Anxiety in the elderly; generalised anxiety disorder

Definition. GAD is excessive, difficult-to-control worry about multiple events or activities, present on most days for at least 6 months, with at least three of: restlessness, fatigue, poor concentration, irritability, muscle tension and sleep disturbance, causing distress or functional impairment.

Epidemiology and onset pattern. GAD is the anxiety disorder next in frequency after agoraphobia and panic disorder in older adults. Crucially, half of older adults with GAD have had symptoms for most of their lives, whereas the other half report developing GAD within the last five years — so both lifelong and genuinely late-onset GAD exist, and late onset should prompt a search for a medical or drug cause.

Clinical presentation in old age. Worry is realistic and health-centred — about illness, pain, disability, falls, finances, dependency and death. Somatic presentation dominates: palpitations, tremor, dizziness, gastrointestinal symptoms, muscle tension and insomnia. Older patients typically present to a physician rather than a psychiatrist and rarely volunteer the word "anxiety".

Differential diagnosis. Depression with anxious distress — the most important, since anxiety symptoms in depression predict antidepressant treatment resistance; medical causes — hyperthyroidism, arrhythmia, angina, COPD, hypoglycaemia, delirium; drug-induced anxiety — sympathomimetics, beta-2 agonists such as albuterol, caffeine, nicotine, steroids; and withdrawal states — alcohol and benzodiazepine. Also consider early dementia and akathisia.

Assessment. History plus informant account; screen for depression first; rate with GAD-7, the Geriatric Anxiety Inventory or HAM-A; conduct a full drug and over-the-counter review; targeted tests — TSH, glucose (mg/dL), calcium (mg/dL), ECG, oxygen saturation. Assess functional impact — avoidance, restricted mobility and carer burden.

Management. Non-pharmacological first — CBT, relaxation training and mindfulness-based interventions are safe and, in the long term, as effective as benzodiazepines; add sleep hygiene, reduction of caffeine and alcohol, and exercise. Drugs: SSRIs (escitalopram, sertraline) first-line; SNRIs and vortioxetine second-line; buspirone is an option primarily for GAD. Warn that the effect may take up to six weeks. Do not use antipsychotics such as quetiapine — the risks exceed the benefits. Benzodiazepines only short-term, short-acting, and only where symptoms are incapacitating.

Mindfulness-based stress reduction is non-inferior to escitalopram (Hoge et al., JAMA Psychiatry 2023) in adults with anxiety disorders including GAD, with fewer adverse events — a particularly important finding in older adults, where drug tolerability is the limiting factor. This is reinforced by the 2023 AGS Beers Criteria, which list benzodiazepines as potentially inappropriate in all older adults irrespective of indication or duration of use. Condensed 6-Mark Version — 5 Textbook Points + 1 Latest Update Textbook Core — 5 Points

Anxiety is not normal ageing. Anxiety disorders are the most prevalent but most under-treated psychiatric disorders in older adults. In order of frequency: agoraphobia and panic disorder → phobias (including fear of falling) → generalised anxiety disorder.

Always exclude the three mimics before diagnosing. (i) Medical disease — hyperthyroidism, arrhythmia, angina, hypoglycaemia, COPD, delirium; (ii) drugs — sympathomimetics, beta-2 agonists, caffeine, nicotine, steroids, dopamine agonists; (iii) withdrawal — alcohol and benzodiazepines. New onset of panic attacks in an older person always requires a thorough medical evaluation.

Then exclude depression. Anxiety symptoms are a common component of late-life depression, and their presence predicts antidepressant treatment resistance. Treating the depression treats the anxiety; treating the anxiety alone with a benzodiazepine is a recognised prescribing error.

Non-drug treatment is first-line. CBT, relaxation training and mindfulness-based interventions are safer than, and in the long term as effective as, benzodiazepines, and many older adults prefer them. Add sleep hygiene, exercise, correction of sensory impairment, and reduction of caffeine, nicotine and alcohol.

Drug treatment with the geriatric rules. SSRIs (escitalopram, sertraline) first-line; SNRIs and vortioxetine second-line; buspirone for GAD; allow up to six weeks for effect. Do not use antipsychotics for anxiety. Benzodiazepines only short-term, short-acting, for incapacitating symptoms — they cause cognitive impairment, falls and fractures, and chronic use beyond 120 days is common and difficult to reverse, requiring psychiatrist-supervised withdrawal over months.

USPSTF 2023 (JAMA). A Grade B recommendation to screen for anxiety disorders in adults aged 19–64, but an explicit I-statement for adults aged 65 and above — the evidence is insufficient, with clinicians advised to screen on the basis of clinical judgement, risk factors, comorbidity and recent life events. Where screening is undertaken, use the GAD-2/GAD-7 or the Geriatric Anxiety Inventory.