Healt Articles healthy trim recipes insurance snacks healthy fast food

ANXIETY DISORDERS
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Hourth Edition (DSM-1V) delineates three broad categories of anxiety disorders: phobic disorders, posttraumatic stress disorder, and anxiety states.
Although phobic disorders affect some older adults, the more severe phobias (eg, agoraphobia and social phobia) begin early and are more common in children and younger adults. There are few data regarding their course through adulthood into late life.
Posttraumatic stress disorder is a relatively new diagnostic entity, even though the adverse impact of severe stress during childhood or young adulthood on future psychologic functioning has long been recognized. Most research and therapy directed toward posttraumatic stress disorder are derived from stress syndromes associated with war experiences and sexual abuse. Onset generally occurs in childhood or young adulthood; little is known about its continuance inlo late life.
In contrast, anxiety states are common in later life. Up to 5% of community-based older adulls experience symptoms of generalized anxiety disorder, making it one of the more common psychiatric problems in the elderly. Obsessive-compulsive disorder, another anxiety state, is also common in later life, although severe symptoms (eg. compulsive handwashing) are not usually prominent (see Perceptions and Beliefs in Ch. 89). Panic disorder often begins in late adolescence or early adulthood, and the symptoms generally recede by later life. Some older adults report episodes of panic, but these are usually less severe than those occurring earlier and are often complicated by depressive symptoms or physical illness (eg, postural hypotension).
Diagnosis
To establish the diagnosis of generalized anxiety, the patient must manifest symptoms from at least three of four DSM-IV categories: (1) motor tension (shakiness. jumpiness, trembling, inability to relax); (2) autonomic hyperactivity (sweating, palpitations, dry mouth, dizziness, hot or cold spells, frequent urination, or diarrhea); Oi apprehensive expectation (worry or anticipation of personal misfortune): and (4) vigilance and scanning (distractibility. poor concentration, insomnia, edgi-ness). These symptoms should persist at least 6 mo to qualify for
diagnosis.
A number of medical conditions are mistaken for generalized anxiety disorder because patients present with symptoms of anxiety. Hyperthyroidism with an atypical presentation can be missed unless thyroid function is tested. Cardiac arrhythmias that produce palpitations and shortness of breath are common in later life and may resemble a generalized anxiety disorder with periodic exacerbations and remissions. Patients with pulmonary emboli or pulmonary edema may also present with shortness of breath and a feeling of anxiety.
History taking will help rule out other possible causes of anxiety. For example, episodic anxiety may resemble panic disorder, but further questioning may reveal possible postural hypotension, which can be verified by checking blood pressure with the patient silling and standing. Other older adults with anxiety symptoms may suffer from hypoglycemia, which can be confirmed by a 5-h. glucose tolerance test.
Drugs may contribute to anxiety states. Caffeine is a frequent offender, as are over-the-counter sympathomimetic drugs (eg, ephed-rine). Anticholinergic agents may subtly impair memory, thereby producing secondary anxiety. Withdrawal from certain drugs, especially alcohol, anxiolytic agents, and sedative-hypnotics, may result in anxiety symptoms.
Other psychiatric disorders may be associated with anxiety. Delirium (acute organic brain syndrome) is oflen coupled with moderately severe anxiety and agitation, especially if the patient is in unfamiliar surroundings. Major depression also may be associated wilh anxiety and agitation. In some cases, agitation (ie. the inability to remain still) may resemble anxiety. However, the agitated older adult does not always report the sense of impending doom and dread that characterizes depressive anxiety. The elderly frequently complain of fear and anxiety that border on panic in the early morning, especially if they awaken in the dark when others in the house are asleep. These symptoms tend to remit as the day progresses. Hypochondriasis may be accompanied by moderately severe generalized anxiety, although the anxiety is usually intermittent and less severe than in other psychiatric disorders (see Ch, 97).
Possibly the most common cause of comorbid anxiety in Ihe elderly is Alzheimer’s disease. Early signs of cognitive dysfunction and memory loss in socially active persons often lead to generalized anxiety, with periodic episodes of panic; this in turn contributes to social withdrawal and isolation. The severe and traumatic behavioral changes that result from this anxiety syndrome frequently mask the underlying dementia.
Occasionally, the anxiety reported by patients is actually fear (possibly appropriate). The syndrome may exhibit itself only in situations that threaten security. For example, some elderly persons fear being mugged while walking along the street, losing their way to the doctor’s office or some other destination, or driving on busy highways. When such stressful experiences are avoided, these persons rarely complain of anxiety and, therefore, do not truly suffer from generalized anxiety disorder.
Treatment
Successful management of generalized anxiety disorder requires a strong physician-patient relationship, counseling, family support, appropriate medication, ami of course, an accurate diagnosis. Once the diagnosis is made, Ihe physician can correct potential organic causes; eg, if postural hypotension contributes to a sense of panic, an effort should be made to withdraw nonessential drugs that may contribute to hypotension.
Appropriate intervention for coexisting psychiatric disorders may alleviate symptoms of anxiety. For example, treating major depression with an antidepressant is usually sufficient to eliminate any associated anxiety and agitation. Providing a more structured environment for the mildly to moderately demented patient may alleviate the associated anxiety. If residual anxiety persists, however, the decision to prescribe an anxiolytic drug must be predicated on (I) the suitability of the pharmacologic agent for generalized anxiety and (2) the possibility of drug interactions between other therapeutic agents and the anxiolytic
Pharmacologic treatment, a major component of the management plan for generalized anxiety, is often the source of difficulties for both patient and clinician. In general, older adults respond satisfactorily but nol exceptionally to anxiolytic drugs. Most patients experience relief but not elimination of tension and agitation, and many symptoms persist. In addition, elderly persons often complain of the side effects associated with anxiolytics.
Unless a tricyclic antidepressant or monoamine oxidase inhibitor is prescribed for panic disorder, the drugs of choice are the benzodiazepines. In general, elderly persons respond better to shorter-acting agents (eg, alprazolam or oxazepam) than Io longer-acting ones (eg, diazepam). Occasionally, the shorter-acting agents may produce a rebound anxiety effect before the next dose is given. In such cases, a longer-acting agent may be preferred. The dosage is usually lower lhan for younger patients (eg. alprazolam 0.125 mg [half of a().25-mg tablet] orally bid or tid). Unless only one or two doses are taken daily, establishing a fixed dosage schedule is better than prescribing the medication as needed. The initial dose for buspirone is 5 mg tid. Divided doses of 10 mg bid or tid are commonly given. Buspirone is an alternative to a potentially addicting drug such as a benzodiazepine. However, buspirone will not bring about subjective improvement as quickly: its anxiolytic effect is usually observed after about 2 wk of continuous therapy. Persons who have responded to benzodiazepines usually do not respond to substitution with buspirone.
Discontinuing benzodiazepines is easier if prescribes make it clear from the outset that treatment is for only a brief period (eg. up to 4 to 6 wk). Once benzodiazepines are used continuousjy for an extended time, discontinuance is difficult. Nevertheless, periodic efforts should be made to withdraw the drug or at least to reduce the dose. Shorter-acting benzodiazepines should be discontinued gradually.
Patients should be monitored closely for development of side effects such as drowsiness, ataxia, slurred speech, impaired coordination, sleep disturbances, and depressive symptoms. Poor concentration and memory loss also may resull from anxiolytics. Drug discontinuance is essential for controlling these side effects, even if Ihe patient must be hospitalized to effect withdrawal.
Antipsychotic agents (neuroleptics) should not be prescribed for generalized anxiety, except when symptoms are secondary to delusions or other signs of psychosis. Such drugs may produce side effects (eg, tremulousness, restlessness and agitation, especially akathisia) that can complicate the symptoms of generalized anxiety. The mosl serious side effect, however, is tardive dyskinesia, which is usually irreversible.

This entry was posted on Thursday, June 25th, 2009 at 5:38 am and is filed under Health. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.