7 Old age psychiatry7.5 Mental disorders in older people
7.5.8 Anxiety disorders in later life
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Written by Resident Doctor Committee · Published
Epidemiology
Specific phobia, most often fear of falling, is the commonest anxiety disorder in older adults living in the community, ahead of generalised anxiety disorder (GAD).
Anxiety disorders remain more common in women than in men after the age of 65.
Anxiety may persist from earlier life or begin late, after loss, illness or reduced independence.
Fear of falling
Fear of falling can follow a fall, illness or loss of confidence, or arise without any previous fall.
Avoiding walking or stairs eases anxiety briefly but causes deconditioning, which raises the actual risk of falling.
Treatment combines graded activity with strength and balance work, and NICE advises considering cognitive behavioural therapy (CBT) if fear persists despite this exercise.
Differential diagnosis
New anxiety needs a search for physical, drug and cognitive causes, including delirium.
Mimic | Pointer |
|---|---|
Thyrotoxicosis | Weight loss, tremor, heat intolerance |
Arrhythmia or cardiac ischaemia | Irregular pulse, exertional symptoms |
Hypoglycaemia | Low measured glucose |
Drugs | Salbutamol, corticosteroids, excess thyroxine, caffeine |
Alcohol or sedative withdrawal | Recent reduction, tremor |
Drug treatment
For GAD, NICE recommends a selective serotonin reuptake inhibitor (SSRI), considering sertraline first on cost-effectiveness grounds, although this use is off-label.
Over 65, maximum daily doses are citalopram 20 mg and escitalopram 10 mg because of QT risk.
Benzodiazepines cause sedation, confusion, falls and dependence, so reserve them for short-term crises and taper long-standing prescriptions gradually.