What is the best approach to manage an episode of anxiety in an elderly patient in a nursing home?

Management of Anxiety Episodes in Elderly Nursing Home Residents

The best approach to manage an episode of anxiety in an elderly nursing home resident is to first address reversible causes and use non-pharmacological interventions before considering medication, with low-dose lorazepam being the preferred pharmacological option when necessary. 1

Initial Assessment

• Address reversible causes of anxiety first by exploring the patient's concerns, ensuring effective communication and orientation, providing adequate lighting, and explaining to caregivers how they can help 2, 1
• Evaluate and treat specific medical conditions that may cause anxiety such as pain, hypoxia, urinary retention, constipation, infections, dehydration, and electrolyte disturbances 1
• Assess for medication side effects that might be contributing to anxiety symptoms 1
• Check for sensory impairments (hearing aids, glasses) that may be exacerbating anxiety 1

Non-Pharmacological Interventions (First-Line)

• Implement verbal de-escalation strategies including respecting personal space, using calm demeanor and facial expressions, designating one staff member to interact with the patient, using simple language, and setting clear expectations 1
• Create a calming environment with decreased sensory stimulation, ensuring safety, and providing orientation cues 1
• Use distraction techniques such as old photographs, objects or songs from the past 2
• Stimulate movement, exercise and creative activities (painting, folding towels, cooking) 2
• Maintain a regular schedule and routine to reduce confusion 2
• Facilitate family contact through phone or video calls to reduce distress 2
• Consider sensory therapy, behavioral interventions, environmental modifications, and social contact interventions which have been endorsed by expert panels 2

Pharmacological Management (Second-Line)

• For anxiety that doesn't respond to non-pharmacological approaches, consider lorazepam 0.25-0.5 mg orally up to four times a day as needed (maximum 2 mg in 24 hours for elderly patients) 2, 3
• Oral lorazepam tablets can be used sublingually (off-label) if needed 2
• For patients unable to swallow, midazolam 2.5-5 mg subcutaneously every 2-4 hours as required can be considered 2
• Reduce midazolam dose to 5 mg over 24 hours if estimated glomerular filtration rate (eGFR) is <30 mL/minute 2
• SSRIs like sertraline and escitalopram may be considered for longer-term management of anxiety due to their favorable safety profiles 3

Special Considerations

• Expert panels have not reached consensus supporting the use of antipsychotics for behavioral symptoms without psychotic features, despite some evidence of efficacy 2
• If delirium is contributing to anxiety, haloperidol 0.5-1 mg orally at night and every 2 hours when required may be considered (maximum 5 mg daily in elderly patients) 2
• Benzodiazepines should be used cautiously in the elderly due to risks of falls, cognitive impairment, and dependence 3, 4
• The DICE approach (Describe, Investigate, Create, Evaluate) is recommended for systematic assessment and management of behavioral symptoms in dementia 2

Monitoring and Follow-up

• Regularly reassess mental status and monitor for medication side effects, particularly when using psychotropic medications 1
• Document changes in health status, mood, or behavior as potential indicators of underlying medical issues 2
• Collaborate with mental health professionals and social workers to deliver comprehensive mental health care 2

Common Pitfalls to Avoid

• Failing to identify and treat underlying medical causes of anxiety 1
• Using high doses of medications in elderly patients without appropriate dose adjustments 1
• Neglecting non-pharmacological approaches before initiating medications 1
• Using psychotropic medications as chemical restraints rather than for specific psychiatric symptoms 2
• Lack of consistent measurement tools to evaluate anxiety interventions in nursing home residents 5