Anxiety disorders, the most common form of mental illness in the U.S., are particularly acute in the elderly population and present in up to 20% of older adults, according to a recently published article in Geriatrics & Aging.

Twice as common as dementias, and four to eight times more prevalent than major depressive disorders, late-life anxiety disorders threaten the quality of many seniors’ golden years.

Although there are five principal forms of anxiety disorders (generalized anxiety disorder, specific phobia disorders, obsessive-compulsive disorder, post-traumatic stress disorder, and panic disorders), GAD is responsible for at least half of cases and typically arises as a late-life exacerbation of an earlier-onset disorder, according to researchers. GAD is characterized by worries lasting longer than six months about health, finances, and relationships, which are difficult to control and result in physical symptoms such as fatigue, insomnia, muscle tension or pain, and restlessness. The presence of a concurrent medical illness increases the risk that an anxiety disorder such as GAD will manifest.

Tuning In
Fear, frustration, tears, and sometimes combative or unresponsive behavior are ways a generalized anxiety episode can present, says Rubye Kendrick, PT, MS, GCS, who works for Protocol Staffing at Southwood Nursing and Rehabilitation Center in Henderson, Texas. Clinical warning signs include an increased heart rate, excessive fatigue, head and muscle pain, and nausea, she adds.

But many members of the older generation try to cover up their anxiety, says Jennifer Bottomley, PT, MS, PhD, an independent consultant based in Boston who co-wrote the textbook “Geriatric Rehabilitation: A Clinical Approach.”

“Fear, anxiety, and depression are seen as character flaws,” she says. They might mask anxiety in physical complaints or other excuses, Bottomley says.

Kendrick agrees that PTs must continually look for clues that anxiety issues may be present in their elderly patients.

“We have to be in a constant assessment mode from the beginning of the session to the end,” Kendrick says. “We should really be listening to our patients, be in tune with what medications they are taking, when the medications are being given, and possible side effects. We must also recognize when you need to consult with a social worker or physician. A team approach is definitely needed.”

Above all, therapists need to respect the mental place their elderly patients are in at the time of interaction.

“There’s still so much bias about the elderly,” Kendrick says. “A patient will be labeled as just a chronic complainer or difficult to work with. Many elderly individuals deal with significant changes in their lives, and some with major losses, at a time when they are least equipped to deal with them. We have to be their advocate; we have to be in tune with what’s going on, and why.”

Functional Focus
Therapists typically see patients when they are at their most vulnerable, and the elderly are no exception. Often, older patients will experience anxiety because they have been placed in a new environment such as a hospital, rehab center, or nursing home, Bottomley says.

“They fear that they won’t return to their independent lifestyles, and this anxiety can be vented on the physical therapist,” she says. “Anxiousness, depression, and disorientation can all happen when they are admitted to a nursing home. It’s a whole different environment for them.”

PTs can calm some of that fear by informing patients that progress in physical therapy can help with their independence. “Focus on function,” Bottomley says. “Set goals with the patient: If we do this, you can get out of this chair, you can take a bath or walk down the hall — whatever goal they want.”

But patients residing in skilled nursing or assisted living facilities have few choices, Bottomley says. Their daily eating, hygiene, and other activities are typically dictated by the institution.

“Instead of demanding that your patients do something, offer it up as a choice,” she advises.

Complex Care
The classic treatment for anxiety disorders in younger patients has been benzodiazepine medications such as Valium and Xanax, says Charles Ciccone, PT, PhD, FAPTA, a professor at Ithaca (N.Y.) College.

“These drugs can give patients what we call the ‘hangover’ effect,” he says, which severely inhibits their ability to function, let alone participate in a physical therapy session.

Because of side effects, those drugs are now generally avoided for the older population, and instead are being replaced by other anti-anxiety drugs such as Paxil or Effexor, which work to increase the amount of serotonin in the brain, Ciccone says. Although they may not work as quickly for an episode of acute or severe anxiety, anti-anxiolytic drugs have fewer side effects than benzodiazepines, and are less likely to result in addiction, incontinence, cognitive impairment, and falls that may lead to hip fractures or death.

In combination with medication or on its own, cognitive behavioral therapy is also proving to be a useful tool that teaches patients progressive anxiety-reducing skills, and seems particularly helpful for older patients.

PTs can play a role in helping their patients move away from anti-anxiety drugs and improve confidence by helping patients regain function, Ciccone says. “We suggest when you see a problem, tell their caseworker or physician about the lack of progress you are seeing in the patient, that they are asleep all the time or there is a lack of carryover,” he says. “Ask if this could be drug-related.”

The more therapists can be objective in their patient assessments, with measurements of strength and balance, for example, the more doctors will respond, Ciccone says.

Practical PT
Physical therapy intervention can help many older patients cope with their anxiety. “Exercise is a great way to decrease stress,” Bottomley says. “Use deep breathing and stretching in your session.”

Calming music, such as classical or new age, during the session also can help patients with anxiety, as well as a working in a room painted with calming colors such as pastels to soothe them, Bottomley says.

“Use a walk in the garden to challenge their balance while they are calmed by the flora and fauna,” Bottomley suggests.

But, be aware that since patients with anxiety disorders often have a fear of failure, therapists must take care to initiate exercises and activities that have a likely outcome of success.

“Instead of attempting something [they think they can’t do], they may avoid it and come up with some reason why they didn’t do it,” Bottomley says. In addition, enlisting the help of a family member during therapy will often provide needed motivation and inspiration for completing a task. Consulting with an occupational therapist to evaluate and pursue desired leisure activities may also help older patients overcome their fears and regain confidence in the process of rehabilitation.

Teresa McUsic is a medical writer for the Gannett Healthcare Group.