What is the safest anxiolytic (anxiety-reducing medication) for geriatric patients with anxiety?

From the Guidelines

For geriatric patients with anxiety, selective serotonin reuptake inhibitors (SSRIs) are generally considered the safest first-line medication option, as they have a favorable side effect profile and minimal drug interactions, according to the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication (PIM) use in older patient populations 1. When considering anxiolytic medications for geriatric patients, it's essential to prioritize their safety and minimize potential risks. The use of benzodiazepines, such as lorazepam, is generally discouraged due to the increased risk of falls, cognitive impairment, and dependence in older adults 1.

Some key points to consider when selecting an anxiolytic medication for geriatric patients include:

• The potential for drug interactions and side effects
• The risk of cognitive impairment and falls
• The patient's medical history and current medications
• The need for non-pharmacological approaches, such as cognitive behavioral therapy

In terms of specific medication options, sertraline (Zoloft) starting at a low dose of 25mg daily, gradually increasing if needed to 50-100mg daily, is often recommended due to its favorable side effect profile and minimal drug interactions. Citalopram (Celexa) at 10mg daily, potentially increasing to a maximum of 20mg daily in elderly patients, is another good option 1.

It's also important to note that non-pharmacological approaches, such as cognitive behavioral therapy, should be used alongside medication when possible. These approaches can help to reduce anxiety symptoms and improve overall quality of life for geriatric patients.

Overall, the goal of anxiolytic medication use in geriatric patients should be to minimize risks and maximize benefits, while also prioritizing the patient's safety and well-being. By choosing the right medication and using non-pharmacological approaches, healthcare providers can help to improve outcomes and quality of life for geriatric patients with anxiety.

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). Review of spontaneously reported adverse clinical events has not identified differences between elderly and younger patients, but greater sensitivity of some older patients cannot be ruled out. There were no effects of age on the pharmacokinetics of buspirone

The safest anxiolytic for geriatric patients with anxiety is buspirone, as it has been shown to have a similar safety and efficacy profile in elderly patients compared to younger patients 2.

• Key points:
  • Similar safety and efficacy profiles in elderly and younger patients
  • No effects of age on pharmacokinetics
  • Greater sensitivity of some older patients cannot be ruled out, but no significant differences were found In contrast, escitalopram has limited data on its use in geriatric patients, and while it may be effective, its safety profile in this population is not as well established as buspirone's 3.

From the Research

Safest Anxiolytic for Geriatric Patients

The safest anxiolytic for geriatric patients with anxiety can be determined by considering the evidence from various studies.

• Selective serotonin reuptake inhibitors (SSRIs) are considered first-line medications for generalized anxiety disorder (GAD) in older adults, with a preference for sertraline or escitalopram 4, 5, 6.
• Buspirone is an option for relatively healthy older adults, especially if avoiding sexual side effects is a priority 4, 5.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine or duloxetine, can be considered as a second-line treatment if response to SSRIs is inadequate 4.
• Benzodiazepines and hydroxyzine should be used with caution in older adults due to potential harms 4, 5, 7.
• Other agents, such as pregabalin, gabapentin, lavender oil, and agomelatine, may be considered as alternative options, but their use should be carefully evaluated 4, 5.

Considerations for Treatment

When selecting an anxiolytic for geriatric patients, it is essential to consider the patient's comorbid conditions, potential drug interactions, and side effect profiles.

• Doses may need to be reduced for elderly or medically ill patients, or those taking other medications 7.
• Cognitive therapy, such as modular cognitive-behavioral therapy (mCBT), can be an effective augmentation strategy when added to SSRI medication 8.
• Regular observation and monitoring are necessary to assess the potential benefits and harms of treatment, especially when using medications that require caution in the elderly 4, 5.