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Anxiety is the most common psychological disorder affecting adults in the United States. In older people, it’s associated with considerable distress as well as ill health, diminished quality of life and elevated rates of disability.
Yet when the US Preventive Services Task Force, an independent, influential panel of experts, suggested last year that adults be screened for anxiety, it left out one group — people 65 and older.
The major reason the task force cited in draft recommendations issued in September: “(T)he current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety” in all older adults. (Final recommendations are expected later this year.)
For the first time, US task force proposes recommendation to screen for anxiety in adults. The task force noted that questionnaires used to screen for anxiety may be unreliable for older adults. Screening entails evaluating people who don’t have obvious symptoms of worrisome medical or psychological conditions.
“We recognize that many older adults experience mental health conditions like anxiety,” and “we are calling urgently for more research,” said Lori Pbert, associate chief of the preventive and behavioral medicine division at the University of Massachusetts Chan Medical School and a former task force member who worked on the anxiety recommendations.
This “we don’t know enough yet” stance doesn’t sit well with some experts who study and treat older people with anxiety. Dr. Carmen Andreescu, an associate professor of psychiatry at the University of Pittsburgh, called the task force’s position baffling because “it’s well-established that anxiety isn’t uncommon in older adults and effective treatments exist.”
“I cannot think of any danger in identifying anxiety in older adults, especially because doing so has no harm and we can do things to reduce it,” said Dr. Helen Lavretsky, a psychology professor at UCLA.
In a recent editorial in JAMA Psychiatry, Andreescu and Lavretsky noted that only about one-third of seniors with generalized anxiety disorder — intense, persistent worry about everyday matters — receive treatment. That’s concerning, they said, considering evidence of links between anxiety and stroke, heart failure, coronary artery disease, autoimmune illness and neurodegenerative disorders such as dementia.
Other forms of anxiety commonly undetected and untreated in older adults include phobias (such as a fear of dogs), obsessive-compulsive disorder, panic disorder, social anxiety disorder (a fear of being assessed and judged by others) and post-traumatic stress disorder.
The smoldering disagreement over screening calls attention to the significance of anxiety in later life — a concern heightened during the Covid-19 pandemic, which magnified stress and worry among older people. Here’s what you should know.
Anxiety is common
According to a book chapter published in 2020, authored by Andreescu and a colleague, up to 15% of people 65 and older who live outside nursing homes or other facilities have a diagnosable anxiety condition.
As many as half have symptoms of anxiety — irritability, worry, restlessness, decreased concentration, sleep changes, fatigue, avoidant behaviors — that can be distressing but don’t justify a diagnosis, the study noted.
Most senior citizens with anxiety have struggled with this condition since earlier in life, but the way it manifests may change over time. Specifically, older adults tend to be more anxious about issues such as illness, the loss of family and friends, retirement and cognitive declines, experts said. Only a fraction develop anxiety after turning 65.
Anxiety can be difficult to identify in older adults
Older adults often minimize symptoms of anxiety, thinking “this is what getting older is like” rather than “this is a problem that I should do something about,” Andreescu said.
Also, they are more likely than younger adults to report “somatic” complaints — physical symptoms such as dizziness, fatigue, headaches, chest pain, shortness of breath and gastrointestinal problems — that can be difficult to distinguish from underlying medical conditions, according to Gretchen Brenes, a professor of gerontology and geriatric medicine at Wake Forest University School of Medicine.
Some types of anxiety or anxious behaviors — notably, hoarding and fear of falling — are much more common in older adults, but questionnaires meant to identify anxiety don’t typically ask about those issues, said Dr. Jordan Karp, chair of psychiatry at the University of Arizona College of Medicine in Tucson.
When older adults voice concerns, medical providers too often dismiss them as normal, given the challenges of aging, said Dr. Eric Lenze, head of psychiatry at Washington University School of Medicine in St. Louis and the third author of the recent JAMA Psychiatry editorial.
Simple questions can help identify whether an older adult needs to be evaluated for anxiety, he and other experts suggested: Do you have recurrent worries that are hard to control? Are you having trouble sleeping? Have you been feeling more irritable, stressed or nervous? Are you having trouble with concentration or thinking? Are you avoiding things you normally like to do because you’re wrapped up in your worries?
Stephen Snyder, 67, who lives in Zelienople, Pennsylvania, and was diagnosed with generalized anxiety disorder in March 2019, would answer “yes” to many of these queries. “I’m a Type A personality and I worry a lot about a lot of things — my family, my finances, the future,” he told me. “Also, I’ve tended to dwell on things that happened in the past and get all worked up.”
Treatments are effective
Psychotherapy — particularly cognitive behavioral therapy, which helps people address persistent negative thoughts — is generally considered the first line of anxiety treatment in older adults. In an evidence review for the task force, researchers noted that this type of therapy helps reduce anxiety in older people seen in primary care settings.
Also recommended, Lenze noted, is relaxation therapy, which can involve deep breathing exercises, massage or music therapy, yoga and progressive muscle relaxation.
Because mental health practitioners, especially those who specialize in geriatric mental health, are extremely difficult to find, primary care physicians often recommend medications to ease anxiety.
Two categories of drugs — antidepressants known as SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) — are typically prescribed, and both appear to help to older adults, experts said.
Frequently prescribed to older adults, but to be avoided by them, are benzodiazepines, a class of sedating medications such as Valium, Ativan, Xanax, and Klonopin. The American Geriatrics Society has warned medical providers not to use these in older adults, except when other therapies have failed, because they are addictive and significantly increase the risk of hip fractures, falls and other accidents, and short-term cognitive impairments.
注释：
Hispanic: adj
表示"西班牙的；"，means "related to a Spanish-speaking people or culture"，如：Hispanic immigration has brought more Catholics. 西班牙移民带来了更多的天主教徒。
Psychiatry: n
表示" 精神病学"，means "the branch of medicine dealing with the diagnosis and treatment of mental disorders"，如：Psychiatry has the character of transdiscipline.精神病学具有跨学科性质。
neurodegenerative: adj
表示" 神经变性的"，如：Alzheimer's and Parkinson's are neurodegenerative diseases in which cell damage and degeneration is seen in certain specific areas of the brain. 早老性痴呆症及帕金森氏症神经退化疾病，是脑的一些特殊部位的细胞出现损坏及退化现象。
Smolder: v
表示" 闷烧；压抑"，means "burn slowly and without a flame;showing scarcely suppressed ange"，如：The wood was smoldering in the fireplace. 木柴在壁炉中闷烧。These people give in easily, but their hidden resentment can smolder into anger and rage. 这类人们容易屈服，但是他们隐藏的怨恨会变为愤怒。
Manifest: v
表示"显示；证实"，means " show clearly"，如：Opportunities will manifest in ways you never even dreamed of. 机会的到来出乎你的意料。
somatic: adj
表示"肉体的；体壁的"，means "affecting or characteristic of the body as opposed to the mind or spirit;"，如：The computerists make no real distinction between behavioral learning and somatic learning.计算机专家没有真正区别行为的学习和肉体的学习。
gastrointestinal: adj
表示"胃肠的"，means "of or relating to the stomach and intestines"，如：Gastrointestinal cancer is uncommon in dogs. 消化道癌在犬类中不常见。
gerontology: n
表示" 老年学"，如：Gerontology has suddenly become popular. 老年学突然变得受欢迎了。
geriatric: adj
adj表示"老年医学的；老人的"，means "of or relating to the aged"，如：Geriatric services are provided in all acute hospitals. 目前，所有急症医院均设有老人科服务。
hoard: v
表示"囤积"，means " collect (sth in quantity) and store it away"，如：A large number of animals hoard plant seeds. 许多动物有贮藏植物种子的行为。
Psychotherapy: n
表示"心理疗法"，如：The psychotherapy is carried out in small interactive groups. 这种心理治疗是在一起活动的小组之间进行的。
Antidepressants: n
表示"抗抑郁药"，means "any of a class of drugs used to treat depression;"，如：The cost of New antidepressants stepped up steadily in clinical use. 新型抗抑郁药的临床使用价格稳固上升。
serotonin：n
表示"血清素"，如：Once in the brain, the tryptophan is converted to serotonin. 一旦进入大脑，色氨酸会被转化成血清素。
reuptake: v
表示"再摄取"，means "a process of using up or consuming again"，如：These antidepressants are known as selective seotonin reuptake inhibitors. 这些抗抑郁药物被称作选择性血清素再摄取抑制剂。
norepinephrine: n
表示"去甲肾上腺素"，如：Some hypertensive patients have defective storage of norepinephrine, thus permitting more to circulate. 有些高血压病人存在去甲肾上腺素贮存缺陷，造成较多的去甲肾上腺素进入循环。
impairment: n
表示"损伤"，means "a symptom of reduced quality or strength"，如：Put it in the flour without impairment of its surface.把它放入面粉中且不损伤它的表面。
中文简要说明：
焦虑与痛苦情绪、健康不佳、生活质量低落、身障率提高有关，然而很多长者不把自身焦虑症状当一回事或未获医护人员留意，因而错失治疗先机或引发中风、失智等其他问题。美国精神医学界学者疾呼，第一线人员不该忽略长者焦虑症状，5个简单的问题可能就会找出需要帮助的老人家。
美国有线电视新闻网报导，美国预防服务工作小组（U.S. Preventive Services Task Force）去年执行成人焦虑筛检时漏掉65岁以上族群，这让后来提出的指南草案参考价值降低。美国医学会精神病学期刊（JAMA Psychiatry）最近一篇评论提及，美国出现广泛性焦虑症（Generalized anxiety disorder，GAD）的65岁以上长者，仅约3分之1接受治疗。广泛性焦虑症患者会对日常生活小事持续过度忧虑。也就是说，多达3分之2的年长GAD患者未获治疗，这个比例令学者忧心。已有证据显示，焦虑与中风、心脏衰竭、冠状动脉疾病、自体免疫疾病、失智等神经退化障碍有关。
除了GAD，恐惧特定事物、强迫症、恐慌症、社交恐惧、创伤后压力症候群（PTSD），都是焦虑的表现形式。新冠肺炎疫情大流行以来，所有人内心的忧虑与压力随之加大，老人家也不例外。专家说，老人对于疾病、失去亲友、退休、认知退化等情形会特别焦虑。
美国匹兹堡大学精神病学助理教授安德里斯古（Carmen Andreescu）与同侪研究发现，有焦虑症状的长者多达半数可能已觉得很难受却未获诊断。症状包括：暴躁易怒、忧虑、坐立难安、注意力下降、睡眠出现变化、疲惫、回避倾向。绝大多数苦于焦虑的长者，往往在尚未步入老年之前就有征兆，但症状表现可能随着时间改变。极少部分的人过了65岁才出现焦虑问题。
安德里斯古指出，老年人常刻意淡化焦虑症状、告诉自己「年纪大了就是这么回事儿」，很少会把焦虑当成问题看待。美国北卡罗莱纳州维克森林大学医学院（Wake Forest University School of Medicine）老年学暨老年医学教授布雷恩（Gretchen Brenes）说，年长者比年轻人更常抱怨生理层面的不适，导致难以辨识潜在健康问题。
亚利桑那大学医学院精神病学主任卡普（Jordan Karp）指出，有些焦虑的表现类型或行为举止在老人家身上更常发现，但很多筛检问卷只字未提。圣路易华盛顿大学医学院精神病学主任兰兹（Eric Lenze）提及，老年人表达担忧时，医疗人员往往觉得没什么大不了，忽视可能有问题存在。兰兹说，几道简单的问题即有助于找出哪些长者让需要接受焦虑评估。例如：
「是否一再出现难以压抑的愁绪？」
「有没有难以入睡的情况？」
「会不会觉得比以前更暴躁、紧张或不安？」
「注意力、思考无法集中？」
「以前喜欢的事物，现在因为忧心忡忡变得不想接触了？」
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