Table 1: Anxiety: Theoretical and pragmatic
underpinnings of algorithm recommendations

Algorithm component	Comments	References
Dual screening: for anxiety and for benzodiazepine or sedative use.	Anxiety is more common than is depression in older people. Similar to depression, it is associated with adverse effects on health and cognition. Many older adults with clinically significant anxiety have not been diagnosed in the past and may not spontaneously report anxiety. Given the high comorbidity of low back pain and anxiety and the potential benefits of treatment, we recommend screening for anxiety disorders with the GAD-2 in all older adults with CLBP. Brief screeners (2 items) have been found to be equally sensitive and specific at detecting anxiety in CLBP patients as widely used longer-form “gold standards.” Long-term benzodiazepine and sedative use is common yet unsafe for older adults. Inappropriate prescribing of these agents for depression or analgesia should be avoided.	Anxiety disorders in older adults: a comprehensive review. Depress Anxiety 2010;27(2):190–211. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006;15(2):192–200. Are 2 questions enough to screen for depression and anxiety in patients with chronic low back pain? Spine 2014;39(7):455–462. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults: The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc 2012;60(4):616–631.
GAD-2 for anxiety screening, using 3 as cutpoint.	GAD-2 is a good screening instrument with high sensitivity and specifity. Lower cutpoints may be used for older adults because they may report lower scores than younger patients.	Improving recognition of late life anxiety disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: Observations and recommendations of the Advisory Committee to the Lifespan Disorders Work Group. Int J Geriatr Psychiatry 2012;27(6):549–556. Assessing Generalized Anxiety Disorder in Elderly People Using the GAD-7 and GAD-2 Scales: Results of a Validation Study. Am J Geriatr Psychiatry 2013;22(10):1029–1038.
If a benzodiazepine or sedative is prescribed, refer to Beers criteria for appropriate use. The Beers criteria suggest that in older adults, benzodiazepines may be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe (disabling) generalized anxiety disorder, peri-procedural anesthesia, and end-of-life care. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults.	Sedative hypnotics are frequently prescribed for older adult with anxiety in primary care settings. Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. Even low doses of benzodiazepines (such as frequently prescribed in primary care) in older adults increases the risk of falls, fractures, cognitive impairment, and delirium.	American Geriatrics Society 2012 Beers Criteria Update Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;60(4):616–631. Outcome of new benzodiazepine prescriptions to older adults in primary care. Gen Hosp Psychiatry 2006;28(5):374–378.
Especially in cases of dependence, consider working with a specialist to reduce benzodiazepine use.	Discontinuing benzodiazepines that have been prescribed long-term is frequently difficult. Issues with which to contend include minimization of physiological withdrawal, addressing psychological dependence, and monitoring for the return of the underlying anxiety disorder.	Effectiveness of current treatment approaches for benzodiazepine discontinuation: a meta-analysis. Addiction 2009;104(1):13–24. Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering; a randomized trial. Can Med Assoc J 2003;169:1015–1020.
If GAD-2 is >/= 3, conduct a more thorough assessment using GAD-7.	Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for generalized anxiety disorder. It is moderately good at screening three other common anxiety disorders – panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%), and post-traumatic stress disorder (sensitivity 66%, specificity 81%).	A brief measure for assessing generalized anxiety disorder. Arch Intern Med 2006;166:1092–1097. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146(5):317–325.
If more thorough assessment indicates the presence of significant anxiety symptoms or disorder, initiate treatment. Strongly consider treatment if GAD-7 ?10.	Untreated anxiety can lead to decrements in health and cognitive function. SSRIs and, to a lesser extent, CBT are efficacious for treating anxiety in older adults. Both of these interventions are safer than benzodiazepines. While SSRIs are superior to placebo, the benefit may not be as durable as the skills acquired with CBT. For example, CBT may boost response among older adults with GAD who are partial responders to an SSRI. In addition, those who receive CBT may be able to discontinue their SSRI and maintain adequate symptom control.	Interventions for generalized anxiety disorder in older adults: systematic review and meta-analysis. J Anxiety Disord 2012; 26(1):1–11. Efficacy of cognitive behavioral therapy for anxiety disorders in older people: a meta-analysis and meta-regression of randomized controlled trials. J Am Geriatr Soc 2012;60(2):218–229. Telephone-delivered cognitive-behavioral therapy and telephone-delivered nondirective supportive therapy for rural older adults with generalized anxiety disorder: A randomized clinical trial. JAMA Psychiatry 2015;72(10):1012–1020. Escitalopram for older adults with generalized anxiety disorder: a randomized controlled trial. JAMA 2009; 301(3):295–303. A randomized controlled trial of the effectiveness of cognitive-behavioral therapy and sertraline versus a waitlist control group for anxiety disorders in older adults. Am J Geriatr Psychiatry 2006;14(3):255–263. Efficacy and tolerability of citalopram in the treatment of late-life anxiety disorders: results from an 8-week randomized, placebo-controlled trial. Am J Psychiatry 2004;162(1):146–150. Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults. Am J Psychiatry 2013;170(7):782–789.
SSRIs are first line pharmacotherapy. If no response to SSRI, consider switch to SNRI or other agent such as mirtazapine or nortriptyline. There is no evidence to suggest augmentation is superior to switching strategies for pharmacologic treatment of anxiety in older adults.	Use with caution in patients taking other highly serotonergic agents or those with history of hypertension. If SNRI medication does not lead to improvement, consider stepwise trials of mirtazapine (15–45 mg/qhs) or nortriptyline 10–50 mg qhs. EKG should be obtained before exposure to tricyclic antidepressants. If anxiety is disabling and/or does not respond to these interventions, referral to Behavioral Health/Psychiatry is indicated.	Venlafaxine ER as a treatment for generalized anxiety disorder in older adults: pooled analysis of five randomized placebo-controlled clinical trials. J Am Geriatr Soc 2002;50(1):18–25.
Once treatment is initiated, monitor response with the GAD-7. Scores of </ = 5 on the GAD-7 may suggest clinically meaningful improvement. The Penn State Worry Questionnaire (abbreviated version) may also be used to monitor improvement. Improvement of 6 points on the PSWQ-A is consistent with a meaningful response. Measurement-based behavioral health is the preferred approach for monitoring response to interventions. Annually for responders: Assess benefits of sustained exposure to medication versus risk of relapse if discontinued.	SSRIs are effective maintenance treatment for late-life anxiety disorders. Reassess at annual intervals to determine if continued treatment is warranted. For example, if patients have engaged in CBT and acquired improved coping skills, a slow taper of the SSRI may be attempted. If a taper is attempted, reassess frequently for re-emergence of anxiety symptoms.	Antidepressant medication augmented with cognitive behavioral therapy for generalized anxiety disorder in older adults. Am J Psychiatry 2013;170:782–789. Efficacy and tolerability of citalopram in the treatment of late-life anxiety disorders: results from an 8-week randomized, placebo-controlled trial. Am J Psychiatry 2004;162(1):146–150. Delivery of evidence-based treatment for multiple anxiety disorders in primary care: A randomized controlled trial. JAMA 2010;303(19):1921–1928
Consider taper of opioids prescribed for CLBP in patients with anxiety syndromes	Anxiety may worsen the experience of pain. Opioid analgesics have both anxiolytic and mood elevating properties. Some older adults with comorbid CLBP and anxiety may be misusing opioids in an effort to reduce their burden of anxiety. Given the risks of prolonged exposure to opioids in older adults, and that opioids are not an approved treatment for anxiety, a taper of opioids may be indicated.	Psychiatric comorbidity is associated prospectively with diminished opioid analgesia and increased opioid misuse in patients with chronic low back pain. Anesthesiology 2015;10(123):861–872.
If GAD-2 is 3 or greater but more thorough assessment is negative, reassess with GAD-2 at least annually.	A stepped care protocol with at-risk primary care patients has been shown to reduce the incidence of anxiety disorders and depression by 50% over 24 months. Annual screening of these at risk patients is efficient and may identify syndromal anxiety in patients who may not spontaneously report it.	Stepped-care prevention of anxiety and depression in late life: a randomized controlled trial. Arch Gen Psychiatry 2009;66(3):297–304. Prevention of late-life anxiety and depression has sustained effects over 24 months: a pragmatic randomized trial. Am J Geriatr Psychiatry 2011;19(3):230–239.