Anxiety in older folks often underdiagnosed
Recent guidance from expert panel excludes those 65, older for screening
Susan Tilton’s husband, Mike, was actually in good health. But after a friend’s husband developed terminal cancer, she began to worry that Mike would soon die, too.
At night, “I’d lie down and start thinking about it,” recalled Tilton, 72, who lives in Clayton, Missouri. “What would I do? What would I do?” The thought of life without her husband — they’d married at 17 and 18 — left her sleepless and dragging through the next day.
“It was very hard to shut it off,” she said of her worrying. “How could I get along by myself ?”
Years earlier, Tilton had been seeing a therapist and taking medication for depression, but she ended therapy when her doctor retired. In 2021, she consulted Dr. Eric Lenze, who heads the psychiatry department at the Washington University School of Medicine in St. Louis, for help with a different health problem, not recognizing that her anxiety was itself a diagnosable disorder.
“I just thought it was the way things were — you worried,” she said. “I believe I’ve had it since I was a child. To me, it was my normal way of thinking.”
A lot of older people can empathize. Anxiety is the most common mental health disorder; a 2017 study of older adults in six countries found that more than 17% had experienced an anxiety disorder within the past year.
Generalized anxiety disorder, Tilton’s diagnosis, is the most common type among seniors. “The
most prominent symptom is severe, difficult-to-control worry,” said Dr. Carmen Andreescu, a geriatric psychiatrist at the University of Pittsburgh School of Medicine and an author of a recent editorial on late-life anxiety in JAMA Psychiatry. “There’s this continuing fear that something bad is going to happen. It can be allconsuming.”
Other forms of anxiety include social anxiety disorder, phobias, panic disorder and post-traumatic stress disorder. Anxiety frequently occurs alongside depression, complicating diagnosis and treatment. The pandemic, of course, led to rising anxiety and depression in all adult age groups.
Recently, attention to anxiety has increased because of a draft recommendation from the U.S. Preventive Services Task Force, an independent expert panel that reviews research on preventive measures.
The panel concluded
that adults ages 18 to 64, including those who are pregnant and postpartum, should be screened for anxiety and gave that recommendation a “B” rating, meaning it had “moderate net benefit.” (Screening means testing patients who don’t exhibit symptoms or raise concerns about a particular health problem but may be experiencing it nonetheless.)
For people 65 and older, though, the task force issued an “I” rating, meaning it found insufficient evidence of benefits and harms.
“It’s a very scientifically rigorous process,” said Lori Pbert, a clinical psychologist and health behavior researcher at the University of Massachusetts Chan Medical School who served on the panel. When it came to older adults, “evidence was lacking on the accuracy of screening tools and the benefits and harms of screening,” she said. The team also wanted more evidence of treatment
effectiveness.
“It’s a strong call for the clinical research that’s needed,” Pbert said.
Andreescu and the other authors of the editorial, including Lenze, strongly disagree. An “I” rating “makes people not look for or treat something that’s already an undertreated condition,” Lenze said.
“With a common disorder that causes a lot of impairment of quality of life and that has simple, inexpensive, straightforward kinds of treatment, I think screening is called for,” he added.
Whatever the final task force recommendation, the discussion of anxiety in older people highlights a prevalent but often overlooked mental health concern. “A lot of these cases fly under the radar,” Andreescu said.
That may reflect the way symptoms of anxiety can differ among older people, whose primary care doctors often lack the training to recognize mental health disorders. In addition to severe worry, seniors often experience insomnia or irritability; they may develop a fear of falling, engage in hoarding or complain of physical discomforts like muscle tension, a choking sensation, dizziness or shakiness.
But underdiagnosis also stems from older patients’ reluctance to ascribe their problems to psychological issues. “Some resent a label of ‘anxious,’ ” Andreescu said. “They’d rather call it ‘high stress,’ something that doesn’t indicate psychological weakness.”
And since aging involves genuine sources of distress, from falls to bereavement, people may see anxiety as normal, as Tilton did.
It has serious consequences, however. Studies have demonstrated connections between anxiety and cardiovascular disease, with greatly increased risks of coronary heart disease, heart failure, stroke and death. Patients with higher anxiety levels are more likely to engage in substance abuse, too.
Research also shows that anxiety is linked to cognitive decline and dementia. Andreescu’s studies have found that “anxiety actually shrinks and ages the brain,” she said.
And it degrades people’s lives. Jim Wright, a Pittsburgh executive who has participated in Andreescu’s research, described having “a lot of sleepless nights.”
“I’ll wake up at 2 a.m. and lie there worrying about every random thing you can think of,” said Wright, 60, who has also developed hypertension that has proved difficult to control.
John Modell, 81, a retired professor in Pittsburgh and another study participant, worries about memory loss and about getting lost on local walks or stranded by airlines on trips. “I’m aware of being anxious 20 or 50 times a day,” said Modell, whose father died of Alzheimer’s disease. His symptoms have led him to stop traveling and have curtailed his social life; he thinks they contributed to his divorce, too.
Neither man has sought treatment for anxiety. “I’ve learned to live with it,” Wright said. Yet anxiety can be treated with antidepressants like Prozac, Lexapro and Zoloft, called selective serotonin reuptake inhibitors, combined with cognitive behavioral therapy.
Because older people require higher doses of antidepressants and are already likely to be taking multiple medications, doctors proceed cautiously. “It’s a bigger challenge” to treat older anxious patients, Andreescu said. “It’s more complicated.”
The drugs can take weeks longer to bring relief than in younger people, she said, which may lead patients to think they aren’t working and stop taking them.
With time, though, “we do get it under control,” Andreescu said. “People do respond to treatment.”