Flint Alastair J
Department of Psychiatry, University Health Network and University of Toronto, Toronto, Ontario, Canada.
Drugs Aging. 2005;22(2):101-14. doi: 10.2165/00002512-200522020-00002.
Generalised anxiety disorder (GAD) is characterised by at least 6 months of excessive uncontrollable worry accompanied by symptoms of motor tension and vigilance and scanning. As with other anxiety disorders, GAD is less prevalent in older adults than younger adults. GAD has a high level of comorbidity with other psychiatric disorders and this has a bearing on estimates of its prevalence. GAD that is comorbid with another psychiatric disorder has a period prevalence of approximately 4% in community-dwelling older people. On the other hand, 'pure' GAD is less common, with a period prevalence of approximately 1%. Pure GAD in late life is a fairly even mix of chronic cases that began earlier in life and cases starting for the first time in later life. The most frequent and consistent finding regarding late-life generalised anxiety is its high level of comorbidity with major depression. There are few longitudinal data pertaining to the temporal association of generalised anxiety and major depression in late life, but the data that do exist suggest that the anxiety is frequently symptomatic of the depression. If generalised anxiety occurs exclusively during episodes of major depression, a separate diagnosis of GAD is not warranted. Cognitive behaviour therapy (CBT) is the most frequently studied psychological treatment for GAD. Although CBT is more effective than a wait-list control condition, it is not more effective than nondirective therapies in late-life GAD. Furthermore, a standard course of CBT appears to be less efficacious for GAD in older adults than younger adults. Further research is needed to develop more efficacious and specific forms of psychotherapy for late-life GAD. The three classes of medications that are most commonly used for GAD are: (i) antidepressants; (ii) benzodiazepines; and (iii) buspirone. Antidepressant medication is the pharmacological treatment of choice for most older adults with generalised anxiety. When generalised anxiety is secondary to an episode of major depression, the selection of an antidepressant is guided by the same principles that apply to treatment of nonanxious depression. Antidepressant medication is also effective for GAD in the absence of an episode of major depression. In this situation, citalopram and venlafaxine have been found to be efficacious in older people. Data from studies of mixed-aged patients suggest that escitalopram, paroxetine and trazodone may also be beneficial in late-life GAD. Despite their widespread use in older persons with anxiety, benzodiazepines have a limited role in the treatment of GAD in the elderly. If a benzodiazepine is initiated, pharmacokinetic considerations favour the use of either lorazepam or oxazepam. Buspirone also has a more limited role than antidepressants in the treatment of late-life GAD.
广泛性焦虑障碍（GAD）的特征是至少6个月的过度且无法控制的担忧，并伴有运动紧张以及警觉和扫描症状。与其他焦虑症一样，GAD在老年人中的患病率低于年轻人。GAD与其他精神障碍的共病率很高，这影响了其患病率的估计。与另一种精神障碍共病的GAD在社区居住的老年人中的期间患病率约为4%。另一方面，“单纯”的GAD较少见，期间患病率约为1%。晚年的单纯GAD是早年开始的慢性病例和晚年首次发病的病例的相当均匀的混合。关于晚年广泛性焦虑最常见和一致的发现是其与重度抑郁症的高共病率。关于晚年广泛性焦虑和重度抑郁症的时间关联的纵向数据很少，但确实存在的数据表明焦虑常常是抑郁症的症状。如果广泛性焦虑仅在重度抑郁发作期间出现，则无需单独诊断为GAD。认知行为疗法（CBT）是针对GAD研究最频繁的心理治疗方法。尽管CBT比等待名单对照条件更有效，但在晚年GAD中它并不比非指导性疗法更有效。此外，标准疗程的CBT对老年人的GAD似乎不如对年轻人有效。需要进一步研究以开发针对晚年GAD更有效和更具特异性的心理治疗形式。最常用于GAD的三类药物是：（i）抗抑郁药；（ii）苯二氮䓬类药物；（iii）丁螺环酮。抗抑郁药是大多数患有广泛性焦虑的老年人的药物治疗选择。当广泛性焦虑继发于重度抑郁发作时，抗抑郁药的选择遵循适用于治疗非焦虑性抑郁症的相同原则。抗抑郁药对不存在重度抑郁发作的GAD也有效。在这种情况下，已发现西酞普兰和文拉法辛对老年人有效。来自混合年龄患者研究的数据表明，艾司西酞普兰、帕罗西汀和曲唑酮对晚年GAD也可能有益。尽管苯二氮䓬类药物在患有焦虑症的老年人中广泛使用，但它们在老年GAD治疗中的作用有限。如果开始使用苯二氮䓬类药物，药代动力学考虑因素有利于使用劳拉西泮或奥沙西泮。丁螺环酮在晚年GAD治疗中的作用也比抗抑郁药更有限。
