GERIATRIC PSYCHIATRY: ANXIETY AND EXERCISE
| ANXIETY DISORDERS IN OLDER PERSONS —Julie L. Wetherell, PhD, Assistant Professor in Residence, Department of
Psychiatry, University of California, San Diego, School of Medicine, and Staff Psychologist, Veterans Affairs San Diego
Healthcare System
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| Myths and facts about late-life anxiety: myths—anxiety rare, and not as common as depression in older people;
“blurry constellation” of anxiety and depressive symptoms more common in elderly than clear-cut anxiety or depression;
when true anxiety disorders occur in elderly, they tend to be comorbid with depression; anxiety disorders in older people start
early in life; older people have more somatic presentation and are more likely to complain of physical symptoms; anxiety in
elderly not serious or disabling; facts—anxiety disorders not rare, and may be more common than depression in older adults;
mixed anxiety-depression not as common as generalized anxiety disorder (GAD) or phobias; although comorbid anxiety disorders
common among elderly with depression, anxiety more likely to occur alone; one-third to one-half of older adults with
anxiety disorders have late onset; somatization is not key feature of late-life GAD; anxiety in older adults is serious, disabling,
and costly
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| Pharmacotherapy for anxiety: surprisingly few studies, given prevalence of anxiety; controlled studies have found
evidence for efficacy of venlafaxine, citalopram, sertraline, and oxazepam, relative to placebo; some data may indicate
increased risk for cardiac events in older people given venlafaxine; almost all research involved GAD, and very little
involved other anxiety disorders (such as posttraumatic stress disorder [PTSD] or panic disorder)
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 | Benzodiazepines: problematic in elderly; can lead to falls and/or cognitive impairment, and risk probably not reduced
with short-half-life benzodiazepines; long-term use associated with cognitive disorders; associated with delirium in
medically ill; abuse potential probably minimal; in general, best used for short term only (however, GAD is chronic);
best as adjunct for short-term relief
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| Principles of pharmacotherapy for late-life anxiety: specific agent may be less important than clinical management;
high risk for drop-out in first few weeks; high risk for side effects; patient may erroneously think that anxiety-related
somatization due to medication, even when symptoms predate start date of medication; start low, go slow (but not
too slow, and do not end low); schedule frequent visits (initially weekly) and provide support; educate patient in advance
about side effects, emphasizing that they are likely to be self-limited and unlikely to be catastrophic; benzodiazepine may
be necessary as short-term adjunct, but reinforce idea that benzodiazepines only for temporary use; evidence limited regarding
augmentation with atypical antipsychotic medications
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| Psychotherapy techniques: psychoeducation (eg, information about anxiety and symptom monitoring); relaxation
training (including diaphragmatic breathing, imagery, progressive muscle relaxation); cognitive therapy (eg, identifying
and changing negative automatic thoughts); worry control (including thought stopping and scheduled worry); exposure
therapy (ie, systematic desensitization); maintenance (eg, relapse prevention, skills review)
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| “Not so standard” techniques of speaker: behavioral activation (eg, scheduling pleasant activities); sleep hygiene; training
in problem-solving skills (ie, specifying problem, brainstorming, evaluating, implementing solutions); life review (eg,
structured journaling to change long-standing negative beliefs); attention training (eg, shifting focus among auditory
stimuli); acceptance (eg, meditation, values, goal setting); assertiveness training (eg, direct communication); time management
(eg, prioritizing, scheduling)
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| Comparison of CBT and attention placebo for late-life GAD: found bigger effect for CBT immediately after treatment
and at 6-mo follow-up
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| Predictors of outcome: amount of at-home practice (more practice yields better results); intact executive functioning; executive
functioning—refers to ability to attend selectively, plan, organize, sequence, switch between tasks, and inhibit
actions; many older adults who do not have dementia do have impaired executive functioning; sometimes executive
functioning improves with improvement in anxiety
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| Recommendation: if patient with only anxiety requests psychotherapy, start with relaxation training; analysis that compared
relaxation training alone, CBT alone, and combination found that relaxation seemed to be effective component
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| Comparison of CBT and sertraline for late-life panic and GAD: to date, only randomized control trial comparing
CBT to medication; found medication superior to CBT, but including patients with panic may have affected results;
speaker opines that based on this study, first-line treatment for late-life anxiety probably should be medication;
however, for some anxiety disorders, such as agoraphobia, behavior must change for patient to get better, and combination
of medication and CBT necessary
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| Conclusions: many psychotherapeutic techniques available, but relaxation training appears to be most effective; in geriatric
GAD, executive dysfunction may compromise results of psychotherapy, especially CBT; at-home practice important;
CBT appears to be less effective than selective serotonin reuptake inhibitors (SSRIs) in acute phase of treatment of
older adults with anxiety (but not older adults with depression or younger adults)
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| IS EXERCISE GOOD FOR YOUR BRAIN ?—George Dawson, MD, Assistant Professor of Psychiatry, University of
Minnesota Medical School, Minneapolis, and Staff Psychiatrist, Department of Behavioral Health, HealthPartners Medical
Group and Clinics, Regions Hospital, St Paul, MN
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| Introduction: does exercise prevent or reverse age-related cognitive decline? does exercise decrease incidence of neurologic
and neuropsychiatric disorders? does exercise decrease symptoms associated with psychiatric disorders? what physiologic
effect does exercise have on brain?
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| Exercise recommendations: American Heart Association—individuals should engage in ≥30 min of moderate-intensity
physical activity on most (preferably all) days of week; Centers for Disease Control and Prevention (CDC)—
same as above, but 5 days/wk; American Diabetes Association—to improve glycemic control, assist with weight
maintenance, and reduce risk for cardiovascular disease, at least 150 min/wk of moderate-intensity aerobic physical activity
(50%-70% of maximum heart rate) and/or at least 90 min/wk of vigorous aerobic exercise (70% of maximum
heart rate); this physical activity should be distributed over at least 3 days/wk and with ≤2 consecutive days without
physical activity; in absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance
exercise 3 times/wk, targeting all major muscle groups, progressing to 3 sets of 8 to 10 repetitions at a weight that
cannot be lifted more than 8 to 10 times
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| Meeting these guidelines: indirectly prevents brain injuries; decreases incidences of stroke and cardiovascular disease;
exercise should include aerobic physical activity and strength training
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| Research questions: what should doses of exercise be for different goals? do aerobic conditioning and strength training
affect brain differently? in what ways? do complex movements affect brain differently than simple movements?
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| Neural adaptation to strength training: earliest adaptation to strength training; electromyography (EMG) studies
show that in first 8 wk of 16-wk strength training, there is minimal muscle hypertrophy, more activation of motor units,
and cross-education of contralateral muscle groups; that is, initially, muscle hypertrophy minimal but increase in strength
significant; posited that this occurs because of change in descending drive to motor units, alterations in agonist-antagonist
coactivation, and increase in firing rates of motor units
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| Muscular adaptation to strength training: increased density of muscle fibers (myofilaments and myofibrils); selective
muscle hypertrophy, depending on activity (ie, hypertrophy of type 1 [slow-twitch] muscle fibers occurs in endurance
athletes, hypertrophy of type 2 [fast-twitch] muscle fibers in sprinters and weight lifters); greater hypertrophy in
type 2 fibers; earliest increase in strength can occur after single session of assessment by physical therapist; for example,
studies show that after single assessment of knee extensor strength by physical therapist, increase in strength can be detected
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| Evidence that exercise affects central nervous system (CNS): basic science (eg, animal studies); human
studies—diagnostic groups; observation and naturalistic studies; cross-sectional studies; uncontrolled studies; controlled
studies; randomized controlled studies
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| Basic science: old rats running on wheel—control group trained in motor skills; running rats had higher density of capillaries
in cerebellum; rats trained in motor skills had higher density of synapses in cerebellum; proteomic analysis—
exercise used as stimulus to look at effect of exercise on rat hippocampal protein classes; exercise dose was voluntary
running on wheel for 5 nights; exercise led to increased proteins involved in energy metabolism and synaptic plasticity;
electrophysiologic experiment—showed exercising animals have higher frequency of cell firing in hippocampus;
conclusion—exercise has significant impact on rat brain
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| Important molecules affected by exercise: insulin-like growth factor 1 (IGF-1)—secreted as hepatic response to
growth factor peaks that occur during exercise; has direct effect on lipolysis; increases transport of amino acids into cell;
increases protein synthesis; has lactogenic effects through prolactin receptor; has immunomodulatory properties; brain-
derived neurotrophic factor (BDNF)—synthesized in CNS; prevents cell death; has effects on cell proliferation, migration,
differentiation, and axonal growth and sprouting, and on complexity of dendrites and plasticity of nervous system
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| Clinical studies: first begun in late 1970s; have become increasingly rigorous over time; most efforts focused on depression,
with few studies of anxiety disorders and no studies of psychotic disorders
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| Fitness and depression: review of literature produced 72 studies, of which 56 eliminated because they were not controlled
or control was poor; remaining 16 studies involved 432 patients; results of analysis showed exercise did not have robust
effect on depression when compared to standard treatments (eg, psychopharmacology, psychotherapy); study author
concluded that quality of studies was problem and better research needs to be done; more recent study showed
exercise group did significantly better than control group on 2 standard rating scales of depression
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| Fitness and human cognition: imaging-study evidence and longitudinal epidemiologic studies indicate that exercise can
preserve or even enhance cognition; exercise does not have to be intense; dose of exercise in some studies quite conservative
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| Observations: aerobic conditioning has significant effect on cognition; effects largest for executive functioning, eg,
working memory, planning, scheduling, interference control (areas thought to be most sensitive to aging and possibly
most amenable to intervention); fitness holds promise as neuroprotective intervention over course of adult lifespan; effects
seen in early human experiments consistent with data from animal studies
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| Unanswered questions: what is optimal dose of exercise? if individual stays at high level of training throughout most
of adult life, is protective effect greater? how does exercise interact with genetic factors that influence longevity, cognition,
and mental disorders? studies show that for exercise intervention in people >50 yr of age, women tend to improve at
faster pace than men (why?) what is joint effect of diet and exercise? what role does enriched environment play in prevention
of cognitive decline? does it augment exercise intervention? study that compared enrichment to exercise in elderly
people found that people who do cognitive activities as they age lose less cognitive function and are less likely to
become demented, and that not all exercise provides benefits (people who engaged in cycling derived no benefit from cycling,
but did derive benefit from cognitively stimulating activities)
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| Conclusions: in some elderly patients, fitness training has potential to exceed utility of commonly prescribed drugs, eg,
cholinesterase inhibitors and memantine; at public policy level, fitness training has potential to prevent cognitive loss, enhance
cognitive function, and improve some psychiatric conditions, eg, depression; donepezil trial—found donepezil
not cost effective, with benefits below minimally relevant thresholds; concluded that more effective treatments than cholinesterase
inhibitors needed for treatment of Alzheimer’s disease; editorial about donepezil trial opined, “results [of the
donepezil trial] are incompatible with many drug-company–sponsored observational studies and advertisements claiming
remarkable effects for cholinesterase inhibitors; for example, claims that donepezil stabilizes cognitive decline or delays
nursing-home placement can now be seen as implausible ; the cost per patient was increased by 40% due to the drug
cost, with no offset in reduction of other treatment resources”
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| Final thoughts: how to optimize physical conditioning so people continue to stay fit? some studies had selection bias in
picking only subjects fit enough to do basic exercises; what about people who are not fit enough? are associated fields
such as cardiology, rheumatology, and orthopaedics able to contribute to sustaining aging body that can exercise? what
are implications for patients with pure psychiatric disorders? can brain atrophy be prevented by enhancing BDNF
through exercise? how much cognitive disorder that accompanies chronic mental illness is due to sedentary lifestyle?
larger studies needed to examine several parameters at once, but early studies suggest that exercise probably very good
for the brain
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Suggested Reading
Abbott RD et al: Walking and dementia in physically capable elderly men. JAMA 292:1447, 2004; Ayers CR et al:
Evidence-based psychological treatments for late-life anxiety. Psychol Aging 22:8, 2007; Barnes DE, Whitmer RA,
Yaffe K: Physical activity and dementia: The need for prevention trials. Exerc Sport Sci Rev 35:24, 2007; Berchtold
NC et al: Exercise primes a molecular memory for brain-derived neurotrophic factor protein induction in the rat hippocampus.
Neuroscience 133:853, 2005; Billings LM et al: Learning decreases A beta*56 and tau pathology and ameliorates
behavioral decline in 3xTg-AD mice. J Neurosci 27:751, 2007; Brenes GA et al: The influence of anxiety on the
progression of disability. J Am Geriatr Soc 53:34, 2005; Caudle DD et al: Cognitive errors, symptom severity, and response
to cognitive behavior therapy in older adults with generalized anxiety disorder. Am J Geriatr Psychiatry 15:680,
2007; Cotman CW, Berchtold NC: Exercise: a behavioral intervention to enhance brain health and plasticity. Trends
Neurosci 25:295, 2002; Hopko DR et al: Assessing worry in older adults: confirmatory factor analysis of the Penn State
Worry Questionnaire and psychometric properties of an abbreviated model. Psychol Assess 15:173, 2003; Kramer AF et
al: Fitness, aging and neurocognitive function. Neurobiol Aging 26(Suppl 1):124, 2005; Larson EB et al: Exercise is
associated with reduced risk for incident dementia among persons 65 years of age and older. Ann Intern Med 144:73, 2006;
Lawlor DA, Hopker SW: The effectiveness of exercise as an intervention in the management of depression: systematic
review and meta-regression analysis of randomised controlled trials. BMJ 322:763, 2001; Meyer T, Broocks A:
Therapeutic impact of exercise on psychiatric diseases: guidelines for exercise testing and prescription. Sports Med 30:269,
2000; Mohlman J, Gorman JM. The role of executive functioning in CBT: a pilot study with anxious older adults.
Behav Res Ther 43:447, 2005; Penninx BW et al: Exercise and depressive symptoms: a comparison of aerobic and resistance
exercise effects on emotional and physical function in older persons with high and low depressive symptomatology.
J Gerontol B Psychol Sci Soc Sci 57:P124, 2002; Schoevers RA et al: Comorbidity and risk-patterns of depression,
generalized anxiety disorder and mixed anxiety-depression in later life: results from the AMSTEL study. Int J Geriatr Psychiatry
18:994, 2003; Schoevers RA et al: The natural history of late-life depression: results from the Amsterdam Study
of the Elderly (AMSTEL). J Affect Disord 76:5, 2003; Schuurmans J et al: A randomized, controlled trial of the effectiveness
of cognitive behavioral therapy and sertraline versus a waitlist control group for anxiety disorders in older adults.
Am J Geriatr Psychiatry 14:255, 2006; van Hout HP et al: Anxiety and the risk of death in older men and women. Br J
Psychiatry 185:399, 2004; van Praag H et al: Exercise enhances learning and hippocampal neurogenesis in aged mice.
J Neurosci 25:8680, 2005; Vaynman S, Ying Z, Gomez-Pinilla F: Hippocampal BDNF mediates the efficacy of exercise
on synaptic plasticity and cognition. Eur J Neurosci 20:2580, 2004; Wang L et al: Performance-based physical
function and future dementia in older people. Arch Intern Med 166:1115, 2006; Wetherell JL et al: Quality of life in
geriatric generalized anxiety disorder: a preliminary investigation. J Psychiatr Res 38:305, 2004; Wetherell JL et al:
Screening for generalized anxiety disorder in geriatric primary care patients. Int J Geriatr Psychiatry 22:115, 2007; Wetherell
JL et al: Anxiety disorders in the elderly: outdated beliefs and a research agenda. Acta Psychiatr Scand 111:401,
2005.
Educational Objectives
| The goals of this program are to enhance treatment of anxiety in older patients and to establish that exercise is good for the
brain in many ways. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Recognize many of the myths about anxiety in older persons.
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| 2. Discuss the comorbidity of anxiety disorders in older persons.
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| 3. Compare pharmacotherapy and psychotherapy as treatments for anxiety disorders in older persons.
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| 4. Cite evidence that exercise has positive effects on the central nervous system.
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| 5. Suggest an exercise regimen that is within the abilities of an older person.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Wetherell was recorded at West Coast Geriatric Psychiatry Conference, held March 7-10, 2007, in San Diego, CA, and
sponsored by the University of California, San Diego, School of Medicine. Dr. Dawson was recorded at 7th Annual Psychiatry
Update: Selected Topics for the Non-Psychiatrist, held April 27, 2007, in Minneapolis, MN, and sponsored by HealthPartners
Institute for Medical Education. The Audio-Digest Foundation thanks the speakers and the sponsors for their
cooperation in the production of this program.
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