Learning Objectives
By the end of this section, you will be able to:
- Understand the presentation, causes, and levels of anxiety in older adults
- Perform a nursing assessment of anxiety in an older adult
- Plan nursing care within a collaborative approach to treating an older adult with anxiety
Older adults frequently experience underdiagnosed and undertreated anxiety. Complex physiological conditions can confuse the older adult’s presentation or report of anxiety. Stress/loss, sadness, underlying medical illness, substance addiction, adverse drug/herb interactions, withdrawal syndromes, or general incapacity may all present as late-life anxiety symptoms.
Levels, Causes, and Support for Anxiety in Older Adults
Hildegard Peplau (1909–1999), the well-known psychiatric-mental health nurse theorist, developed a model describing four levels of anxiety: mild, moderate, severe, and panic. Behaviors and characteristics can overlap across these levels, but it can be helpful to tailor interventions based on the level of anxiety the client is experiencing. Nurses should learn to recognize these levels and utilize approaches most effective (Table 24.3).
| Anxiety Level | Behavior | Nursing Approach | Example Statement |
|---|---|---|---|
| Mild | Client may be irritable, restless | This stage actually may increase ability to learn; nurse should use most communication here | “Let’s talk this through.” |
| Moderate | Client verbalizes feeling tense, may complain of headache | Perceptual field narrowed; nurse’s communication should be focused | “Walk with me.” |
| Severe | Client loses perspective, needs assistance, may cry, cannot learn | Give specific direction and repeat, offer comfort measures | “Put your sweater on, I will stay here with you.” |
| Panic | Client must get relief, loses personal control, heart rate increases, safety risk, seeks escape | Manage the environment, reduce stimuli, repeat simple directions in calm manner, use client’s name and verbalize intent before taking any action | “Sarah, here is your wheelchair, we are going to another room now.” |
Link to Learning
Mental Health America offers fact sheets on anxiety in older adults including types, risk factors, screening, treatment, and Medicare coverage.
Etiology and Symptoms
Anxiety disorders are thought to have a complex etiology, with major contributions from both hereditary and environmental factors. Heritable factors, however, have less of an effect on older adults; instead, more attention is paid to the role of the biochemical changes that come with aging, illness, and neurodegenerative changes. In the context of polypharmacy, the role of medications, including drug interactions and side effects, should be taken into account. In this population, social and psychological factors are also important in the development of anxiety. Older adults may experience anxiety, for instance, in stressful situations like driving in heavy traffic. Anxiety may be precipitated by changes in the older adult’s routine, pain, fear, stressors in the environment, or worry. Frustration with mobility limitations, sensory impairment, or attitudes and behaviors of others can manifest as anxiety. It is imperative to take into account concerns related to life transitions, including but not limited to bereavement, financial strains, and relocation or downsizing. Feelings of helplessness resulting from the following circumstances can trigger anxiety: losing a partner or other sources of support, experiencing medical conditions that impair senses, and losing control or mastery over oneself.
In contrast to younger adults, older adults are more likely to exhibit physical symptoms like tachycardia or digestive problems. They may also be more prone to fatigue, tense muscles, and sleep disturbances. The following are indicators and symptoms of anxiety disorders in older adults:
- tachycardia, dyspnea, trembling, nausea, diaphoresis
- depression
- lack of routine or consumed by routine
- excessive or irrational worry/fear
- sleep disturbances (insomnia, oversleeping, nightmares)
- avoidant behavior, especially of social environments
- excessive concern for safety
- muscle tension, pain, or weakness
- hoarding
- alcohol or other CNS depressant misuse
Supporting Older Adults with Anxiety
Having a relationship with an individual who is compassionate and addresses inactivity and isolation directly can be very beneficial for some older adults suffering from anxiety disorders. This could be a friend, relative, health-care provider, employee of an assisted living facility, chaplain or clergyman, or someone else entirely. Getting anxious people involved in creative, social, or other enjoyable activities can be quite beneficial. It can make a big difference to assist older adults in managing issues that could cause anxiety, such as handling health issues, financial matters, and worries about burdening others. Some tasks support people can help with include the following:
- acknowledge concerns and deal with any fears that are manageable
- assist in implementing deep abdominal breathing, prayer, meditation, and stress-reduction strategies
- encourage talk with family, a friend, or a spiritual leader
- arrange for or join in exercise
- caution avoidance of triggers for anxiety, such as caffeine, smoking, alcohol, or other substance use
- share news of current events to keep them informed but not trigger anxiety
- allow time for treatment to work
Table 24.4 provides the most common signs and symptoms of anxiety as well as possible nursing interventions.
| Type | Signs and Symptoms | Interventions |
|---|---|---|
| Physical | Restless, agitated, fatigued, headache, gastric distress, body aches, heart racing, sweating, trembling, trouble sleeping | Remain supportive. Encourage safe physical activity: walking, stretching, yoga, deep breathing, meditation, reading, music. Teach to reduce triggers like alcohol, tobacco, and caffeine. |
| Shortness of breath, chest pain | Nursing assessment: vital signs, rule out need for emergency care. | |
| Psychological | Difficulty concentrating, irritability, excessive worry, feeling of being out of control or in danger | Remain supportive. Ensure safety. Assess cognition for education on coping, healthy lifestyle, and medications. |
Nursing Assessment
As discussed, recognition of behavioral cues can prompt focused care planning. Clients who are restless, tremulous, agitated, or socially withdrawn may benefit from anxiety reduction, which the nurse can plan. Anxious clients may not be capable of identifying the cause of their feelings, so nursing assessment becomes important. An inability to employ personal strategies to manage psychological distress, or ineffective coping, may be another priority problem.
The behaviors of anxiety in older adults are often different than in younger people. Behaviors may overlap with illnesses and other medical conditions. Complaints may present as medical or somatic, such as pain as opposed to psychological distress. Anger, agitation, or sleep disturbance may be results of underlying anxiety. This frequently leads health-care practitioners to miss the anxiety and possibly misdiagnose the client.
Older individuals who are anxious may become less self-reliant, which could place stress on family. Low compliance with medical treatment is linked to anxiety problems, and this could exacerbate chronic medical diseases and raise the chance of nursing home admission. Older adults who are anxious report having less life satisfaction, memory loss, a worsening self-perception of their health, and more loneliness.
Older adults may have more topics of worry than younger people, such as memory loss, medical illnesses, and fear of falls. One component of anxiety is worry, persistent, uncontrollable negative thoughts, ideas, and verbalizations resulting from attempts to problem-solve issues with uncertain outcomes (Makovac et al., 2018). Worry can have a protective role by shielding individuals from the full effects of the fear and motivating them to take prompt action toward resolution which, in effect, is a coping mechanism. As a coping mechanism, the person is creating a scenario where they rehearse and anticipate a fearful event so that they can prevent or mitigate the effects of the scenario in question. Worry is a problem when it becomes a negative feedback loop that the person struggles to escape.
Nurses’ Role in Collaborative Management
The primary role of the nurse in collaborative management is one of assessment, support, advocacy, and education of the client. Support and advocacy are built into the framework of all types of nursing care and are essential qualities in mental health care, especially with older adults. This population is high risk and frequently requires a high level of support and frequent advocacy, particularly if there is no or minimal family support. It is not uncommon for adults and older adults with mental health issues to become estranged from family and therefore no longer have support. In these cases, the nurse may be the one person who makes the difference in advocating for an older adult who, due to anxiety, has difficulty advocating for themselves and interacting with the team. The nurse can also serve as a major communicator for the medical provider in the client’s care. The nursing assessment is valuable to the client and their management team. As the person who spends the most time with the client, the nurse can see the bigger picture of how the client’s anxiety is affecting the thought process, functioning, and daily life. Nurses provide supportive care in helping with coping techniques and nonpharmacological interventions. Nurses also provide education about coping mechanisms.
Nurses can educate clients about the symptoms of their anxiety and techniques to manage it. For some individuals, even being aware that something is a symptom of anxiety, naming it, and connecting it to anxiety can help reduce the intensity of the anxiety.
Certain substances, such as caffeine, some over-the-counter cold medicines, illicit drugs, and herbal supplements may aggravate the symptoms of anxiety or interact with prescribed medications. Clients should be advised to avoid or minimize use of these substances.
Physical exercise and meditation are highly effective in reducing stress. Older adults can learn progressive muscle relaxation to refocus away from emotional stress. Other stress reduction activities include sharpening cognitive skills with puzzles, games, music, and art. Spending time outdoors or interacting with companion animals can be effective as well.
Nurses can teach and coach self-management and offer honest praise for the older person’s accomplishments. These interventions serve to promote the activities, and also to enhance the person’s self-esteem.