What are the risk factors, initial screening tool, and treatment options for a 55-year-old female with generalized anxiety disorder (GAD) and dyslipidemia, experiencing worsening anxiety and poor sleep?

Risk Factors for Anxiety in This Patient

This patient has three clear risk factors for anxiety: familial history of GAD (mother and daughter affected), recent major life stressor (forced early retirement and divorce), and presence of chronic medical illness (dyslipidemia). 1

• Familial history of anxiety is a well-established risk factor, particularly when first-degree relatives are affected 1, 2
• Major life transitions and personal stressors such as forced retirement and divorce represent significant precipitating factors for anxiety exacerbation 1
• Presence of chronic medical illness (dyslipidemia) increases vulnerability to anxiety disorders 1

Initial Screening Tool

The GAD-7 (Generalized Anxiety Disorder-7 scale) is the recommended initial screening tool for this patient. 1, 3, 4

• The GAD-7 assesses seven key symptoms: feeling nervous/anxious/on edge, inability to control worry, excessive worry, trouble relaxing, restlessness, irritability, and feeling afraid 1, 3
• Scoring interpretation guides treatment intensity: 0-4 (none/mild), 5-9 (moderate), 10-14 (moderate to severe), 15-21 (severe) 1, 3
• Supplement with PHQ-9 screening given the high comorbidity between GAD and depression, particularly in patients with chronic anxiety 3, 5
• Obtain TSH (thyroid-stimulating hormone) as routine screening since thyroid dysfunction commonly presents with anxiety symptoms and has significant comorbidity with anxiety disorders 5

Two Pharmacological Treatment Options

Given this patient's 20+ year history on benzodiazepines with declining efficacy, the two best pharmacological options are: (1) initiate an SSRI such as sertraline or escitalopram, or (2) initiate an SNRI such as venlafaxine extended-release. 1, 6, 4, 7

Option 1: SSRI (Sertraline or Escitalopram)

• SSRIs are first-line pharmacotherapy for GAD with demonstrated efficacy (SMD -0.55,95% CI -0.64 to -0.46) 4
• Escitalopram and paroxetine have specific evidence in older adults with GAD 6
• Antidepressants are the pharmacological treatment of choice for most older adults with generalized anxiety, superior to benzodiazepines for long-term management 6

Option 2: SNRI (Venlafaxine Extended-Release)

• Venlafaxine provides both short- and long-term symptom improvement with evidence of remission and relapse prevention 7
• Venlafaxine has specific efficacy data in older adults with GAD 6
• SNRIs show small to medium effect sizes compared to placebo (SMD -0.55) 4

Critical consideration: Benzodiazepines have limited role in elderly GAD treatment due to decreased long-term effectiveness, minimal treatment of psychic symptoms, and performance degradation 6, 7. The patient's 20-year benzodiazepine use requires gradual taper while initiating alternative therapy.

Two Education Areas When Initiating/Augmenting Medication

The provider must address: (1) the chronic nature of GAD requiring long-term treatment (not just symptom relief), and (2) the timeline for medication efficacy and importance of adherence despite delayed onset of action. 1, 7, 8

Area 1: Chronic Nature and Treatment Duration

• GAD follows a chronic course with low remission rates and moderate relapse/recurrence rates over 5-20 years 8
• Treatment aims for remission, not just response, requiring sustained pharmacotherapy 7
• Relapse prevention is critical as GAD is often chronic and requires maintenance treatment 1

Area 2: Medication Timeline and Adherence

• SSRIs/SNRIs require 4-6 weeks for initial therapeutic effect, with full benefits emerging over 8-12 weeks 4
• Reassess symptoms every 4-6 weeks using GAD-7 to monitor treatment response 2
• Discuss common side effects and strategies to manage them to prevent premature discontinuation 4
• Address the need for gradual benzodiazepine taper if transitioning from long-term use 6

Three Non-Pharmacotherapeutic Treatment Options

The three evidence-based non-pharmacological options are: (1) individual cognitive behavioral therapy (CBT), (2) guided self-help or computerized CBT programs, and (3) group psychosocial interventions. 1, 2, 4

Option 1: Individual Cognitive Behavioral Therapy

• CBT is the psychotherapy with the most evidence of efficacy for GAD (Hedges g = 1.01, large effect size) 4
• Should be delivered by licensed mental health professionals using treatment manuals including cognitive change, behavioral activation, biobehavioral strategies, education, and relaxation 1
• CBT may be less efficacious in older adults compared to younger adults, requiring potential modifications 6

Option 2: Guided Self-Help or Computerized CBT

• Appropriate for moderate symptom severity (GAD-7 scores 5-9) 1, 2
• Includes behavioral activation and problem-solving components 1
• Offers accessibility advantages for patients with transportation or scheduling barriers 1

Option 3: Group Psychosocial Interventions

• Effective for low to moderate intensity symptoms 1, 2
• Provides peer support and normalization of anxiety experiences 1
• Cost-effective option that addresses social isolation, particularly relevant given her recent retirement and divorce 1

Note: While the patient had prior "talk therapy" group experience years ago, current evidence-based CBT approaches are more structured and effective than general supportive therapy 6, 4

Two Factors for Prescribing in Geriatric/Older Adult Population

The two critical factors are: (1) pharmacokinetic considerations favoring specific medication selection and dosing, and (2) the higher comorbidity burden and polypharmacy risk in older adults. 6

Factor 1: Pharmacokinetic Considerations

• If benzodiazepines must be used, pharmacokinetic considerations favor lorazepam or oxazepam due to simpler metabolism in older adults 6
• However, benzodiazepines have a limited role in elderly GAD treatment despite widespread use 6
• Antidepressants (SSRIs/SNRIs) are preferred, with citalopram and venlafaxine having specific efficacy data in older adults 6
• Start at lower doses and titrate more gradually in older adults to minimize side effects 6

Factor 2: Comorbidity and Drug Interactions

• GAD has high comorbidity with major depression in late life, requiring assessment for both conditions 6, 9
• Evaluate for medical conditions that mimic anxiety (hyperthyroidism, cardiac conditions, hypoglycemia) 5
• Consider interactions with existing medications (in this case, dyslipidemia treatment) 5
• Assess for substance use disorders as these commonly co-occur with anxiety 5
• Monitor for cognitive impairment and adjust treatment approaches accordingly 1