Roger S. McIntyre, MD, FRCPC

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Abstract: Research has shown that nocturia and major depressive disorder are often correlated. The clinician should take a complete history along with performing a physical examination when patients present with symptoms that may be associated with nocturia. Patients rarely seek medical attention solely for treatment of nocturia, so direct questions along with use of the Frequency Volume Chart (FVC) should be used to assess whether underlying disorders or conditions are present. Clinicians should also be alert to the possible presence of nocturia in patients who suffer from major depressive disorder since nocturia rates for this population is significantly higher. Behavioural modifications alone may be insufficient to improve nocturia where clinically depressive symptoms are also present. Pharmacological treatments may provide improvement when nocturia and major depressive disorder are both present.

Key Words: Nocturia, major depressive disorder, anxiety, lithium, SSRIs, Frequency Volume Chart (FVC), sleep hygiene, desmopressin.

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Research has shown that nocturia and major depressive disorder are often correlated.

It is essential that the clinician take a comprehensive history since patients often report symptoms associated with nocturia rather than nocturia itself.

The Frequency Volume Chart (FVC) is a reliable tool the clinician can use to assess whether underlying disorders or conditions are present, which will help determine treatment.

Given the poor physical and mental health that can result when nocturia and major depressive disorder are both present, the clinician should consider pharmacological treatment for nocturia if behavioural changes prove ineffective.

When a patient suffers from nocturia, the clinician should also screen for major depressive disorder.

Individuals who suffer from nocturia are more likely to report feelings of anxiety and depression than the general population.

Individuals who suffer from major depressive disorder are more likely suffer from nocturia.

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Keri-Leigh Cassidy, MD, Department of Psychiatry, Dalhousie University, Halifax, NS; Department of Psychiatry, University of Toronto, Toronto, ON.
Neil A. Rector, PhD, Department of Psychiatry, University of Toronto, Toronto, ON.

Late-life anxiety can often be “silent”--missed or difficult to diagnose as older adults tend to somatize psychiatric problems; have multiple psychiatric, medical, and medication issues; and present anxiety differently than do younger patients. Yet late-life anxiety disorders are a “geriatric giant,” being twice as prevalent as dementia among older adults, and four to eight times more prevalent than major depressive disorders, causing significant impact on the quality of life, morbidity, and mortality of older adults. Treatment of late-life anxiety is a challenge given concerns about medication side effects in older, frail, or medically ill patients. Antidepressants are recommended but not always tolerated, and benzodiazepines are generally to be avoided in this population. Effective psychotherapies such as cognitive behavioural therapy (CBT) are of particular interest for the older adult population, and the combination of CBT and medication is often needed to optimize treatment.
Key words: anxiety, late life, management, cognitive behavioural therapy.

Eric M. Morrow, MD, PhD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
William E. Falk, MD, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.

Anxiety in older patients, when excessive in degree and duration, can cause significant impairment and, if left untreated, may result in profound comorbidity--in particular, depression. Anxiety symptoms emerging in the older patient necessitate an extensive medical and psychosocial workup. There is a paucity of data for pharmacological treatment of anxiety disorders in older adults. In this review, we will discuss some of the research in the area of diagnosis and treatment of anxiety in older adults. We will also summarize some practice parameters common in our clinic when data are absent or lacking. The use of psychotherapies (such as cognitive behavioural therapy) and of medications such as the SSRIs, as well as benzodiazepines and other agents including the atypical antipsychotics, are discussed. The differential diagnosis of anxiety symptoms in the older patient, including careful attention to underlying medical and neurologic causes of anxiety, are emphasized.

Key words: SSRIs, benzodiazepines, psychotherapy, anxiety, depression, dementia.

D'Arcy L. Little, MD, CCFP
Director of Education and Research
York Community Services, Toronto, ON

Epidemiology
Many studies and review articles have emphasized the fact that anxiety disorders, in general, are less prevalent among the elderly than among young adults.^1-5 However, some degree of controversy regarding the prevalence of anxiety among the elderly does exist in the literature. A recent review by A. Flint of the University of Toronto concludes that these disorders are rare in the elderly.¹ Fuentes and Cox of the University of Manitoba argue, on the other hand, that current research on anxiety in the elderly uses instruments and criteria that may not be valid vis-à-vis the elderly. It is their contention, therefore, that these instruments underestimate the validity of findings concerning anxiety in this age group.^1,2

Statistically, anxiety disorders are the second most common type of psychiatric disorder affecting older people next to cognitive impairment.² They are relatively common in late life, and are a cause of significant morbidity.⁸ While actual prevalence rates vary slightly from study to study, anxiety "feelings" reportedly occur in up to 20%² of the North American population of elderly people, and anxiety disorders in 3.5 to 5.5% in this population.