Anxiety in later life is common and rarely treated

Anxiety disorders are at least as common as depression in older adults and receive a fraction of the clinical attention. Community estimates vary widely with methodology, but generalised anxiety disorder, phobias and panic disorder all persist into later life, and new-onset anxiety after sixty-five is more common than generally assumed.

It is under-diagnosed for several converging reasons. Presentation is somatic, so investigation goes down a physical route. Worry is normalised — "she's always been a worrier" — as though it were a trait rather than a treatable condition. Older adults are less likely to use psychological language to describe distress. And it very frequently coexists with depression, which then gets treated alone.

What it looks like

Physical symptoms usually dominate: palpitations, breathlessness, chest tightness, gastrointestinal disturbance, muscle tension, tremor, dizziness, sweating, fatigue and insomnia. These lead, reasonably, to cardiac and gastrointestinal investigation.

The cognitive content in older adults tends to differ from that in younger people. Worry concentrates on health, on memory, on finances, on being a burden, on falling, and on the wellbeing of adult children.

Fear of falling deserves separate mention because it is so common and so consequential. It occurs in people who have fallen and in people who have not, it produces activity restriction, and that restriction causes deconditioning which genuinely increases falls risk. It is an anxiety disorder with a physical outcome, and it responds to graded exposure and to CBT-based approaches — but it is usually treated, if at all, as a mobility problem.

Anxiety also degrades concentration and working memory, which can present convincingly as cognitive decline. Distinguishing anxiety from early dementia in an older adult complaining of memory problems is a common and genuinely difficult clinical task.

The benzodiazepine problem

A substantial number of older adults are on long-term benzodiazepines, often started decades earlier for a situational problem and never reviewed.

They work quickly, which is why they are prescribed. In older adults they cause falls, fractures, cognitive impairment, daytime sedation and road traffic accidents, and they appear on every list of medications to avoid in this age group. Tolerance to the anxiolytic effect develops within weeks, so a person on long-term treatment is frequently taking a drug that is preventing withdrawal rather than treating anxiety.

Deprescribing is worthwhile and must be gradual. Abrupt withdrawal can cause seizures. Tapers over months, with support and with something offered in place of the drug, have reasonable success rates — the EMPOWER trial, which sent patients direct-to-consumer educational material about the risks, achieved discontinuation in a meaningful proportion, which says something about how rarely the conversation had been had.

What works

Cognitive behavioural therapy is effective in older adults, with effect sizes somewhat smaller than in younger populations in some analyses but clearly worthwhile. Adaptations that help: slower pace, more repetition, written materials, larger print, attention to hearing, and addressing beliefs about ageing that maintain the anxiety.

Relaxation training and applied relaxation have reasonable evidence and are well accepted by people who resist the idea of therapy.

Exercise reduces anxiety symptoms, and for fear of falling specifically, strength and balance training addresses both the fear and its physical basis.

SSRIs and SNRIs are first-line pharmacological treatment. Start low, titrate slowly, and expect a longer time to response. The same cautions apply as in depression: hyponatraemia, falls, bleeding risk with NSAIDs or anticoagulants.

Pregabalin is licensed for generalised anxiety disorder and has real efficacy; in older adults it causes sedation, dizziness and falls, needs renal dose adjustment, and has misuse potential.

Health anxiety specifically

Common in later life and often reinforced by the system. A person with genuine multimorbidity, several specialists, regular tests and real symptoms is in an environment that supplies constant material for worry.

Repeated reassurance and investigation reduce anxiety briefly and worsen it over time, which is a well-documented pattern. The more effective approach involves a consistent clinician, planned rather than symptom-triggered review, an explicit agreement on what will and will not be investigated, and CBT targeting the checking and reassurance-seeking behaviours.

That is a harder conversation than ordering another test, and it is the one that helps.

Raising it

Two questions have reasonable screening performance and are easy to ask of yourself: over the past two weeks, how often have you felt nervous, anxious or on edge, and how often have you been unable to stop or control worrying?

Anxiety in later life is not a personality trait, it is not an inevitable response to ageing, and it does not have to be tolerated for another twenty years.