Anxiety is a natural adaptation phenomenon: in response to danger our body will change its functioning to prepare itself to react in the event of danger. But when the danger does not exist or the signs are too invasive in an individual’s daily life, then we will speak of anxiety or anxiety disorders.
What is anxiety?
The expression of anxiety is a little different in older people. In addition to irritability, impulsivity or difficulty concentrating which are common symptoms in most anxious people, certain signs are more specific after the age of 75. “We observe more somatization, gastrointestinal complaints but also sleeping troubles and appetite. With insomnia and excessive nocturnal ruminations which generate awakenings”, explains Anne-Julie Vaillant-Ciszewicz, clinical psychologist. Elderly people can also suffer from headaches and dizziness, but they are more rarely affected by specific phobias (fear of flying, fear of spiders, etc.), which can be present in younger patients.
In elderly people who present with neurocognitive disorders (Alzheimer’s disease and related diseases), anxiety can result in psycho-behavioral disorders (wandering, aggressiveness, verbal or motor agitation). As the High Authority of Health (HAS) points out, these symptoms must be identified and managed with the help of non-drug interventions,
What are the symptoms of generalized anxiety?
In generalized anxiety disorder, anxiety will take over all areas of life. “The person is blocked from leaving the house, everything is a source of anxiety. The person is unable to relax and will avoid all situations that generate anxiety. In the elderly, this is an additional factor of isolation and loss of autonomy.”, observes the psychologist.
Anxiety and depression in the elderly: how to distinguish them?
Depression and anxiety can be associated, but they are two different entities. “There are similarities in physical and emotional symptoms, but it is different in thoughts and beliefs. In depression, we observe an amotivational syndrome, a persistent feeling of sadness and/or despair, the person no longer wants to move or do things, they have the impression that life has no meaning (loss of interest). It can be sad but it is not systematic, there are forms of depression that we call ‘masked’ in older people. With anxiety, we are more concerned with fear, excessive dysfunctional beliefs which result in somatic signs and which affect the person themselves and/or the outside world.”, explains the psychologist.
Why do we become anxious as we age?
We notice in fact that anxiety is more present among older people. Several factors can explain it. There are of course people who have always had anxiety, even when they were young. Just like those who have other co-occurring psychiatric illnesses, or who have a history of depression, these people are at greater risk of suffering from anxiety as they age. They must therefore be the subject of particular attention.
Another factor is linked to physical changes due to age (aging of the body, health problems, questions about death, etc.). “Older people are in the latter part of their lives and anxiety is often linked to Autonomy lossto the fear of aging and illness”, observes Anne-Julie Vaillant-Ciszewicz. The latter also emphasizes the difficult milestone that the transition to retirement can represent. “There is a loss of reference points, of social links and we see a lot of changes at that time. If there are no plans for the future, these questions can generate anxious issues”, she explains.
Post-traumatic stress: older people also affected
“We talk a lot about the disorder of post-traumatic stress in young adults but this is an area that is still under-investigated in the elderly. We often wrongly think that this is a common sign of anxiety.”, indicates the psychologist. In reality, significant life events (bereavement, sexual assault, war-related trauma, etc.) can reappear very late, sometimes 10, 20 or 30 years later when they have not been emotionally digested. This may particularly be the case in people who suffer from severe neurocognitive disorders such as Alzheimer’s disease. With the loss of cognitive functions, emotions come to the fore and all these traumas come to the fore and could even result in behavioral disorders in Alzheimer’s disease and related illnesses.
What are the scales for diagnosing anxiety?
For depression, the reference scale is the Geriatric Depression Scale (GDS): 5, 15 or 30 items. “The patient answers the questions or, if he suffers from cognitive disorders, relatives or the healthcare team complete the questionnaire”, explains Anne-Julie Vaillant-Ciszewicz. The latter specifies that for anxiety, the Hamilton scale is used, even if it is not specific to elderly people. No diagnostic scale specific to anxiety in the elderly has been validated in French. But there is one in Canada, the GAI (Geriatric Anxiety Inventory), which is best suited to people over 70 years old. In other cases, the neuropsychiatric inventory (NPI) can be used with healthcare teams or relatives with the “anxiety” item.
Anxiety in the elderly: who to consult?
The attending physician is the preferred contact at the start of treatment. Sometimes, the person consults on their own, but it often happens that the alert comes from those around them. “In the case of mild to moderate anxiety, when the doctor does not wish to give psychotropic medication straight away, he or she refers to the psychologist who can carry out appropriate psychotherapy” explains Anne-Julie Vaillant-Ciszewicz.
The latter specifies, however, that if it is severe anxiety and/or the person has a psychiatric history, the general practitioner will refer the patient to a psychiatrist. But medication and psychotherapy follow-up are not incompatible, on the contrary. “A little medication is sometimes necessary to progress in psychotherapy. But the objective is to be able to stop it in the end or in any case reduce it”, confirms the specialist.
Treatment and management of anxiety in the elderly
Cognitive and behavioral therapies (CBT) have a high level of evidence, they are effective and recommended. After taking stock of the life history and the reason for consultation, the psychologist uses the scales that we have mentioned to make a diagnosis, also supported by the doctor. “We develop a therapeutic plan with the person, it is truly collaborative work, around the management of emotions. We carry out a functional analysis of the situation to see what can be changed and improved.”, explains Anne-Julie Vaillant-Ciszewicz.
The therapy also offers work on dysfunctional beliefs and thoughts. “CBT allows precisely this cognitive restructuring work which aims to modify patients’ thought patterns.”, explains the psychologist. The work focuses on emotions, thoughts but also behaviors. The sphere of behavior is very important. “Let’s take a patient who feels very anxious because he is afraid of falling in the street (post-fall syndrome). We will help him to expose himself to this situation through imagination, in the office, then in the street so that he stops avoiding situations that generate anxiety. These are therefore active therapies, with exercises to be done between sessions.”, explains Anne-Julie Vaillant-Ciszewicz.
“We also offer the person relaxation and cardiac coherence exercises to work on their anxiety and there is also work on lifestyle, in particular on sleep and diet.she adds.
Other tools may be used depending on patient needs. Virtual reality, for example, makes it possible to work directly in concrete situations in the office. As for EMDR (integrative and emotional psychotherapy), it can prove very useful in patients who have signs of psychotrauma and whose anxiety is linked to negatively charged memories.
How to reassure an anxious elderly person? The role of the entourage
The role of those around you is very important. When there is a reduction in social bonds, no more feeling of social usefulness, it is the beginning of difficulties and the door opens to anxiety disorders and depression. Those around you are also there to offer alternatives and motivate people to go out. “When we receive an elderly person, it is good to have the opinion of the family, the children, the spouse, to have another perspective”, observes the psychologist. “Our role is also to provide psychoeducation for loved ones who often need to be supported and do not always understand what their parent is going through.”, she concludes.
Thanks to Anne-Julie Vaillant-Ciszewicz, doctor of psychology and clinical psychologist at Nice University Hospital, specializing in gerontology.
Thanks to the French Society of Geriatrics and Gerontology (SFGG).