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Recommendation # 1

Health care providers should be familiar with risk factors for anxiety in older adults.

Explanation: Targeting higher-risk older adults for anxiety screening is effective, especially when factors like cognitive decline, depression, multimorbidity, pain, and social isolation are present. Chronic conditions, high stress, and social determinants like low income and discrimination also increase anxiety risk. Protective factors include life satisfaction, positive affect, spirituality, and strong social ties.

Evidence: “One or a combination of these factors may contribute to the risk of anxiety or fear of falling which increases with age. These risk factors can cause heightened feelings of vulnerability and danger, worry about independence, or compromised ability to cope or access support (Brenes et al., 2008; Silva et al., 2022; Vink et al., 2008).”

Recommendation #2

Healthcare providers should familiarize themselves with tools to detect anxiety symptoms and disorders in older adults and consider using these tools to facilitate case finding in individuals at risk or who describe symptoms of anxiety.

Explanation: Healthcare providers should use tools to detect anxiety in older adults, particularly those at risk or showing symptoms. Clinical history alone often misses anxiety, so a systematic approach is needed. General screening isn't recommended, but targeted screening based on risk factors is advised. Providers should use detection tools or ask about symptoms when risk factors are present. Most tools are designed for English and Western contexts, so cultural adaptations are necessary.

Evidence:  “Anxiety disorders in older adults are under-diagnosed, so a rigorous approach is needed (Bower et al., 2015).”

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Recommendation 7: Older adults who screen positive for anxiety, or who are presenting with new or worsening anxiety that affects their daily functioning or well-being, should undergo a comprehensive assessment, including a history, physical examination, and appropriate investigations

Recommendation 8: The anxiety history should include the nature of the symptoms, their onset and duration, the severity of the symptoms (in terms of impact on daily functioning, presence of avoidance behaviours, and degree of distress associated with symptoms), the psychosocial stressors contributing to the symptoms, and the past mental health history

According to Moult et al (2020), Older adults with anxiety most often present in primary care settings, but may not specifically endorse anxiety.

Older adults feel panic but are less likely to endorse full symptoms.

Older adults may not recognize that they are having symptoms of anxiety (Wetherell et al., 2009)

It is important to provide education about anxiety symptoms without stigmatizing or invalidating their experience

Cultural understanding, stigma, language barriers and preferences to confide in s/o may impact on reporting of symptoms, resulting in the experience of emotional distress through physical symptoms. (Kim et al., 2012; Marques et al., 2011)

Indigenous and non-western cultures draw few distinctions between the mind and body resulting in experience of emotional distress through physical symptoms. (Kim et al., 2012; Marques et al., 2011)

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Recommendation #13: Stepped care, beginning with bibliotherapy, psychoeducation, and/or self-guided Cognitive

Behavioural Therapy (CBT), should be considered to reduce anxiety symptoms and prevent the development of anxiety disorders in older adults. (B)

Stepped care improves anxiety symptoms and prevents the development of anxiety disorders in individuals however it does not treat people with diagnosed

anxiety disorders.

Initial Interventions: Low-intensity interventions (guided self-help, bibliotherapy, relaxation techniques, social prescribing, psychoeducation). Monitor response and escalate to more intensive interventions (therapist-led CBT, medications, specialist referrals) if symptoms persist.

This study often excludes older adults with cognitive impairment

Adaptations Needed: Older adults, even with cognitive impairments or dementia, can benefit from psychological interventions, requiring modifications (simplified materials, behavioral focus)

Recommendation #14: Psychosocial support should be offered to older adults presenting with anxiety symptoms, tailored to address risk factors and contributing stressors. (D)

Identify stressors or social determinants of health (such as finances, food insecurity, housing, social isolation, discrimination) when developing care plan (Davison et al., 2020; Ross et al., 2017; Thapa et al., 2020

Work collaboratively with the adults

Social prescribing - approach to expand existing support network (Percival et al., 2022)

Some Staretegies:

social prescribing to non-medical community - mitigate some psychosocial risk factors such as social isolation

scheduling regular contact, active listening and validation skills

referrals to community-based senior serving agencies

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Recommendation #9 - Older adults presenting with anxiety should be screened for depression and suicidality.

About half of older adults with depression have a comorbid anxiety disorder.

20% of those with a primary anxiety disorder will also meet criteria for depression. (Wolitzky-Taylor et al., 2010)

Anxiety is also a risk factor for suicide, with or without depressive symptoms. (Beghi et al., 2021; Fernandez-Rodrigues et al., 2022)

Recommendation #10 - A medical history and physical examination should be used to identify medical conditions that may be contributing to the symptoms of anxiety. Consider investigations that may help to rule out the presence of medical conditions that can cause symptoms of anxiety.

Late-life anxiety symptoms may indicate underlying medical or neurological disorders such as Parkinson’s disease, dementia, arrhythmias, thyroid disorders, and obstructive sleep apnea. (Ann et al., 2023; Gallagher et al., 2011; Schrag et al., 2015)

Anxiety can be a symptom of adjustment to a medical condition or disability

An exacerbation of illness can lead to delirium which

often presents with anxiety.

A cognitive screening assessment should be considered when assessing anxiety symptoms. High levels of anxiety have a negative effect on cognitive performance by impairing attention and executive function.

Anxiety can also be an early presenting symptom of dementia.

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Recommendation #11

A medication and substance-use history should be gathered in all older adults presenting with anxiety, including prescribed, over-the-counter and recreational drugs, and caffeine.

1. Anxiety Symptom as a Secondary to Medications or Recreational Drugs: It is important to take a thorough medication history to establish a temporal relationship (if any) between medication initiation and the onset of anxiety symptoms (Akathisia).

2. Medication Adherence Assessment:

1. Medication Errors might lead to delirium/toxicity presenting as anxiety (Thyroid Medication/Insulin)

2. Missed Medication Doses may result in withdrawal (Benzodiazepines, Opioids, and Antidepressants)

3. Substance Use Screening: assess any potential role of substance intoxication, withdrawal, and chronic use on symptoms of anxiety

4. Drug Interactions: older adults in polypharmacy may have certain drugs that interact with each other and can cause symptoms like anxiety.

5. Use of OTC Medications:

1. Assessing for use misuse of OTCs

2. Noting the use of anticholinergic agents (has sedative properties that may be addictive)

6. Natural Products with Psychoactive Properties: contribute to anxiety (e.g., ginseng, gingko biloba)

Recommendation #12

Non-pharmacological interventions should be offered first, given the potential risk of adverse events associated with pharmacotherapy, except in circumstances dictated by patient preference, severity of symptoms, and risk assessment. (D)

1. While the overall effect sizes for psychotherapy and medications for anxiety are similar (Pinquart & Duberstein, 2007), given that some older adults with anxiety symptoms improve with non-pharmacological interventions and psychosocial support alone, we recommend that these be offered first, before the use of pharmacotherapy.

2. It is important to monitor symptoms and response to non-pharmacological interventions and continue to revisit and optimize the treatment plan when there is a poor response.

3. Patient values and preferences should always be considered when choosing a treatment, as numerous studies suggest that patients are more willing to initiate and adhere to treatments that match their preferences (McHugh et al., 2013; Swift et al., 2018, 2021; Winter & Barber, 2013).

4. When anxiety symptoms are secondary to a medical condition, adjustment of the treatment or management of the medical condition should be implemented first (American Psychiatric Association, 2013).

1. Example: Treatment of anxiety secondary to substance use should focus on addressing the substance use.

5.  It is also important to keep in mind the patient’s previous psychiatric history (e.g., history of bipolar disorder that increases the risk of hypomania or mania with antidepressant use, or previous adverse events with specific psychotropic medications or classes) when considering treatment options.

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Group 6 - Hannan, Hisanath, Shasid, Eunice

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Group 6 - Hannan, Hisanath, Shasid, Eunice

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5. We recommend the use of Rating Anxiety in Dementia (RAID) for identifying clinically important anxiety symptoms in older adults with dementia within specialty care settings.

Those with dementia have difficulties expressing or recalling their symptoms of dementia.

Raid is the most recommended and accurate tool for assessing a patient's view and care-partner's validity. (Shankar et al., 1999)

Mostly used in nursing homes, geriatric clinics, memory and veteran clinics.

6. Health care providers should ask about fear of falling and activity avoidance as part of the geriatric falls risk assessment

Key element of older adults risk assessment are falls history and falls risk assessments.

Assessment for fear of falls: Falls efficacy scale international (FES-I) has strong evidence to support its validity. (McGarriigle et al., 2023)

Asking questions concerning the risk of developing fall-related psychological issues or avoidance behaviours from benefitting in the intervention.

Are you afraid of falling? Have you restricted activities due to fear? (Belloni et al., 2020)