A 78-year-old widow who lost her spouse 3 years ago presents to the outpatient clinic with complaints of increased anxiety and difficulty sleeping. In addition she complains of headaches, queasy stomach and fatigue. What is the best initial treatment option for her?

Choice A reason: Diphenhydramine is a first-generation antihistamine with potent anticholinergic effects. In a 78-year-old patient, it is listed on the Beers Criteria as potentially inappropriate due to the high risk of confusion, urinary retention, dry mouth, and falls. It does not address the underlying anxiety and provides poor-quality sleep architecture, making it a sub-optimal choice for geriatric care. Choice B reason: Temazepam is a benzodiazepine. In older adults, benzodiazepines significantly increase the risk of cognitive impairment, delirium, falls, and fractures due to decreased drug clearance and increased CNS sensitivity. They are generally avoided in the elderly as an initial treatment, especially when symptoms suggest a chronic anxiety or depressive process rather than an acute, short-term crisis. Choice C reason: Lexapro (escitalopram) is a Selective Serotonin Reuptake Inhibitor (SSRI) and is considered first-line treatment for anxiety and depressive symptoms in the elderly. A low starting dose (5 mg) is appropriate for a 78-year-old ("start low and go slow"). SSRIs address both the psychological anxiety and the somatic symptoms (headaches, fatigue) often associated with late-life anxiety or prolonged grief. Choice D reason: Seroquel (quetiapine) is an atypical antipsychotic. Using antipsychotics as a first-line treatment for insomnia or anxiety in a non-psychotic elderly patient is inappropriate and carries a Black Box Warning for increased mortality in older adults with dementia-related psychosis. It should be reserved for cases where other treatments have failed and the benefit clearly outweighs the significant metabolic and cardiac risks.