What is the recommended approach for treating anxiety in the elderly?

Treatment of Anxiety in the Elderly

For elderly patients with anxiety, selective serotonin reuptake inhibitors (SSRIs), particularly sertraline and escitalopram, are recommended as first-line pharmacotherapy due to their favorable safety profiles and low potential for drug interactions. 1, 2

First-Line Treatment Options

Pharmacotherapy

• SSRIs are the preferred first-line medication for anxiety in elderly patients 1, 2
  • Sertraline and escitalopram are specifically recommended due to their favorable safety profiles and minimal drug interactions 1, 2
  • Start with lower doses than used in younger adults and titrate slowly ("start low, go slow" approach) 3
• SNRIs such as venlafaxine and duloxetine are alternative first-line options 4
  • For geriatric patients with generalized anxiety disorder (GAD), duloxetine should be initiated at 30 mg once daily for 2 weeks before considering dose increases 4

Psychotherapy

• Cognitive Behavioral Therapy (CBT) is the psychotherapy with the highest level of evidence for anxiety disorders 5, 6
• Individual therapy sessions are generally preferred over group therapy due to superior clinical effectiveness 5
• Self-help CBT with professional support is a viable alternative if face-to-face CBT is not feasible or desired by the patient 5

Second-Line Treatment Options

• If first-line treatment is ineffective, consider:
  • Switching to a different SSRI or SNRI 2
  • Buspirone may be considered for relatively healthy older adults, especially when avoiding sexual side effects is a priority 2, 7
  • Pregabalin/gabapentin may be considered as third-line options 2

Medications to Use with Caution or Avoid

• Benzodiazepines should generally be avoided in elderly patients due to:
  • Increased risk of cognitive impairment 8
  • Higher risk of falls and fractures 8
  • Risk of dependence and withdrawal symptoms 7
• Paroxetine and fluoxetine should generally be avoided in older adults due to higher rates of adverse effects 1
• Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have suboptimal safety profiles in the elderly 7
• Antipsychotics should be used with extreme caution due to increased mortality risk in elderly patients with dementia 7

Special Considerations for Elderly Patients

• Dosing considerations:
  • Start with lower doses (approximately half the standard adult dose) 3
  • Titrate more slowly than in younger adults 3
  • For GAD in geriatric patients, initiate duloxetine at 30 mg once daily for 2 weeks before considering an increase to the target dose of 60 mg/day 4
• Address non-pharmacological approaches concurrently:
  • Explore the patient's specific concerns and anxieties 1
  • Ensure effective communication and orientation 1
  • Treat any reversible causes of anxiety 1

Treatment Duration

• For a first episode of anxiety, treatment should continue for at least 4-12 months after symptom remission 1
• For recurrent anxiety, longer-term or indefinite treatment may be beneficial 1
• Regular reassessment is necessary to determine continued need for maintenance treatment 4

Monitoring and Follow-up

• Frequent follow-up during the first few weeks of treatment is recommended to:
  • Monitor for adverse effects 3
  • Address concerns about medication 3
  • Assess treatment response 3
• Elderly patients may misattribute somatic symptoms of anxiety to medication side effects, so clear communication about potential adverse effects is essential 3

Common Pitfalls and Caveats

• Anxiety in the elderly often co-occurs with depression and should be assessed concurrently 7, 8
• Late-onset anxiety (first occurrence in old age) should prompt investigation for underlying medical conditions, medications, or substance use that could be contributing 3
• Anxiety symptoms in dementia are common but poorly understood; they may require different treatment approaches 8
• Elderly patients may present with fewer or less severe anxiety symptoms compared to younger adults, making diagnosis more challenging 3