Late-life Anxiety Disorders: A Review

Abstract

Anxiety disorders are a major clinical problem in late life; estimated prevalence rates vary from 6% to 10%, and the disease impact is considerable and equal to that of depression. However, anxiety disorders often remain undetected and untreated in older adults. This discrepancy may be accounted for by a combination of patient variables (eg, a lack of help-seeking behavior and long duration of illness) and variables related to current clinical practice (eg, a lack of knowledge regarding late-life anxiety and ageism). Because anxiety disorders usually have an age at onset earlier in life, patients and mental health professionals may be inclined to attribute the anxiety and avoidance symptoms to personality factors instead of a treatable syndrome. Comorbidity with other psychiatric disorders, such as depressive disorder, may complicate the appropriate diagnosis. Identification may be further obscured because the phenomenology of anxiety disorders in older adults tends to differ from the phenomenology in younger adults. Randomized controlled trials have yielded support for the effectiveness of cognitive-behavioral therapy and serotonergic antidepressants. However, both treatments seem hampered by relatively high dropout rates, and the available data are based primarily on a relatively healthy, well-educated, and "young" older population. The dissemination of knowledge regarding late-life anxiety disorders is vital, as evidence-based treatments are available but are still rarely implemented.

Full text

Late-life Anxiety Disorders: A Review
Josien Schuurmans &Anton van Balkom
#Springer Science+Business Media, LLC 2011
Abstract Anxiety disorders are a major clinical problem in
late life; estimated prevalence rates vary from 6% to 10%,
and the disease impact is considerable and equal to that of
depression. However, anxiety disorders often remain
undetected and untreated in older adults. This discrepancy
may be accounted for by a combination of patient variables
(eg, a lack of help-seeking behavior and long duration of
illness) and variables related to current clinical practice (eg,
a lack of knowledge regarding late-life anxiety and ageism).
Because anxiety disorders usually have an age at onset
earlier in life, patients and mental health professionals may
be inclined to attribute the anxiety and avoidance symptoms
to personality factors instead of a treatable syndrome.
Comorbidity with other psychiatric disorders, such as
depressive disorder, may complicate the appropriate diag-
nosis. Identification may be further obscured because the
phenomenology of anxiety disorders in older adults tends to
differ from the phenomenology in younger adults. Ran-
domized controlled trials have yielded support for the
effectiveness of cognitive-behavioral therapy and seroto-
nergic antidepressants. However, both treatments seem
hampered by relatively high dropout rates, and the available
data are based primarily on a relatively healthy, well-
educated, and “young”older population. The dissemination
of knowledge regarding late-life anxiety disorders is vital,
as evidence-based treatments are available but are still
rarely implemented.
Keywords Anxiety disorders .Anxiety .Aged .Older
adults .Late life .Review
Introduction
Until recently, the concept of anxiety in late life had been
disregarded in clinical practice and the scientific commu-
nity. This disregard is still often thought to be justified by
the fact that older adults with anxiety disorders rarely
present to mental health care settings. In light of these
circumstances, it is understandable that clinicians and
researchers alike used to believe that anxiety disorders
were not very prevalent in late life. However, recent
epidemiologic studies have shown that prevalence rates of
late-life anxiety disorders are equal to or may even exceed
prevalence rates of depressive disorders in late life.
Estimates of prevalence rates vary widely due to conceptual
and methodologic differences between studies, but most
estimates of current (6-month to 1-year) prevalence rates
fall within the range of 6% to 10% (Table 1)[1].
When examining prevalence rates for specific types of
anxiety disorders, generalized anxiety disorder (GAD) is
often referred to as the most common late-life anxiety
disorder [2]. When reviewing the literature, one might get
the idea that GAD is the only late-life anxiety disorder
worthy of discussion. However, a closer look at the
available research data shows considerable variation in the
prevalence estimates of this disorder, ranging from 1% [3]
to 7.3% [2]. Which of these numbers is closer to the truth is
a question that has yet to be answered. It has been
suggested that due to the diffuse nature of the DSM-IV
J. Schuurmans (*)
Department for Older Adults, GGZinGeest,
Osdorpplein 880,
1068 TD, Amsterdam, The Netherlands
e-mail: j.schuurmans@ggzingeest.nl
A. van Balkom
Academic Department, VU Medical Centre/GGZinGeest and
EMGO+Institute,
Amsterdam, The Netherlands
e-mail: t.balkom@ggzingeest.nl
Curr Psychiatry Rep
DOI 10.1007/s11920-011-0204-4

criteria for GAD, it serves as a convenient miscellaneous
category for other more specific anxiety disorders that may
simply be overlooked in older adults.
As for other types of anxiety disorders, the current state of
knowledge indicates that panic disorder, agoraphobia, hypo-
chondriasis, and obsessive–compulsive disorder are probably
equally prevalent in older adults as in the general population
of adults younger than 65 years of age. Specific phobias and
social phobia appear to be less prevalent in older adults, but as
prevalence rates in epidemiologic studies are always an
estimate, no firm conclusions can be drawn.
Burden of Disease
Clinical opinion used to proclaim that anxiety disorders in
late life were not very serious or incapacitating. In fact,
recent studies show that the opposite is true: late-life
anxiety has been proven to be just as disabling as late-life
depression [4,5]. Use of somatic health care services (visits
to the general practitioner and to medical specialists,
hospital admissions) is increased in anxious older adults,
while the appropriate use of mental health care services is
low [5]. Furthermore, findings from recent studies suggest
that anxiety is associated with an increased mortality rate in
older men [6] and in frail or chronically ill older adults [7,
8]. Among older adults who have suffered a myocardial
infarction, anxiety has been found to be predictive of
recurrent cardiac events and increased use of health care
services [8,9]. Anxiety disorders also have been found to
be more prevalent in chronically ill older adults [10].
Comorbidity with Depression
Anxiety in late life has been thought to be comorbid with
depression or a symptom of mixed anxiety/depression.
Indeed, comorbidity between anxiety and depression is
high in mixed-age and older populations. However, recent
findings indicate that most older adults (74%) with an
anxiety disorder do not suffer from comorbid depression,
while depression without comorbid anxiety is much less
common in late life [11]. Furthermore, mixed anxiety/
depression seems to be less prevalent in late life than major
depression or anxiety disorders [12]. Comorbidity between
anxiety and depression appears to be higher among older
adults living in residential care facilities [13]. This study
reportedaprevalencerateof4.8%forpureanxiety
disorders without comorbid depression, 17.1% for pure
depression without comorbid anxiety, and 5.1% for comor-
bid anxiety disorders with depression. The higher incidence
of depression in this group may be explained by several
factors, including adaptation to a new residential environ-
ment and experiences of loss, which are more common in
very old adults and frail older adults (eg, loss of loved ones,
loss of control of bodily functions, loss of autonomy).
Anxiety and Dementia in Late Life
Anxiety symptoms, especially late-onset anxiety disorders,
often have been labeled as a prelude to or a sign of
dementia. This is a seemingly plausible hypothesis, but
anxiety disorders and symptoms do not seem to be
predictive of cognitive decline in longitudinal studies [14].
Although symptoms of agitation and anxiety frequently
accompany dementia, the prevalence of anxiety disorders
among individuals with dementia is comparable to the
prevalence of anxiety disorders in the general older adult
population [15]. In a report on the comorbidity of anxiety
disorders in older adults in The Netherlands, no significant
association was found between the presence of an anxiety
disorder and the presence of cognitive impairment [16]. A
recent study of the association between dementia and
anxiety even reported that symptoms of generalized anxiety
are less common in older adults suffering from dementia
Table 1 The 6-month prevalence of anxiety disorders in mixed-age populations vs older adults
Diagnosis Mixed-age populations (age <65 years), % Older adults (age >55 years), %
All anxiety disorders 12.4 6–10
Panic disorder 2.2 1–2
Agoraphobia 0.8–1.6 0.65
Simple phobia 7.1 4
Social phobia 4.8 1.3
Generalized anxiety disorder 1.2 1–7.3
Obsessive–compulsive disorder 0.9 0.6
Post-traumatic stress disorder 0.4 0.9
Hypochondriasis 4.2–6.3 4.2–6.3
Data from Beekman et al. [2], Kessler et al. [18], and Bijl et al. [48]
Curr Psychiatry Rep

[17]. On a different note, one may wonder whether it is
appropriate to diagnose anxiety disorders according to the
DSM-IV criteria in those who have passed the initial stages
of a dementia process. To put it differently, the symptoms
accompanying or preceding the onset of dementia are
presumably very different in nature than anxiety disorders
classified according to the DSM-IV criteria. When trying to
establish whether anxiety symptoms could be a sign of
cognitive decline, it is important to investigate closely the
etiology of the anxiety symptoms. Most anxiety disorders
in late life have an onset in early or middle adulthood [18],
which makes it highly unlikely that there is any connection
with dementia.
Age at Onset
There has been some debate over age at onset in late-life
anxiety disorders. In some studies, GAD in late life is
presumed to have a bimodal distribution, with equal rates of
early onset (before age 50 years) and late onset (after age
50 years) [19,20]. However, these studies established age
at onset in patients who participated in intervention studies
of late-life anxiety. Those with a shorter duration of anxiety
symptoms are probably more inclined to seek help, and
these data may not be representative of late-life anxiety
disorders in general. In a recent large-scale epidemiologic
survey, a late onset of anxiety was found to be much less
common [18]. Seventy-five percent of all anxiety disorders
are said to have an onset before the age of 21 years, and
95% of all anxiety disorders have an onset before age
51 years. Late onset does appear to be more common for
GAD than for other anxiety disorders, with 10% of GAD
cases commencing after age 58 years.
Identification of and Referral for Late-life Anxiety
Disorders
In light of the high prevalence of anxiety in late life, it is
puzzling that only a very small minority of older adults who
are referred to mental health care settings are diagnosed
with an anxiety disorder. Several factors may contribute to
the fact that anxiety disorders are not easily identified in
older adults.
One factor that may contribute to the lack of appropriate
identification and referral is a lack of help-seeking behavior
in older anxiety patients. Because most anxiety disorders
appear to have an onset before the age of 21 years [18], one
may conclude that most patients have been struggling with
anxiety symptoms for decades. Because effective treat-
ments for anxiety have only been developed in the past 20
to 30 years, it is understandable that older adults with a long
duration of symptoms who have never been (adequately)
treated may not be suddenly inclined to start demanding
treatment for their ailment. This is particularly relevant
because older adults are probably less informed on the
existence of appropriate treatments.
Anxiety in late life also may go unnoticed through
effective avoidance behavior. It is probably easier for older
adults to avoid certain activities because they have fewer
obligations than younger adults, and society readily accepts
that older adults may be incapable of physical exercise or of
doing their own shopping. People surrounding an older
individual (eg, children, neighbors) are probably more
likely to relieve the older adult of the burden of certain
tasks than they would be when confronted with a younger
adult with similar problems. Although it may be well-
intended, this helpfulness may contribute to the onset and
persistence of avoidance behavior and the camouflaging of
anxiety symptoms.
Another related factor contributing to the lack of appropri-
ate identification of and referral for anxiety in late life lies
within the (mental) health care profession rather than within
the anxious older adult. Ageism is probably involved in the
fact that anxiety and avoidance behavior in late life is often
interpreted as “normal”or “realistic”and therefore deemed
untreatable [21]. For example, when an older person’s
mobility is affected by arthritis or other age-related ailments,
or when an older person trips and falls in the street, it is often
considered an appropriate response for that person to be too
anxious to leave the house or to travel by bus, train, or tram.
On the same note, when we are confronted with an older
person who obsesses over the possibility of becoming
seriously ill or cognitively impaired, our own fears of what
might happen when we grow old may hinder the correct
appraisal of such obsessive thoughts as symptoms of an
anxiety disorder. Physical conditions and symptoms often
play a role in the etiology or worsening of anxiety symptoms
in older adults. Because medical comorbidity is more
common in late life, the physician is inclined to assign a
high priority to the appropriate diagnosis of possible somatic
disorders. However, after excluding a somatic condition, the
diagnostic enquiry often stops.
Furthermore, the phenomenology of anxiety in late life
may be different from that of anxiety in early adulthood:
older adults may fear different stimuli or situations or may
have a different reason for fearing certain stimuli or
situations than younger adults [22]. For example, older
adults may show agoraphobic avoidance behavior that is
driven by the fear of falling. Similarly, avoidance of social
situations may arise from the fear that other people will
label one’s forgetfulness as a symptom of dementia. Current
diagnostic instruments and the DSM-IV classification
system may not be cut out to identify the specific age-
related content of late-life anxiety disorders.
Curr Psychiatry Rep

Feasibility and Effectiveness of Treatment
Psychological Interventions
Despite the prevalence and impact of anxiety in late life, the
belief that it is not sensible or feasible to undertake a
psychological intervention in anxious older adults is still
common among general practitioners and mental health
care professionals. This belief dates back to the early days
of psychoanalytic theory. Freud proclaimed that psycho-
therapy would not be feasible for an older individual
because an individual’s psychological flexibility was
supposed to diminish through the years, and the amount
of material that had to be addressed in the analysis would
have become too expansive [23].
In response to this reluctance to treat anxious older
adults, a counter movement has been set in motion that
holds that the same treatments that have been found to be
effective in younger adults can and should be applied to
older adults. Research efforts that stem from this counter
movement have focused on establishing the effectiveness of
cognitive-behavioral therapy (CBT) for late-life anxiety, as
empiric evidence suggests that CBT is the most effective
form of psychotherapy for anxiety disorders in mixed-age
populations [24]. Several studies and several meta-analyses
have been published, and they all provide modest support
for the effectiveness of CBT for late-life anxiety [25,26].
However, a few comments must be made. Although late-
life anxiety is more often the topic of scientific study in recent
years, most available randomized controlled trials (RCTs) still
focus on late-life GAD, and very few studies have included
other anxiety disorders [27•,28,29]. Effect sizes tend to be
somewhat smaller than those found in mixed-age popula-
tions, but due to the focus on GAD, which is not as
responsive to treatment as some of the other anxiety
disorders, these results are difficult to interpret. A recent
RCT of late-life panic disorder reports similar effect sizes as
those reported in mixed-age populations [27•]. However, this
is just one small study that needs to be replicated.
Another major point of concern is that intervention
studies to date are primarily based on relatively healthy,
cognitively unimpaired, and “young”older adults who live
independently in their own homes. Therefore, results
cannot be extrapolated to the frail, cognitively impaired,
and “older”old. Some exceptions exist. Mohlman and
Gorman [30] have done some pioneering and successful
work in the area of adapting CBT to (mildly) cognitively
impaired older adults. Stanley et al. [31•] have adapted
CBT for use in primary care facilities to render it more
accessible to a wider range of older adults. Veer-Tazelaar
and colleagues [32••] have achieved amazing success in
implementing and testing a stepped-care model to prevent
anxiety and depression in adults older than 75 years of age.
Another point of concern regards the fact that late-life
anxiety intervention studies are characterized by an arduous
recruitment process and a relatively high early dropout rate.
This phenomenon is only partially explained by a lack of
appropriate referrals. Treatment refusal and dropout are
both important in evaluating the feasibility and effective-
ness of a certain type of treatment [33], and the fact that
dropout and refusal rates tend to be high suggests that a
large proportion of anxious older adults are not readily
motivated for treatment at a specialized mental health care
facility. Recent intervention studies focus on providing care
closer to home—in primary care or in the home environ-
ment—with the hope of resolving this issue.
Apart from reflecting on the feasibility of treatment, high
dropout rates may lead to a bias in research findings, as
dropouts have been found to differ from those who
complete treatment in several studies [34]. Finally, because
older adults do not readily apply for referral to a mental
health care setting, recruitment for late-life anxiety treat-
ment studies is primarily accomplished through media
announcements [35,36]. Media recruitment of participants
also carries the risk of biased research findings, as has been
put forward by several publications on media recruitment in
mixed-age populations [37].
It is often stated that CBT should be modified to
accommodate the needs of older adults. This is why CBT
in studies of older adults is often provided in a group
format [38,39] rather than the individual format in which it
is usually provided to younger adults. The rationale behind
this approach is that older adults may be more socially
isolated than younger adults and will benefit more from
treatment in a group [38]. It is unclear if this rationale is
justified or whether it reflects another well-intended form of
ageism. In younger populations, group treatment is still
often deemed less effective for anxiety disorders than
individual treatment. Other recommended modifications
for older adults involve a greater emphasis on psycho-
education, increasing patient motivation, and repeating the
explanation of new coping strategies. It is often suggested
that psychoeducation is more important in older adults
because the present older cohort may have unrealistic views
of what psychotherapy entails and may also have more
trouble identifying and talking about psychological prob-
lems. More emphasis on increasing the motivation of
patients is presumed to be needed because people often
have been living with their symptoms for decades and are
reluctant to believe that recovery is possible. Treatment
studies all claim to have incorporated some or all of these
modifications into their CBT protocols, but no systematic
study has been performed to establish if modifications are
necessary, and if so, which modifications are needed to
improve the effectiveness of CBT for late-life anxiety
disorders. Recently, a published study comparing standard
Curr Psychiatry Rep

CBT with an adapted CBT protocol for older adults in the
treatment of GAD provided some indication that the
adapted protocol may yield better results [40]. Adaptations
involved the use of learning and memory aids, more
attention to the (repeated) explanation of the rationale of
treatment, and weekly calls from the therapist to help
participants with any problems they may have encountered
in doing the homework assignments.
In conclusion, CBT appears to be effective for the
treatment of anxiety in older adults, and the state of
knowledge does not justify an attitude of therapeutic
nihilism. However, the evidence is still mostly limited to
specific subgroups of patients (GAD, relatively healthy,
well-educated, cognitively unimpaired, relatively young).
Pharmacologic Interventions
The paucity of data on the effectiveness of existing treatments
for late-life anxiety is even greater for pharmacologic
interventions. Common practice still entails the prescription
of benzodiazepines. This is a troubling phenomenon, as the
long-term use of benzodiazepines is associated with serious
adverse effects, especially in older adults (eg, heightened risk
of accidents and falls, heightened risk of cognitive impair-
ment, development of tolerance and addiction) [41].
Furthermore, benzodiazepines are indicated for incidental
use when individuals are confronted with infrequent anxiety
symptoms, whereas in older adults, anxiety disorders tend to
be chronic in nature. In trying to reverse the wide distribution
of benzodiazepines among anxious older adults, several
authors have warned against pharmacologic treatments of
late-life anxiety in general because even the prescription of
safer psychotropic drugs, such as selective serotonin reuptake
inhibitors (SSRIs), may be problematic in older adults [42].
Recent studies indicate that SSRIs and tricyclic antidepres-
sants may also induce a heightened risk of falls, fractures,
and cognitive impairment [43]. On the other hand, a
psychological intervention may not always be feasible or
successful. In seriously incapacitating cases, when comorbid
severe depression is present, and in older adults reluctant to
start a psychological treatment, SSRIs can be a suitable
alternative. The available data imply that SSRIs are as
effective in older adults as in mixed-age populations in
reducing anxiety, and that they are generally well-tolerated
[20,44]. One recent meta-analysis even suggests that SSRIs
may be more effective in reducing late-life anxiety than
psychological interventions [26], but as the available
research data are scarce and hampered by various methodo-
logic shortcomings, this conclusion is premature.
From the limited available research data on this topic, no
firm conclusions can be drawn with regard to heightened
effectiveness or better tolerability for a certain type of SSRI.
Older adults generally report that they prefer a psychological
intervention, although dropout rates in intervention studies
tend to be similar in both conditions. Severely anxious older
adults may refuse pharmacologic treatment due to an
excessive fear of side effects and addiction. CBT intervention
techniques may be used to counter this anxiety [45].
Conclusions
In 2005, the guest editors of the Acta Psychiatrica
Scandinavica made an appeal for more systematic research
into anxiety disorders in older adults [46]. In the meantime,
the number of published papers on anxiety disorders in
older adults has increased rapidly. More and more has
become known regarding the epidemiology, recognition,
diagnosis, and treatment of anxiety disorders in late life.
These developments have given rise to the creation of
evidence-based multidisciplinary guidelines for anxiety
disorders in late life [45]. However, data are still scarce
and focused on late-life GAD, without much consideration
for any of the other anxiety disorders. Research findings to
date are also primarily based on the relatively healthy, the
well-educated, and the “young.”More knowledge is needed
with regard to the phenomenology of anxiety syndromes in
older people, as well as long-term treatment outcomes. In
addition, no data are available on the implementation of
these research findings or on the implementation of guide-
lines in everyday clinical practice. It is common knowledge
that adherence rates to guidelines in clinical practice are
relatively low and that adherence yields superior results
compared with nonadherence [47]. In 2005, it was
concluded that “implementation can only succeed when
the gap between researchers and clinicians is bridged
successfully”[46]. This conclusion still holds and is a
major challenge for both groups of professionals dealing
with older patients with anxiety disorders.
Disclosure No potential conflicts of interest relevant to this article
were reported.
References
Papers of particular interest, published recently, have been
highlighted as:
•Of Importance
•• Of major importance
1. Bryant C, Jackson H, Ames D. The prevalence of anxiety in older
adults: methodological issues and a review of the literature. J
Affect Disord. 2008;109:233–50.
Curr Psychiatry Rep

2. Beekman AT, Bremmer MA, Deeg DJ, van Balkom AJ, Smit JH,
De Beurs E, et al. Anxiety disorders in later life: a report from the
Longitudinal Aging Study Amsterdam. Int J Geriatr Psychiatry.
1998;13:717–26.
3. Grant BF. Prevalence, correlates, co-morbidity and comparative
disability of DSM-IV generalized anxiety disorder in the USA:
results from the National Epidemiologic Survey on Alcohol and
Related Conditions. Psychol Med. 2005;35:1747–59.
4. Wetherell JL, Thorp SR, Patterson TL, Golshan S, Jeste DV, Gatz
M. Quality of life in geriatric generalized anxiety disorder: a
preliminary investigation. J Psychiatr Res. 2004;38:305–12.
5. De Beurs E, Beekman AT, van Balkom AJ, Deeg DJ, van Dyck R,
van Tilburg W. Consequences of anxiety in older persons: its
effect on disability, well-being and use of health services. Psychol
Med. 1999;29:583–93.
6. van Hout HP, Beekman AT, de Beurs E, Comijs H, van Marwijk
H, de Haan M, et al. Anxiety and the risk of death in older men
and women. Br J Psychiatry. 2004;185:399–404.
7. Crockett AJ, Cranston JM, Moss JR, Alpers JH. The impact of
anxiety, depression and living alone in chronic obstructive
pulmonary disease. Qual Life Res. 2004;11:309–16.
8. Strik JLMH, Denollet J, Lousberg R, Honig A. Comparing
symptoms of depression and anxiety as predictors of cardiac
events and increased health care consumption after myocardial
infarction. J Am Coll Cardiol. 2003;42:1801–7.
9. Huffman JC, Smith FA, Blais MA, Januzzi JL, Fricchione GL.
Anxiety, independent of depressive symptoms, is associated with in-
hospital cardiac complications after acute myocardial infarction. J
Psychosom Res. 2008;65:557–63.
10. Kim HFS, Braun U, Kuni ME. Anxiety and depression in
medically ill older adults. J Clin Geropsychol. 2001;7:117–30.
11. Beekman AT, de Beurs E, van Balkom AJ, Deeg DJ, van Dyck R, van
Tilburg W. Anxiety and depression in later life: co-occurrence and
communality of risk factors. Am J Psychiatry. 2000;157:89–95.
12. Schoevers RA, Beekman ATF, Deeg DJH, Jonker C, Van Tilburg W.
Comorbidity and risk-patterns of depression, generalised anxiety
disorder and mixed anxiety-depression in later life: results from the
AMSTEL study. Int J Geriatr Psychiatry. 2003;18:994–1001.
13. Smalbrugge M, Pot AM, Jongenelis K, Beekman AT, Eefsting JA.
Prevalence and correlates of anxiety among nursing home
patients. J Affect Disord. 2005;88:145–53.
14. Bierman EJM, Comijs HC, Jonker C, Scheltens P, Beekman ATF.
The effect of anxiety and depression on decline of memory function
in Alzheimer’s disease. Int Psychogeriatr. 2009;21:1142–7.
15. Chemerinski E, Petracca G, Manes F, Leiguarda R, Starkstein SE.
Prevalence and correlates of anxiety in Alzheimer’s disease.
Depress Anxiety. 2005;7:166–70.
16. van Balkom AJ, Beekman AT, De Beurs E, Deeg DJ, van Dyck R,
van Tilburg W. Comorbidity of the anxiety disorders in a
community-based older population in The Netherlands. Acta
Psychiatr Scand. 2008;101:37–45.
17. Janzing JGE, van Eijndhoven P. Gegeneraliseerde angst en
dementie. een studie naar de effecten van risicofactoren en
comorbiditeit. Tijdschr Psychiatr. 2007;49:S103–4.
18. 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.
19. Le Roux H, Gatz M, Wetherell JL. Age at onset of generalized
anxiety disorder in older adults. Am J Geriatr Psychiatry.
2005;13:23–30.
20. Lenze EJ, Mulsant BH, Shear MK, Dew MA, Miller MD, Pollock
BG, et al. Efficacy and tolerability of citalopram in the treatment
of late-life anxiety disorders: results from an 8-week randomized,
placebo-controlled trial. Am J Psychiatry. 2005;162:146–50.
21. Fuentes K, Cox B. Assessment of anxiety in older adults: a
community-based survey and comparison with younger adults.
Behav Res Ther. 2000;38:297–309.
22. Sheikh JI, Swales PJ, Carlson EB, Lindley SE. Aging and panic
disorder. Phenomenology, co-morbidity and risk factors. Am J
Geriatr Psychiatry. 2004;12:102–9.
23. Jacobs M. [Psychodynamische psychotherapie]: Psychodynamic
psychotherapy. [Leidraad Psychogeriatrie B2]: Guideline Psycho-
geriatrics B2. Deventer: Bohn Stafleu van Loghum; 1994.
24. Emmelkamp PMG. Behavior therapy with adults. In: Lambert M,
editor. Bergin and Garfield’s handbook of psychotherapy and
behavior change. 5th ed. New York: Wiley; 2004. p. 393–446.
25. Hendriks GJ, Oude Voshaar RC, Keijsers GP, Hoogduin CA, van
Balkom AJ. Cognitive-behavioural therapy for late-life anxiety
disorders: a systematic review and meta-analysis. Acta Psychiatr
Scand. 2008;117:403–11.
26. 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;15:639–51.
27. •Hendriks GJ, Keijsers GP, Kampman M, Oude Voshaar RC,
Verbraak MJPM, Broekman TG, Hoogduin CAL. A randomized
controlled study of paroxetine and cognitive-behavioral therapy
for late-life panic disorder. Acta Psychiatrica Scandinavica
2010;122:11–9. This is the only published RCT on the treatment
of late-life panic disorder, yielding similar effect sizes for CBT as
those found in mixed-age populations.
28. Schuurmans J, Comijs H, Emmelkamp PM, Gundy CM, Weijnen
I, van den Hout HM, et al. A randomized, controlled trial of the
effectiveness of cognitive-behavioral therapy and sertraline versus
a waitlist control group for anxiety disorders in older adults. Am J
Geriatr Psychiatry. 2006;14:255–63.
29. Barrowclough C, King P, Colville J, Russell E, Burns A, Tarrier
N. A randomized trial of the effectiveness of cognitive-behavioral
therapy and supportive counseling for anxiety symptoms in older
adults. J Consult Clin Psychol. 2001;69:756–62.
30. Mohlman J, Gorman JM. The role of executive functioning in
CBT: a pilot study with anxious older adults. Behav Res Ther.
2003;43:447–65.
31. •Stanley MA, Wilson NL, Novy DM, Rhoades HM, Wagener PD,
Greisinger AJ, et al. Cognitive behavior therapy for generalized
anxiety disorder among older adults in primary care: a randomized
clinical trial. JAMA 2009;301:1460–7. This was the first RCT to
test the effectiveness of CBT for late-life GAD delivered in
primary care facilities; it yielded promising results.
32. •• Veer-Tazelaar, PJ, van Marwijk HW, van Oppen P, van Hout HP,
van der Horst HE, Cuijpers P et al. Stepped-care prevention of
anxiety and depression in late life: a randomized controlled trial. Arch
Gen Psychiatry 2009;66:297–304. This RCT tested the effectiveness
and feasibility of a stepped-care prevention program for late-life
anxiety and depression in adults older than 75 years of age. It
yielded impressive results in the successful recruitment of adults
older than 75 years of age, as well as in providing evidence for the
feasibility and effectiveness of a short problem-solving therapy
intervention delivered by nurse practitioners in primary care.
33. Emmelkamp PMG, van der Hout M. Failure in treating agora-
phobia. In: Foa EB, Emmelkamp PMG, editors. Failures in
behavior therapy. 1st ed. New York: Wiley; 1983. p. 58–81.
34. Issakidis C, Andrews G. Pre-treatment attrition and dropout in an
outpatient clinic for anxiety disorders. Acta Psychiatr Scand.
2004;109:426–33.
35. Akkerman RL, Stanley MA, Averill PM, Novy DM, Snyder AG,
Diefenbach GJ. Recruiting older adults with generalized anxiety
disorder. J Ment Health Aging. 2001;7:385–94.
36. Wetherell JL, Gatz M. Recruiting anxious older adults for a
psychotherapy outcome study. J Clin Geropsychol. 2001;7:29–38.
Curr Psychiatry Rep

37. Rapaport MH, Frevert T, Babior S, Seymour S, Zisook S, Kelsoe
J, et al. Comparison of descriptive variables for symptomatic
volunteers and clinical patients with anxiety disorders. Anxiety.
1996;2:117–22.
38. Stanley MA, Beck JG, Novy DM, Averill PM, Swann AC, Diefenbach
GJ, et al. Cognitive-behavioral treatment of late-life generalized
anxiety disorder. J Consult Clin Psychol. 2003;71:309–19.
39. Wetherell JL, Gatz M, Craske MG. Treatment of generalized
anxiety disorder in older adults. J Consult Clin Psychol.
2003;71:31–40.
40. Mohlman J, Gorenstein EE, Kleber M, de Jesus M, Gorman JM,
Papp LA. Standard and enhanced cognitive-behavior therapy for
late-life generalized anxiety disorder: two pilot investigations. Am
J Geriatr Psychiatry. 2003;11:24–32.
41. Wang PS, Bohn RL, Glynn RJ, Mogun H, Avorn J. Hazardous
benzodiazepine regimens in the elderly: effects of half-life, dosage, and
duration on risk of hip fracture. Am J Psychiatry. 2001;158:892–8.
42. Nordhus IH, Pallesen S. Psychological treatment of late-life anxiety:
an empirical review. J Consult Clin Psychol. 2003;71:643–51.
43. French DD, Campbell R, Spehar A, Cunningham F, Foulis P.
Outpatient medications and hip fractures in the US: a national
veterans study. Drugs Aging. 2005;22:877–85.
44. Bourin M. Use of paroxetine for the treatment of depression and
anxiety disorders in the elderly: a review. Hum Psychopharmacol.
2003;18:185–90.
45. Trimbosinstituut: [Addendum ouderen bij de MDR angststoornissen].
Addendum older adults to the multidisciplinary guidelines for anxiety
disorders. www.ggzrichtlijnen.nl.
46. Loebach Wetherell J, Maser JD, van Balkom AJLM. Anxiety
disorders in the elderly: outdated beliefs and a research agenda.
Acta Psychiatr Scand. 2005;111:401–2.
47. van Balkom AJLM, Oosterbaan D. [Leiden richtlijnen tot een
betere klinische praktijk?] Do guidelines improve common
clinical practice? Tijdschr Psychiatr. 2008;50:323–8.
48. Bijl RV, Ravelli A, van Zessen G. Prevalence of psychiatric
disorder in the general population: results of the Netherlands
Mental Health Survey and Incidence Study (NEMESIS). Soc
Psychiatry Psychiatr Epidemiol. 1998;33:587–95.
Curr Psychiatry Rep