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The Aviator Draws Attention to Anxiety Disorders
in Older Adults
Until recently, anxiety disorders were believed to
decline with age
Dec. 30, 2004 - "The Aviator," the new film
starring Leonardo DiCaprio as Howard Hughes, has introduced or
reintroduced audiences around the world to the eccentric billionaire.
They see Hughes' love of flight, his courtship of women, the power of
his money, as well as his struggles with obsessive compulsive disorder (OCD).
Anxiety disorders are not uncommon in older adults.
Until recently, anxiety disorders were believed to
decline with age, according to the Anxiety Disorders Association of
America. But now experts are beginning to recognize that aging and
anxiety are not mutually exclusive: anxiety is as common in the old as
in the young, although how and when it appears is distinctly different
in older adults.
OCD is a type of anxiety disorder, in which
time-consuming obsession and compulsions significantly interfere with a
person's routine, making it difficult to work or to have a normal social
life or relationships.
There are many symptoms of the illness, called
behaviors, including cleaning, repeating, completing, checking, being
meticulous, avoiding and hoarding. Individuals with OCD can exhibit any
number of these symptoms, as well as other varieties of compulsions,
including excessive and ritualized praying, counting and list making.
Hughes' illness manifested in his inability to
leave his home and an overwhelming fear of being contaminated by germs,
leading him to live as a recluse. Although his symptoms were moderate in
the beginning, by the time he died in 1976, because of a lack of
effective treatment, the illness left him debilitated.
In the years since Hughes' death, there have been many great strides
made in understanding and treating OCD. Today, Hughes could be treated
with new medications and therapy that would enable him to lead a healthy
and productive life.
"Thirty years ago, OCD was a rare diagnosis and
those who had it were considered eccentric," said Michael Jenike, MD,
medical director of the Obsessive Compulsive Disorders Institute at
McLean Hospital (OCDI) . "Today, four million Americans have been
diagnosed with the illness, but the good news is that it can be
effectively treated through a combination of medication and behavioral
therapy."
For instance, says Jenike, treating someone like
Hughes requires a stay for several weeks in a residential treatment
setting, such as the OCDI, where the person can work one-on one in
treatment sessions with a behavioral therapist to identify target
obsessions, compulsions and avoidance behaviors. Once the behaviors are
identified, the individual and therapist can begin response-prevention
exercises.
"During these treatment sessions, patients are
asked to gradually expose themselves to things that they fear and thus
they gradually learn to control their anxiety," explains Jenike.
"Response-prevention exercises have proven extremely effective in
treating OCD."
In addition to behavior therapy, individuals with
OCD are often treated with medication. Selective serotonin reuptake
inhibitors (SSRIs), including Prozac, Paxil, Luvox, Celexa, and Zoloft,
are often successful in treating OCD.
"If we had these medications and a better
understanding treatment three decades ago, Hughes' OCD would have been
treated and people would be more apt to remember him as a pioneer rather
than as the eccentric billionaire who shut himself away from the world,"
said Jenike.
McLean Hospital, where Jenike is medical directoer,
claims the largest research program of any private, U.S. psychiatric
hospital. It is the largest psychiatric clinical care, teaching and
research facility of Harvard medical School, an affiliate of
Massachusetts General Hospital and a member of Partners HealthCare
System.
About
Anxiety in the Elderly
Anxiety Disorders Association of America -
http://www.adaa.org/
Research, on both the course and treatment of
anxiety in older adults, lags behind that of other mental conditions,
such as depression and Alzheimer's. Until recently, anxiety disorders
were believed to decline with age. But now experts are beginning to
recognize that aging and anxiety are not mutually exclusive: anxiety is
as common in the old as in the young, although how and when it appears
is distinctly different in older adults.
Anxiety disorders in the elderly population are
real and treatable, just as they are in younger people. Another
commonality between old and young is the high incidence of depression
with anxiety. Depression and anxiety go together in the elderly, as they
do in the young, with almost half of those with major depression also
meeting the criteria for anxiety and about one-quarter of those with
anxiety meeting criteria for major depression. As with younger persons,
being a woman and having less formal education are risk factors for
anxiety in older adults.
Most older adults with an anxiety disorder had one
when they were younger. What "brings out" the anxiety are the stresses
and vulnerabilities unique to the aging process: chronic physical
problems, cognitive impairment and significant emotional losses.
Late-life anxiety disorders have been
underestimated for several reasons, according to experts. For example,
older patients are less likely to report psychiatric symptoms and more
likely to emphasize their physical complaints, and some major
epidemiological studies have excluded
Generalized Anxiety Disorder, one of the most prevalent
anxiety disorders in older adults.
Recognizing Anxiety in the Aging
Recognizing an anxiety disorder in an older person poses several
challenges. Aging brings with it a higher prevalence of certain medical
conditions, realistic concern about physical problems, and a higher use
of prescription medications. As a result, separating a medical condition
from physical symptoms of an anxiety disorder is more complicated in the
older adult. Diagnosing anxiety in individuals with dementia can be
difficult, too: agitation typical of dementia may be difficult to
separate from anxiety; impaired memory may be interpreted as a sign of
anxiety or dementia, and fears may be excessive or realistic depending
on the person's situation.
Treatment
Diagnosis and treatment in most cases should start with the primary care
physician. Many older people feel more comfortable opening up to a
doctor with whom they already have a relationship. Also, if they already
trust their primary care physician, the chances are increased that they
will go along with treatment or a referral to a mental health
professional."
Both medication and psychosocial therapies are used to treat anxiety in
older persons, although clinical research on their effectiveness is
still limited. Anti-depressants (specifically the selective serotonin
reuptake inhibitors or SSRIs), rather than anti-anxiety medication (such
as the benzodiazepines), are the preferred medication for most anxiety
disorders. Cognitive Behavioral Therapy (CBT) is being used increasingly
to reduce anxiety in older adults. CBT may involve relaxation training,
cognitive restructuring (replacing anxiety-producing thoughts with more
realistic, less catastrophic ones) and exposure (systematic encounters
with feared objects or situations). CBT can take up to several months
and has no side effects.
Success in treating anxiety in the older patient
depends, in part, on a partnership between the patient, the family and
the doctor. Everyone needs to agree on what the problem is and make a
commitment to stick with treatment until the patient can return to
normal functioning. Family members may need to advocate for the older
person, ensuring that issues encountered during treatment-such as drug
side effects-are dealt with promptly.
See "Guide
to Treatment"
Diagnosing Anxiety in the Aging
Often the elderly are reluctant to report psychiatric problems. To help
identify anxiety it may be useful to phrase questions in the following
way:
To identify anxiety:
-
Have you been concerned about or fretted over a
number of things?
-
Is there anything going on in your life that is
causing you concern?
-
Do you find that you have a hard time putting
things out of your mind?
-
To identify how and when physical symptoms
began:
-
What were you doing when you noticed the chest
pain?
-
What were you thinking about when you felt your
heart start to race?
-
When you can't sleep, what is usually going
through your head?
Adapted from Ariel J. Lang, Ph.D., and Murray B.
Stein, M.D., "Anxiety Disorders: How to Recognize and Treat the Medical
Symptoms of Emotional Illness," Geriatrics. 2001 May; 56 (5): 24-27,
31-34.
Worried about an Aging Parent?
Talking to your elderly parent or loved one about any changes in their
lives is one of the best ways to find out if there is a problem. Ask
about any changes you notice in the following:
-
Daily routines and activities. Is Grandma
refusing to do previously routine activities or avoiding social
situations she used to enjoy?
-
Worries. Does Dad seem to have more worries
than before and do those worries seem out of proportion to reality
(such as a real threat to his safety).
-
Medication. Has Mom recently started taking
another medicine? Is she using more of a particular medication than
before? Medication side effects (such as breathing problems,
irregular heartbeat, or tremors) can simulate symptoms of anxiety.
Also, an increased use of medication (or alcohol) may indicate an
attempt to "self-medicate."
-
Overall mood. Depression and anxiety often
occur together. Tearfulness, apathy, and a loss of interest in
formerly enjoyable activities are possible signs of depression.
Take an Anxiety Disorders Self-Test for Family Members
Find a Treatment Provider
About Obsessive-Compulsive
Disorder (OCD)
Obsessive-Compulsive Disorder is characterized by
uncontrollable obsessions and compulsions which the sufferer usually
recognizes as being excessive or unreasonable. Obsessions are recurring
thoughts or impulses that are intrusive or inappropriate and cause the
sufferer anxiety. Some common obsessions are:
-
Thoughts about contamination, for example, when
an individual fears coming into contact with dirt, germs or
"unclean" objects;
-
Persistent doubts, for example, whether or not
one has turned off the iron or stove, locked the door or turned on
the answering machine;
-
Extreme need for orderliness;
-
Aggressive impulses or thoughts, for example,
being overcome with the urge to yell 'fire' in a crowded theater.
Compulsions are repetitive behaviors or rituals
performed by the OCD sufferer, performance of these rituals neutralize
the anxiety caused by obsessive thoughts, relief is only temporary.
Compulsions are incorporated into the person's daily routine and are not
always directly related to the obsessive thought, for example, a person
who has aggressive thoughts may count floor tiles in an effort to
control the thought. Some of the most common compulsions are:
-
Cleaning. Sufferers concerned with germs and
contamination tend to clean constantly, either repeatedly washing
their hands, showering, or constantly cleaning their home;
-
Checking. Individuals may check several or even
hundreds of times to make sure that stoves are turned off and doors
are locked;
-
Repeating. Some repeat a name, phrase or action
over and over;
-
Slowness. Some individuals may take an
excessively slow and methodical approach to daily activities, they
may spend hours organizing and arranging objects;
-
Hoarding. Hoarders are unable to throw away
useless items, such as old newspapers, junk mail, even broken
appliances; sometimes the hoarding reaches the point that whole
rooms are filled with saved items.
In order for OCD to be diagnosed, the obsessions
and/or compulsions must take up a considerable amount of the sufferers
time, at least one hour every day, and interfere with normal routines (a
person, for example, who cannot make left turns when driving),
occupational functioning, social activities, or relationships. OCD can
interfere with one's ability to concentrate, and it is not uncommon for
a sufferer to avoid certain situations, for example, someone who is
obsessed with cleanliness may be unable to use public restrooms.
Onset of OCD is usually gradual and most often
begins in adolescence or early adulthood. Unlike adults, children with
OCD do not realize that their obsessions and compulsions, which are most
often of the washing, checking, and ordering variety, are excessive.
Take an OCD Self-Test
Treatment Options
Find a Treatment Provider
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