Late-Life Anxiety Disorders

  • Sachin Sarin
  • Zainab Samaan


Anxiety disorders are among the most common and costly psychiatric disorders impacting the geriatric population. While anxiety is a normal human emotion, pathological anxiety can lead to functional impairment and suffering. The high prevalence of anxiety disorders may be explained through understanding the differential costs of missing a threat compared to anxious misery (the smoke detector principle). In the geriatric population, generalized anxiety disorder is the most common anxiety disorder, while panic disorder is less common, and fear of falling represents a specific phobia that is known to specifically affect older adults. Diagnosis is often complicated by the increased presence of comorbid systemic medical illnesses, bereavement, increased prevalence of somatic complaints, and difficulty discerning adaptive from pathological anxiety in the context of aging. A thorough clinical examination, including physical examination, and laboratory studies are required to help elucidate the differential diagnosis. Cognitive testing should be conducted in order to establish a baseline, to allow for future monitoring, and to guide treatment. Treatment should include providing psychoeducation, psychotherapeutic approaches (e.g., cognitive-behavioral, behavioral, interpersonal, and mindfulness-based psychotherapies), and pharmacotherapy. Comorbid systemic medical illnesses can pose additional challenges to management, often requiring simultaneous treatment of systemic medical and psychiatric symptoms.


Late-life anxiety Geriatric age Fear Avoidance Fear of falling Panic disorder Generalized anxiety disorder Phobias 


  1. 1.
    Tovote P, Fadok JP, Lüthi A. Neuronal circuits for fear and anxiety. Nat Rev Neurosci. 2015;16(6):317–31.CrossRefPubMedGoogle Scholar
  2. 2.
    Porensky EK, Dew MA, Karp JF, et al. The burden of late-life generalized anxiety disorder: effects on disability, health-related quality of life, and healthcare utilization. Am J Geriatr Psychiatry. 2009;17(6):473–82.Google Scholar
  3. 3.
    De Beurs E, Beekman AT, Van Balkom AJ, et al. Consequences of anxiety in older persons: its effect on disability, well-being and use of health services. Psychol Med. 1999;29(03):583–93.CrossRefPubMedGoogle Scholar
  4. 4.
    Brenes GA, Penninx BW, Judd PH, et al. Anxiety, depression and disability across the lifespan. Aging Ment Health. 2008;12(1):158–63.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Wetherell JL, Thorp SR, Patterson TL, et al. Quality of life in geriatric generalized anxiety disorder: a preliminary investigation. J Psychiatr Res. 2004;38(3):305–12.CrossRefPubMedGoogle Scholar
  6. 6.
    Peters R, Pinto E, Beckett N, et al. Association of depression with subsequent mortality, cardiovascular morbidity and incident dementia in people aged 80 and over and suffering from hypertension. Data from the Hypertension in the Very Elderly Trial (HYVET). Age Ageing. 2010;39(4):439–45.CrossRefPubMedGoogle Scholar
  7. 7.
    Tully PJ, Cosh SM, Baune BT. A review of the affects of worry and generalized anxiety disorder upon cardiovascular health and coronary heart disease. Psychol Health Med. 2013;18(6):627–44.CrossRefPubMedGoogle Scholar
  8. 8.
    Lambiase MJ, Kubzansky LD, Thurston RC. Prospective study of anxiety and incident stroke. Stroke. 2014;45(2):438–43.CrossRefPubMedGoogle Scholar
  9. 9.
    Rosenberg PB, Mielke MM, Appleby BS, et al. The association of neuropsychiatric symptoms in MCI with incident dementia and Alzheimer disease. Am J Geriatr Psychiatry. 2013;21(7):685–95.CrossRefPubMedGoogle Scholar
  10. 10.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.CrossRefGoogle Scholar
  11. 11.
    Stahl SM. Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. Cambridge, NY: Cambridge University Press; 2013.Google Scholar
  12. 12.
    Bryant C, Jackson H, Ames D. The prevalence of anxiety in older adults: methodological issues and a review of the literature. J Affect Disord. 2008;109(3):233–50.CrossRefPubMedGoogle Scholar
  13. 13.
    Lenze EJ, Wetherell JL. Anxiety disorders: new developments in old age. Am J Geriatr Psychiatry. 2011;19(4):301.Google Scholar
  14. 14.
    Bower ES, Wetherell JL, Mon T, Lenze EJ. Treating anxiety disorders in older adults: current treatments and future directions. Harv Rev Psychiatry. 2015;23(5):329–42.CrossRefPubMedGoogle Scholar
  15. 15.
    Gum AM, King-Kallimanis B, Kohn R. Prevalence of mood, anxiety, and substance-abuse disorders for older Americans in the national comorbidity survey-replication. Am J Geriatr Psychiatry. 2009;17(9):769–81.CrossRefPubMedGoogle Scholar
  16. 16.
    Beekman AT, Bremmer MA, Deeg DJ, et al. Anxiety disorders in later life: a report from the Longitudinal Aging Study Amsterdam. Int J Geriatr Psychiatry. 1998;13(10):717–26.CrossRefPubMedGoogle Scholar
  17. 17.
    Byers AL, Yaffe K, Covinsky KE, et al. High occurrence of mood and anxiety disorders among older adults: the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2010;67(5):489–96.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Flint AJ. Anxiety and its disorders in late life: moving the field forward. Am J Geriatr Psychiatry. 2005;13(1):3–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Zijlstra GA, Van Haastregt J, Van Rossum E, et al. Interventions to reduce fear of falling in community-living older people: a systematic review. J Am Geriatr Soc. 2007;55(4):603–15.CrossRefPubMedGoogle Scholar
  20. 20.
    Baxter AJ, Scott KM, Vos T, Whiteford HA. Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychol Med. 2013;43(05):897–910.CrossRefPubMedGoogle Scholar
  21. 21.
    Le Roux H, Gatz M, Wetherell JL. Age at onset of generalized anxiety disorder in older adults. Am J Geriatr Psychiatry. 2005;13(1):23–30.CrossRefPubMedGoogle Scholar
  22. 22.
    Sheikh JI, Swales PJ, Carlson EB, Lindley SE. Aging and panic disorder: phenomenology, comorbidity, and risk factors. Am J Geriatr Psychiatry. 2004;12(1):102–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Flint A, Bradwejn J, Vaccarino F, et al. Aging and panicogenic response to cholecystokinin tetrapeptide: an examination of the cholecystokinin system. Neuropsychopharmacology. 2002;27(4):663–71.PubMedGoogle Scholar
  24. 24.
    American Psychiatric Association. Practice guideline for the treatment of patients with panic disorder, second edition. American Psychiatric Association; 2009.Google Scholar
  25. 25.
    Nesse RM. The smoke detector principle. Ann NY Acad Sci. 2001;935(1):75–85.Google Scholar
  26. 26.
    Bowlby J. Attachment and loss. Harmondsworth, Middx: Penguin; 1984.Google Scholar
  27. 27.
    Tooby J, Cosmides L. The past explains the present: emotional adaptations and the structure of ancestral environments. Ethol Sociobiol. 1990;11(4–5):375–424.CrossRefGoogle Scholar
  28. 28.
    Tooby J, Cosmides L. The theoretical foundations of evolutionary psychology. In: The handbook of evolutionary psychology. Ed. Buss. D. John Wiley & Sons, Inc., Hoboken, NJ, USA. 2015. Google Scholar
  29. 29.
    Brüne M. Textbook of evolutionary psychiatry and psychosomatic medicine: the origins of psychopathology. Oxford: Oxford University Press; 2015.Google Scholar
  30. 30.
    Wolitzky-Taylor KB, Castriotta N, Lenze EJ, et al. Anxiety disorders in older adults: a comprehensive review. Depress Anxiety. 2010;27(2):190–211.CrossRefPubMedGoogle Scholar
  31. 31.
    Ninan PT, Berger J. Symptomatic and syndromal anxiety and depression. Depress Anxiety. 2001;14(2):79–85.CrossRefPubMedGoogle Scholar
  32. 32.
    Lang PJ, McTeague LM, Bradley MM. RDoC, DSM, and the reflex physiology of fear: a biodimensional analysis of the anxiety disorders spectrum. Psychophysiology. 2016;53(3):336–47.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Braam AW, Copeland JR, Delespaul PA, et al. Depression, subthreshold depression and comorbid anxiety symptoms in older Europeans: results from the EURODEP concerted action. J Affect Disord. 2014;155:266–72.CrossRefPubMedGoogle Scholar
  34. 34.
    Fava M, Rush AJ, Alpert JE, et al. Difference in treatment outcome in outpatients with anxious versus nonanxious depression: a STAR* D report. Am J Psychiatry. 2008;165(3):342–51.CrossRefPubMedGoogle Scholar
  35. 35.
    DeLuca AK, Lenze EJ, Mulsant BH, et al. Comorbid anxiety disorder in late life depression: association with memory decline over four years. Int J Geriatr Psychiatry. 2005;20(9):848–54.CrossRefPubMedGoogle Scholar
  36. 36.
    Oude Voshaar RC, Veen DC, Hunt I, Kapur N. Suicide in late-life depression with and without comorbid anxiety disorders. Int J Geriatr Psychiatry. 2016;31(2):146–52.CrossRefPubMedGoogle Scholar
  37. 37.
    Davies MN, Verdi S, Burri A, et al. Generalised anxiety disorder–a twin study of genetic architecture, genome-wide association and differential gene expression. PLoS One. 2015;10(8):e0134865.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Hettema JM, Neale MC, Kendler KS. A review and meta-analysis of the genetic epidemiology of anxiety disorders. Am J Psychiatry. 2001;158(10):1568–78.CrossRefPubMedGoogle Scholar
  39. 39.
    Jones PB. Adult mental health disorders and their age at onset. Br J Psychiatry. 2013;202(s54):s5–10.CrossRefGoogle Scholar
  40. 40.
    Demirkan A, Penninx BW, Hek K, et al. Genetic risk profiles for depression and anxiety in adult and elderly cohorts. Mol Psychiatry. 2011;16(7):773–83.CrossRefPubMedGoogle Scholar
  41. 41.
    Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14(1):S1.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Taylor D, Paton C, Kapur S. Prescribing guidelines in psychiatry12th edition. London: Wiley-Blackwell; 2015.Google Scholar
  43. 43.
    Lenze EJ, Wetherell JL. A lifespan view of anxiety disorders. Dialogues Clin Neurosci. 2011;13(4):381–99.PubMedPubMedCentralGoogle Scholar
  44. 44.
    Pachana NA, Byrne GJ. The Geriatric Anxiety Inventory: international use and future directions. Aust Psychol. 2012;47(1):33–8.CrossRefGoogle Scholar
  45. 45.
    Segal DL, June A, Payne M, et al. Development and initial validation of a self-report assessment tool for anxiety among older adults: the Geriatric Anxiety Scale. J Anxiety Disord. 2010;24(7):709–14.CrossRefPubMedGoogle Scholar
  46. 46.
    Howland J, Peterson EW, Levin WC, et al. Fear of falling among the community-dwelling elderly. J Aging Health. 1993;5(2):229–43.CrossRefPubMedGoogle Scholar
  47. 47.
    Scheffer AC, Schuurmans MJ, Van Dijk N, et al. Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing. 2008;37(1):19–24.CrossRefPubMedGoogle Scholar
  48. 48.
    Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716–24.CrossRefPubMedGoogle Scholar
  49. 49.
    Karaiskos D, Pappa D, Tzavellas E, et al. Pregabalin augmentation of antidepressants in older patients with comorbid depression and generalized anxiety disorder—an open-label study. Int J Geriatr Psychiatry. 2013;28(1):100–5.CrossRefPubMedGoogle Scholar
  50. 50.
    Gould RL, Coulson MC, Howard RJ. Efficacy of cognitive behavioral therapy for anxiety disorders in older people: a meta-analysis and meta-regression of randomized controlled trials. J Am Geriatr Soc. 2012;60(2):218–29.CrossRefPubMedGoogle Scholar
  51. 51.
    Baer RA, editor. Mindfulness-based treatment approaches: clinician’s guide to evidence base and applications. Amsterdam: Academic Press; 2015.Google Scholar
  52. 52.
    De Picker L, Van Den Eede F, Dumont G, Moorkens G, Sabbe BG. Antidepressants and the risk of hyponatremia: a class-by-class review of literature. Psychosomatics. 2014;55(6):536–47.CrossRefPubMedGoogle Scholar
  53. 53.
    Sinoff G, Werner P. Anxiety disorder and accompanying subjective memory loss in the elderly as a predictor of future cognitive decline. Int J Geriatr Psychiatry. 2003;18(10):951–9.CrossRefPubMedGoogle Scholar
  54. 54.
    Palmer K, Berger AK, Monastero R, Winblad B, Bäckman L, Fratiglioni L. Predictors of progression from mild cognitive impairment to Alzheimer disease. Neurology. 2007;68(19):1596–602.CrossRefPubMedGoogle Scholar
  55. 55.
    El-Gabalawy R, Mackenzie CS, Shooshtari S, Sareen J. Comorbid physical health conditions and anxiety disorders: a population-based exploration of prevalence and health outcomes among older adults. Gen Hosp Psychiatry. 2011;33(6):556–64.CrossRefPubMedGoogle Scholar
  56. 56.
    Kemp AH, Quintana DS, Felmingham KL, et al. Depression, comorbid anxiety disorders, and heart rate variability in physically healthy, unmedicated patients: implications for cardiovascular risk. PLoS One. 2012;7(2):e30777.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Willgoss TG, Yohannes AM. Anxiety disorders in patients with COPD: a systematic review. Respir Care. 2013;58(5):858–66.PubMedGoogle Scholar
  58. 58.
    Maurer J, Rebbapragada V, Borson S, et al. Anxiety and depression in COPD: current understanding, unanswered questions, and research needs. Chest J. 2008;134(4_suppl):43S–56S.CrossRefGoogle Scholar
  59. 59.
    Eisner MD, Blanc PD, Yelin EH, et al. Influence of anxiety on health outcomes in COPD. Thorax. 2010;65(3):229–34.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Hill K, Geist R, Goldstein RS, Lacasse Y. Anxiety and depression in end-stage COPD. Eur Respir J. 2008;31(3):667–77.CrossRefPubMedGoogle Scholar
  61. 61.
    Brenes GA. Anxiety and chronic obstructive pulmonary disease: prevalence, impact, and treatment. Psychosom Med. 2003;65(6):963–70.CrossRefPubMedGoogle Scholar
  62. 62.
    Kellner R, Samet J, Pathak D. Dyspnea, anxiety, and depression in chronic respiratory impairment. Gen Hosp Psychiatry. 1992;14(1):20–8.CrossRefPubMedGoogle Scholar
  63. 63.
    Yohannes AM. Depression and COPD in older people: a review and discussion. Br J Community Nurs. 2005;10(1):42–6.CrossRefPubMedGoogle Scholar
  64. 64.
    Aydin IO, Uluşahin A. Depression, anxiety comorbidity, and disability in tuberculosis and chronic obstructive pulmonary disease patients: applicability of GHQ-12. Gen Hosp Psychiatry. 2001;23(2):77–83.CrossRefPubMedGoogle Scholar
  65. 65.
    Cafarella PA, Effing TW, Usmani ZA, Frith PA. Treatments for anxiety and depression in patients with chronic obstructive pulmonary disease: a literature review. Respirology. 2012;17(4):627–38.CrossRefPubMedGoogle Scholar
  66. 66.
    Hynninen MJ, Bjerke N, Pallesen S, Bakke PS, Nordhus IH. A randomized controlled trial of cognitive behavioral therapy for anxiety and depression in COPD. Respir Med. 2010;104(7):986–94.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.McMaster UniversityHamiltonCanada

Personalised recommendations