New Canadian guidelines outline how to assess and manage anxiety in older adults

The first Canadian guidelines for anxiety in older adults provide practical and evidence-based recommendations for prevention, assessment, diagnosis and treatment.1 The guidelines, produced by the Canadian Coalition for Seniors’ Mental Health, were developed by a multidisciplinary working group led by geriatric psychiatrist Dr. Andrea Iaboni (associate professor, University of Toronto) and psychologist Dr. Sébastien Grenier (associate professor, Université de Montréal).1,2 Excessive or prolonged anxiety can have a negative impact on older adults’ quality of life and day-to-day function. It can interfere with relationships, activity levels, social engagement and well-being. Late-life anxiety is also associated with depression, aging-related stressors and physiological changes such as medical illness (e.g., heart disease), disability and cognitive decline.1 Differences in the presentation of anxiety, ageism and stigma contribute to under-recognition and underdiagnosis of anxiety disorders in older adults. Older adults are also less likely to seek care or be referred for care for mental health issues.1 The 36-page anxiety guidelines outline risk factors, assessment, diagnosis and treatment, including nonpharmacologic and pharmacologic therapies. The guidelines offer 32 recommendations. Key recommendations are summarized below.1RecommendationsRisk factorsHealthcare providers should be familiar with risk factors for anxiety in older adults. (Risk factors include cognitive impairment or decline, depression, female sex, functional limitations, insomnia, multimorbidity, pain, polypharmacy, poor health status, social isolation/loneliness, older age, history of falls or impaired balance.)Assessment 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. (The Geriatric Anxiety Inventory, the Rating Anxiety in Dementia and other tools are discussed in the guidelines. A diagnostic algorithm is also provided.) Healthcare providers should ask about fear of falling and activity avoidance as part of the geriatric falls risk assessment. Older adults who screen positive for anxiety, or who present with new or worsening anxiety that affects their daily functioning or well-being, should undergo a comprehensive assessment, including a history, physical exam and appropriate investigations. An anxiety history should include the nature of the symptoms, onset and duration, severity (in terms of impact on daily functioning, presence of avoidance behaviours, and degree of distress associated with symptoms), psychosocial stressors contributing to the symptoms, and a mental health history. Older adults presenting with anxiety should be screened for depression and suicidality. A medical history and physical exam should be used to identify medical conditions that may be contributing to the symptoms of anxiety. (A table of medical conditions associated with anxiety in older adults is provided in the guidelines.)A medication and substance-use history should be gathered in all older adults presenting with anxiety, including prescribed, over-the-counter drugs and recreational drugs, as well as caffeine. (A table of medications and substances that may contribute to anxiety symptoms in older adults is included in the guidelines.)Nonpharmacologic interventionsNonpharmacological interventions should be offered first, except when dictated by patient preference, severity of symptoms and risk assessment. 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. Psychosocial support should be offered, tailored to address risk factors and contributing stressors. Treatment response and efficacy should be monitored using standardized rating scales. (The same scales used to detect anxiety can be used for monitoring.)Psychotherapy should be made available to older adults with anxiety in all settings (e.g., community, long-term care). CBT should be offered to older adults to treat anxiety. (Individual, remote and group CBT are effective, as well as brief and full CBT.) Specific CBT strategies can be used on their own to treat anxiety in older adults including exposure, relaxation therapy, abdominal breathing, cognitive restructuring, and problem-solving training. CBT should be considered for older adults who have a fear of falling, particularly those whose function or quality of life is severely limited due to anxiety around falls. Mindfulness interventions may be used to effectively treat anxiety in older adults. Other forms of psychotherapy or psychosocial treatments (e.g., supportive therapy, acceptance and commitment therapy, reminiscence therapy, relaxation therapy) may be offered to older adults with anxiety. Exercise (aerobic exercise and strength training) reduces anxiety and may be recommended to older adults with anxiety symptoms. Tai Chi and yoga are effective to reduce fear of falling. PharmacotherapySelective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) should be used as first-line pharmacologic treatment for anxiety disorders in older adults. (A summary table of pharmacotherapies for anxiety disorders in older adults, including starting doses, therapeutic doses, maximum doses and other considerations, is included in the guidelines.)Benzodiazepines should not be used in the management of anxiety in older adults, except when nonpharmacologic interventions and first-line pharmacologic alternatives have failed, or for short-term use (2–4 weeks) until first-line treatments become effective. Buspirone may be considered for the treatment of mild-to-moderate generalized anxiety disorder in older adults, in individuals where first-line treatments are not effective or tolerated. Quetiapine or pregabalin should not be routinely used in the management of anxiety disorders in older adults, except when nonpharmacologic and first-line treatments have failed. The guidelines are accompanied by two single-page “infosheets.” The first highlights four key points for healthcare providers: screening for anxiety, ruling out other diagnoses, nonpharmacologic interventions and pharmacologic treatments.3 The second focuses on five key points for older adults: what is anxiety, symptoms of anxiety, how to manage anxiety, speaking with a healthcare provider and medication.4 A pamphlet titled “When is worry too much?” is also available to help inform older adults about anxiety symptoms, treatments and when to seek help from a healthcare professional.5References1. Canadian Coalition for Seniors’ Mental Health. Canadian guidelines for the assessment and treatment of anxiety in older adults 2024. (accessed January 29, 2024).2. Canadian Coalition for Seniors’ Mental Health. First Clinical guidelines to address anxiety in older adults developed by the Canadian Coalition for Seniors' Mental Health. News release January 25, 2024. (accessed January 29, 2024).3. Canadian Coalition for Seniors’ Mental Health. Canadian guidelines for anxiety in older adults. Key takeaways for health care providers. (accessed January 29, 2024).4. Canadian Coalition for Seniors’ Mental Health. Canadian guidelines for anxiety in older adults. Key takeaways for older adults and care partners. (accessed January 29, 2024).5. Canadian Coalition for Seniors’ Mental Health. When is worry too much? (accessed January 29, 2024).

New Canadian guidelines outline how to assess and manage anxiety in older adults

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