Anxiety disorders can be successfully treated in older adults using psychological interventions, with the strongest evidence for cognitive behavioural therapy (CBT).
One of the core CBT skills for treating all anxiety disorders, graded exposure, involves gradually facing feared situations or activities to learn that the situations or activities are not as threatening and/or that fear is tolerable.
For example, an older adult with excessive concerns about being negatively evaluated, graded exposure might involve gradually reducing avoidance of talking to new people, attending social groups or practising being more assertive (Wuthrich & Rapee, 2013).
In late-life generalised anxiety disorder, common excessive worry behaviours include frequently seeking reassurance and checking health indicators such as blood pressure more often than is clinically required (Wuthrich et al., 2022). In these instances, exposure therapy would be used to deliberately reduce excessive reassurance seeking and checking behaviours.
Exposure therapy can also be used to reduce disproportionate fear of falling by gradually reducing avoidance associated with walking on uneven surfaces, without an aid
or at night (Wetherell et al., 2018).
How is it being used with older adults?
Despite the empirical support for exposure therapy, it is unclear how many community-dwelling older adults with anxiety disorders receive this intervention. Prior research in other age groups indicates that most clinicians trained in exposure therapy rarely use this treatment technique in their clinical practice (Becker et al., 2004; Hipol & Deacon, 2013).
Where exposure therapy is used, it is often delivered in a suboptimal manner, such as overemphasising client self-directed exposure while underusing therapist-assisted in vivo exposure, or incorporating arousal-reduction strategies, e.g. relaxation retraining, during exposure tasks which hinders the client’s learning that their anxiety is tolerable (Deacon et al., 2012; Hipol & Deacon, 2013),
Current research
In a recent research survey (Chen et al., 2022), we examined the use of exposure therapy compared to other treatment techniques among clinicians who treat older adults with anxiety disorders.
Clinicians reported using exposure therapy significantly less frequently in treatment of older anxious clients compared to younger anxious clients. Negative therapist beliefs about the safety and tolerability of exposure therapy, as measured on the Therapist Beliefs about Exposure Scale (Deacon et al., 2013), were significantly associated with infrequent use of exposure therapy in older adult clients. Clinical qualification was also associated with therapist beliefs about the exposure therapy, with clinicians who hold postgraduate qualifications reporting less negative therapist beliefs about exposure.
What do these findings mean?
These preliminary findings indicate there may be a need to address negative clinician attitudes towards the use of exposure therapy when working with anxious older clients. Ageist beliefs may play a role in clinicians’ hesitancy about using an evidence-based therapeutic technique in this age group which might potentially reduce the effectiveness of the interventions delivered. This is concerning as there is ample evidence from clinical trials supporting the benefits of exposure therapy in older populations (see meta-analyses by Gould et al., 2012; Wuthrich et al., 2021).
In addition, while not specifically tested in our study, ageist beliefs and stereotypes among clinicians regarding older adults’ need for and ability to change are likely to lead to clinicians not using evidence-based treatment, doing cognitive therapy without exposure or teaching relaxation techniques in the context of exposure, out of the beliefs about protecting older clients. Our research findings also suggest that exposure therapy training for working with older adults may need to address therapist beliefs about the necessity of these safety behaviours (Meyer et al., 2020).