Late-life anxiety disorders — assessment and management (MEQ)

(i) Formulation and differentials. This is most consistent with late-life generalised anxiety disorder (multi-domain excessive worry more than 6 months, tension, insomnia, avoidance, elevated GAD-7) with functional disability and possible anxious distress short of a full major depressive episode — still screen depression carefully given passive death-related thoughts.[1][7][8] Differentials: comorbid or primary major depression; illness anxiety focus on heart disease; panic/agoraphobia spectrum given shopping avoidance; benzodiazepine-related rebound anxiety or dependence maintaining insomnia; medical mimics (arrhythmia, thyroid disease, anaemia) — baseline work-up still required even if GP “unremarkable” needs confirmation; mild cognitive impairment contributing to worry about competence.[1]

(ii) Assessment and risk. Full history of onset (early vs late), alcohol, full medication list, falls, cognition screen, collateral from daughter/GP. Structured suicide assessment: passive ideation already present — explore intent, plan, means (medications, heights), protective factors; older adults have high lethality even with fewer attempts.[6] Capacity for treatment decisions; fear-of-falling and function (IADLs). Repeat vitals, ECG if cardiac worry/symptoms, labs including sodium before SSRI because she is on a thiazide.[4]

(iii) Management plan. Psychoeducation that late-life GAD is treatable and not “normal ageing.” Offer late-life adapted CBT (worry monitoring, cognitive restructuring, relaxation, behavioural activation/exposure to avoided activities) — Stanley primary-care RCT supports CBT for older adults with GAD.[2] Pharmacotherapy: start an SSRI low and slow, e.g. sertraline 25 mg orally daily or escitalopram 5 mg orally daily, titrate cautiously toward an effective dose within older-adult product limits; Lenze RCT supports escitalopram efficacy in late-life GAD.[3] Monitor early for activation, falls, GI effects, and hyponatraemia (check sodium within 1–2 weeks and if confusion/falls occur), especially with thiazide diuretic.[4] Measurement-based care with serial GAD-7.[7] Involve PT/OT if fear of falling dominates; optimise sleep hygiene and reduce caffeine.

(iv) Benzodiazepine management. Four years of nightly diazepam is potentially inappropriate long-term therapy in older adults (AGS Beers) — discuss risks (falls, cognition, dependence) and negotiate a slow supervised taper while CBT/SSRI take effect, rather than abrupt cessation (withdrawal risk).[5] Do not increase diazepam as definitive care.

(v) Follow-up and disposition. Initially primary care collaborative follow-up with psychology referral; step up to old-age CMHT if risk escalates, depression deepens, or community supports fail. Early review after SSRI start; crisis plan for worsening suicidal thinking; carer education. Reassess cognition and function after anxiety improves.[1][6]