry exposure (Wetherell, Gatz, & Craske, 2003).

Client Support

In order to improve interventions with anxious older adults, more knowledge is needed on the effectiveness of available treatments (Pinquart & Duberstein, 2007). Whichever treatment method older adult choose it is important to have the support of family members and friends. It can be a debilitating mental disorder that disrupts normal activities and functioning in addition to any other present mental or physical limitations. Social workers can facilitate this process by educating members of the client’s family on the negative effects of GAD. Clients unfortunately feel like prisoners in their own minds and others may not be able to fully grasp or understand the magnitude of this disorder. In addition, primary care physicians should also be able to help clients through this difficult process by presenting options to treat this disorder. For many client’s self-help plans are enough but for more serious cases therapy or medication or a combination of both may be necessary. Older adults in particular are likely to be more satisfied with integrated mental health services rather than referrals to specialty mental health services, potentially due to the stigma of receiving care in specialty mental health services and older adults’ greater burden of chronic illness (Hundt, Armento, Porter, Cully, Kunik, & Stanley, 2013). Moreover, finding support groups for older adults with anxiety disorders can also be a tremendous help to clients by reassuring them that they are not alone and that it can be treated with the continued support of love ones and strangers experiencing similar obstacles in their lives.

Excessive anxiety that causes stress or that interferes with daily activities is not a normal part of aging, and that it can lead to a variety of health problems and decreased functioning in everyday life (“Mental Health in Older Adults,” 2015). Between 3% and 14% of older adults meet the criteria for a diagnosable anxiety disorder, and a recent study from the International Journal of Geriatric Psychiatry found that more than 72% of older adults under the care of an aging service provider have symptoms of anxiety that may not amount to a diagnosis of a disorder, but significantly impact their functioning (“Mental Health in Older Adults,” 2015).

Conclusion

In conclusion, GAD and other anxiety disorders in older adults can disrupt quality of life. It is important to spread awareness on this issue, so it can be easily identified and treated appropriately. Social workers and practitioners should also take initiative in obtaining additional training that focuses on anxiety disorders with older adults and share that information with the community and family members that have someone affected in order to provide the appropriate services and support.

References

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