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anxiety disorder

Etiology: 1) fear is the central emotion in anxiety disorders 2) precipitating emotional stressor (50%) - bereavement 3) disturbance in neurotransmitters 4) medications associated with anxiety 5) hypoxia 6) ill-health, comorbid medical illness a) cardiovascular disease b) pulmonary disease 7) comorbid psychiatric disease Epidemiology: 1) most common psychiatric disorders in the elderly 2) prevalence 2.8% in elderly [14] - mosy have comorbid Axis 1 or Axis 2 disorder [14] 3) 1/3 of elderly with depression 4) older patients are less likely to present with anxiety as a chief complaint [3] 5) prevalence of ~34% in the U.S., 6) generalized anxiety disorder (lifetime prevalence = 6%) 7) social anxiety disorder (lifetime prevalence = 13%) 8) panic disorder (lifetime prevalence = 5%) [38] Genetics: - offspring of a parent with anxiety disorder are more likely to develop an anxiety disorder [39] Clinical manifestations: 1) excessive worry that is intrusive & interferes with daily functioning - at least 6 months duration [2,4] - social & performance fears [38] - agoraphobia [38] - panic attacks - avoidance behaviors [38] 2) arousal symptoms a) fatigue b) irritability c) insomnia d) muscle tension, restlessness 3) autonomic dysfunction a) indigestion b) sweating 4) chest pain 5) palpitations 6) smothering sensation, dysnea 7) agitation 8) tremor 9) scattered mentation, difficulty concentrating 10) hyperventilation 11) dizziness Laboratory: 1) complete blood count (CBC) 2) serum glucose 3) serum electrolytes 4) thyroid function testing 5) urinalysis 6) urine toxicology 7) pulse oximetry (rule out hypoxia-induced anxiety) [3] Special laboratory: 1) electrocardiogram (if associated with cardiac symptoms) 2) generalized anxiety disorder scale (GAD-2, GAD-7) 3) other specialized testing: a) Sheehan patient rated anxiety scale b) Hopkins symptom checklist (SCL90) c) Hamilton anxiety & depression scale d) Zung anxiety self-assessment scale e) Covi anxiety & Raskin depression scales f) Beck anxiety inventory Differential diagnosis: 1) somatic disorders - hyperthyroidism - coronary artery disease, cardiac arrhythmia - chronic obstructive pulmonary disease - hypoglycemia - carcinoid (flush, asthma, diarrhea) - pheochromcytoma (elevated pulse pressure, tachycardia) 2) mental disorder a) bipolar disease b) depression - symptoms common to anxiety & depression - fatigue, tearfulness, eating disturbances, irritability, worry, difficulty concentrating - symptoms characteristic of anxiety - difficulty falling asleep or staying asleep - pain tends to be sharp & acute - nervous & seeking help - mood may be elevated - prominent autonomic symptoms - symptoms characteristic of depression - early morning awakening - pain tends to be dull & chronic - often unaware of problem & not seeking help - mood may be depressed - anhedonia - suicidal thoughts - depression may coexist with anxiety disorder [13] c) agitation d) substance abuse e) panic attack (intense fear of impending doom) Management: 1) psychotherapy a) cognitive behavioral therapy [3,6,9,15,17] - best response rates - most durable effects [2] - durability of effects > 12 months dependent upon specific disorder [31] b) psychodynamic psychotherapy c) both effective [5] d) effective in elderly [3] e) cognitive therapy alone not effective in elderly [3] f) mindfulness-based stress reduction as effective as escitalopram [37] 2) pharmaceutical agents a) antidepressants - selective serotonin reuptake inhibitor (SSRI)* - serotonin-norepinephrine reuptake inhibitor (SNRI) - SSRI or SNRI generally drugs of choice in the elderly [3,7] - duloxetine, venlafaxine, escitalopram effective [29] - fluoxetine, sertraline also effective [29] - escitalopram safe & effective for reducing anxiety in patients with coronary artery disease [33] - SSRI & SNRI modestly better than placebo for treating anxiety in children & adolescents [26,27] - SNRI benefit limited to clinician-reported, not child- or parent-reported symptoms [27] - mirtazapine is sometimes useful as an alternative or adjunctive agent, especially if sedation may be beneficial [3] - tricyclic antidepressants - generally used in connection with another agent - occasionally effective alone - evidence of benefit for children insufficient [27] - increased risk for relapse in the year after treatment discontinuation [28] - continue antidepressant for at least a year after treatment response [28] b) buspirone (BuSpar) - initial treatment of anxiety in younger patients - generally well tolerated - does not cause drug dependency - very slow to work (2-4 weeks) - not always effective c) benzodiazepines - prompt action - effective for patients with history of substance abuse - rarely addicting; ref [34] notes addiction potential - avoid if history of substance use disorder (MKSAP19) [3] - reserve long-term use for patients with refractory panic disorder - although both benzodiazepines & anxiety disorders increase risk of dementia in the elderly, benzodiazepine use in elderly with anxiety disorder does not increase risk of dementia [26] - evidence of benefit for children insufficient [28] d) pregabalin effective e) vilazodone & vortioxetine efficacy is poor [29] f) quetiapine less tolerated than placebo [29] g) high dose vitamin B6 may reduce generalized anxiety & social anxiety [39] 3) SSRI + cognitive behavioral therapy may provide benefit over either alone [6,28] 4) integrated mental health & primary care can improve overall function [11] 5) screening for anxiety - generalized anxiety disorder scale (GAD-2, GAD-7) - screening for anxiety recommended for females >= 13 years of age [32] - depression frequently coexists with anxiety; also screen for depression [32] - USPSTF recommends screening for anxiety disorders in adults, including pregnant & postpartum women [40] - USPSTF concludes that current evidence is insufficient to assess the balance of benefits & harms of screening for anxiety disorders in older adults [40] 6) patient education - patient & family psychoeducation helpful for elderly [3] 7) exercise has antianxiety effects [3] - effects on anxiety inconsistent [33] 8) supportive groups probably offer nonspecific benefits [3] 9) meditation & relaxation helpful, meditation may be more so [30] * according to [3] patients should be counseled on potential of adverse effects & when they due occur are likely to be benign & shortlived, often a manifestation of the underlying disorder

Interactions

disease interactions

Related

anxiety assessment medications associated with anxiety Screen for Child Anxiety Related Disorders (SCARED) screening for anxiety

Specific

death anxiety; fear of death generalized anxiety disorder (GAD) obsessive-compulsive disorder (OCD) panic disorder phobia posttraumatic stress disorder (PTSD); includes acute stress disorder social phobia; social anxiety disorder

General

anxiety chronic mental disorder

References

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