From the Guidelines
For anxiety in the elderly, selective serotonin reuptake inhibitors (SSRIs) like sertraline or escitalopram are generally preferred first-line medications, as they have a more favorable side effect profile and are effective in managing anxiety symptoms 1.
Medication Options
- SSRIs: sertraline (starting at 25mg daily, gradually increasing to 50-100mg if needed) or escitalopram (starting at 5mg daily, potentially increasing to 10mg) are recommended due to their efficacy and relatively low risk of side effects 1.
- Benzodiazepines: should be used cautiously and only short-term due to increased fall risk, cognitive impairment, and dependence potential in older adults 1.
- Buspirone: is another option with fewer side effects, starting at 5mg twice daily, gradually increasing to 15-30mg daily in divided doses 1.
Non-Pharmacological Approaches
- Cognitive behavioral therapy: should be considered alongside medication to address anxiety symptoms and improve overall mental health 1.
Important Considerations
- Elderly patients often require lower starting doses due to altered metabolism and increased sensitivity to side effects 1.
- Regular monitoring for adverse effects is essential, and medication should be tapered slowly when discontinuing to avoid withdrawal symptoms 1.
- Any new medication should be started only after consultation with a healthcare provider who can consider the individual's complete medical history and current medications 1.
From the FDA Drug Label
Approximately 6% of the 1144 patients receiving escitalopram in controlled trials of Escitalopram in major depressive disorder and GAD were 60 years of age or older; elderly patients in these trials received daily doses of Escitalopram between 10 and 20 mg 10 mg/day is the recommended dose for elderly patients [see Dosage and Administration (2. 3)]. In one study of 6,632 patients who received buspirone for the treatment of anxiety, 605 patients were ≥ 65 years old and 41 were ≥ 75 years old; the safety and efficacy profiles for these 605 elderly patients (mean age = 70. 8 years) were similar to those in the younger population (mean age = 43. 3 years).
Meds for anxiety in elderly:
- Escitalopram: 10 mg/day is the recommended dose for elderly patients 2
- Buspirone: safety and efficacy profiles for elderly patients were similar to those in the younger population 3
From the Research
Medications for Anxiety in the Elderly
- Antidepressants, such as SSRIs and SNRIs, are considered first-line treatment for anxiety in the elderly, as they are efficacious and well-tolerated 4
- Mirtazapine and vortioxetine are also considered safe treatment options for anxiety in the elderly 4
- Buspirone may have benefit in treating anxiety in the elderly, but lacks studies in this population 4, 5
- Benzodiazepines and beta blockers should generally be avoided when treating anxiety in the elderly due to their potential for cognitive impairment, falls, and fractures 4, 6
- Tricyclic/tetracyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be effective in the elderly, but their side effect and safety profiles are suboptimal and thus are not recommended in late-life 4
- Antipsychotics and mood stabilizers are not recommended for treating anxiety in the elderly due to their risk of problems in both the long and short term, and antipsychotics have a black box warning for increased mortality in elderly patients with dementia 4
Considerations for Treatment
- Selection of an appropriate medication is guided by pharmacokinetic properties of individual drugs, and long half-life medications are usually not preferred for older patients due to cumulative toxicity 5
- Clinicians should endeavor to use medications for short periods when treating the elderly, and long-term use may be effective but can lead to subtle and gradual cognitive impairment 5
- Treatment of anxiety in elderly persons has typically involved the use of benzodiazepines, but antidepressants, particularly serotonergic medications, are considered first-line treatment due to their safety and efficacy 6
- Psychotherapy, particularly cognitive-behavioral therapy, may be effective in treating anxiety disorders in the elderly, but research is underway to adapt this therapy to the needs of elderly persons 6