Welcome back, everybody. My name is Dr. Brandon Yarns, and I'm an assistant professor at UCLA and a geriatric psychiatrist at VA Greater Los Angeles Healthcare System. And I'm delighted to join you today to talk about anxiety disorders in older adults. I do not have any disclosures for this presentation or conflicts of interest. So here are the objectives of our talk today. So we will first describe the public health impact of anxiety disorders in older adults, and we will also discuss the appropriate assessment and differential diagnosis of anxiety disorders in older adults. Then we will understand briefly the evaluation and treatment of anxiety that occurs in dementia. And then we will talk about treatments for anxiety disorders among older adults. And while I'm speaking, if any questions come up, I believe you are able to enter them in the Q&A as you did for the morning, and we will reserve about 10 minutes at the end of the presentation to go over any questions or comments that you may have. All right, so let's begin with the public health impact. We're going to discuss the epidemiology, risk factors, some of the comorbidities, and the consequences of anxiety disorders in older adults. So when I start talking about anxiety disorders, I tend to make the point that a lot of our field of geriatric psychiatry focuses on primarily two conditions, which are very important and impactful in older adults. They are late-life depression and dementia, particularly behavioral disturbances of dementia. So I'm involved in a program called the Ask the Expert program through the VA, where people throughout the VA healthcare system can submit email questions about geriatric psychiatry, and a majority of those questions are about behavioral disturbances in dementia from non-geriatric psychiatrists. And older epidemiologic studies show that anxiety disorders may be not as big of a problem as these other conditions in older adults. So compared to younger adults, there are studies going back to the 1990s that show lower rates of anxiety disorders in older adults. However, there are new studies, more recent than these studies from the 1990s and early 2000s, that show anxiety disorders are actually very common and impactful in older adults. So a large epidemiologic study was performed in the last decade in the United States that showed that mood disorders like late-life depression have a prevalence of about 6.8 percent, whereas anxiety disorders are almost double that prevalence among adults age 55 years and older. And a similar study in Europe found that the prevalence of anxiety disorders was even higher than that found in the U.S. study at about 17 percent for adults age 65 years and older. So this is two to three times the prevalence rates of past year anxiety versus mood disorders such as late-life depression. So the first point that I can make is that anxiety disorders, at least in the most recent cohort of older adult patients that we're seeing in our clinics now, are very, very common. So the U.S. study broke down the prevalence of anxiety disorders by the particular diagnosis, and you see here that they did include specific phobia, which is maybe not as disabling as some of the other conditions perhaps, and that accounted for about half of the anxiety disorders that they observed in their survey. But also there was a prevalence of panic disorder, social phobia, GAD, and they included PTSD that summed up to over 11 percent of older adults suffering from these disorders. So in addition to a diagnosed DSM anxiety disorder, there has been research indicating that clinically significant anxiety symptoms are present in even more of older patients. 17 percent of men, over a fifth of women, and over 40 percent of those with chronic medical illness or disability have clinically significant anxiety symptoms while not necessarily meeting the threshold for an anxiety disorder. And so I'm going to be talking a little bit more about the interplay between anxiety and chronic illnesses in a few moments. Just so we're all on the same page, I want to make sure that we are just checking off here that we're not talking about the adaptive response of anxiety or fear, as we often call it, which is an evolutionary response to a perceived stressful stimulus and provide appropriate motivation for action and function. What we're really talking about is maladaptive anxiety or unhealthy anxiety, which is pathological. It's not necessarily a stressful stimulus. It's severe, it's enduring, and it impairs functioning. So the risk factors for anxiety disorders in older adults are somewhat similar to younger adults in that they are more common in women, and that's in older adults as well as younger adults. Among older adults, there is some indication that there's a decreased prevalence with increasing age. So once again, the greater prevalence, we don't know why this is exactly. Do people become less anxious? Is there changes in the brain systems? Is there experience, life experience? There are studies showing that older adults may have more positive affect than younger adults, can focus more on the positive than the negative. So as people age, is that really taking care of their anxiety, or is it a cohort effect that previous generations of older adults may have had fewer anxiety symptoms as well as fewer other psychiatric complaints or symptoms, and the newest cohort of geriatric psychiatry patients, which at the VA where I work, includes Vietnam veterans, may have higher prevalences of anxiety disorders. Finally, anxiety disorders in the elderly attempt to be chronic, and they are continued from younger life. So somebody who is a young person may suffer from panic disorder, and that continues later in their life, except in the case of GAD. And so there are studies that show between 25 and 50% of GAD cases in older adults are actually new onset. So similar to what you may have heard already, or will be hearing in another lecture on late life depression, that some people get depressed later in life, which can have biological and psychosocial causes. The same is true for GAD, that some people can develop generalized anxiety disorder, start worrying, and have the accompanying physical symptoms later in life with life transitions, with psychosocial stressors, and with changes to brain structure and function. So anxiety disorders in older adults are associated with quite a few different consequences. So again, in an anxiety disorder, these are disorders that cause functional impairments, and they are associated with reduced physical activity, greater disability, poorer self-perceptions of health, decreased life satisfaction, increased loneliness, worse quality of life, increased healthcare utilization, and an overall greater cost of their healthcare. And so you can see that anxiety disorders do have an impact and are worth assessing and treating in older adult patients. So one of the other consequences of anxiety, which may be obvious to astute clinicians, is that anxiety, high levels of anxiety, can affect cognition. And so there have been research studies showing that older adults with significant anxiety have impairments in their working memory, short-term memory, attention, and problem-solving ability. And so a big thing that is a confounder when we're doing a cognitive screener like the MMSC or slums or MOCA, is that anxiety can impair their performance. And so in our geriatric psychiatry clinic at the VA, we have patients come in sometimes and over time, their MOCA score actually improves. And that is attributable sometimes often, I would say, to anxiety when they come in for their first appointment. And once we're able to address their anxiety, then their performance on the cognitive screening instruments can improve over time. So it's really important when you are performing cognitive screening instruments with your older adult patients to take into account anxiety and assess for anxiety and consider that because it can have a negative impact on their cognition. Interestingly, there are also several studies that show an association between anxiety and actually the onset of dementia or cognitive impairment over time. So it is obvious perhaps that anxiety is going to create a stress response and over time that may impair brain structure or function and can actually be a risk factor for dementia onset. And so depression is not the only risk factor for dementia onset in the psychiatric realm, but anxiety can also lead to dementia presentation over time. And so just taking a look at one of these studies, a three-year prospective study in which patients with MCI were recruited and some of the patients had anxiety and some did not, there was actually a progression to Alzheimer's dementia in 83.3% of the patients with MCI and anxiety versus only about half that in the patients who did not have anxiety but did have MCI. So it's a major risk factor, it would seem, to have anxiety. So again, it should be a focus of clinical assessment and treatment. In another study, there was, people investigated the effects of anxiety on mortality and they found that there was an increased adjusted mortality risk of about 1.8 in men but not women. In another study a few years later, there was an increased mortality rate for depression in men but not for GAD with 10-year follow-up. So it's unclear about whether there is an association between anxiety and increased risk of mortality and what the mechanisms of that would be if it is the case, but there are studies that have looked into that and it may be an issue in men in particular. So the aging brain undergoes quite a few changes and so this is a slide just to review some of the impacts on the brain and anxiety disorders. So hypoactivation in the cingulate and prefrontal regions are associated with PTSD, whereas prefrontal whereas greater OFC volume is associated with GAD. And then there's hyperactivation in the ventral affective system, amygdala and insula that are associated with PTSD, social anxiety, and specific phobia. So this is really to get us thinking about whether if there's processes of brain changes with aging, how they might affect anxiety. So those are some of the risks and the possible consequences of anxiety in older adults so that we can understand that it is a really clinically significant problem that we should be addressing in our older patients and not just focusing exclusively on other symptoms that they may be having. So if you do want to assess anxiety in an older adult patient, where would we start? So of course we want a comprehensive history and I put a note on there just to put another plug in for obtaining collateral information with older patients. Of course I'm sure other presentations have already addressed the importance of collateral with older adults, particularly those with cognitive impairment. And of course we want to do a thorough mental status examination and then cognitive screening including a screening assessment and ADL and IADL assessment in older patients. That's really when I'm supervising residents, one of the main things that I emphasize is the difference in geriatric psychiatry from younger adults is that we always think about their cognition, are they having problems with memory, performing a cognitive screener if they do, and also an assessment of their functioning. So how do they do with IADL such as their meal prep, cooking, shopping, transportation, their medication management, as well as ADLs and whether that is affected by their cognition or psychiatric symptoms or both. A targeted physical and neurologic examination is important particularly with new onset symptoms and typical laboratory testing that you might perform in other conditions. So there are some self-report assessment scales for anxiety in older adults that have been validated. So the GAD2 and GAD7 or GAD2, GAD7 scales have been validated in older adults as well as the Beck Anxiety Inventory, but there are two geriatric focused anxiety assessments, the Geriatric Anxiety Scale which is 30 items and Geriatric Anxiety Inventory which is 20 items. So you see they're a little bit longer assessments but are geriatrics focused that you can use. So when making a differential diagnosis, of course we want to consider the major causes, particularly new onset symptoms in older adults, which we think about dementia, is there an association with dementia that is causing perhaps anxiety or contributing to it in the older adult or do they have a primary anxiety disorder which would be chronic unrelenting worry and again mostly, most cases starting in childhood, anxiety due to depression, associated depressed mood, anhedonia, hopelessness, suicidal thoughts, or in older adults we have to be very careful about anxiety due to medical conditions or medications. So older adults tend to have multi-morbidity much more commonly than younger adults. So here's a list of conditions that may be associated with anxiety including hypoxia, ischemia, hypoglycemia, cardiac arrhythmias, and various conditions precipitating delirium. And then substances, many of the medications older adults take can be associated with anxiety including the usual suspects like anticholinergics, caffeine containing medications, amphetamines, anything that's activating and stimulating to the patient can precipitate anxiety of course. So we want to make sure that we're assessing these things in particular in the older patient. So just a note here about how diagnosis is not always straightforward of anxiety disorders in older adults. So the current diagnostic criteria for our anxiety disorders, they were really developed for use among younger individuals and so there is presumed to be a poor sensitivity in detecting these disorders among older adults. So I think it's important that we really be conscious about assessing anxiety and inquiring about it with our older patients such it is common and potentially disabling. There's also this interesting study I like to mention. It's from 2009, but I think it's still relevant, that a group took patients who were older and had a confirmed diagnosis of GAD that the researchers established. Then they did a chart review to see if anybody had diagnosed them with GAD in their charts. Primary care physicians had only correctly made the diagnosis and documented the diagnosis of GAD in 1.5% of patients. They are very much undetected in younger patients, and we know that that may be the case for older patients. When we're focused on other conditions as well. So why are they so difficult to diagnose in older patients? Why do the diagnostic criteria potentially have poor sensitivity? Well, I think it's likely because of the high degree of comorbidity between anxiety disorders and physical medical problems and symptoms that older adults have, as well as psychiatric comorbidity. So I'm going to discuss the comorbidity here for a moment. So as in younger adults, anxiety and depression are highly comorbid in older patients as well. And there's an interesting longitudinal study in older adults that found that GAD often preceded the onset of depression or a mixed condition, arguing that the two conditions may exist on somewhat of a continuum. Remember, GAD is the condition, the anxiety disorder, that a significant number of cases are new onset in older adults, similar to new onset, late life depression. In addition, GAD and the mixed GAD depression condition were more associated with longstanding vulnerability, whereas depression was associated with illness loss and recent functional impairment. So anxiety in older patients are associated with alcohol use disorder and heavy drinking. So among patients with older adults who had GAD, in one study, 42% had had a drink in the last, in the past week, 9% had at risk drinking and 5%, what they called heavy drinking, which was more than 14 drinks per week. Probably you're already aware, you're going to learn today that the guidelines indicate that over seven drinks a week in older patients is potentially considered problematic. And so they're calling it at risk drinking for eight to 14 drinks in this study. So we see that's a fairly decent prevalence rate. And then interestingly, 25% of older adults with comorbid anxiety and alcohol use disorder also have a personality disorder in another study. So there is a high degree of comorbidity between anxiety and physical medical illnesses. So anxiety in older adults has been associated with allergies, pain conditions, arthritis, back pain, migraines, headaches, as well as cataracts and even gastrointestinal lung and heart disease. So it's interesting to see how anxiety, which will obviously affect the stress response, the HPA axis can have physiologic, produce physiologic changes in the body can exacerbate, or perhaps even lead to some of these physical medical conditions. And the diagnostic issue comes in because we have requirements for physical symptoms in the DSM criteria for GAD, for instance, these are the physical symptoms required, feeling fatigued, muscle tension, problem sleeping, restless. And so these physical symptoms, are they separate from the anxiety in a patient with GAD or are they part of the same system? Are they caused by sympathetic nervous system hyperactivity? Does they have a unitary cause? And so sometimes disentangling what is a medical condition and what is attributable to GAD is complicated. And of course, with panic disorder, panic attacks are required to have a whole range of physical symptoms that affect pretty much every system in the body. So panic attacks are associated with palpitations and sweating and trembling, shaking, shortness of breath, choking, chest pain, discomfort, nausea, abdominal distress, dizziness, chills, and paresthesias. I mean, you get the idea. So I think it's interesting for us to consider the role of anxiety when somebody has an exacerbation of any kind of physical medical condition. And if we do an experiment and we do a safe, reasonable treatment of anxiety, and we can see then if the physical medical condition improves, then we can answer that question. So I think just because somebody's coming in with a new physical symptom, anxiety is something that we should be thinking about whether we can address it in a safe way that can lead to improvement in both the anxiety and the physical symptoms. So how might we do that? What are the safe and effective treatment options for anxiety disorders in older adults? So there is evidence to support both non-pharmacologic and pharmacologic treatment of anxiety disorders in older adults. And there have been several randomized clinical trials, quite a few actually, which I will be walking you through pretty much the entire literature in the next few minutes on clinical treatments for anxiety disorders in older adults. Because there really are far fewer randomized clinical trials in older patients versus younger patients with anxiety disorders. And so one of the points is we need a lot more research and understanding how best not just to identify and diagnose anxiety in older adults, but also how to treat it. But I will be going over the available literature here. So what should you choose in terms of pharmacologic or referring a patient for a non-pharmacologic treatment when they have anxiety? So I will just say before you start trying to read this slide with lots of numbers on it, that in older patients, we are concerned about adverse effects from medications. Older adults, because of their changing physiology and because of medical comorbidities and polypharmacy, are more sensitive to our psychiatric medications. And so caution is warranted. So is it reasonable to start by referring a patient for a non-pharmacologic treatment who has anxiety disorders? And I think the answer is yes. But there was a very interesting meta-analysis. Yes, this is a few years old at this point, but I think it's worth discussing. That they found in general for older adults with anxiety disorders, pharmacologic treatments have this effect size, D equals 1.76. So just to check in on our Ds, Cohen's D, you know, 0.2 is small, 0.5 is medium, and 0.8 or larger is a large effect size. So 1.76 is a whopping big effect size. But non-pharmacologic treatments had a large effect size, but it was much smaller than pharmacologic treatments. So they looked at the control group effect sizes in this meta-analysis and found pharmacologic treatments for anxiety had a much larger effect size for their placebo group, for the control group, the non-pharmacologic controls. So adjusted for the placebo effects, the pharmacologic treatment and non-pharmacologic treatment is about as effective. But as in younger patients, treating a patient with a medication for anxiety is going to produce a large placebo response, or there's going to be nonspecific effects beyond the effects of treatment. So when you're in clinical practice, it may be that providing the patient with a pharmacologic treatment, even a placebo, is going to have a major impact on them that may exist beyond the effects of a non-pharmacologic treatment. Of course, this will vary with individual patients, and so it's worth considering, though, that they're going to get, in your clinical practice, potentially more out of a pharmacologic treatment option due to the added placebo response. If a safe treatment is chosen. So I'm going to briefly review non-pharmacologic treatments so you can just get a sense of what has been tested and what you might recommend to your older patients with anxiety disorders. So there have been randomized clinical trials on quite a few different non-pharmacologic treatments for anxiety disorders in older adults, and that includes just relaxation training, meditation, several trials of cognitive behavioral therapy, things called worry discussion groups, even supportive counseling, modular psychotherapy where they cover lots of different topics, enhanced community treatment, and exercise training is another non-pharmacologic treatment that's been evaluated, and all of these have shown somewhat positive results. So anything that you do basically in a non-pharmacologic treatment from supportive counseling to exercise training to meditation or even relaxation can potentially benefit your older adult patients, and these are all relatively safe. So just to drill down a little bit, I'm going to go over two meta-analyses. So this one is interesting in from 2009 because they compared a full CBT package to just relaxation training, and there were 19 studies that evaluated one or both of these treatment options. So the simple relaxation training, you know, which is usually a component of a non-pharmacologic treatment, usually a component of a CBT package versus a whole CBT, and although they found very high heterogeneity of the controlled studies, they found an effect size of zero for CBT, a small effect size for relaxation training plus CBT, and a larger effect size just for relaxation training. So it may be that the cognitive exercises in CBT have less of an effect than just the relaxation components for older adults with anxiety disorders, and a simpler intervention may be just as good or even better than a full treatment package. So in this study, CBT for GAD that was a little more recent, they did a meta-analysis on 14 randomized clinical trials, and CBT outperformed waitlist at post-treatment and CBT, a six-month follow-up, but it really did not have any significant advantages over any other treatment, and that includes other forms of psychotherapy or escitalopram. So really, referring your patient for a full CBT course is perhaps not necessary or not any better than any other simpler non-pharmacologic treatment the patient could engage in. So there is, I don't know if any of the other speakers have mentioned this, but there are forms of enhanced CBT that have been used that I think these are good when dealing with older adults with sensory impairments or with possible cognitive impairments, and that includes, you want a greater emphasis on psychoeducation, slower pace, repeated explanations, reminder phone calls, requirements for completing homework, and photocopying homework to return to the participants. So it's just more comprehensive to use an enhanced CBT approach that really makes sure that they're participating, remembering from week to week, and engaging with the treatment as well as the homework. So these are ways that that your work can be enhanced with older adults, I think beyond just presenting a CBT course. So the bottom line on non-pharmacologic treatments is that they are, I think, CBT is clearly better than doing nothing, but not necessarily better than other non-pharmacologic options, and non-pharmacologic interventions overall have a medium, maybe up to a large effect size on some things like relaxation training, but further research is needed, perhaps testing some other approaches other than CBT, which doesn't appear to be particularly effective, especially for GAD. Now, how about your pharmacologic interventions? What should you be prescribing for older adults? So for this section, first I'm going to go over the clinical trials, and then I'm going to tell you what I would actually do, because, again, you notice some of my references are a little older. Unfortunately, this is not an exciting research area. I hope it is in the future, anxiety disorders in older adults. So many of the medications tested are older, many of the trials are older, much of the research is older here. So there have been randomized placebo-controlled trials of antidepressants, including two TCAs, two SSRIs, and the SNRIs, venlafaxine, XR, and duloxetine, as well as anxiolytics. So three benzos have been tested, buspirone, and then some things that are not available in the U.S., and carbamazepine, actually, which is probably the worst thing you can prescribe for older adults, so I'd stay away for that one. There have been some other controlled medication trials, the sertraline versus CBT trial. As mentioned, sertraline is better because, probably, of the additional placebo benefit from prescribing a medication. A trial of sertraline versus buspirone found that they were equal, but buspirone actually worked quicker. And then a trial of paroxetine, which is another one that we don't recommend for the potential of anticholinergic side effects and drug-direct interactions in older adults, was found to actually be equivalent to CBT for panic disorder, not GAD, but panic disorder in one trial. There have additionally been uncontrolled trials pointing to efficacy for nifazodone, risperidone, and fluvoxamine. So, what do I actually do, though? Because there's this smattering of evidence, and we're probably unlikely to have many future trials on older pharmacologic agents because there's not funding to perform clinical trials for safe medications in older adults, so only new innovative treatments are likely to be sponsored with new clinical trials. So, I think we need to focus on some clinical wisdom here. So, as in every condition in older adults, you've probably heard that we have our geriatric psychiatry wisdom of starting a medication slow and increasing the dose slowly. But for anxiety disorders, we do need to go, and usually, not all the time, but frequently, usual therapeutic doses of medications are required in older adults. So, in other words, a sertraline dose, I think, in younger adults, there's research indicating that the effective dose is like 103 milligrams or something like that. That's not different in older adults. So, we might take longer to get to 100, 150 milligrams in an older adult patient, but the usual therapeutic dose may be required. And this is in contrast to antipsychotics, where we would definitely want to use the minimally effective dose and have regular dose tapering in older adults. You don't necessarily need to do that for antidepressants in older adults, if that makes sense. So, I would say that SSRIs and SNRIs are first-line medications in older patients. And among those, citalopram, escitalopram, and sertraline interact with other medications the least. Of course, interactions are less common in venlafaxine and duloxetine as well, but you've got to caution with duloxetine with blood pressure increases in patients who are older and may have hypertension. And then, citalopram used to be the standard treatment when I was in my residency for older adults. It was relatively side effect-free. There were no drug interactions and older adults tolerated citalopram very well. But then, you realize in 2000, what was it, 2011, 12, this black box warning came out with citalopram limiting the dose in adults to 40 milligrams. And in older adults, the recommendation was made that the maximum dose of citalopram should not exceed 20 milligrams. So, that really limits the talocram, especially for certain disorders where higher doses are needed, as I said. And so, pretty much everybody that I know is a geriatric psychiatrist switched over to sertraline as first line, because it does not produce as many side effects, and also using s-sitalocram, which the S enantiomer, as I'm sure you're mostly aware, is supposed to impact the QTC prolongation and the risk of torsad less than the R enantiomer, which is present in sitalocram, it's the racemic mix. So, s-sitalocram is considered safer, as well as sertraline does not have that same risk as sitalocram. So, in addition, I'm going to say some things that I can tell you are commonly used in older adults without clinical trial, randomized clinical trial data, but because of their side effect profile and their infrequency of interacting with other medications, we do, geriatric psychiatrists, use these medications frequently for anxiety in older adults. And those include mirtazapine, especially when the patient has comorbid depression, and also appetite and insomnia problems. Mirtazapine is used and is typically well-tolerated, and many of my older patients, from my own anecdotal experience, have a very good response to mirtazapine. So, I would definitely consider that if your patient's coming in anxious and they can't fall asleep. Gabapentin is not studied, but is also a safe, well-tolerated option. And some of my patients have gotten benefit to their anxiety from gabapentin. Trazodone is also not studied, but it's something that you can use at a very small dose, 12.5 to 25 milligrams in the daytime. And we frequently use this for patients with dementia. Hydroxazine is also another option that we can use in older adults. I think there is some idea out there that hydroxazine is anticholinergic, which that would mean we would wanna avoid it in older patients. But in fact, hydroxazine is not anticholinergic, and so it is safe in older adults. But the caution here with these trazodone or hydroxazine that maybe you wanna use on a PRN basis, is that if you do that, any medication can be reinforcing if you use it on a PRN basis in an anxiety disorder. I'm not talking about the patient really becomes addicted to the medication, but they may become of the point of view that they need the medication. So we advocate with any of these medications that you do schedule them and encourage the patient to take it at the same time every day, rather than using it on a PRN basis. So what about my don'ts? So the thing is, while we have clinical trials supporting efficacy on a short-term basis for benzodiazepines, in geriatric psychiatry, we really discourage the use of benzodiazepines for older patients. There are new studies that continue to come out showing that benzodiazepines can precipitate all sorts of problems in older adults. Fall risk, over sedation, newer studies showing they can exacerbate cognitive impairment and are even a risk factor for dementia. So to the extent that we would provide a benzodiazepine for a patient, it would only be on a short-term basis, such as during a crisis, but we would always tell the patient that we would not recommend this medication on a long-term basis with benzodiazepines. And so I really strongly encourage you to consider that and potentially have an SSRI medication, maybe with hydroxazine while the SSRI medication is building its efficacy over the coming weeks, and to try to avoid a benzodiazepine except for severe cases, crises, suicidal ideation, et cetera, on a short-term basis. We also want to caution about TCAs and MAOIs. They're potentially inappropriate because of anticholinergic effects, orthostatic hypotension, drug-drug interactions, and dietary restrictions are present with MAOIs. So we really think of these as like fourth line, fifth line, and in that case, really focusing on the TCAs like nortriptyline that may interact and have fewer side effects, interact less and have fewer side effects. And antipsychotics, I mentioned that some had been studied. We really do not recommend antipsychotics as a first line, second line, or even third line treatment due to side effect risk. And there is a black box warning of increased risk of stroke and death for older adults who have dementia. So always thinking as we're going along about drug-drug interactions, exacerbating medical difficulties, and increased side effect risk due to the patient's physiologic changes with aging as well as medical comorbidities and polypharmacy. So I will also note that more important than the specific agent chosen is the accompanying clinical care. So we really encourage close follow-up when you're starting a new medication in an older adult, even as much as weekly, if you can swing it in your practice setting, as well as comprehensive management, really attending to treatment of comorbidities and side effects. So as we get to the end here, I want to talk just a moment about anxiety in dementia. So patients who have dementia are at an increased risk of developing anxiety due to executive dysfunction, inability to resolve anxiogenic situations, loss of functional status. Symptoms of anxiety as well as other symptoms in dementia often present as neurobehavioral metaphors of various psychiatric disorders. So when we have a dementia patient, I was asked recently to participate in a root cause analysis about a patient who fell in one of our units, and it really became available, obvious to me that the patient was delirious in the 48 hours preceding the fall. And some of the members of the team thought, oh, well, that's just his dementia. But in many cases, there can be superimposed delirium, medical illnesses on top of a dementia and anxiety symptoms result as a consequence of the delirium. So don't forget about that when dealing with older adults. And also consider environmental causes and modify those as needed. If the patient has anxiety around a particular staff member, time of day or activity, modifying those procedures or personnel can relieve the anxiety without giving a patient with dementia a potentially costly medication to their health. So as I was just alluding to there, the first line is non-pharmacologic treatment and seeing if environmental cues can be modified. Medications, if an inadequate response to the non-pharmacologic modifications, or if there are other comorbidities. So antidepressants and mood stabilizers may be effective. Once again, anxiety disorders really should not be addressed with antipsychotics or benzodiazepines routinely. And finally, there's some small bit of evidence that cholinesterase inhibitors and memantine may reduce anxiety by addressing underlying cognitive dysfunction if the patient is anxious about being forgetful or their cognitive impairment. So in summary, thank you all for participating and making it through. The major points here are that anxiety disorders are more common in the elderly than previously thought or that perhaps were the case in older cohorts that have now passed on. In the newer cohorts, anxiety disorders are quite common. They are associated perhaps bi-directionally with physical illness, disability, depression, and dementia. So all of these things must be taken into account and they may be improved by addressing underlying anxiety. Anxiety disorders are hard to diagnose. Sorry, that should say diagnose, not diagnosis in older adults. Given their frequent psychiatric and physical multi-morbidity, it's complicated as is the case with all older patients with cognitive and mental health conditions. And then finally, non-pharmacologic and pharmacologic interventions are useful, although pharmacologic interventions may produce larger effects due to an added placebo response. Although again, you wanna be cautious, go slow, use standard treatments before non-standard treatments, always be considering drug-drug interactions, medical comorbidities, and side effect risk. So I have here in the slide some of the key, what I would consider key references, summaries here where I got some of the information for this presentation. And then now I am going to check out the Q&A. Thank you all for participating. So let's see here. So first question I am seeing from Melissa Scott, can you review how the results of an MMSE may illustrate cognitive impairment secondary to anxiety versus neurocognitive disorders? Well, that's a great question. And it's hard to answer because neurocognitive disorders can have differential findings on cognitive screening. And so classically with Alzheimer's dementia, we're looking for deficits in memory and deficits in executive function, which is poorly tested on the MMSE. You really need a MOCA for that. Whereas with vascular dementia, it can be more widespread deficits across attentional domains. There can be less direct impact of memory there can be executive dysfunction, but all sorts of things. And so in anxiety, the patient can also have problems on all of the different areas of the cognitive screening instrument, attentional problems, and also problems with memory because they're not paying attention. And so they're not registering the words that you're asking about because they're anxious. And so I think we have to apply our clinical judgment in trying to evaluate where the patient is anxious and that's precipitating the problem. But I, so I think it's a challenging question. I hope that helps you a little bit, but it can really be any of the domains. Have you seen much alexithymia as a barrier to diagnosing anxiety in older adults? Well, yeah, I mean, it's possible that older adults may under report their symptoms that in previous generations, they may be stoic. They could also be alexithymic, which of course as everybody knows, that means you're not in, not in touch with your feelings. You're not aware of your feelings. You can't name your feelings. You can't describe your feelings. So can they communicate whether they're anxious? And so, yeah, I think that alexithymic individuals frequently may express their anxiety or their distress as physical symptoms, chronic pain and alexithymia are highly comorbid. So a patient may be coming in expressing new physical symptoms, new pain symptoms without necessarily conveying any emotional distress even though they just had a stressor, not necessarily a change in their medical condition. That might be a clue that anxiety is there. So sometimes you have to dig deep and be paying attention to the details. I'm confused, hydroxyzine is on the 2023 beers list where it says it is anticholinergic. So yeah, I mean, I totally recommend the beers list. And the thing is, if you dig into it, like practically every psychiatric medication is on it somewhere. So, I mean, there is a bit of judgment that has to be used because we can't avoid using all psychiatric medications in older adults. So I would say that my point is that hydroxyzine as well as the SSRIs, mirtazapine, trazodone are less anticholinergic, less risky in older adults compared to medications like benzodiazepines, older antidepressants, antipsychotics, that sort of thing. But definitely use your clinical judgment. We got five more minutes and the questions are rolling in. So is it being an antihistamine a problem? Yeah, if it's sedating, medications that are sedating can increase fall risk in older adults. And so definitely wanna watch out for overly sedating medications. What do you do if you have a patient with REM sleep behavior disorder on clonazepam for control of nighttime behaviors? So that's an excellent, excellent question, Kelsey. And what I would say about that is that that's an exception, that clonazepam is an evidence-based treatment. Neurologists frequently start it for REM sleep behavior disorder. For those of you who are not familiar with that, that's when people are basically acting out their dreams. It's associated with like Parkinson's disease, Lewy body dementia. But again, it is a long-acting benzodiazepine. So we want to at least assess, evaluate the patient to see if they're having any problems with over sedation or dizziness when they get up or feeling intoxicated and communicate that to the neurologist if that's an issue for the patient. Is there any evidence that treating anxiety reduces sundowning and dementia? In that setting, would you stop an SNRI and switch to mirtazapine or buspirone or would you add to the SNRI? Okay, so multi-part question. Let me give the 30-second answer. So is there evidence that treating anxiety reduces sundowning and dementia? I would say I'm not too familiar with like clinical trial, like quantitative research evidence, if that's what you're asking. But a common clinical strategy for agitation that we use is saying, can we conceptualize that agitation as anxiety? Is the patient anxious about meal routines, mealtime changes in activities at a particular time of day? And can we address anxiety and therefore reduce the agitation? And I think that's a common strategy and an approach that we use with agitation. So would I stop an SNRI and switch to mirtazapine and buspirone? I would have to say it's a very difficult question that would probably depend on a lot of factors. I'm not a huge fan of SNRIs. I just haven't seen huge benefits with a lot of patients with duloxetine. I have seen benefits from some patients and venlafaxine potentially has that blood pressure issue. And so it may be appropriate to switch your patient to mirtazapine if there's insomnia, if the patient has agitation at night, getting up, getting dressed, going out, that's one of the things we see. So I would be cautious about making that switch, but mirtazapine can be used theoretically with an SNRI or an SSRI as well. You talk about how to change from 200 milligrams sertraline to mirtazapine, secondary to hyponatremia. So you can add mirtazapine to sertraline, that's fine as you do a cross taper. We tend to do a cross taper for virtually everything in older adults because our approach is slow and cautious. So I would go down 150, start the mirtazapine. Sometimes if you have a frail older adult, it sounds like your patient has a lot of medical problems. We might even start with 3.75 milligrams, if that's right, half of the 7.5 milligram tablet when we're initiating mirtazapine to do a very slow cross taper. And then there's some questions about products over the counter that I'm not familiar with. So I'm gonna have to defer. I would caution a lot of over-the-counter products are not particularly safe for older adults as a consequence of them being mixed with things that can increase blood pressure, things that are anti-cholinergic, other substances like that. So I believe, unfortunately, we're coming to the end. And so I would say that I would have best of luck. Alprazolam as the final point. Yeah, sometimes patients who are older are stuck on that. So you have to do a very, very slow dose titration. So I did wanna address that Alprazolam thing. Sometimes you can switch to a long acting and get them off, but it's very difficult. Okay, so thank you very much, everybody. It's been a pleasure speaking to you. I hope you enjoyed the presentation and thank you very much. ♪♪♪

anxiety disorders

older adults

geriatric psychiatry

treatment options

SSRIs

SNRIs

cognitive impairments

non-pharmacologic treatments

public health impact