Anxiety in Older Adults: Why It Is Missed So Often
Anxiety is common in later life, yet it is one of the most frequently missed conditions in older people. It rarely arrives with the words "I feel anxious". More often it appears as poor sleep, restlessness, stomach upsets, a racing heart, repeated visits about physical complaints, or a gradual withdrawal from going out.
Those symptoms are easy to put down to age or to physical illness, and sometimes they are. But when anxiety is the real cause, it is treatable — and the way it is treated in older people needs particular care, because some of the most commonly used calming medicines cause more harm at this age than at any other.
🔍 Why it is missed. Older people are often less likely to describe emotional distress in psychological terms, and more likely to report physical symptoms. Anxiety also frequently overlaps with depression, physical illness and early memory problems, so it hides among other explanations. The result is that it can go unrecognised for years.
🧓 How anxiety looks in later life
| What people report | What may lie behind it |
|---|---|
| Poor sleep, waking early, feeling on edge | Persistent worry, often about health, money or family |
| Racing heart, breathlessness, dizziness | Physical symptoms of anxiety — though heart and lung causes must be checked first |
| Stomach upsets, loss of appetite | Anxiety affecting the gut |
| Avoiding going out | Fear of falling, of becoming unwell away from home, or of crowds |
| Repeated reassurance-seeking | Worry that is not relieved by reassurance |
| Irritability and restlessness | Tension that is hard to put into words |
A particular pattern deserves attention: anxiety appearing for the first time after about sixty. Most anxiety disorders begin earlier in life, so new anxiety in later years is a reason to look carefully for a medical cause, for depression, or for early changes in memory and thinking.
🩺 Medical causes to rule out first
Several physical conditions and medicines produce symptoms that look exactly like anxiety. They are worth checking before concluding that anxiety is the diagnosis.
| Cause | Examples |
|---|---|
| Heart and lungs | Irregular heart rhythms, heart failure, chronic lung disease causing breathlessness |
| Hormones and metabolism | Overactive thyroid, low blood sugar in people on diabetes medicines, low sodium |
| Blood and nutrition | Anaemia, low B12 |
| Pain | Poorly controlled pain is a common and overlooked driver of restlessness |
| Medicines | Steroid tablets, inhalers for breathing, too high a dose of thyroid medicine, decongestants in cold remedies |
| Stopping medicines | Suddenly stopping sleeping tablets, benzodiazepines or antidepressants |
| Caffeine and alcohol | Including alcohol withdrawal |
🔴 Sudden agitation or confusion is not anxiety until proven otherwise. In an older person, restlessness or confusion that develops over hours or days can be delirium, often caused by an infection, dehydration, a new medicine or another acute illness. Delirium is a medical emergency and needs same-day assessment.
🧠 Anxiety, depression and memory
Anxiety and depression often occur together in older people, and treating one without recognising the other gives poorer results. Anxiety is also common in the early stages of dementia, when a person senses that their memory is slipping and feels unsettled by it.
The reverse also happens: depression and anxiety can impair concentration and memory enough to look like dementia. The article on depressive pseudodementia explains how the two can be told apart, and why treating mood can restore memory.
⚠️ The medicines to avoid
This is the most important section for families and carers. Some medicines commonly used to calm anxiety or help sleep carry much higher risks in older people, and international guidance recommends avoiding them where possible.
| Medicine type | Why it is risky in older people |
|---|---|
| Benzodiazepines, such as diazepam and lorazepam | Increase falls and hip fractures, impair memory and concentration, cause dependence, and can trigger confusion |
| Sleeping tablets of the Z-drug type | Similar risks of falls, confusion and next-day drowsiness |
| Sedating antihistamines, such as hydroxyzine and promethazine | Strongly anticholinergic: confusion, constipation, urinary retention, dry mouth and falls |
| Older tricyclic antidepressants | Anticholinergic effects, dizziness on standing and heart rhythm effects |
The broader problem of anticholinergic medicines and memory is covered in the article on anticholinergic drugs.
🛑 Do not stop a benzodiazepine suddenly. Many older people have taken one for years. Stopping abruptly can cause severe withdrawal, including seizures. Reducing gradually over weeks or months with medical guidance is safe and often brings real benefits: fewer falls, clearer thinking and better daytime alertness.
✅ Safer treatment options
| Option | Points for older people |
|---|---|
| Talking therapy | Cognitive behavioural therapy works well in later life, sometimes adapted with a slower pace or memory aids |
| SSRI antidepressants, such as sertraline | Usually first-choice medicines. Start low and increase slowly. Blood sodium should be checked, and bleeding risk considered with blood thinners or anti-inflammatory painkillers |
| Lower maximum doses for some | Citalopram and escitalopram have lower maximum doses after 65 because of effects on heart rhythm |
| Buspirone | Does not cause sedation, memory impairment or dependence. Takes two to four weeks and must be taken regularly, as described in the article on buspirone |
Practical steps help as much as medicine: treating pain properly, correcting hearing and vision problems, reducing caffeine, building a regular routine, and reducing isolation through regular social contact.
👪 Tips for families and carers
- Take physical complaints seriously, but ask gently about worry and mood too
- Bring a full list of medicines, including over-the-counter and herbal products, to appointments
- Notice changes over days — sudden confusion needs urgent attention
- Ask about sleeping tablets or calming medicines that have been taken for years
- Watch for falls, which may be linked to medication
- Encourage social contact and meaningful activity
🆘 When to seek help
- Sudden confusion or agitation over hours or days — same day, possible delirium
- Chest pain, palpitations or breathlessness — rule out heart and lung causes urgently
- Thoughts of suicide — same day. Older men in particular have high suicide rates, and warning signs are often missed
- New anxiety starting after sixty
- Falls, especially after starting or changing medicines
- Worry or low mood affecting eating, sleep or daily life
- Wishing to reduce a long-term sleeping tablet or benzodiazepine — plan it with a doctor
Buspirone, which does not cause sedation or dependence, is stocked in the anti-anxiety category as Buspar. SSRIs such as Sertafine (sertraline) are available in the antidepressants category. In older people, all medicines for anxiety should be started at low doses and reviewed regularly by a prescriber.
❓ Frequently asked questions
How is anxiety different in older people?
It more often shows up as physical symptoms, such as poor sleep, a racing heart, stomach upsets or dizziness, rather than as described worry. It also overlaps with depression, physical illness and memory problems, which is why it is frequently missed or put down to age.
Is new anxiety after sixty normal?
It is not unusual, but it deserves investigation. Most anxiety disorders begin earlier in life, so anxiety starting for the first time in later years may point to a medical cause, a medicine side effect, depression or early changes in memory.
What medical problems can look like anxiety?
Irregular heart rhythms, heart failure, lung disease, an overactive thyroid, low blood sugar, low sodium, anaemia and poorly controlled pain. Medicines such as steroid tablets, breathing inhalers, excess thyroid medicine and decongestants can also cause anxiety-like symptoms.
Why are benzodiazepines risky for elderly people?
They increase the risk of falls and hip fractures, impair memory and concentration, cause dependence and can trigger confusion. International guidance recommends avoiding them in older people where possible. Anyone already taking one should not stop suddenly but reduce gradually with medical guidance.
Is hydroxyzine safe for older people with anxiety?
It is generally avoided. Hydroxyzine and similar sedating antihistamines are strongly anticholinergic, which in older people can cause confusion, constipation, difficulty passing urine, dry mouth and falls.
What is the safest medicine for anxiety in the elderly?
SSRI antidepressants such as sertraline are usually first choice, started at a low dose, with sodium levels and bleeding risk monitored. Buspirone is another option that does not cause sedation, memory problems or dependence. Talking therapy is effective and can be used alongside or instead of medicine.
Can anxiety be a sign of dementia?
Anxiety is common in the early stages of dementia, often when a person senses their memory changing. The reverse can also happen: anxiety and depression can affect memory enough to look like dementia. A careful assessment helps separate the two.
What if confusion comes on suddenly?
Sudden confusion or agitation developing over hours or days may be delirium, often caused by infection, dehydration or a new medicine. It is a medical emergency and needs same-day assessment, not treatment as anxiety.
Does therapy work for older people?
Yes. Cognitive behavioural therapy is effective in later life, sometimes adapted with a slower pace, shorter sessions or memory aids. It avoids medicine side effects and can be combined with other treatment.
How can families help?
Take physical complaints seriously while gently asking about worry and mood, bring a full medicine list to appointments, watch for sudden changes or falls, ask about long-term sleeping tablets, and encourage regular social contact and activity.
📑 Sources and editorial
- Epidemiological studies on anxiety disorders in older adults
- Guidance on assessing anxiety in later life, including age-adapted screening tools
- International criteria on potentially inappropriate medicines in older adults, including benzodiazepines, Z-drugs and anticholinergic antihistamines
- Evidence linking benzodiazepines to falls, fractures and cognitive impairment in older people
- Trials of cognitive behavioural therapy for late-life anxiety
- Guidance on SSRI use in older adults, including hyponatraemia and dose limits for citalopram and escitalopram
- Guidance on recognising delirium
- Related reading: buspirone, depressive pseudodementia, anticholinergic drugs
- Related products: anti-anxiety category
- RXshop Editorial Team — reviewed by Emily Chen, MD, Internal Medicine
Medical Disclaimer: The information in this article is for educational and informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek guidance from a qualified healthcare provider with any questions you may have regarding a medical condition, and before starting, stopping or changing any medication.