Late-life anxiety disorders

Meet the patient

A 74-year-old woman has been to ED four times in eight weeks with chest tightness. Three ECGs, two troponin sets and a CT coronary angiogram are all normal. The last discharge letter says non-cardiac chest pain, reassure.[2][4]

She has not been on a bus since March. Her daughter now does the shopping. She phones her GP most weeks and apologises each time for wasting everyone's time.[2][4]

Two questions decide this consultation. Is there a body problem still hiding in here? And why has nobody offered her a treatment that works? Older adults under-report emotion and lead with the chest, which is exactly how disabling anxiety gets discharged as reassurance.[2][4]

Etymology worth one line in a viva: anxiety comes from Latin angere — to choke, to press tight — the same root as angina*. The word was built out of a chest symptom. When your 74-year-old leads with tightness rather than worry, she is using the older and more accurate vocabulary.*[2][4]

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1. [1]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.PMID 9818308
2. [2]Wolitzky-Taylor KB, Castriotta N, Lenze EJ, Stanley MA, Craske MG Anxiety disorders in older adults: a comprehensive review Depress Anxiety, 2010.PMID 20099273
3. [3]Byers AL, Yaffe K, Covinsky KE, Friedman MB, Bruce ML High occurrence of mood and anxiety disorders among older adults: The National Comorbidity Survey Replication Arch Gen Psychiatry, 2010.PMID 20439830
4. [4]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.PMID 19472438
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9. [9]Ayers CR, Sorrell JT, Thorp SR, Wetherell JL Evidence-based psychological treatments for late-life anxiety Psychol Aging, 2007.PMID 17385978
10. [10]Wetherell JL, Petkus AJ, White KS, et al. Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults Am J Psychiatry, 2013.PMID 23680817
11. [11]Schuurmans J, Comijs H, Emmelkamp PM, et al. A randomized, controlled trial of the effectiveness of cognitive-behavioral therapy and sertraline versus a waitlist control group for anxiety disorders in older adults Am J Geriatr Psychiatry, 2006.PMID 16505130
12. [12]Fabian TJ, Amico JA, Kroboth PD, et al. Paroxetine-induced hyponatremia in older adults: a 12-week prospective study Arch Intern Med, 2004.PMID 14769630
13. [13]Billioti de Gage S, Moride Y, Ducruet T, et al. Benzodiazepine use and risk of Alzheimer's disease: case-control study BMJ, 2014.PMID 25208536
14. [14]By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults J Am Geriatr Soc, 2023.PMID 37139824
15. [15]Spitzer RL, Kroenke K, Williams JB, Löwe B A brief measure for assessing generalized anxiety disorder: the GAD-7 Arch Intern Med, 2006.PMID 16717171
16. [16]Conwell Y, Van Orden K, Caine ED Suicide in older adults Psychiatr Clin North Am, 2011.PMID 21536168