Late-Life Anxiety

To the Editor: Anxiety disorders often begin in early adulthood 1 and an initial onset of these disorders after the age of 60 is usually associated with a traumatic event. 2 Numerous factors can predispose this population to high levels of anxiety, including medical illness, psychosocial changes, depression, and dementia. 1, 3 The symptoms are similar to those in younger patients, 1, 4 but they are usually associated with unfavorable prognosis in the elderly. 1

Anxiety disorders in the elderly are often underdiagnosed and, when treatment is provided, benzodiazepines are overused and antidepressants are underused. 5

The use of benzodiazepines is usually effective but is associated with increased risk of cognitive impairment, sedation, falls, and fractures. 6 Based on the safety, efficacy, and high rate of comorbid depression, 4 the serotonergic antidepressant medications are preferred to benzodiazepines as a first-line of treatment for anxiety disorders in the elderly. 6 Psychotherapy, particularly cognitive behavior therapy, is often effective in these disorders as well. 6

We reviewed symptoms of three cases in which onset of anxiety symptoms developed after age 60 as a result of having a medical procedure. They were highly functioning individuals and anxiety symptoms led to impairment of their social and occupational life. They were all successfully treated with selective serotonin reuptake inhibitor medications without any side effects and achieved the overall level of functioning.

The first case was a 61-year-old male who worked in graphic art. He developed severe neck pains and a magnetic resonance imaging scan (MRI) of cervical spines was recommended. After having the MRI, he developed recurrent unexpected panic attacks and anxiety about being in a closed place. Commuting to work caused marked distress and he subsequently avoided traveling in a bus, train, or car, and his daily activities were restricted. He initially refused to consider any medications that might limit his creativity. He agreed to a trial of sertraline, 50 mg/day, which was increased gradually to 100 mg. He noted significant improvement in intensity and frequency of his panic attacks and regained the ability to use the public transportation without any fear.

The second case involved a 61-year-old female who was a medical technician.

She suffered gastrointestinal reflux disease and underwent diagnostic upper endoscopy. Since then, she had been feeling anxious, and had poor concentration, frequent unpredicted panic attacks, and anxiety about being in a crowd. She could not resume her work and preferred to stay home to avoid situations that might provoke her anxiety. She was prescribed sertraline and was maintained on 150 mg/day. She reported lower anxiety level, became comfortable in public, and decided to look for a part-time job.

The third case was a 75-year-old male. He was a retired photographer and developed minor neurological deficits. Computed tomography scan (CT) of the head was conducted. After the image study, he started to have periods of intense fear and excessive worry cued by his presence in places from which escape might be difficult. He isolated himself at home, stopped going to church services and the senior citizen center, and suffered depression. He showed significant symptom response on paroxetine, 40 mg/day.