What is the best management approach for a patient over 60 with a fall risk experiencing a panic anxiety attack?

Management of Panic Anxiety Attacks in Older Adults with Fall Risk

For older adults with fall risk experiencing panic anxiety attacks, a multifactorial approach that addresses both the anxiety symptoms and fall prevention is strongly recommended, with careful medication selection to avoid increasing fall risk.

Initial Assessment and Management of Panic Attack

• During an acute panic attack, provide a calm environment and reassurance while assessing for medical emergencies that may mimic panic symptoms 1
• Use grounding techniques and controlled breathing exercises to help manage acute symptoms 2
• Avoid benzodiazepines as first-line treatment despite their effectiveness for panic disorder, as they significantly increase fall risk in older adults 3

Medication Management

• When pharmacotherapy is necessary, selective serotonin reuptake inhibitors (SSRIs) are the preferred first-line treatment for panic disorder in older adults with fall risk 2, 4
• Paroxetine and fluoxetine have stronger evidence of efficacy among SSRIs for panic disorder 4
• Start with low doses and titrate slowly to minimize side effects that could contribute to fall risk 1
• Review and modify all current medications, as polypharmacy (taking four or more medications) increases fall risk 3
• Pay particular attention to psychotropic medications (neuroleptics, benzodiazepines, antidepressants) which have a consistent association with falls 3

Fall Prevention Strategies

• Perform risk stratification and assessment tests for gait and balance to determine fall risk level 3
• Implement exercise programs with balance training as a key component, which can reduce falls by up to 26% in high-risk individuals 1, 5, 6
• Consider Tai Chi as a promising balance exercise that may help with both anxiety and fall prevention 3, 1
• Modify the home environment by removing tripping hazards and improving lighting 1, 5
• Evaluate and address vision problems and ensure appropriate footwear 3
• Assess for orthostatic hypotension and other cardiovascular disorders that may contribute to falls 3, 1

Comprehensive Approach

• For older adults with recurrent falls and anxiety, a multifactorial intervention including medication review, exercise, and environmental modification is recommended 3
• The American Geriatrics Society recommends multifactorial risk assessment with multicomponent intervention in older adults who have had 2 falls in the past year or have gait/balance problems 3
• Exercise interventions have shown the most consistent statistically significant benefit across multiple fall-related outcomes 6, 7
• Home fall-hazard interventions are particularly effective in people at higher risk of falling, reducing falls by 38% 5

Common Pitfalls to Avoid

• Prescribing benzodiazepines for anxiety without considering their significant impact on fall risk 3
• Focusing only on anxiety management without addressing fall prevention strategies 1
• Implementing fall prevention strategies without considering how anxiety and panic symptoms might affect adherence 1
• Overlooking medication review, especially psychotropic medications that increase fall risk 3
• Relying solely on fall risk screening without implementing targeted interventions 1

Follow-up Recommendations

• Schedule regular follow-up appointments to monitor both anxiety symptoms and fall risk 1
• Reassess medication efficacy and side effects, particularly those that might increase fall risk 3, 1
• Provide ongoing education to patients and caregivers about both panic disorder management and fall prevention strategies 1