Anxiety in later life: why it gets missed after 65

Anxiety after 65 almost never arrives with the word anxiety attached. It arrives as a stomach that has not been right since Christmas, a heart that races in the evenings, or a run of appointments about something that keeps not being found. I have sat opposite a lot of people in their seventies who had been thoroughly investigated and never once asked how worried they were.

The short version

• Anxiety is not more common after 65. It is less common than in working-age adults. It is just far less likely to be named and treated.
• Older people tend to bring anxiety to a GP as physical symptoms rather than as worry.
• Thyroid problems and ordinary medicines produce the same symptoms, so check both. It is not one instead of the other.
• Treatment works at least as well later in life, and you do not need a GP's permission to ask for it.

What the numbers actually say

There is a widespread assumption that getting older makes you anxious. The national data says the opposite. In the Adult Psychiatric Morbidity Survey for England, 22.6 per cent of 16 to 64 year olds had a common mental health condition, against 10.2 per cent of people aged 75 and over, a figure that has barely moved in twenty years.

So about one in ten. Not an epidemic of miserable old age. Not nothing, either.

The gap opens up in what happens next. In 2021/22, people over 65 made up 5.6 per cent of referrals to NHS Talking Therapies, when the NHS positive practice guide for older people puts the figure it should be, on England's age profile, at around 12 per cent. People over 75 accounted for just 2 per cent.

The problem after 65 is not that anxiety is more common. It is that it is far less likely to get named.

Why it gets missed

It turns up as a body, not a feeling

The NHS positive practice guide is blunt about this: older people with generalised anxiety disorder are more likely to arrive in primary care with physical symptoms, such as gut trouble and aches and pains, than with worry. So the appointment is about the stomach. And the stomach is genuinely what hurts.

The words are different

Ask "do you have anxiety or depression?" and you will often get a firm no from someone who would have said yes to "have you been feeling out of sorts?" The guide notes that older people tend to describe their own mental health as feeling down, low, or out of sorts. Put the question in clinical language and the answer can be technically true and completely wrong.

Everybody blames the age, patients included

One of the most persistent myths in healthcare, in the guide's words, is that low mood is a natural outcome of ageing and that older people will not want or benefit from psychological therapies. Plenty of older people believe it too, so two people can leave the same ten minute appointment having quietly agreed to do nothing.

It is usually not new

Most anxiety in later life is not a fresh arrival. Worry that got heavier when the body, the money or the household changed is far more common than a first episode at 70, and it has often never been named. Stress or anxiety? covers where that line sits.

What else is worth ruling out

An overactive thyroid produces almost the whole anxiety symptom list. The NHS lists nervousness, anxiety and irritability, mood swings, difficulty sleeping, palpitations, trembling and sweating. A blood test settles it, and a 68 year old with a racing pulse and unexplained weight loss should have one.

Medicines matter too. Steroid tablets are the clearest example: the NHS advises speaking to a doctor about mood changes on prednisolone, including feeling anxious and sleeping badly, and notes that the higher the dose, the more intense they can be.

The trap runs both ways: anxiety produces real physical symptoms, not imaginary ones. The physical symptoms of anxiety goes into why.

Treatment works, and the door is open

NICE guidance on generalised anxiety disorder applies to everyone aged 18 and over, with no separate, lesser set of rules after 65. Reviewing the evidence in older adults, NICE concluded that both drug treatment and psychotherapy work for generalised anxiety disorder in older people, so management strategies do not seem to need to differ between age groups.

The outcomes are better still. In NHS Talking Therapies, people aged 65 to 74 recorded a recovery rate of 61 per cent, against 51 per cent for adults aged 26 to 64. Older people do well in therapy. They are simply not being sent to it, and are more likely to be offered a prescription than a conversation, even though research suggests they would prefer the conversation.

One thing does change with age, and it rarely gets discussed: stamina. Fifty minutes is a long stretch to concentrate for if you are tired, in pain, or working hard to hear. That is a large part of why we built brightloaf around twenty minute sessions rather than an hour you have to clear the diary for. Shorter is not a watered down version of therapy, and for some people it is the only version they will finish.

On medication, NICE recommends benzodiazepines only as a short-term measure in a crisis, because of tolerance and dependence. That is a caution I weigh more heavily, not less, the older my patient is.

What to say, and to whom

• Lead with the physical symptom, then add the sentence people leave out: "and I have been worried about it constantly."
• Ask whether a thyroid test and a medication review are worth doing.
• Say so if you would rather try talking therapy than a tablet. That preference is reasonable, and more likely to be honoured if you voice it.
• You can refer yourself to NHS Talking Therapies without going through a GP. There is no age bar.

How to get the most from a short GP appointment about anxiety covers how to prepare.

This article is general information and is not a substitute for personal medical advice. New or changing physical symptoms always deserve a proper look. If you are struggling with your mental health, please speak to your GP or a qualified professional. If you are in crisis or at immediate risk, contact your GP urgently, call 111, call 999, or contact the Samaritans on 116 123. brightloaf is not a crisis service.