Give an account of anxiety disorders and their management

Core principle. Disabling anxiety symptoms are not a normal part of ageing. Anxiety disorders are the most prevalent but most under-treated psychiatric disorders in older adults — under-recognised because symptoms are attributed to physical illness or to ageing itself.

Characteristic themes in late life. Worries centre on physical illness and its impact on quality of life — pain, disability and the possibility of death, and are exacerbated by feelings of isolation and dependence in hospital or long-term care. The content is realistic and health-focused, unlike the occupational and existential worries of younger adults.

Classification and relative frequency. Agoraphobia and panic disorder are the most common anxiety disorders in older adults, followed by phobias — including the geriatric-specific fear of falling — and then generalised anxiety disorder. Half of older adults with GAD have had symptoms for most of their lives; the other half developed GAD within the last five years. Also relevant are PTSD, which may re-emerge in late life, and obsessive-compulsive disorder.

The central diagnostic difficulty — comorbidity. There is substantial comorbidity of medical and anxiety disorders, and physiological symptoms of anxiety may themselves be a manifestation of a medical condition or an adverse effect of a prescribed drug — this frequently confounds detection. Incapacitating anxiety symptoms are common in COPD, in patients with pacemakers, and in Parkinson's disease.

Anxiety as a component of depression. Anxiety symptoms are a common component of depression in older adults, and their presence is associated with an increased likelihood of treatment resistance with antidepressants. DSM-5 recognises this through the "with anxious distress" specifier. Always screen a newly anxious older patient for depression — and treat the depression.

Secondary and drug-induced anxiety. Hyperthyroidism, hypoglycaemia, phaeochromocytoma, arrhythmia, angina, pulmonary embolism, COPD and delirium. Drugs: over-the-counter sympathomimetics, beta-2 agonists (albuterol/salbutamol), caffeine, nicotine, corticosteroids, dopamine agonists and thyroxine; and withdrawal states — alcohol and benzodiazepine withdrawal. New onset of panic attacks in an older person requires a thorough evaluation for an underlying general medical condition.

Assessment. Detailed history plus informant account; screen for depression, cognitive impairment, alcohol and drug use; rate with GAD-7, the Geriatric Anxiety Inventory, the Geriatric Anxiety Scale or HAM-A. Investigations directed by the presentation — TSH, glucose (mg/dL), calcium (mg/dL), ECG, oxygen saturation — plus a full drug review including over-the-counter preparations.

Non-pharmacological management — first-line. Relaxation training, mindfulness-based interventions and cognitive behavioural therapy are safer than and, in the long term, as effective as benzodiazepines. Add psychoeducation with family, sleep hygiene, reduction of caffeine, nicotine and alcohol, exercise, correction of sensory impairment, and graded exposure for phobic avoidance. Many older adults prefer counselling to psychopharmacological intervention.

Pharmacological management. SSRIs — escitalopram and sertraline — are considered first-line. SNRIs and vortioxetine are second-line. Buspirone is an option, primarily for GAD. The therapeutic effects of antidepressants and buspirone may take up to six weeks to become noticeable — warn the patient, or treatment will be abandoned early. Antipsychotics such as quetiapine should generally not be used for anxiety disorders, as the risks outweigh the benefits.

Benzodiazepines — the key caution. They are often effective in the short run but problematic, carrying a high risk of cognitive impairment, falls and fractures. Judicious short-term use of a short-acting agent such as lorazepam may be necessary if symptoms are incapacitating, only until other interventions become effective. Chronic use (beyond 120 days) is prevalent, growing, commoner in women, and at higher doses in older adults; discontinuation is complex, best supervised by a psychiatrist, and may need several months. Note that depression presenting with anxiety features is often inappropriately treated with a benzodiazepine rather than an antidepressant or psychotherapy.

USPSTF 2023 (JAMA). For the first time, a Grade B recommendation to screen for anxiety disorders in adults aged 19–64, but an explicit I-statement — the evidence is insufficient to assess the balance of benefits and harms of screening in adults aged 65 and above, with clinicians advised to use clinical judgement based on risk factors, comorbidity and life events. This is the single most quotable current statement on anxiety in old age and highlights the evidence gap.

Mindfulness as an equal alternative to drug therapy (Hoge et al., JAMA Psychiatry 2023). In a randomised trial in adults with anxiety disorders, an 8-week mindfulness-based stress reduction programme was non-inferior to escitalopram, with fewer adverse events — supporting mindfulness-based intervention as a genuine first-line alternative in older adults, in whom drug adverse effects and interactions are the limiting factor.