A successful former businessman develops a sudden fear of driving. A longtime homemaker is convinced she never has enough groceries in the house. It's a pattern familiar to many of us with aging parents: the overwhelming worry or constant nervousness over day-to-day tasks, from taking medications to parking the car. Left untreated, this anxiety-related agitation in the elderly can disrupt sleep and eating, exacerbate chronic medical conditions, and ultimately contribute to a downward spiral of fear and isolation.
Anxiety occurs in older Americans with surprising frequency. In fact, some reports estimate anxiety affects between 10 and 20 percent of the older population -- although exact numbers are hard to pin down since the condition often goes undiagnosed. The prevalence is even greater among older adults with chronic illness or physical disability, with some 40 percent of that population reporting anxiety symptoms.
"Anxiety in the elderly is far more common than we thought -- maybe more common than depression and dementia," says Kathleen Wolfe, LCSW, who is director of social work and behavioral health at my organization, VNSNY CHOICE Health Plans. "Anxiety is characterized by feeling incapable or not having the coping skills to handle whatever challenges you're faced with. If you consider that being elderly often means being frail and vulnerable to begin with, you can see how it really sets the stage for anxiety."
Late-life anxiety can come in many forms. The most common type of clinical anxiety is generalized anxiety disorder, marked by excessive worry and feelings of fear and dread, often for no concrete reason. Physical symptoms can include sleeplessness, an inability to concentrate, irritability and lack of focus. Other seniors may suffer symptoms of anxiety that fall short of a diagnosable condition but still affect their daily lives. You might find your elderly mother spending all day by the window, for instance, nervously watching comings and goings outside, or staying up all night, worried that she won't be able to keep her medications straight. Or your 80-year-old father may be unwilling to leave the house because he's afraid he'll suffer a fall.
While anxiety is common among older people, it's important to realize that this condition is not an inevitable part of aging. Late-life anxiety, like late-life depression, is diagnosable and treatable through approaches such as medication and talk therapy. And even when your loved one's anxiety symptoms aren't severe enough to constitute a diagnosable disorder, they should be addressed by medical professionals who can help identify underlying causes and provide supports and coping mechanisms.
The Importance of Social Support
For any older person experiencing anxiety symptoms, a social support system is critical. Anxiety can feed off itself when there's no one around to provide support or an alternate point of view, causing irrational fears to grow -- which in turn can lead to increasing isolation and a downward spiral of health. Where I work, we try to make sure all of our members have a support system in place. Kathleen, for example, encourages our members to write a list of all people in their support system, along with phone numbers and email addresses (if appropriate). She also encourages them to take advantage of senior centers and reach out to religious organizations, which offer a community and a place to visit regularly.
As noted, late-life anxiety in older individuals is commonly linked to chronic medical conditions. Once that link is understood and addressed -- again, with the help of a support system -- the anxiety can often be alleviated. For example, one of our members with congestive heart failure, who had been relatively stable, suddenly began going into the hospital more frequently. Following up on that red flag, his care manager discovered that his doctor had added another drug to his already considerable daily regimen, causing the member to stop taking his medications entirely.
"He became so overwhelmed with the complexity of the care that he just gave up," notes Lisa George, our organization's Medical Director. "Living with chronic conditions and managing multiple medications -- especially if you don't fully understand your situation and don't have a good support system -- can often trigger anxiety in elderly people."
Reducing Stress by Breaking Things Down
The solution begins with communication, support and education. In this case, the care manager worked with the member and his primary care physician to reevaluate the medications, reducing them wherever possible and making sure the member understood what he was taking and why, what the desired effect was, and what side effects he could expect. "We really break things down to the level of the patient," says Lisa. "What happened with this member is so common. People forget what the doctor told them, they're unsure of their medication, and life intervenes."
To help prevent or ease anxiety symptoms related to medical issues, a caregiver or family member should accompany an older person to each doctor's visit. Bring a notebook, come with written questions, and take notes or have another family member take notes. You can also ask the doctor's office to write up the care plan and prescribed medications at the end of each appointment.
Ideally, the older person's health plan or physician's practice has a care coordinator who can help clarify these details as well. Our care managers are a vital resource in ensuring that there is two-way communication between the member and their doctors, and that everyone is on the same page in terms of care plan and medications. "That way, patients don't get overwhelmed and caught in the middle," explains Lisa. If they like our members can even arrange for their care manager to call in and "join" a patient by phone at a pre-scheduled doctor's appointment.
Diagnosing -- and Treating -- Root Causes
If symptoms like nervousness, dread or hypervigilance (being overly aware of potential threats) are seriously impairing an older person's day-to-day functioning, then it's time to talk with their primary care provider about a possible clinical anxiety disorder. Lisa George cautions that if doctors do diagnose an anxiety disorder, that's just the beginning of the conversation. "After you make the diagnosis, it's important to address the root causes rather than just labeling the symptoms. Often that means helping the person navigate care, working with the primary care doctor to streamline medications, and connecting them to resources in the community."
If clinical anxiety is diagnosed, older people -- like people of any age -- can often benefit from psychological counseling, including cognitive behavioral therapy (CBT), a specific type of psychotherapy that focuses on reframing thoughts and behaviors and challenging assumptions underlying irrational fears. Stress management techniques may also be helpful.
There are a number of medications that can be effective in reducing anxiety symptoms, as well. It might seem counterintuitive to add more medications to the daily routine if a multi-drug regimen is already adding to an individual's stress. But by working with a physician who looks at the patient's whole picture, reducing or streamlining medications where possible, the safe and efficient addition of an appropriate anti-anxiety medication can make a major difference in the life and outlook of an older person suffering from a clinical anxiety disorder.
Working With Providers to Keep Anxiety at Bay
At VNSNY CHOICE Health Plans, we're working to infuse behavioral health and comprehensive health strategies across the spectrum of care, so we can intervene early to address late-life mood disorders like anxiety and depression among our members in a systemic and lasting way. In one new initiative, we've begun exchanging information with our members' physicians around behavioral health issues, such as how a member's anxiety or depression might be impacting their health outcomes, medication adherence and quality of life.
"We've already been addressing these topics with individual physicians in a limited way," notes Dr. Lisa George. "But with this initiative, we'll be sending out interdisciplinary teams to meet with local physician practices in a systematic fashion. Our goal is to establish an integrated, holistic approach that partners with community physicians to provide our members with the support they need to age successfully in a home environment."