From the Guidelines
For elderly patients with anxiety, selective serotonin reuptake inhibitors (SSRIs) are the preferred first-line medication choice due to their favorable side effect profile and lower risk of adverse reactions compared to other anxiolytics. When selecting an SSRI, consider starting with a low dose of sertraline (25 mg daily) or escitalopram (5 mg daily) and gradually increase over 4-6 weeks if needed, as older adults are at a greater risk of adverse drug reactions 1. The maximum dose for elderly patients is typically lower than for younger adults; for example, up to 100 mg daily for sertraline or 10 mg daily for escitalopram. While effective, benzodiazepines should be used cautiously in the elderly due to increased risk of falls, cognitive impairment, and dependence, and if necessary, use a short-acting agent like lorazepam at 0.25-0.5 mg as needed, not exceeding 3 doses per week 1. It's also important to combine medication with non-pharmacological approaches such as cognitive-behavioral therapy, relaxation techniques, and regular exercise, and monitor patients closely for side effects, particularly in the first few weeks of treatment 2. Additionally, be aware of potential drug interactions, especially with other CNS depressants or medications that affect serotonin levels, and consider alternative treatments such as gabapentinoids, which can be used with a combination of acetaminophen and NSAIDs, but should be dose-adjusted according to age and renal function 3. Some studies suggest that preoperative education can reduce patient anxiety to an acceptable level without the need for anxiolytic medication, highlighting the importance of non-pharmacological approaches in managing anxiety in elderly patients 3. Overall, the goal is to minimize the risk of adverse reactions and optimize the patient's quality of life, and SSRIs are generally the best choice for elderly patients with anxiety due to their safety profile and efficacy.
Some key points to consider when treating elderly patients with anxiety include:
- Starting with a low dose and gradually increasing as needed
- Monitoring closely for side effects and potential drug interactions
- Combining medication with non-pharmacological approaches
- Avoiding benzodiazepines whenever possible due to their risks in the elderly population
- Considering alternative treatments such as gabapentinoids and non-pharmacological interventions like cognitive-behavioral therapy and relaxation techniques. It's essential to prioritize the patient's safety and quality of life when selecting an anxiolytic medication, and SSRIs are generally the preferred choice due to their favorable side effect profile and lower risk of adverse reactions 1, 2.
From the FDA Drug Label
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). 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)].
Appropriate anxiolytic medications for geriatric patients include:
- Buspirone: The safety and efficacy profiles for elderly patients were similar to those in the younger population.
- Escitalopram: 10 mg/day is the recommended dose for elderly patients. These medications can be considered for the treatment of anxiety in geriatric patients, with careful consideration of the recommended dosages and potential interactions 4, 5, 6.
From the Research
Anxiolytic Medications for Geriatric Patients
- Selective serotonin reuptake inhibitors (SSRIs) are considered first-line medications for the treatment of generalized anxiety disorder (GAD) in older adults, with a preference for sertraline or escitalopram 7, 8, 9, 10
- Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine or duloxetine, may be considered as a second-line treatment option if response to SSRIs is inadequate 7, 8
- Buspirone may be an option for relatively healthy older adults, particularly if avoiding sexual side effects is a priority 7, 8
- Pregabalin/gabapentin, lavender oil, and agomelatine may be considered as additional alternatives for the treatment of GAD in older adults 7
- Benzodiazepines and hydroxyzine should be used with caution in the treatment of anxiety in older adults due to potential risks and side effects 7, 8
- Antipsychotics and mood stabilizers are not recommended for the treatment of anxiety in older adults due to potential risks and side effects 8
Specific Medications
- Escitalopram has been shown to be effective and well-tolerated in the treatment of GAD, panic disorder, social anxiety disorder, and obsessive-compulsive disorder in older adults 9, 10
- Sertraline has been recommended as a first-line treatment option for GAD in older adults 7
- Venlafaxine and duloxetine may be considered as second-line treatment options for GAD in older adults 7, 8
- Buspirone may be an option for relatively healthy older adults, particularly if avoiding sexual side effects is a priority 7, 8
Treatment Considerations
- Treatment selection should be based on an individual assessment of the risks and benefits of each type of treatment, taking into account comorbid psychiatric and physical conditions, patient preference, cost, and the availability of therapists skilled in cognitive behavioral techniques 11
- Antidepressant medication is preferable to benzodiazepines as a first-line treatment for panic disorder in older adults, especially given the high level of comorbidity between panic disorder and depressive disorders 11
- Starting antidepressant medication at a low dosage and gradually increasing the dosage to the therapeutic range may help enhance adherence with treatment and minimize initial exacerbation of anxiety 11