Is Anxiety in Late Life an Uncharted Territory?—Questioning the Federal Guidelines for Anxiety Screening in Older Adults

Recently, the US Preventive

Services Task Force (USPSTF) has updated their recommendations for Screening for Anxiety in Adults.¹ While the USPSTF recommends screening for anxiety in young adults, including pregnant and postpartum persons, it does not recommend the same for older adults 65 years and older. The USPSTF states that “the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety in older adults.”

This perplexed many, who must have wondered why anxiety screening was specifically not recommended for older adults. Do anxiety disorders not exist in older adults? Are they not important in older adults? Are there no treatments for anxiety in older adults?

Anxiety Disorders Exist in Older Adults

We have dedicated decades to the treatment and research of anxiety in late life and we stand by the growing body of evidence pointing toward the pervasive and pernicious nature of anxiety disorders in older adults. While the prevalence of many anxiety disorders appears to decrease with age, this may reflect an underestimation due to the challenge of assessing and diagnosing anxiety in elderly individuals.² Many older adults have atypical anxiety syndromes difficult to capture by the current nosology and thus frequently ignored (eg, severe worry, fear of falling, somatic anxiety). Loneliness, which is common in older adults, and which has been exacerbated by the COVID-19 pandemic, is another atypical anxiety syndrome (anxious distress related to feeling isolated) and it is specifically associated with increased morbidity and mortality. Similarly to major depression in late life, older adults with anxiety tend to minimize symptoms and to attribute them to physical illness, thus complicating the diagnosis process.³ Anxiety disorders in late life are both underrecognized and undertreated (eg, only about one-third of older adults with generalized anxiety disorder receive any kind of treatment).⁴ Overall, anxiety in late life is associated with greater disability and poor health-related quality of life, after controlling for medical burden and depressive symptoms.⁵

The USPSTF draft evidence review emphasizes that “direct evidence for screening for anxiety was extremely limited and did not suggest a benefit.” We agree with the USPSTF that “the limited tools used for screening provide little diagnosis accuracy,” but the lack of adequate tools does not imply a lack of need. It does point toward an area that requires more attention, not less.

Anxiety Disorders Are Important in Older Adults

Over the last decade, the accumulated evidence points toward a need to screen and diagnose anxiety disorders in older adults. Thus, several large studies have emphasized that anxiety (either as a disorder or a symptom) is a redoubtable risk factor for multiple diseases of aging, including cardiovascular disease and autoimmune and neurodegenerative disorders. Several large meta-analyses have linked anxiety to higher risk of stroke,⁶ heart failure, coronary artery disease, and cardiovascular death.⁷ This association remained significant in prospective studies⁶ that controlled for other risk factors, including depression.

Moreover, a recent meta-analysis including 9 prospective cohorts (N = 29 608) concluded that anxiety is significantly associated with an increased risk of all-cause dementias.⁸ Individuals with an anxiety disorder diagnosis have a 29% and 45% greater risk of having all-cause dementia and Alzheimer disease (AD), respectively.⁸ The brain of an older adult with severe anxiety ages faster—so fast that for every point on the 80-point worry severity scale they lose 3 months of brain age.⁹

Is anxiety just a prodrome, the canary in the mine signaling an impending deterioration? Or rather are its consequences, such as chronic activation of the cardiovascular, hypothalamic-pituitary-adrenal axis, and immune systems, a causal risk factor for cardiovascular and neurodegenerative diseases? We know that these systems are implicated in molecular correlates of brain and body aging (such as β amyloid accumulation, proinflammatory status, higher vascular burden). We know that the effect of anxiety on cognition appears as early as midlife: in the Nurses’ Health Study,¹⁰ a 4-year longitudinal study of community-dwelling older women (N = 16 351), higher midlife anxiety was related to worse later-life overall cognitive function and verbal memory. We also know that the evidence associating anxiety with an increased risk of coronary heart disease starts in midlife.¹¹ Just as depression has been identified as a major modifiable risk factor for diseases of aging, including AD, so too might anxiety disorders.

The current USPSTF draft recommendations do not help in changing these perceptions. These recommendations are particularly disconcerting in the face of rapid global population aging and may result in the worsening of an already widespread ageism bias.

There Are Treatments for Anxiety in Older Adults

It may be that the USPSFT draft recommendations authors, aware of the high rate of benzodiazepine use in older adults, coupled with problems such as confusion and falls ensuing from these medications, did not wish to further increase the use of these and other tranquilizer medications in this age group. One should always consider the risk of such unintended consequences with Screening for psychiatric disorders. Yet, simple straight forward treatments such as selective serotonin reuptake inhibitors, relaxation-focused cognitive behavioral therapy, and their combination have been shown to be highly effective. Collaborative care programs that are now being implemented nationwide could use safe medications together with brief psychotherapies to make a significant dent in the suffering and morbidity of anxiety disorders. Older adults should not be denied the opportunity to benefit.

Anxiety represents a highly prevalent problem and a potentially modifiable risk factor for diseases of aging. Opposite to the opinion expressed in the USPSTF, we do not anticipate any harm in recommending anxiety screening in older adults but consider this a great tool leading to prevention of mental and cognitive disorders of aging. Screening for anxiety in older adults would allow us to capture the large number of cases currently going undetected and unmanaged, decrease morbidity and mortality, and improve quality of life.