Anxiety and Older Adults

We’ve all experienced anxiety in our lives that have been brought on by different situations. Perhaps you asked your manager for some time off work on short notice. What was that experience like? You may have noticed several rehearsed hypothetical scenarios racing through your mind, your heart beats probably felt much more sensitive, and your armpits and palms may have also gotten a bit more sweaty than usual. More serious forms of anxiety can come from loss of a loved one, not landing the job interview that you were hoping to get, or excessive worrying about your health. 

Feelings of anxiousness can easily dominate our day to day life. You become more tense than your usual self, your self-confidence feels lower, you have uncontrolled thoughts that invade your mind, and irritability seems to become part of you whether you like it or not. All of these feelings and experiences, of course, are unwelcomed and invite itself to ultimately destruct the best version of yourself. Your behavioral changes also easily become noticeable to those that we love most. What usually follows are persistent forms of apologies for your change in behaviors, countless reassurances that you’re feeling fine when in fact you’re still struggling, and much more. 

The journey through anxiety should not be travelled alone. Whether it be with your loved ones, a healthcare professional such as a psychologist, or a combination of both, the key to success with tackling anxiety is sharing what you’re going through and finding the best strategies to piece together the puzzle and construct the best version of yourself again. 

Although the blueprint for feelings of anxiety are typically the same for most people, detecting anxiety in older adults must be taken with much more caution. ‘Late-life anxiety’ is a unique form of anxiety displayed only in older adults. In this piece, we’ll tackle: 

• The difficulties of late-life anxiety in older adults. 
• How to recognize the signs of anxiety as an older adult. 
• The best techniques and strategies to manage late-life anxiety.  

Recognizing Late-life Anxiety

Worrying is a natural feature of the human experience when it comes to dealing with different scenarios. The act of worrying is in fact a built-in instinct for us to learn about dangerous situations, detecting fishy situations often referred to as your ‘gut feeling’, and allows for us to reflect on past and future experiences that lead to improvement and preparedness. When worrying becomes unhealthy is a very subjective matter, but the answer can usually be understood better when framed as:

• A chain of thoughts and/or images negatively that affect your normal daily activities and are relatively uncontrollable. 
• Excessive worrying disrupts your functioning of everyday activities and reduces your overall quality of life. 

If you tend to be a visual learner or learn better with numbers, there is a formal questionnaire developed by researchers that can be taken to determine if you are in fact having excessive worrying. The instructions for the questionnaire asks you to rate each statement and rate it on a scale one (not at all typical) through five (very typical of me):

1. If I do not have enough time to do everything, I do not worry about it.

2. My worries overwhelm me.

3. I do not tend to worry about things.

4. Many situations make me worry. 

5. I know I should not worry about things, but I just cannot help it.

6. When I am under pressure I worry a lot.

7. I am always worrying about something.

8. I find it easy to dismiss worrisome thoughts.

9. As soon as I finish one task, I start to worry about everything else I have to do.

10. I never worry about anything. 

11. When there is nothing more I can do about a concern, I do not worry about it any more.

12. I have been a worrier all my life. 

13. I notice that I have been worrying about things.

14. Once I start worrying, I cannot stop.

15. I worry all the time.

16. I worry about projects until they are all done.

Don’t stress about interpreting the results of this questionnaire. A healthcare professional helps administer and interpret the findings for you. The purpose of introducing these 16 statements give you a good idea of common worrying habits that people tend to exhibit when feeling anxious. It’s important when given a questionnaire from a healthcare professional to answer truthfully as best you can and take your time to think about each statement thoughtfully. This allows your healthcare professional to understand the difficulties that you are going through and it helps with tracking your overall progress with having either a healthy or unhealthy amount of worrying habits. 

What does anxiety feel like? Mentioned earlier, there is a blueprint for feelings of anxiousness. The three main things will be experienced when in a state of anxiety: 

• Somatic: A fancy word for the way your body is physically feeling or how it responds to a scenario. Examples include a racing heart beat, becoming short of breath, having an upset stomach (i.e, butterflies), difficulty sleeping, becoming restless, feeling tired, tense muscles, and generalized pain or muscle cramps. 
• Cognitive: Your thinking skills, memory, or train of thought may also be altered when feeling anxious. Examples include feeling like things were not real, feeling like you’re outside of your own body, feelings of losing control, feelings of being in a daze, excessive worrying, inability to control worrying thoughts, feeling like you have no control over your life, or feeling like something terrible is going to happen. 
• Affective: This refers to your emotional state. Examples include afraid of being judged by others, afraid of being humiliated or embarrassed, becoming easily irritable, outbursts of anger, easily startled or upset, decreased interest in things you typically enjoy, feeling detached or isolated from others, and feeling on the edge. 

Frequency is critical when it comes to understanding if you’re inhabiting a healthy amount versus an unhealthy amount of these three blueprint feelings. If, within the past week or so, you’ve been experiencing these three sets of feelings either ‘most of the time’ or ‘all of the time’, it’s likely that you’re teetering on the side of having an unhealthy amount of anxiety that would require coping strategies to help alleviate the feelings. 

Still on the fence about how much worrying and feelings of anxiousness that you’re experiencing? If you’re the slightest bit concerned about having anxiety, it’s highly suggested that you reach out and let your primary care doctor know about how you’ve been feeling. The bottom line is that we all tend to underplay how serious our anxiety is and we continue brushing off our difficulties until things eventually get worse. 

More importantly, research has shown that anxiety is common among community dwelling older adults – a prevalence varying up to an anticipated 15 percent with a formal anxiety disorder and over 24 percent reporting feeling anxious quite commonly. Older adults seldomly report their anxiety symptoms to their primary care doctors and even more rarely receive care under a mental health specialist. Because it can be an uncomfortable topic to bring up to your primary care doctor, here are a few scripts you can bring up at your next doctor visit towards the end of the session when your doctor asks, “What other questions or concerns do you have for me?”

• “Lately, I’ve been feeling more anxious than I usually am and it’s been very concerning for me. I’ve been experiencing ____ feelings and it’s been affecting my day to day life.” 
• “I have these uncontrolled feelings and thoughts that I think are related to anxiety. My feelings usually include ____ and my thoughts usually include ____ . It happens (frequency of hours) during the day.”
• “I’ve noticed my mood has changed and my family and friends have noticed as well. It started (name specific event or timeline) and it hasn’t gotten any better since. I was hoping you would be able to refer me to someone that can help.” 

Late-life Anxiety vs Anxiety in Younger Adults

Understanding late-life anxiety in older adults has a lot more grey areas compared to younger adults. Because most general healthcare professionals only understand the tip of the iceberg when it comes to understanding the complexity of caring for older adults, it’s recommended to consult with a geriatrician. Geriatricians are experts when it comes to understanding the full picture of older adults and their difficulties. 

Age related differences in the way in which older adults and younger adults experience anxiety are profound. For example:

• Older adults report more concern regarding their health whereas younger adults tend to focus on finances and familial concerns. 
• Older adults tend to report the absence of any negative symptoms (depression, anxiety, guilt, shyness, and hostility) that are present in those with formal anxiety disorders when compared to younger adults. 
• Older adults experience anxiety in different contexts such as having feelings of being ‘fearful, scared, afraid’ compared to younger adults that report feelings such as ‘shameful, guilt, doing something wrong’. 
• Older adults report more specifics about being a burden on their families. 

A lot of grey areas complicate the ability of determining if anxiety is actually occurring in older adults or if it’s a product of something else. Examples include: 

• Symptoms of anxiety can be similar to the ‘normal aging process’ such as a decline in memory, fatigue, or difficulty concentrating. This particular issue is the most difficult to bypass. It’s encouraged that you don’t dismiss your feelings and experiences of anxiety if your healthcare professional suggests this. Think back to the three blueprint feelings of anxiety mentioned earlier and state specifically how these feelings have been affecting your day to day life in order to bring a sense of urgency to your own care. 
• Late-life anxiety versus depression or a combination of both? Anxiety is almost always present when having depression. Because both depression and anxiety have similar symptoms, it’s difficult to tease out which is actually occurring. 
• Late-life anxiety and other health complications can often be the driver of increased anxiousness. Naturally, older adults go through health challenges that are accompanied by increased worrying thoughts. 
• Misuse of prescription drugs also complicate the identification of anxiety in older adults. A new amount of growing research is starting to look at the relationship between misuse of prescribed drugs that create similar symptoms that would be seen in older adults with anxiety disorders. 

Clear differences certainly exist when it comes to understanding anxiety in older adults. Painting a full picture and providing as much context as possible to your healthcare professional can help narrow down the cause of anxiety versus other potential underlying health complications. Things to consider when providing context to your healthcare professional can include: 

• How long you’ve been having feelings of anxiety. 
• What are the feelings you share at the time of your episode and how often does it occur? 
• Describe specifically the intrusive thoughts that invade your mind. 
• Provide the prescription drugs that you are currently taking. 
• Describe how your body reacts when you are experiencing an anxiety episode. 
• If your memory skills have changed, describe when it started. 
• If you can recount a specific anxiety episode, describe step by step how it occurs from start to finish. 

Why Seek Treatment? 

Ambivalence will be your worst enemy when deciding to confront your anxiety. It’s easy to discount the severity of your anxiety because there’s no physical form to be seen other than your changed behaviors or bodily reactions – both of which can be easily hidden. 

To help put things in perspective, a group of researchers found that excessive worrying occurs in 37 percent of community dwelling adults along with 20 percent reporting uncontrollable worrying within the past month. Could an unhealthy amount of worrying and anxiety have harmful health challenges? You bet. It’s difficult to wrap our heads around this because we often think, “How can our thoughts affect our physical health?” Here are some insightful health risks that can come with an unhealthy amount of worrying: 

• Worse quality of life. 
• Increase rates of depression. 
• Poor overall health outcomes. 
• Higher risk for heart diseases. 

Now that it’s been established how anxiety and excessive worrying can affect both your mental and physical health, let’s dive into the best and most research supported strategies to help alleviate anxiety in older adults. 

Strategies and Interventions

Multiple strategies exist out there to treat anxiety. Although many of these strategies prove useful, there are special considerations that prove more useful in older adults. A fantastic group of researchers developed a protocol known as ‘Controlling Anxiety in Later-life Medical Patients’, or otherwise known as ‘CALM’. Reasons the CALM approach has been successful in assisting to alleviate anxiety in older adults is because the research team: 

• Organized and incorporated the strategies that have been proven most useful in older adults aged 60 and over from previous research studies. 
• Paired rigorous research strategies that have worked only moderately well in older adults with multiple different research strategies to amplify the effectiveness specifically for older adults.
• Incorporates a formal intake of your specific experiences with anxiety and targets the strategies that have proven most useful in your form of anxiety. This allows for the healthcare professional to disregard strategies that are not as useful given your specific form of anxiety. 
• Considers each older adult’s personal abilities when using specific strategies. Because many of the strategies to alleviate anxiety require high level thinking or memory, older adults with a decline in memory still have useful strategies to help alleviate their anxiety levels. 
• Identified problems and symptoms that are most commonly encountered among anxious older adults. 
• Based their protocol on clinical experience and experts specializing in the care of older adults and anxiety. 

The CALM protocol can be broken down into 12 sessions of individual one on one sessions with a healthcare professional. One on one sessions are preferred because it allows the healthcare professional to fully concentrate their time to customize and make changes on an individual basis. Seen below is a table with 14 modules that are implemented in the 12 sessions. 

 Let’s dive into the breakdown of how the 12 sessions will roughly look like: 

• The first and last days of the program focus on ‘Recognizing Anxiety’ and ‘Maintaining Your Progress’, respectively. 
  • Recognizing Anxiety: involves education about anxiety, how to self-monitor strategies to identify anxiety-related physical sensations, thoughts, and behaviors (three blueprints mentioned earlier). 
  • Maintaining Your Progress: a comprehensive review of all learned skills to ensure you are able to independently implement strategies to alleviate your anxiety episodes without the guidance of a healthcare professional. 
• Remaining 10 sessions: a selection of the modules will individually be chosen and taught to you based on your specific needs. This is determined by: 
  • Your perception of your own challenges and symptoms regarding anxiety. 
  • The healthcare professional’s perception of your challenges and symptoms including other past medical history such as depression or other specific concerns. 
  • Your score on an initial questionnaire that looks at challenges you are currently facing. 

Do some of the modules sound a little confusing, funky, or just irrelevant? Understanding the rationale and basis can help provide further insight. 

• Learning to relax: If anything, you lose the ability to relax completely when in a state of anxiety. It remains important to teach strategies to learn how to breathe and lose the tense feelings throughout your body. Strategies include deep breathing (we often hold our breath when anxious), progressive muscle relaxation (focusing on individual muscles to take your mind off stressful thoughts), and guided imagery (training your mind to think of positive things). 
• Getting to sleep: Insomnia, although not present in all older adults with anxiety, is very common because of the uncontrolled intrusive thoughts that invade your mind at night. If experiencing poor sleep habits, a sleep schedule will be implemented in an attempt to start a routine to allow for those much needed eight hours of rest. The eight hours of sleep will also play a large role with healing your brain. 
• Solving problems and Asserting yourself: Older adults struggling with anxiety often have excessive and unhealthy worrying that lead to low confidence levels when it comes to being able to take action in your own hands. In addition, older adults are challenged with real life issues such as new medical conditions or caregiver problems. Methods taught in this module help break down problems into small steps, brainstorm and look closely at various options. You also learn how to create, carry out, and determine an action plan to resolve problems. 
• Accepting the inevitable and Controlling worry: This module teaches you how to let go of things that are within and outside of your direct control. The goal of this module essentially gives you the skills to learn that you have control over worrying, rather than the other way around. For example, it’s pointless to worry and stress about the results of a test 8 hours of the day for a week if you have to wait one week for the test results. Your time and health is better spent focusing on your day to day activities or relaxing. 
• Reviewing your life: This may sound quite philosophical, but a life review has proven to help cope with your life challenges when faced with anxiety. During this module, you are instructed to think about an emotionally significant period or aspect of your life, such as childhood, teenage years, young adulthood, parenthood, job or career, middle age, and older age, and write your response to a series of questions. 
• Increasing your pleasure: As most older adults struggle through the challenges of anxiety, they lose pleasure in taking joy in activities and commonly give up doing the things they used to once love. It’s ever more important to once again find solace in your hobbies. A rule you often forget when you’re overwhelmed by anxiety – you still deserve to be happy. 
• Challenging your thoughts: When your mind is flooded with intrusive thoughts because of anxiety, it becomes difficult to tell the difference between what’s real and what isn’t real. These uncontrolled thoughts born from excessive worrying can lead you down a dark rabbit hole that often tells you things like ‘you’re worthless’, ‘you’re not good enough’, ‘you’re a failure’, etc. This module provides you with strategies to stop these intrusive thoughts, challenge whether or not your thinking is rational or irrational, then rid your mind of the negative thoughts.  
• Facing your fears: Modules for coping with depressive symptoms and with phobic avoidance are included because depression and phobias are often present with anxiety and other specific forms of anxiety in older adults. 
• Coping with pain: Whether it be emotional or physical pain, both should be treated equally. Just because you’re not able to physically see your pain doesn’t mean it doesn’t exist. Arguably, emotional pain can be more dangerous as it lingers for a much longer time and often goes untreated or unreported. This module teaches you how to bring all forms of pain to surface, learn how to pace oneself, and learn how to focus on other things that are not distressful. 
• Managing your time: Time becomes almost irrelevant as anxiety dominates your life. You lose interest in many of your previously loved activities, spend the majority of your time ruminating over your intrusive thoughts, and your entire day may seem like a hazy experience. This module incorporates and promotes use of a routine to allow for engagement in activities rather than sitting at home in your own thoughts. The core principle is that if you’re busy with a task on a given schedule, you would not have time to ruminate over pointless worrying. 

Conclusion

Piecing back together the best version of yourself isn’t an easy task when confronted by anxiety. Anxiety is one of the most difficult challenges that people face and healthcare professionals continue to struggle with treating. Older adults with anxiety are by no means easier to treat as there are several factors that make the identification of anxiety difficult.

Although it seems like an uphill battle, it’s possible to overcome anxiety and it’s been done successfully with the right help, attitude, and hard work. Don’t take the journey through anxiety alone. The first part is the hardest – accepting anxiety is real. Second, reach out to your social supports and healthcare professionals. Third, start a program that is fitting for you with a healthcare professional that you feel can tackle on your journey with you. Lastly, make sure you continue implementing the learned strategies to re-create a new and better version of you that you deserve to be for yourself and for your loved ones.