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Why Aren’t Doctors Screening Older Americans for Anxiety?

Anxiety disorders are common among seniors, but an influential panel seems likely to recommend against routine screening. Some experts disagree.

Susan Tilton’s husband, Mike, was actually in good health. But after a friend’s husband developed terminal cancer, she began to worry that Mike would soon die, too.

At night, “I’d lie down and start thinking about it,” recalled Ms. Tilton, 72, who lives in Clayton, Mo. “What would I do? What would I do?” The thought of life without her husband — they’d married at 17 and 18 — left her sleepless and dragging through the next day.

“It was very hard to shut it off,” she said of her worrying. “How could I get along by myself? What would I do with the house?”

Years earlier, Ms. Tilton had been seeing a therapist and taking medication for depression, but she ended therapy when her doctor retired. In late 2021, she consulted Dr. Eric Lenze, who heads the psychiatry department at the Washington University School of Medicine in St. Louis, for help with a different health problem, not fully recognizing that her anxiety was itself a diagnosable disorder.

“I just thought it was the way things were — you worried,” she said. “I believe I’ve had it since I was a child. To me, it was my normal way of thinking.”

“There’s this continuing fear that something bad is going to happen,” she added. “It can be all-consuming.”

The panel concluded that adults ages 18 to 64, including those who are pregnant and postpartum, should be screened for anxiety and gave that recommendation a “B” rating, meaning it had “moderate net benefit.” (Screening means testing patients who don’t exhibit symptoms or raise concerns about a particular health problem but may be experiencing it nonetheless.)

For people 65 and older, though, the task force issued an “I” rating, meaning it found insufficient evidence of benefits and harms.

“It’s a very scientifically rigorous process,” said Lori Pbert, a clinical psychologist and health behavior researcher at the University of Massachusetts Chan Medical School who served on the panel.

When it came to older adults, “evidence was lacking on the accuracy of screening tools and the benefits and harms of screening,” she said. The team also wanted more evidence of treatment effectiveness.

“It’s a strong call for the clinical research that’s needed,” Dr. Pbert said. The task force will publish its final recommendation later this year.

Dr. Andreescu and the other authors of the editorial, including Dr. Lenze, politely but strongly disagree. An “I” rating “makes people not look for or treat something that’s already an undertreated condition,” Dr. Lenze said.

“With a common disorder that causes a lot of impairment of quality of life and that has simple, inexpensive, straightforward kinds of treatment, I think screening is called for,” he added.

Whatever the final task force recommendation, the discussion of anxiety in older people highlights a prevalent but often overlooked mental health concern. “A lot of these cases fly under the radar,” Dr. Andreescu said.

That may reflect the way symptoms of anxiety can differ among older people, whose primary care doctors often lack the training to recognize mental health disorders. In addition to severe worry, seniors often experience insomnia or irritability; they may develop a fear of falling, engage in hoarding or complain of physical discomforts like muscle tension, a choking sensation, dizziness or shakiness.

But underdiagnosis also stems from older patients’ reluctance to ascribe their problems to psychological issues. “Some resent a label of ‘anxious,’” Dr. Andreescu said. “They’d rather call it ‘high stress,’ something that doesn’t indicate psychological weakness.”

And since aging involves genuine sources of fear and distress, from falls to bereavement, people may see anxiety as normal, as Ms. Tilton did.

And it degrades people’s everyday lives. Jim Wright, a Pittsburgh executive who has participated in Dr. Andreescu’s research, described having “a lot of sleepless nights.”

“I’ll wake up at 2 a.m. and lie there worrying about every random thing you can think of,” said Mr. Wright, 60, who has also developed hypertension that has proved difficult to control.

Neither man has sought treatment for anxiety. “I’ve learned to live with it,” Mr. Wright said. Yet anxiety can be treated with antidepressants like Prozac, Lexapro and Zoloft, called selective serotonin reuptake inhibitors, combined with specialized forms of cognitive behavioral therapy.

Because older people require higher doses of antidepressants and are already likely to be taking multiple medications, doctors proceed cautiously. “It’s a bigger challenge” to treat older anxious patients, Dr. Andreescu said. “It’s more complicated.”

The drugs can take weeks longer to bring relief than in younger people, she said, which may lead patients to think they aren’t working and stop taking them. Older patients may also relapse and require a different regimen.

With time, though, “we do get it under control,” Dr. Andreescu said. “People do respond to treatment.”

Ms. Tilton, for instance, said she had regained her equilibrium. Dr. Lenze increased her dosage of duloxetine (sold under the brand name Cymbalta) and added mirtazapine (Remeron). “I’m feeling really good right now,” she said.

A particular pleasure: improved sleep. “I can lie down on the bed and conk out in a second,” she said. “It’s a real treat.”

Category: Science

Source: NYTimes Science

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