Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0102Acute Management of Anxiety and PhobiasJavaid I. Sheikh 1,2 , Erin L. Cassidy 1,2 and Pamela J. Swales 21 Stanford University School of Medicine, Stanford, CA, and2Veterans Affairs, Palo Alto Health Care System, CA, USAAnxiety disorders are among the most common psychiatricconditions occurring in the elderly 1 . Although most of thesedisorders are of rather chronic nature, acute exacerbations, undera variety of conditions, can produce states of extreme anxiety andagitation that can require immediate attention. For example,patients in treatment for an anxiety disorder may seek anemergency appointment with their doctor/therapist due to amagnification of symptoms. Similarly, in a general hospital apsychiatrist may be called to consult on the management of acuteanxiety of an elderly patient on a medical or surgical floor; or aresident may be called upon to evaluate and manage an acutelyanxious elderly patient in the emergency room. It is also notunusual for patients with a primary anxiety disorder to present foremergency room services, thinking that they have acute medicalproblems 2 , e.g. patients having a panic attack might fear animpending heart attack and seek medical treatment. Since olderanxious patients are more likely to have concomitant medicalproblems than their younger counterparts, they may require acareful medical evaluation to rule out any organic causes ofanxiety 3 .The goal of acute management is relief of marked distress; thus,the treatment approach described here will focus on decreasingpatients’ symptomatology to manageable proportions as expeditiouslyas possible. Therefore, treatment approaches for long-termmanagement of anxiety and phobias will be omitted. Further,most situations requiring acute management will necessitatecombined pharmacological and psychological interventions. Dueto a lack of systematic studies of anxiety management in theelderly, much of our discussion will be based on evidence fromstudies in younger populations and our own clinical experience.GENERAL PRINCIPLES OF ACUTE MANAGEMENTAlthough acute management of various anxiety disorders mayvary somewhat according to the diagnosis, certain guidelines canbe useful in a majority of situations. To begin, it is important toremember that during states of extreme anxiety, patients canmanifest grossly impaired judgment and might appear to besuffering from a psychotic condition, but a few minutes ofquestioning will usually clarify the issue. A supportive interactionwith the patient is essential to successful treatment. A calm,reassuring manner can be very comforting in itself to alleviate theterror of extreme anxiety. Having a keen awareness of the uniquepsychosocial issues of the elderly, including retirement, possibledeaths of close friends and loved ones and a gradual deteriorationof physical functioning, is usually very helpful in developing theTable 102.1For patients: understanding your anxiety. The intense physical symptoms you experience when you are highlyanxious are those that are natural to the human body; they are notharmful to you as such. All people have an instinctive ‘‘fight-or-flight’’response to danger. It is the apparent lack of real danger to you thatmakes your feelings of fear or anxiety seem so uncomfortable andoverwhelming.. A number of factors may have led to your anxiety experience(s). Yourdoctor or another clinician may have discussed some of these with you.You may have been given medication to help control your anxiety. It isimportant for you to take your medication exactly as directed. Anxietymay also be controlled by other methods. Some of these are breathingand muscle relaxation skills, visualization (imagination) techniques, andexposure to anxiety-producing situations with the aid of a therapist. Nomatter what type of treatment you receive, keep your therapist or doctoraware of any problems, questions or concerns you may notice.. You and your doctor/therapist will be working together to help you inunderstanding and controlling your anxiety. In your efforts to cope(deal) with anxiety reactions, it is important to keep in mind that youare not alone. Many people suffer from intense and seeminglyoverwhelming periods of anxiety. Remember also, ‘‘there is light atthe end of the tunnel’’. Anxiety symptoms can be controlled. Thismay take time, practice, courage and a ‘‘stick-to-it attitude’’, but it isdefinitely do-able.initial rapport that will allow the patient to comply withsubsequent treatment.Patient education about their condition and various forms oftreatment can be especially beneficial to geriatric patients. Patientswith an anxiety disorder benefit from a discussion of thoughts,feelings and behaviors with their therapist or doctor, which canenhance rapport and facilitate patient understanding, decreaseglobal anxiety and foster patient compliance. Information thatmay be provided to patients during acute management of anxietyreactions is included in Table 102.1.The specific interventions may be pharmacological and/orpsychological. Before describing specific treatments for variousanxiety syndromes, it will be helpful to review general principlesof pharmacological and psychological therapies with older adults.PHARMACOLOGICAL MANAGEMENTCommon age-related changes in absorption, distribution, proteinbinding, metabolism and excretion of drugs and their implicationshave been covered in detail elsewhere in this book, and thus wewill only address the relevance of these changes to anxiolytics,Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd