Hello, my name is Dr. Brandon Yarns, and I'm a geriatric psychiatrist at UCLA and the VA in Los Angeles, and I'm joining you today to discuss anxiety disorders in late life. The presentation today will cover the following topics. I will first introduce anxiety disorders in older adults, talk about their impact, the phenomenology and epidemiology of anxiety disorders in older adults. We'll also discuss risk factors, the detection of anxiety disorders, comorbidities, assessment and differential diagnosis, treatments. I will make a few comments about anxiety in dementia, and then we will have conclusions and some Q&A. So in general, the practice of geriatric psychiatry focuses a lot of attention on late life depression and dementia, behavioral disturbances of dementia and psychiatric manifestations. And historically, the clinical and public health burden of late life anxiety has been underestimated, and anxiety disorders in older adults are perhaps under-recognized and under-treated. And maybe that is for a reason, because some epidemiologic studies show that anxiety disorders in older adults may not be as much of a problem as they are in younger adults. Yet, new studies are showing that anxiety disorders are very common in older adults. And indeed, the prevalence of past year mood disorders in older adults is estimated at around 7%, whereas past year anxiety disorders may be more like 11% in adults age 55. And in one study in Europe, they found an even higher prevalence, that it may be 17% for adults age 65 and older. So it could be that anxiety disorders are actually up to twice as common as mood disorders in older adults, or maybe more. In addition to clinically diagnosed anxiety disorders, anxiety symptoms have been found to be present in at least 17% of older men, 21% of older women, and over 40% in those with chronic medical illnesses or disability, which we will talk about more in the section on comorbidities. So anxiety symptoms in older adults are associated with lots of clinical and public health adverse impacts. And these are just some of them that are compiled from several studies going all the way back to the 1990s. And this includes reduced physical activity from anxiety, 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 care. So what exactly do we mean by anxiety symptoms or an anxiety disorder? So generally, I just like to make this clear in my presentations. We think about there being a difference between fear, which is adaptive, it is an evolutionary biological response to a perceived stressful or threatening stimulus. And it provides the appropriate motivation for action and function. It makes you feel teed up and anxious, nervous in your body, which causes you to want to move and get out of there, fight or flight. Whereas we think of anxiety as a maladaptive reaction that is a pathological response to a stressful stimulus or a perceived stressful stimulus. And it can be severe, it is enduring, and it impairs patients' function when they have anxiety symptoms or an anxiety disorder. So just how common are anxiety disorders? I mentioned a moment ago the comparison between the prevalence rates of mood disorders and anxiety disorders in older adults. And this is more detail from one of those studies I referenced, where, as you see on the bottom line, the prevalence of any anxiety disorder for past year was 11.4%. As you can see, panic disorder and social phobia are 1 to 2% past-year prevalence rates. Specific phobias is higher, about 5 to 6%. GAD is around 3%, as is PTSD. So what are some risk factors for anxiety disorders in older adults? So as is the case in younger adults, anxiety disorders in older adults are more common in women. Among older adults, there is a decreased prevalence with increasing age. So that doesn't necessarily mean that they're dramatically less common in older adults than younger adults as a whole, but there is a decreased prevalence among older adults with increasing age. So what's the reason for that? Does anxiety go away at a certain age? Or is it possible, as some have asserted, that there's an increased prevalence of anxiety disorders in certain younger cohorts of older adults? So perhaps the, I work at the VA, the Vietnam-era veterans might have a higher prevalence rate of anxiety disorders than earlier cohorts, such as our Korean War or World War II veterans. So it may be a generational thing, or it may be that anxiety disorders do decrease in prevalence at a certain age. So in addition, anxiety disorders in the elderly are chronic and continue from earlier life in most cases, possibly except for GAD, which is 50% early onset and 50% late onset in epidemiologic studies. So family and twin studies show that the heritability for panic disorder is 0.43, whereas for GAD, again, it is lower at 0.32. And non-shared family environment would explain the additional variance for panic disorder and GAD. In addition, what causes anxiety disorders in the brain? So generally we think about the cortical areas and subcortical areas, and there is largely a hypoactivation that's thought to occur in areas of the cortical areas, like the cingulate and the dorsolateral prefrontal cortex, particularly in anxiety disorder PTSD. And in addition, there's a greater volume thought to be in the orbitofrontal cortex, which is associated with anxiety, or excuse me, with symptoms of worry in GAD. Whereas there's a hyperactivation in the amygdala and insula, those subcortical areas in anxiety disorders, including PTSD, social anxiety, and specific phobia. So I've already mentioned that anxiety disorders are thought to have a lower prevalence rate in older adults, but especially in older epidemiologic data, but that's not necessarily the case in more recent data. In addition, I mentioned that anxiety disorders are often underdiagnosed, and I'm going to talk a little more about that now. So in one study, researchers performed diagnostic interviews with 141 primary care patients who were found to have a diagnosis of GAD on those diagnostic interviews. Then they looked back in the medical records for those patients, and they found that primary care physicians had made a correct diagnosis of GAD in only 1.5% of the patients. So a diagnosis of any anxiety disorder, usually anxiety NOS, was made in 9% of the patients, and 34% of the charts mentioned anxiety with no diagnosis of an anxiety disorder. So that is out of 141 patients who had a diagnosis of GAD on a diagnostic interview. So it was in these older adult patients, very, very little was diagnosed. So why are anxiety disorders in older adults so difficult to detect? Well there are several thoughts on that. The first idea is that the current diagnostic criteria to diagnose anxiety disorders were developed among younger individuals, leading to a lower sensitivity in detecting anxiety disorders in older adults. So in that study I mentioned where primary care physicians correctly identified GAD in only 1.5% of older patients, there was another study in which primary care physicians made the correct diagnosis of GAD over a third of the time in younger patients. So that's not a fantastic record, but it was many times greater than making the correct diagnosis of GAD in older patients. In addition to perhaps the diagnostic criteria not being sensitive in older adults, older adults also have substantial comorbidities that may make the diagnosis of an anxiety disorder more difficult. So as in younger adults, there's often psychiatric comorbidity leading to diagnostic complexity in older adults with anxiety disorders, including comorbid depression, substance use disorders, personality disorders, and cognitive disorders. Like younger adults, older adults may also have many more physical symptoms that are associated with anxiety that overlap with their medical disorders that they have. So older adults can have a whole range of medical problems that may not be present in younger adults, and anxiety is highly associated with physical symptoms itself. So that can add to diagnostic complexity specifically in older adults. Now I'm going to talk a little bit more about some of the comorbidities. So the co-occurrence of anxiety disorders with depression, as in younger adults, anxiety and depression are highly comorbid in older adults. And in fact, there was this interesting study, it's a few years old now, but it was a three-year longitudinal study that looked at GAD and depression in older adults, and they found that GAD often preceded the onset of depression or a mixed GAD depression condition. And the authors argued that the two may be on a continuum. So there could be a late-life GAD preceding a late-life depression, which as you may be aware from our depression talk as part of this series, that late-life depression could be a risk factor for dementia. However, they found that GAD and the mixed condition were more associated with long-standing vulnerability, so unsure what that means. Because depression was associated with illness, loss, and recent functional impairment. But the bottom line is there may be a relationship with GAD and depression beyond them just being co-occurring, but there may be some etiologic mechanistic relationship where GAD may precede depression in older adults. One more mention of the study about diagnosis of GAD in primary care, 23% of the GAD patients had a chart diagnosis of depression from their primary care physician, even though they did not have a depressive disorder on the diagnostic interview, the SCID. So that's interesting. Part of the diagnostic problem with GAD and anxiety disorders in older adults may be that the word hasn't gotten out among primary care physicians as much as it has for depression, say, where we have a lot of screening tools that have been introduced in primary care practices. However, in that study, an anxiety disorder was diagnosed more often when the patient had a comorbid depressive disorder, 4.5% versus 4.3%. So do they sometimes misdiagnose anxiety and they call it depression instead, or can depression help increase the detection of anxiety as well? In addition, I'll make brief mention of the co-occurrence with alcohol. In a couple of studies, older patients with GAD showed that 42% had had a drink in the past week, 9% had at-risk drinking, which was 8 to 14 drinks per week, and 5% had heavy drinking of greater than 14 drinks per week. So one hypothesis here may be that if the GAD is not diagnosed, then it could be patients are self-medicating with alcohol. And also the other bullet point here is that it should be noted that 25% of older adults with comorbid anxiety and alcohol use disorder also had a personality disorder in another study. So there is a triple comorbidity to be on the lookout for. So I mentioned earlier that anxiety has physical symptoms as a component of anxiety disorders. And older adults also have a lot of medical conditions leading to physical symptoms. So in one study, they found that anxiety in older adults is associated with a range of physical medical illnesses, including allergies, pain conditions, cataracts, gastrointestinal disease, lung disease, and heart disease. But as mentioned, physical symptoms are part of anxiety. Even in the DSM-5 criteria for GAD, the patient has to have certain physical symptoms to meet criteria, including restlessness, being keyed up, easily fatigued, muscle tension problems, sleeping and difficulty concentrating, or the mind going blank. And everybody knows that physical symptoms are a major part of panic attacks. In the criteria for panic disorder, patients can experience palpitations, sweating, trembling, shaking, shortness of breath, choking, chest pain, discomfort, nausea, abdominal distress, dizziness, chills, and paresthesias that are a component of their anxiety disorder. So I would finally add that part of the problem with diagnosis may be that symptoms of anxiety in older adults are attributed to medical disorders, medical comorbidities that the older adults have. And so you have to be on the lookout to make sure that anxiety is not missed because it happens to be presenting with physical symptoms in older adults. We don't want to undertreat anxiety, which can exacerbate potentially their physical condition as well as their mental health. I will also mention the effects of anxiety on cognition. So in studies of older adults, anxiety results in impairments in working memory, short-term memory, attention, and problem-solving abilities. So anxiety can greatly impair performance on cognitive screening instruments often used in clinics, such as the MMSC and the MOCA. So I have several patients in our clinic here who came into the clinic for their first visit and showed an impaired score on the MOCA, but were highly anxious. And over time, their MOCA score actually improved into the normal range. So part of the assessment, which I'll get to in a moment, is going to be longitudinal screening and making sure to screen for anxiety for proper interpretation of cognitive screening results. So what about anxiety and cognitive disorders? So this slide shows four studies, which I think are representative of a possible relationship between anxiety and cognitive disorders. In the first study, Palmer 2007, they took patients with MCI and followed them for three years, and some of the patients had anxiety and others did not. And they found among those with anxiety as well as MCI, there was a much higher rate of transition to dementia in the follow-up period. In the second study, they followed clinically intact, or excuse me, cognitively unimpaired older adults for three years, and they evaluated self-reported neuroticism, which was kind of their proxy for anxiety. And the risk of Alzheimer's disease was higher over the follow-up with higher levels of anxiety and vulnerability to stress. In the third study, Potvin 2011, they looked at the one-year incidence of cognitive impairment in men and women, and they found an interesting result which showed that the odds of cognitive impairment in patients with baseline anxiety differed by sex. So it was a dramatically increased odds of cognitive impairment in men, but still about double the risk of cognitive impairment in women with anxiety. And in the final study, which was a 17-year longitudinal prospective study with nearly 1,500 patients, they found that when patients had a higher score on the Spielberger State Anxiety Inventory, the odds ratio for cognitive impairment, not dementia, was increased more than double, and the odds ratio for dementia was increased even more than that. So the bottom line is that anxiety may actually be a risk factor for the development of cognitive impairment or a cognitive disorder in your patients. So finally, I will mention that there have been a couple of studies looking at the risk of mortality in patients with anxiety disorders, and one study found that there was a slightly increased risk of mortality of death in men with anxiety disorders over a follow-up period, but another study showed that there was no increased risk in GAD of mortality, but there was an increased risk with depression in men with a 10-year follow-up. So mortality risk is plus-minus there need to be more studies on this issue. So I've referenced assessment of anxiety disorders a couple of times already. Of course, it's important to gather a comprehensive history, and in older adults, you have probably heard in other presentations from this Updates in Geriatric Psychiatry series, it's important to get collateral information, especially if there's cognitive impairment that the older adult patient is suffering, a thorough mental status examination, and a formal cognitive screening instrument such as the MMSC, although it's not very sensitive for mild cognitive impairments, the MOCA test, although you now have to complete an online training to use that, or something we use at the VA called the SLUMS is another option for you, and repeated assessments are often important. We also recommend a physical neurologic examination and laboratory testing for certain medical disorders that I'll get to in a moment. And then there are a number of options for self-report assessments of anxiety in older adults. You can use the GAD-2 or 7, the Beck Anxiety Inventory, and there are two scales that have been developed for older adults that I'll mention, the Geriatric Anxiety Scale and the Geriatric Anxiety Inventory. They're both a little longer at 30 items and 20 items respectively. So in terms of differential diagnosis, when you are considering a possible anxiety disorder in the older adult that you're evaluating, I'll mention the number one rule of geriatric psychiatry, which is to rule out medical and medication causes first. Now I mentioned the caveat that we don't want to miss an anxiety disorder by an inappropriate attribution of some new onset symptoms to a medical cause, but it is important to look for medical conditions. And I'll just also mention the number two rule of geriatric psychiatry, which is to consider dementia, that it's actually resulting from cognitive decline due to dementia and the symptoms, the new psychiatric symptoms are part of that dementia illness. So as far as differential diagnosis, a primary anxiety disorder is usually chronic, unrelenting, often as I mentioned, starting earlier in life. Number two, anxiety due to depression is another possibility, but it's associated with depressed mood, anhedonia, hopelessness, perhaps suicidal thoughts, and it's recurrent and severe. Anxiety due to dementia is a later onset perhaps, and that marked cognitive decline and functional impairment should be a component of it. Anxiety due to another medical condition is usually with an acute onset and will resolve with the treatment of the underlying condition. And things to be suspecting are hyperthyroidism or hyperparathyroidism, hypoxia or ischemia with a patient with COPD, hypoglycemia, alcohol withdrawal, cardiac arrhythmias, a rarer one I've mentioned is pheochromocytoma or other causes of delirium. And anxiety finally due to substances or medications or withdrawal from certain substances or medications, and those can include some pathomimetics, amphetamines, anticholinergics, antidepressants, vasopressors, antipsychotics, and caffeine-containing medications. I have had patients in my clinic that drink an enormous amount of coffee and have substantial anxiety, so that's something important to evaluate in your older patient with anxiety. Now we're going to shift gears to talk about treatment. So the headline is that evidence exists to support both pharmacologic and non-pharmacologic treatment of anxiety disorders in older adults. And I will review that in detail, but I will note also that there are far fewer clinical trials in older adults compared to younger adults and more research is necessary. So what do we do? Do we treat with non-pharmacologic treatments or pharmacologic treatments? So I'm going to talk a little bit here in detail about effect sizes and such things comparing non-pharmacologic and pharmacologic treatments. So there was a large meta-analysis comparing pharmacologic and non-pharmacologic treatments and anxiety disorders and they found that uncontrolled effect sizes were much larger for pharmacologic than non-pharmacologic treatments. For pharmacologic treatments, the Cohen's d was about 1.76, which is huge, and for non-pharmacologic treatments it was about 0.86, which is also a large effect size, but much smaller. But they found that the control group effect sizes were larger in pill placebo controlled trials of medications. So when they had a placebo that the patient was receiving, the effect size was about 1.06, whereas non-pharmacologic controls were about 0.1. So the point of this is to say that with pharmacologic treatment of anxiety disorders, there's a very large placebo effect that may account for some of the response. So when they adjusted the effect sizes for the non-specific effects of the control group, they found that pharmacologic and non-pharmacologic treatments of anxiety disorders were approximately equivalent with large effect sizes. So, of course, this is a research thing. When you're treating patients in clinical practice, you want all of the effect size you can get, non-specific placebo effects to try to get the patient better. But this is just food for thought for you. This is a diagram that I present in a lot of my talks where we look at different control groups that have different effects. So it looks like your intervention effect is much different in studies with different control groups. So that's, again, a research point. But I thought an important one just for you to keep in mind as you're selecting treatments for your patients. So there was a study comparing non-pharmacologic and a pharmacologic treatment that I'll highlight that really reinforces this point. It compared CBT and sertraline for older adults with anxiety disorders. There was, first of all, a high dropout rate of the study. The response rates were slightly higher for sertraline, and the effect size was much larger for sertraline. So for CBT, at post-treatment, the effect size was small to moderate, and at follow-up, for sertraline, it was a large effect size at post-treatment and follow-up. So if you do have a patient, however, that is not interested in taking a medication, there are a number of non-pharmacologic interventions that have been evaluated in older adults. Including relaxation training, meditation, CBT, worry discussion groups, supportive counseling, a modular psychotherapy, enhanced community treatment, and exercise training. In addition, there have been three meta-analyses of non-pharmacologic interventions for older adults with anxiety disorders. In this first one in 2003, there were 20 separate treatment interventions. So they included a wide range of different non-pharmacologic things, such as the ones I mentioned on the previous slide. Nearly 500 patients. The mean age was 55, so not a very old group, but really more of a middle-aged group. And the post-treatment effect size was moderate. So there is an effect, as I mentioned, if your patient doesn't want to take a medication. In the second meta-analysis in 2009, they did a head-to-head comparison of relaxation training and CBT. In 19 studies, there was very high heterogeneity. So they looked at just the controlled studies, which were 10 studies. And they found some interesting results here in these older studies, but the controlled ones. That CBT really had an effect size of zero. And when they combined relaxation training and CBT, it had a small effect size. But relaxation training alone had a large effect size in this meta-analysis. So it's very interesting that relaxation training seems to outperform CBT. And this was specifically for older adults with anxiety disorders. And in the third meta-analysis, they evaluated 14 randomized clinical trials of CBT for GAD in nearly 1,000 patients. And CBT outperformed waitlist and treatment as usual, and had a small, non-significant advantage over active controls, which included other psychotherapy or escitalopram. But it really, again, went down to a close to zero effect size during a follow-up period. So a couple more studies to mention that compared CBT to other non-pharmacologic interventions. In this top study, it was for mixed anxiety disorders. And they just compared CBT to supportive counseling, which was intended to be a control intervention. And they found that they were essentially equivalent except for one scale at post-treatment and at follow-up, but not for any other measure. And in 2003, they looked at CBT in a group of older adults that the mean age was 67.1 years old. And they found that CBT was equivalent to a discussion group in older adults. And then there were some pilot studies involving an enhanced CBT for older adults with anxiety disorders, since it didn't look like CBT, as usually performed, was doing a very good job. And this included memory and learning aids, such as a greater emphasis on psychoeducation, a slower pace, repeated explanations of things, requirements for completing homework that was required. And they reminded patients to do their homework and photocopied homework and returned it to the participants. And they found that it was perhaps more promising. But I will say that the evidence seems to indicate that CBT has a good small to medium effect size compared to no intervention. But it's really not any better than any other non-pharmacologic treatment. And most likely, something like relaxation training could be of greater benefit to older adults with anxiety disorders. But definitely more studies are needed in this realm. Because in my experience, there are older adults who are taking lots of medications and they're not really interested in another pharmacologic option. And so we really need to find out what's the best practice in terms of non-pharmacologic treatments for older adults with anxiety disorders. So now let us turn to pharmacologic interventions. There have been randomized placebo-controlled trials in older adults with anxiety disorders for the following medications. For antidepressants, there are older studies looking at TCAs, imipramine and nortriptyline. SSRIs, citalopram and escitalopram, SNRIs, venlafaxine, XR, and duloxetine. There have been studies of anxiolytics, including benzodiazepines, buspirone, and two medications not available in the U.S. And in addition, there is a randomized placebo-controlled trial of carbamazepine. All of these studies were positive, indicating that these were potentially promising for older adults with anxiety disorders. So these may be the treatments that you want to reach for first because of the randomized clinical trials. But I will make some more specific comments and recommendations in a couple minutes. So there were a couple of other studies that were clinical trials, but not necessarily a placebo-controlled design. So the sertraline versus CBT study that I already mentioned, in which sertraline performed better. There was a comparison study of sertraline versus buspirone, which found that the ultimate effects were equivalent. But the buspirone worked more quickly for older adults with anxiety disorders. And there was also a clinical trial comparing paroxetine and CBT for panic disorder that found them to be equivalent. Keep in mind, this is for panic disorder, whereas most of the trials showing little effect for CBT were in GAD. But I'll also mention paroxetine has potentially some side effects like a greater anticholinergic burden than other antidepressants and a risk of med-med interactions that we typically avoid that in our current practice with older adults. We tend to reach for other SSRIs first. And then I'll mention there are additional uncontrolled trials pointing to efficacy for nifazodone and risperidone and fluvoxamine. So now I will just mention some of my clinical wisdom from my experience with pharmacologic interventions for treating anxiety disorders in older adults. So, as with all medications, in older adults, you want to start low and go slow. So that is due to changing physiology in older adults, such as a decreased volume of distribution, a greater side effect risk, greater risk from polypharmacy because they're often on more medications than younger patients, the greater risk from medical comorbidity, and a greater sensitivity to anticholinergic effects, which I just mentioned as well. However, when treating anxiety disorders, I will note that it's usually the case that the therapeutic doses that you would use in younger adults are usually necessary to generate the clinical benefit that is desired in older adults. So we say start low and go slow in older adults, but do go. And that is in contradistinction to medications like antipsychotics, where we tend to want to use the lowest effective dose, especially in older adults where there may be increased risk from those medications. But for your SSRIs and antidepressants to treat anxiety disorders, for those medications in those disorders, you usually need therapeutic doses. You just want to go slowly to monitor for side effects. In addition, I would recommend SSRIs and SNRIs being first line, particularly venlafaxine in terms of SNRIs. Duloxetine also potentially could have some minor anticholinergic side effects. I will note that citalopram, escitalopram, and sertraline interact with other medications the least out of the SSRIs, so we tend to reach for those options sooner. But do caution the black box warning with citalopram doses greater than 20 milligrams in older adults. None of your patients older than 65 should be on a large dose of citalopram anymore because of the risk of QTC prolongation. In addition, I will mention some options that we use in clinic rather frequently that unfortunately have not been studied in clinical trials, but seem to be effective for older adults with anxiety disorders. Mirtazapine helps with anxiety and also benefits patients with difficulties in their appetite and with insomnia. Gabapentin is also a relatively safe option that we use in older adults occasionally for anxiety or for insomnia in the evening. You do tend to want to start in older adults with anxiety with a lower dose, like about 100 milligrams, not with the big 300 milligram TID dose that they might start in younger patients for neuropathic pain. Trazodone we occasionally use for insomnia in older adults. It's a great choice, and sometimes even a small dose, 12.5 to 25 milligrams, in the daytime for anxiety. And particularly, this really micro dosing can be used for patients with dementia who have anxiety symptoms. And finally, I'll mention that hydroxazine is actually not anticholinergic. I think many people believe that it is, but it is actually a safe option to use in older adults for anxiety. But once again, I recommend as first line SSRIs. So I list here under my clinical wisdom, don't benzodiazepines. Like, don't do it. There has been some suggestion of short-term efficacy. As mentioned, there have been some benzodiazepines in randomized clinical trials for older adults with anxiety disorders. But they are potentially inappropriate for older adults, per the BEERS criteria. And there is a little bit newer data you may have heard of in the past few years showing that they can exacerbate cognitive impairment and may even increase the risk of developing dementia, independent of the risk we discussed earlier from untreated anxiety. Additionally, under my don'ts are TCAs and MAOIs. They are potentially inappropriate because of anticholinergic effects and orthostatic hypotension. And of course, the drug-drug interactions and dietary restrictions with MAOIs. So a moment ago, I mentioned antipsychotics. And recently, quetiapine and olanzapine have shown promise for anxiety in younger adults. And there is one uncontrolled trial of risperidone in older adults with anxiety. But we do advise against reaching for antipsychotics for older adults with anxiety due to their side effect risk. In addition, they do have a black box warning of increased risk of stroke and death for older adults with dementia. So we definitely don't recommend using antipsychotics for anxiety symptoms that occur in the context of dementia in older adults. Therefore, the bottom line on pharmacologic treatment of anxiety disorders in older adults is that more clinical trials are needed. And I would suggest that some of the options I mentioned, which we really do use routinely, such as mirtazapine, really should be studied in clinical trials because it's only clinical wisdom and experience that shows that they are effective in older adults. However, I will also add that more important than the specific agent used is the importance of the accompanying clinical care in older adults. We do recommend a close follow up, particularly with your older patients, because you have to watch for the effects of comorbidities and potential side effects. So we recommend possibly as frequently as weekly, early in the course of treatment. Once it seems that the older adult can tolerate the medication, then you can advance the dose and result in possibly even the typical dose that you would use in younger adults. And we recommend a comprehensive management. Consider combining pharmacologic treatment with the non-pharmacologic options that I mentioned earlier to optimize the effects of treatment. Before we conclude, I'll just make a couple more comments about anxiety in the context of dementia. There is thought to be an increased risk of anxiety developing in dementia, particularly when there's executive dysfunction that results in an inability to resolve situations that can be anxiety provoking. Another thing that may precipitate anxiety is a loss of functional status when the patient starts having difficulty, and especially if there's insight into the development of those difficulties, it can be very anxiety provoking about what's next. And symptoms of anxiety often present within dementia, as is the case with other psychiatric symptoms, as neurobehavioral metaphors of various psychiatric disorders, and therefore, you want to try to figure out what syndrome, what DSM disorder does the patient's symptoms look like, and then treat it according to similar guidelines and the way that you would treat the disorder without the dementia. So, I will also remind you, within dementia, you also want to rule out and treat underlying medical illnesses or delirium, and consider any environmental causes and see if there's a possibility of addressing environmental causes first that are anxiety provoking, rather than reaching for pharmacologic intervention first when you have dementia. So, I would say treating anxiety and dementia, the first line is non-pharmacologic behavioral interventions. If there's something that can be done to figure out what's causing the patient to be anxious, and if that underlying issue can be resolved, then you can avoid polypharmacy and all of the difficulties that come with medications. There really are not clinical trials of anxiety, of medications that result, or medications for treating anxiety in dementia, but some options to consider is that you can use antidepressants or mood stabilizers. Antipsychotics and benzodiazepines, as in older adults without dementia, are only to be used with the utmost caution, and we prefer that you avoid those. And then I'll also mention that cholinesterase inhibitors and memantine may reduce anxiety by addressing the underlying cognitive dysfunction. So, that's something to evaluate your patients to see if they would possibly be eligible for cholinesterase inhibitor or memantine as well, and that may address the anxiety. So, I will now make some concluding comments. First, I want to emphasize again that anxiety disorders are more common in older adults than previously thought. Older epidemiologic data, for whatever reason, showed that anxiety disorders are not common in older adults, but more recent studies show that they really are common. They are the most common psychiatric disorders in older adults and are associated with physical illnesses, disability, and depression. So, really, we hope that you'll be able to identify anxiety in your older adults and provide effective treatment to prevent that kind of limitations and quality of life impairments that come from anxiety disorders. So, I will say about treatment that non-pharmacologic and pharmacologic interventions appear useful. Although pharmacologic interventions may produce larger effects due to an added placebo response, so it may be the case that you want to offer medication, but we also understand that some patients may not want to add an additional medication and some non-pharmacologic interventions are effective. But future research in late-life anxiety should include prospective trials of medications and additional trials of non-pharmacologic options, because so many medications are in use and, really, anxiety disorders and their treatment in older adults are very much understudied. So, I will now conclude this presentation by presenting you with some questions and answers. I will read off the questions and the answer choices and give you a moment to think before I reveal the answer. So, number one, which of the following is most common among older adults? A, anxiety disorders, B, mood disorders, C, psychotic disorders, or D, stimulant use disorder? And the answer is anxiety disorders. I hope you got that one. I think I emphasized that quite a bit in the talk. Number two, which of the following is most likely to be new onset in older adults? A, GAD, B, panic disorder, C, PTSD, or D, specific phobia? The answer is GAD. Number three, anxiety disorders in older adults may be missed because of comorbidity with? A, cognitive symptoms, B, physical symptoms, C, substance use disorders, or D, all of the above? And the answer is D, all of the above. There can be cognitive symptoms that the patient may have which are hard to tease apart from the cognitive symptoms, the impairments in working memory, short-term memory, attention that can result from anxiety disorders. Physical symptoms, I mentioned older adults with frequent medical illnesses, their anxiety may be mistaken for some sort of physical cause and may thus be ignored. And substance use disorders and withdrawal may also produce anxiety. Number four, which dose of citalopram should not be exceeded in patients age 65 years and older due to the elevated risk of QTC prolongation and to SOD deployment? A, 5 milligrams, B, 10 milligrams, C, 20 milligrams, or D, 40 milligrams? The answer is 20 milligrams.

anxiety disorders

older adults

prevalence

underdiagnosed

comorbid conditions

pharmacologic interventions

non-pharmacologic interventions

cognitive behavioral therapy

research