What are the recommended first-line medications for treating anxiety in older adults?

First-Line Medications for Anxiety in Older Adults

Selective serotonin reuptake inhibitors (SSRIs), particularly sertraline and escitalopram, are the recommended first-line medications for treating anxiety in older adults due to their favorable safety profiles and efficacy. 1

First-Line Treatment Options

• SSRIs are considered first-line pharmacotherapy for anxiety disorders in older adults, with sertraline and escitalopram being preferred options due to their favorable side effect profiles and lower risk of drug interactions 1, 2
• When prescribing SSRIs to older adults, start with lower doses (approximately 50% of the standard adult starting dose) and titrate slowly to minimize side effects 3
• For escitalopram, the recommended starting dose in elderly patients is 10 mg/day, which is also the recommended dose for patients with hepatic impairment 4
• Lorazepam may be used for short-term management of anxiety in older adults, but with reduced dosing (0.25-0.5 mg orally, maximum 2 mg in 24 hours) compared to younger adults 3

Second-Line Treatment Options

• If first-line SSRIs are ineffective or not tolerated, consider switching to:
  • Another SSRI with a different side effect profile 1
  • A serotonin-norepinephrine reuptake inhibitor (SNRI) such as venlafaxine or duloxetine 1, 2
  • Buspirone may be considered for relatively healthy older adults, particularly if avoiding sexual side effects is a priority 1

Medications to Use with Caution or Avoid

• Benzodiazepines should generally be avoided for routine or long-term use in older adults due to increased risk of falls, cognitive impairment, and dependence 1, 2
• Paroxetine should be used cautiously in older adults due to its anticholinergic effects 3
• Fluoxetine should be used cautiously in older adults due to its greater risk of agitation and overstimulation 3
• Tertiary-amine tricyclic antidepressants (e.g., amitriptyline) should be avoided due to significant anticholinergic effects 3

Treatment Duration and Monitoring

• After achieving remission, medications should be continued for 6-12 months to prevent relapse 5
• If discontinuation is warranted, taper gradually rather than abrupt cessation to minimize withdrawal symptoms 4
• Regular reassessment is necessary to determine the continued need for maintenance treatment 4

Special Considerations for Older Adults

• Older adults are at significantly greater risk of adverse drug reactions compared to younger populations 3
• When treating anxiety that begins in late life, conduct a careful search for underlying depressive disorders, physical illness, or medications that could be contributing to anxiety symptoms 6
• Cognitive behavioral therapy (CBT) is an effective non-pharmacological option that can be used alone or in combination with medication 5, 7
• Although a randomized controlled trial found sertraline to be more effective than CBT for anxiety in older adults (particularly for worry symptoms), both treatments showed significant improvement compared to waitlist control 7

Common Pitfalls to Avoid

• Failing to screen for bipolar disorder before initiating antidepressant treatment 4
• Not accounting for potential drug interactions, particularly in older adults who may be on multiple medications 2
• Using standard adult doses rather than starting with lower doses in older adults 3
• Overlooking non-pharmacological approaches such as CBT, which can be effective either alone or in combination with medication 5