Generalized anxiety - characteristics and prevalence

Generalized anxiety is pervasive, excessive worry that is difficult to control, and is characterized by restlessness, fatigability, difficulty in concentration, muscle tension, and sleep disturbance. Generalized anxiety is the most common type of pervasive anxiety disorder diagnosed in older adults. It occurs in between 4.6% and 7.1% of older adults¹,², and is more common in elderly who live in nursing homes or other institutional settings, as well as in older adults with reduced mobility.³

Although generalized anxiety is common among older adults, some health care researchers have expressed concern that this public health problem is not being treated as effectively as it could be. The researchers in this study made two advances that may improve provision of services. They (1) identified differences in how older adults experience and express anxiety, compared to younger adults, and they (2) reviewed treatment studies of cognitive-behavior therapy (described below) in older adults.

Special considerations in older adults

Although generalized anxiety disorder has the same diagnostic criteria across the lifespan, there are special considerations with older adults:

• Older adults may have different content in their worry - in particular, they have more concerns about health compared to younger adults, who are generally more concerned about work-related issues
• Older adults describe their anxiety with emotionally-neutral words such as fret, compared to younger adults, who were raised in an era where more "psychological" words, such as worryor anxietyare common - as a result, older adults may be under-reporting their distress because they do not use emotional words to describe it
• Older adults have higher rates of other disorders, such as depression, sleep disturbances, and health problems associated with advanced age, that overlap with generalized anxiety and may make differential diagnosis more challenging
• Older adults tend to focus most on the physical symptoms of anxiety, so they usually seek treatment in a primary care medical setting. The patients expect a medical diagnosis to explain their unpleasant physical sensations, and individuals of this age may be reluctant to accept the physician's explanation that anxiety has a psychological component and that it could respond to non-medical treatment

Treatment with benzodiazepines

Generalized anxiety is most commonly treated with benzodiazepines. Prevalence rates for benzodiazepine use among older adults ranges from 17% to 50%.⁴, adverse effects such as cognitive and psychomotor impairment may put elderly patients at increased risk of falling, or it may reduce their mobility because of an inability to drive while taking the medications. Possible dependence on benzodiazepines is also a concern. Although use of benzodizaepines or other drugs is sometimes indicated for quick or short-term relief of anxiety, research indicates that non-medical treatments such as cognitive-behavioral therapy may be safer for many older adults and the elderly.

Treatment of anxiety with cognitive-behavior therapy

"Cognitive-behavioral" therapy, or CBT, is a type of treatment where patients learn to change their behaviors and beliefs in order to better cope with or alleviate a particular condition. Regardless of the age of the patient, the basic elements are the same. The components of CBT are:

• Relaxation training
• "Exposure" sessions where the patient experiences anxiety-provoking situations in a graduated, controlled way in order to habituate to the uncomfortable emotions and physical symptoms associated with anxiety
• Cognitive restructuring, which includes new interpretations of the physical symptoms of anxiety and development of "replacement" thoughts for the constant worry

Treatment time varies. Researchers in this study reported a range of 1 or 2 hours weekly over 4 to 10 weeks. CBT can be administered in either individual or group formats, which allows some flexibility for patient preference, cost of therapy, or treatment availability. Further studies are currently underway to more closely examine outcomes of individual vs. group formats for CBT in older adults.

Advantages of cognitive-behavior therapy over benzodiazepines

Although using benzodiazepines or other medications to treat generalized anxiety may be necessary when the patient requires rapid relief, there are advantages to using CBT. First, as noted above, benzodiazepines often have adverse cognitive and psychomotor symptoms that may interfere in the patient's daily functioning. And second, anxiety treated with any medication tends to rebound soon after the drug treatment is stopped.

In this review, patients who had CBT to treat generalized anxiety maintained treatment gains for up to one year after therapy had been discontinued (based on a 20% or greater decrease in the outcome measures compared to baseline data). Early research points to patients being able to manage anxiety across their lifespan by having annual "booster" sessions where cognitive-behavioral techniques are reviewed and patients' skills are refreshed.

In one treatment study still in progress, researchers found that cognitive-behavior therapy was used very effectively to help patients reduce or wean off their medications. This required careful supervision by the physician, and close collaboration between the medical and mental health providers. The physician reduced medication by approximately 20% each week, while the patient received CBT. This multidisciplinary approach to treatment had impressive results. Not only were patients able to reduce or stop drug treatments, but they showed statistically significant reductions in their levels of anxiety beyond that with just medication alone.

Comment

Many older studies of CBT efficacy were hampered by small sample size and lack of control groups. However, recent studies have been larger and better controlled, and have included randomization of subjects. These improved research methods add to the mounting evidence that CBT is an effective treatment for generalized anxiety in older adults.