Behavioral disturbances in the elderly are probably the most important facet of dementia prompting institutionalization. The referral for pharmacologic intervention is often the result of the need for management of mood and behavior. Symptoms tend to be superficially described as “agitated,” “combative,” “depressed,” “acting out,” “inappropriately accusing,” etc., by spouses, family members, and caregivers.
Dementia may be the most common cause of anxiety in the elderly, with an increased risk of anxiety seen in patients initially transferred to a long-term care facility from the hospital or from home. Trauma or a stressful event may induce an acute, short-lived, situational anxiety. Anxiety disorders (also known as anxiety and phobic neuroses) are classified as phobic disorders, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and panic disorder (Table 1).
Table 1: Classification of Anxiety Disorders
|Phobic disorders: Intense, persistent, unrealistic anxiety; may severely inhibit social interactions in elderly, although more common among children and younger adults. Examples: claustrophobia (fear of confinement) and agoraphobia (fear of public or open places)|
|Posttraumatic stress disorder (PTSD): Intense fear, helplessness, horror caused by trauma; avoidance of stimuli related to trauma. Late-life psychologic functioning may be adversely affected by severe stress in childhood/young adulthood|
|Generalized anxiety disorder (GAD): Almost daily worry/anxiety >=6 months; up to 5% of community-dwelling elderly are affected; more common in women than in men|
|Obsessive-compulsive disorder (OCD): Obsessions (intrusive, recurrent, unwanted ideas, images, or impulses) and compulsions (urges of action that will lessen discomfort of obsessions) characterize this disorder. Although symptoms are not usually prominent, it is common among elderly and more common in women than in men|
|Panic disorder: Recurrent, abrupt periods of intense fear/discomfort known as panic attacks; rare in elderly. If they occur in late-life, they are less severe than in younger adults.|
Attempts at alleviating anxiety in the elderly, and especially in those with dementia, should be attempted through nonpharmacologic intervention whenever possible. This may include providing a more structured environment with consistent routines, simplifying everyday tasks, avoiding over- or understimulation in the environment, providing soothing background music, and providing support to caregivers. Testing for adequate hearing and vision is also essential. Supportive psychotherapy, behavioral therapy, biofeedback, relaxation therapy, and paced exercise therapy may be used as nonpharmacologic and adjunctive therapy where appropriate.
Reversible etiologies of anxiety related to adverse drug effects and concomitant medical disorders should not be overlooked. When possible, eliminating medications known to contribute to or induce anxiety and treating medical conditions that may cause anxiety or similar symptoms (Table 2) may help avoid unnecessary intervention with an anxiolytic. For example, eliminating anxiety and agitation secondary to depression with the use of an antidepressant may be sufficient.
|Table 2: Drugs and Medical Conditions That May Cause Anxiety|
|Caffeine, theophylline, anticholinergics, antihypertensives, digoxin, drug withdrawal (e.g., alcohol, sedatives, hypnotics), over-the-counter sympathomimetics (e.g., pseudoephedrine), corticosteroids, beta-adrenergic agonists (e.g., albuterol)|
|Hyperthyroidism, hypoglycemia, depression, delirium, pulmonary edema, pulmonary emboli, cardiac arrhythmias, postural hypotension, dementia, chronic obstructive pulmonary disease|
Benzodiazepines are often prescribed for elderly dementia patients with behavioral disorders because of a prescriber preference over the antipsychotics that carry a liability of extrapyramidal symptoms (EPS) and tardive dyskinesia (TD). Extrapyramidal reactions are more common in the elderly, with up to 50% of patients developing these reactions after age 60; incidence may be more common in dementia patients. The prevalence rate of tardive dyskinesia in the elderly may be as high as 40%; elderly women are especially at risk. Up to 20% of older adults take benzodiazepines, and their use is more common among women than men. Benzodiazepines are useful in treating general anxiety disorders, panic disorders, and depression, as an adjunct to antidepressants. They are also indicated in insomnia, on a short-term basis. In addition, they are useful for preprocedure/preoperative sedation (e.g., dental procedures, MRI screenings) and in cases of status epilepticus.