Aging With Anxiety: A Comprehensive Approach To Anxiety Disorders In The Elderly
By Debbie Eisenstadt Mandel, M.A. and Laszlo Papp, M.D.
“We must endure our thoughts all night,
until the bright obvious stands motionless in the cold”
The elderly are confronted by many real life stresses such as: illness, disability, retirement, poverty, alienation, widowhood and the empty nest. These stressors may cause the elderly to present with a variety of physical and emotional problems warranting a visit to the family practitioner who might not even consider the possibility that these symptoms are due to anxiety. A common patient doctor scenario is “well, at your age with all that you are experiencing, what do you expect?” It is also possible that this scenario reflects a prejudice against the elderly. For example, we accept and understand an identity crisis in teenagers, but ignore it in the elderly. For women, widowhood may be compounded by the dilemma of holding on to their married name which is an important part of their identity. Dismissing their anxiety disorders, their tears, as part of “generalized aging,” may parallel the earlier medical approach to dementia, until we began to understand the pathophysiology and course of Alzheimer’s disease.
The truth is that Generalized Anxiety Disorder (GAD) is more prevalent in the elderly than in the young. At least 20% of the elderly suffer from clinically relevant anxiety, yet the diagnostic criteria are the most deficient and the disorder is the least researched. First, the symptoms of GAD are highly variable including signs of motor tension, autonomic hyperactivity and hyper-arousal. Patients are restless, unable to relax and experience fatigue. Motor tension causes frequent headaches, chronic muscle pain in the shoulders, neck and lower back. Second, recall in some of the elderly is poor and therefore most symptoms are not communicated. Third, many elderly see their non-mental health practitioners for gastrointestinal, cardiac symptoms, endocrine abnormalities, and nutritional deficiencies, etc. and therefore the underlying or concomitant condition of GAD is rarely addressed.
Recent studies exploring late life anxiety disorders suggest that most patients can benefit from medical management including tapering medications when appropriate, along with Cognitive Behavioral Therapy (CBT). This strategy should help patients realize a reduction in drug use and an alleviation of both psychological and physical symptoms.
The long term use of anxiolytic medications in older patients is controversial. While the benefits are numerous, (e.g., rapid onset, effective symptom relief and gradually improving side effect profiles of newer compounds) these benefits need to be weighed against drug dependence, cognitive impairment and accidental falls. It has been confirmed in several well controlled trials that Cognitive Behavioral Therapy as an adjuvant to medications has many advantages for the elderly. In addition to facilitating medication taper, CBT can be easily extended to address co-morbid conditions most commonly, depression. Almost every psychological measure, whether of anxiety, depression or collateral symptoms such as somatization or hostility, show significant improvement following CBT treatment.
One of the most attractive features of CBT is its flexibility and hospitality to alternative treatments. A wide variety of techniques, strategies and exercises are easily incorporated without undermining the main tenets of the treatment. Nowadays, complementary medicine is on the rise because patients feel that traditional medicine may not have all the answers. Through traditional and progressive medical programs, many of them mind/body workshops, patients learn to participate actively in their own healing. The success of CBT techniques suggest that simple tools of self-empowerment, easily learned cognitive strategies and behavioral exercises may transform the lives of many elderly even without formal medical intervention.
Increasingly, senior citizens are attending workshops on de-stressing and coping with anxiety, depression, anger and resentment. They are taught auto-hypnosis, meditation and breathing practices as well as gentle yoga and qi-gong exercises. The regularity and consistency of these workshops at senior centers establish continuity for the participants who in turn socialize and share in these support groups. In addition to the specific techniques learned, the group setting also alleviates the social isolation that frequently fosters and exacerbates anxiety. Learning to relax by creating auto hypnotic affirmative statements could also supplement CBT. Learning to reinterpret the personal stressful picture, as well as bringing attention to rhythmic and deep breathing, provide the elderly with a sense of much needed control. As some of the elderly do not even report their anxiety and depression because of the stigma attached, these workshops could provide a non-judgmental first line recourse, paving the way for a comprehensive evaluation and treatment, if needed.
Mainstream medicine is finally recognizing the value of non-traditional approaches, much of it from Eastern traditions. Hopefully, we can also garner the respect attributed to the elderly inherent in these traditions.
Laszlo Papp, M.D.- Columbia University College of Physicians and Surgeons
Debbie Eisenstadt Mandel, MA is the author of Turn On Your Inner Light: Fitness for Body, Mind and Soul, a stress-reduction specialist, motivational speaker, a personal trainer and mind/body lecturer at Brooklyn College. She is the host of the weekly Turn On Your Inner Light Show on WLIR 92.7FM in New York City and has been featured on radio/ TV and print media. To learn more visit: www.turnonyourinnerlight.com