Lost in anxiety: treatment-resistant anxiety in older people

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Anxiety in the elderly is a really difficult issue to tackle.

Most anxiety disorders tend to start very early in life (Kessler et al. 2005) and can persist if not treated correctly. In later life they are probably more prevalent than previously thought as they can go unrecognised or misattributed to the process of aging (Wolitzky-Taylor et al. 2010) and they are a great source of distress in those affected.

I certainly see a lot of patients affected by this problem in the clinic and at the hospital. The problem is made worse by the fact that when someone is anxious, they often can suffer from another mental health problem; depression being the most frequent (Wolitzky-Taylor et al. 2010).

I have experience in treating working age adults and older adults and (from a purely anecdotal point of view) it always seemed to me that treating anxiety in older adults was harder. In younger adults if there are no serious comorbidities, like substance dependence, one can expect a reasonable rate of recovery. In older adults it seems to me to be harder to get the same results even when anxiety is presenting by itself.

The literature seems to suggest that pharmacological treatments are reasonably effective and may be more cost-effective than psychological treatments (Pinquart and Duberstein 2007). In fact, it is not clear how effective psychological treatments are in this population; in general they seem to be less effective than in younger adults (Gould et al. 2012).

It's estimated that 3-14% of older people have an anxiety disorder.

It’s estimated that 3-14% of older people have an anxiety disorder.

Treatment resistance in anxiety disorders

Regardless of whether they are harder to treat or not, it is not clear what to do when your first approach fails. There is no clear definition of treatment resistance in anxiety disorders (except OCD), which makes it harder to make clinical decisions. In the literature, this tends to be divided into refractory (no response at all) and resistant (partial, inadequate response). Psychological therapies when the first approach has failed do not seem to be the way forward in older adults, so how should I proceed if my patient does not respond well to treatment?

I came across a Health Technology Assessment entitled ‘Clinical effectiveness of interventions for treatment-resistant anxiety in older people: a systematic review.’ (Barton et al. 2014) and I thought ‘great, here’s the answer to my question’. Let us see what they found.

Methods

They looked through MEDLINE, MEDLINE In-Process and Other Non-Indexed citations, EMBASE, The Cochrane Library databases, PsycINFO and Web of Science from inception to September 2013. They also hand-searched through the references in relevant systematic reviews and looked at clinicaltrials.gov for ongoing studies.

They were looking for randomised controlled trials (RCTs) or prospective comparative observational studies (matched control studies, case series and case–control studies) evaluating pharmacological, psychological and alternative therapies for treatment-resistant anxiety in older people.

Two of the reviewers looked through all the studies independently using the following inclusion criteria:

  • Evaluate at least one intervention of interest
  • Include only people aged ≥65 years or reported data for a subgroup of patients aged ≥65 years
  • Compare the intervention with another intervention of interest
  • Report at least one of the following outcomes:
    • Reduction in symptoms of anxiety
    • Response defined as proportion of people experiencing ≥50% reduction in symptom score from baseline
    • Remission
    • Functional disability
    • Sleep quality
    • Change in symptoms of depression
    • Change in adherence to treatment
    • Change in quality of life
    • Change in carer outcomes
    • Change in adverse effects
On the whole this is a well conducted review, but the researchers could have done more to identify unpublished

On the whole this is a well conducted review, but the researchers could have done more to identify unpublished or ongoing research.

Results

Their search efforts yielded no studies. The problem seemed to be that most studies identified looked at adults of working age. Those studies that included adults aged 65 and over had mean ages much younger than 65 and they did not separate the results of the adults over 65.

Limitations

From the point of view of the design of the review itself, I thought their methodology was solid. They were not overly restrictive in their definition of treatment-resistance or the type of studies that they were willing to include in the review. They did search far and wide although I would have liked for them to contact authors of published trials to see if they have other ongoing studies. In particular I think it would have been worth while talking to those authors of trials that did include older adults and see if either they are planning to publish the results of that sub-sample or perhaps whether they are currently studying that population.

I would say that the evidence for non-treatment resistant anxiety disorders in older adults is not that abundant either and that the latest good quality meta-analysis was done to my knowledge in 2007 (Pinquart and Duberstein 2007). I wish they would have done a health technology assessment on the treatment of anxiety in older adults rather than limit themselves to studies on treatment-resistant anxiety.

Would a systematic review

Would a systematic review on the treatment of anxiety in older people have been a better idea?

Conclusions

Unfortunately I only have one conclusion to draw. When it comes to helping older people with difficult to treat anxiety we are still completely in the dark, having to rely on guesswork and our own long list of anecdotes. We could be doing everything completely wrong, which is a particularly hard reality to face.

I will try to be as candid as possible with my older patients. This is particularly challenging when I am also trying to foster hope and to get them to give me their trust and give whatever intervention we are trying a fair go.

Hopefully, soon we will have some solid evidence so I can talk to my patients with some conviction and give them a proper solution to their problem.

Links

Barton S, Karner C, Salih F, Baldwin D, Edwards SJ. Clinical effectiveness of interventions for treatment-resistant anxiety in older people: a systematic review (PDF). Health Technology Assessment, Volume 18 Issue 50 August 2014 ISSN 1366-5278

Gould RL, Coulson MC, Howard RJ. Efficacy of cognitive behavioral therapy for anxiety disorders in older people: a meta-analysis and meta-regression of randomized controlled trials. J Am Geriatr Soc. 2012 Feb;60(2):218-29. doi: 10.1111/j.1532-5415.2011.03824.x. Epub 2012 Jan 27.

Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication Arch Gen Psychiatry 2005;62:593–602. http://dx.doi.org/10.1001/archpsyc.62.6.593

Pinquart M, Duberstein PR. Treatment of anxiety disorders in older adults: a meta-analytic comparison of behavioral and pharmacological interventions. Am J Geriatr Psychiatry. 2007 Aug;15(8):639-51. [PubMed abstract]

Wolitzky-Taylor KB, Castriotta N, Lenze EJ, Stanley MA, Craske MG. Anxiety disorders in older adults: a comprehensive review. Depress Anxiety 2010;27:190–211. http://dx.doi.org/10.1002/da.20653

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Andres Fonseca

Andres Fonseca

Dr Andrés Fonseca is a consultant psychiatrist with 16 years of clinical experience. He is a member of the Royal College of Psychiatrists and dual qualified in old age and adult psychiatry. He holds an MSc in psychiatric research methodology from UCL and is honorary lecturer at UCL (division of psychiatry) and University of Roehampton (psychology department). He is co-founder and CEO of Thrive, a company that develops software to improve mental health combining computerised cognitive behavioural therapy and other eTherapy techniques with games and game dynamics to enhance engagement.

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