Clinical practice guidelines for geriatric anxiety disorders

INTRODUCTION Anxiety is one of the most common symptoms seen in the elderly. Sub-syndromal anxiety is more prevalent than depression and cognitive disorders. The commonest anxiety disorder seen in the clinical practice is Generalised Anxiety Disorder(GAD)(7.3%) followed by phobias(3.1%), the panic disorder(1%) and Obsessive Compulsive Disorder(OCD)(0.6%). Two relatively recent Indian studies have demonstrated an overall prevalence of anxiety disorders to be10.8% and 10.7%, respectively. Thus anxiety is quite common in the elder, among all the disorders of the geriatric population. These clinical practice guidelines intend to provide the practicing psychiatrists a ready reckoner to identify anxiety disorders, assess them, treat and manage side-effects of medications among elder individuals. The classificatory systems (Table 1) now have a difference as far as anxiety disorders are concerned, with DSM 5 introducing changes in the classification of anxiety disorders.Table 1: Classificatory Systems for Anxiety DisordersOn the basis of their distinct clinical features anxiety disorders can be divided into three categories. Worry/distress disorders- GAD, PTSD, Acute stress disorder Fear disorders- Panic disorder, phobia OCD Since we are used to evaluating younger individuals, the usual symptoms we expect might not be seen in the elder. Commonly seen differences between the young and the old in the presentation of anxiety are shown in Table-2.Table 2: Differences in clinical presentation of anxiety disorders among young and elderly patientsAssessment A comprehensive assessment of anxiety disorders includes interviewing the older adult and her/his caregiver. There is a tendency to underplay or normalize certain behaviours, which may be indicative of anxiety for e.g., avoidance to go out of the house or fear of falls. It is thus important to assess not only the severity of these symptoms; but also impairment in functioning because of the symptoms. This can be achieved by interviewing the patient and the caregiver, keeping the following in mind: Fears and concerns as a part of normal aging e. g. Limited mobility in an elderly leading to avoidance of going out of the house Anxiety associated with dementia Medical disorders which may mimic anxiety symptoms. Co-morbidities like cardiac illness, depression, malignancy, Parkinson's disease, auto-immune disorders, collagen vascular diseases, endocrine disorders etc. Clinical presentation in young adults and elderly differs. For e.g., in elderly phobia is experienced as a fear of situations or inanimate stimuli, such as lightening whereas among young people phobia is usually of animals. The ‘worried well’ Worry as a symptom in older adults, independent of a diagnosable disorder. The hallmark of any complete assessment starts with a detailed history. History: The following points (Table 3) need to be kept in mind while detailing a history of elder anxiety, to give a clearer picture. The basic history forms a base or a skeleton on which we have to build the further points which will lead us systematically towards a diagnosis. Elder individuals are considered to be a vulnerable population, and it is this vulnerability which makes them at risk to develop anxiety.Table 3: Pertinent issues in history while evaluating for Elder anxietyMultiple risk factors have been identified, which are known to be associated and specific anxiety disorders (Table-4).Table 4: Risk factors for various anxiety disorders in the elderlyA comprehensive history and assessment of risk factors will be the most important ingredients towards making a diagnosis of the specific anxiety disorder that will emerge as a diagnosis. While narrowing down on the same, the specific characteristics that one can look for, in elder individuals, when one looks for the symptoms of various disorders, are highlighted below (Table 5). The disorders appear from common to uncommon, as seen from various population studies.Table 5: Specific presentations of various anxiety disorders in the elderlyAny psychiatric history cannot be complete without the inclusion of negative history too. Anxiety is such a pervasive symptom, that it not only is seen in specific anxiety disorders, but can be seen in other psychiatric disorders, as well as many medical disorders (Table 6). An astute clinician will keep an eye out for the same, and eliminate that whilst taking the history.Table 6: Medical conditions in the elderly which can be mistaken for anxietyIt is not only medical disorders that one must rule out. Usually elder individuals are already on medications for medical co-morbidities, commonest being diabetes or hypertension. They may or may not be on analgesics too. There are some drugs and substances however, that are peculiar in contributing to anxiety. A red flag on any of these would point toward non-idiopathic anxiety, and prompt the treating psychiatrist to first alter the existing prescription, before staring yet another molecule and adding to the prescription load. It becomes important to liaison with the treating physician/specialist to reduce/replace the suspected offending agent with another acceptable molecule As one can see, the history, along with medical and drug history, can be quite exhaustive in the elderly, but to get a comprehensive account, it is very much worthwhile investing time into that. Investigations Elder individuals are prone to changes in metabolic parameters and nutritional deficiencies, by virtue of a variety of reasons which include decreased appetite, increased frailty and drug-drug interactions. As a baseline, it is advisable to rule out metabolic abnormalities (Table 7) such as:Table 7: Investigations which may be done in a case of Elder AnxietyOnce the basic medical work-up and evaluation is done, then a scale may be used to measure or quantify the anxiety, which would also aid as a prognostic indicator. Various anxiety rating scales (Table 8) have been used in elderly to substantiate the diagnosis and to assess severity of the disorder. These scales also assist in diagnosing anxiety symptoms not amounting to a disorder. This is particularly helpful as anxiety in elderly is under-diagnosed.Table 8: Rating Scales for Geriatric AnxietyThe choice of the scale would largely depend on the time and purpose that it is being used for. The Geriatric Anxiety Inventory has become the gold standard for assessment in elder anxiety. At the end of the above exercise, one would be sufficiently equipped with a preliminary diagnosis or differential diagnosis at the back of the mind. Whilst we come to a definite diagnosis, the following differentials must be ruled out as these commonly will be the underlying cause of the anxiety, and our treatment may then show only a partial response. Differential Diagnosis of Anxiety in Elder individuals(in order of likelihood) Side Effects of Medication use, including self medication Drug and alcohol use Medical comorbidities Other Psychiatric disorders(including cognitive disorders) Trimming a prescription or changing medication might be a challenge initially, the tricky aspects at times are when one funnels down to a psychiatric diagnosis. Here, there are two pertinent issues which often crop up while assessing the elder individual for anxiety. These are: Distinguishing anxiety and depression in the elder (Table 9) Table 9: Comparative Symptom Overview for Normal Ageing versus Anxiety versus Depression in the ElderThis simple overview is very helpful in distinguishing the above Distinguishing anxiety from cognition(Table 10) Table 10: Comparative Symptom Overview for Late Life Anxiety versus DementiaAnxiety has reported high prevalence rates among people with dementia. It has a negative impact on cognitive impairment and is associated with agitation and poor quality of life. The presence of excessive anxiety can be difficult to establish in people with dementia, especially when expressive or receptive speech is impaired. Unfortunately, there is a lack of research on the treatment of anxiety in dementia, and also on the wider issue of the management of anxiety disorders in old age. Behavioural and psychological symptoms of dementia are not limited to the later stages of the disease. The following comparative chart helps with clinical differentiation of the two. Once one has been able to differentiate between normal ageing, anxiety, depression and a cognitive disorder or dementia, and come to a definitive diagnosis of anxiety - one can then proceed on deciding how to manage the patient. Choice of treatment setting Most of the anxiety disorders can be treated in outpatien setting. Inpatient management of anxiety disorders is indicated when Comorbid severe depression(and at times suicidality) is present. Anxiety disorder is severe and treatment resistant. e.g. OCD. In case of poor social support and presence of chronic stressor separation from the stressful situation is needed. Concurrent medical illnesses and treatment need evaluation and management. Non-Pharmacological treatments Treatment of geriatric anxiety actually involves more of non-pharmacological approaches which are first recommended rather than pharmacological approaches. The usual non-pharmacological measures advised are: Lifestyle modification: Sleep, diet, exercise, socialisation –all in moderation. Eliminate medical and non-medical triggers Structured daily activities are one of the mainstays of elder care. The premise behind the same being, that activities provide some stimulation and interaction with the environment, give a sense of control and reduce overall anxiety. Apart from managing one's own daily routine, the following are commonly advocated. Physical Exercise: Regular physical exercise, even for just a few minutes daily, improves cerebral blood flow and metabolism. Sedentary individuals who are bound to their beds have a distinct reduction in cerebral blood flow. Exercise need not be strenuous in the form of aerobic exercises or gym based exercises. A simple walk in the garden or outdoors should suffice, that too at the pace of the individual concerned. If wheelchair bound, then upper body can be exercised with simple stretches, use of a ball and hand exercises. Other forms of physical exercise could include - Walking in the house if too frail - Swimming or aqua exercises or playing around in a large tub to mobilize the limbs - Physical games like playing ball, carrom, table tennis etc Sleep: We are aware that the sleep architecture gets altered with advancing age, hence a shorter night time sleep, phase advancement and more fragmented sleep are all seen in the elder. Hence while teaching about sleep hygiene, it is also important to counsel the elder individual about lowering their expectations about sleep duration. Nutrition: By virtue of decreasing appetite and increasing social isolation, elderly often have compromised nutrition and imbalanced electrolytes. Minor changes in blood levels of sodium, potassium, chloride, vitamin D etc. could give rise to anxiety symptoms. Monitoring through a simple nutrition chart, helps maintain basic parameters, and at times is the only intervention required to manage the anxiety. Behaviour Therapy: Relaxation Therapy: Classical Jacobson's technique of progressive muscle relaxation can be taught to the individual with anxiety. This can also be coupled with guided imagery, or practiced alone. Systemic desensitization : This works particularly for phobias and unspecified fears for eg. fear of falling. Creating a hierarchy and controlling the response helps. Exposure and Response Prevention: For OCD Eye Movement Desensitisation and Reprocessing (EMDR): For PTSD. Cognitive Therapy: Cognitive Behaviour Therapy : The aim of CBT in older adults is to target cognitive symptoms, physical symptoms as well as behavioural symptoms. First and foremost psycho-education is a must –about the anxiety in general and management of the same. Acceptance that the symptoms may not be suggestive of a medical emergency, at the same time being vigilant of associated co-morbidities, becomes a tricky issue to deal with and require a lot of awareness and self-monitoring. The principles of relaxation and hierarchal construction may also be used. The core of CBT, however, remains cognitive restructuring using the ABC model(antecedents-behaviour-consequences), wherein cognitive errors and maladaptive behaviour are identified and worked upon. The pace may have to be a little slow, as with age new learning takes time, and the template of old learned behaviours is hard to change. Mindfulness: Mindfulness as a therapeutic intervention is finding applicability in a wide range of disorders. Mindfulness is inculcating the ability to focus on ‘the now’. It involves focussing initially on individual senses for eg. taste, smell, vision, hearing etc. and then graduating to focussing on one's emotions, reactions, responses etc. The aim is to harmonise the difference between the mind and body. Mindfulness is particularly important in the elderly, where there are so many transitions taking place not only in the body, but also in the mind, social interactions and roles within the family as well as outside. All of these can contribute to and worsen anxiety. Mindfulness then becomes a very effective tool, under these circumstances. Miscellaneous- Yoga : Based on the medical condition of the individual, various asanas can be taught. Yoga an also be done sitting on a chair, and not on the floor. More importantly relaxation, stretches and pranayamas can be taught to senior citizens. There is mounting evidence of control of elder anxiety with Yoga. Art Therapy: Free art in the form of drawing, sketching or colouring as well as structured art in the form of following instructions, are both recommended. Art therapy can be planned as an individual or group activity. Art is said to be soothing and stimulates relaxation, which is paradoxical to anxiety. Dance therapy: Dance as a structured art form, or free dance to music of one's choice both are advocated. Even for wheel chair bound and individuals confined to bed, movement of the upper body can help with some stimulation. Music Therapy: Music as a form of environment modification has already been discussed. Music can also be used as an activity—either singing or playing an instrument. This can be done as individual therapy or in a group, though there is more evidence for group therapy. Cognitive Rehabilitation: As much as the body needs physical exercises, the mind too needs to exercise itself. In our daily routine we do not even realize how much we use the brain for planning, sequencing and executing tasks. Cognitive training involves activities like sorting by colour, shape, sequence etc. It also involves memory games wherein memorizing by loci, chunking, pneumonics, visual imagery, su doku etc. Social Activities or Networking : Interacting with others not only is an important stimulus, but it also improves synaptic connections between the neurons in the brain. Social activity can be within a small locus, or could be extended to external activities like meeting in a senior citizen's group, laughter clubs, book clubs, ‘satsangs’ etc. Alternative Therapies: Complementary and alternative therapies like touch therapy, reflexology, massage, reiki etc have been tried with not very robust evidence. There are more of anecdotal reports of the same. While it is important to try out any of the above approaches, one must not forget to keep in mind the caregivers dealing with a patient of elder anxiety. Educating them about the illness, expectations, response etc. are equally important in the measure of overall response. Apart from information related to the illness per se, it is vital that they learn the art of communication, which can reduce the anxiety in the elder individual. A few do's and don'ts in this regard are: Do's Talk in a neutral tone Use very simple words and sentences. And speak slowly. If instructing, please give one instruction at a time If asking for something, please give maximally two choices at a time Don'ts Use a harsh tone or Use negative words or a and caregiver, is the A at can even learn most of the therapies by and if a of the above non-pharmacological not or the anxiety is too then pharmacological treatment can be but is for as a as management the of first the various disorders. of response to with an and then the of the drugs should be to use, and to that they may lead to in the Treatment a pharmacological it is to the go and usually of the adult the following (Table are for commonly used is advisable to treatment for for OCD and PTSD, before a response is The above can be with but with use of both as well as should be limited to in the are associated with increased risk of and in the elderly. in are quite to which have in them, to There use can also cause paradoxical Hence as far as we should using them, but when required use in very and them There are certain for in the elderly alcohol and in very severe anxiety. it is to with and there be response with the first of then the can be tried as to the drug of another or The of the same are under specific anxiety disorders. Other of treatment of treatment have been tried in a few studies of anxiety disorders in adult but studies in elderly have not been has been shown to be in geriatric depression and it has been in these that anxiety symptoms also research is in this to establish these treatment in anxiety disorders. Side As the elder are more to of most it is important for us to of the common (Table of the commonly so we can keep a on the same. The overview below as a Side of medication seen in are two commonly which are often difficult to deal with and These are: is as a of below and is considered to be severe if it is below Usually below would lead to and and the elderly to be more prone to even small changes in be leading to depression and even may be or or to In chronic there are increased of to two and to impairment activity and decreased leading to and frail which to falls. Hence it is important that is at the In order to one should the is to disease, may be of drug : to In order to the in to the the along with and will give a In of and may be Once the cause is the is - the offending molecule if it is drug are for the same in the elderly, and along with the offending molecule should be - levels by of standard for - by etc. very specific issue is managing or is usually seen in two or to use - drug taking with and at the same may be in two with a Elder individuals may be to the and paradoxical with and this becomes with hence is The rule of is reduction the is then reduction the is then reduction is and then the and For eg. If of is the reduce by daily, is reduce by daily is this the have to be largely reduction can be by a on the patient is Once is increasing the between the then a then a then The response to on more difficult to if use for therapeutic reasons medications Acceptance of need to by the patient patient to daily of and In order to deal with the like may be used for about two In or may also be tried for a of two Treatment It is recommended that the of treatment should be a of from the time of up to If the is to the should be with for Monitoring should be done keeping two in mind: or of anxiety cognitive symptoms Specific If we have to the overall management and it to the various anxiety disorders in the elderly, the following may be 1: Anxiety 2: Overview of to an elder individual with of anxiety disorder Based on characteristics and management Treatment of anxiety disorders in elderly is by psychiatric and medical conditions and medications that these may be medical illnesses in older individuals require as may lead to anxiety disorders (Table of of