First-Line Treatment for Geriatric Anxiety
Selective serotonin reuptake inhibitors (SSRIs), specifically sertraline or escitalopram, are the recommended first-line pharmacological treatments for anxiety in older adults, with cognitive behavioral therapy (CBT) as the preferred psychotherapy approach. 1, 2
Preferred SSRI Options
- Sertraline and escitalopram are the top choices due to their favorable safety profiles, low potential for drug interactions, and established efficacy in the geriatric population 1, 2
- Escitalopram demonstrated a 69% cumulative response rate versus 51% for placebo in older adults with generalized anxiety disorder over 12 weeks 3
- Avoid paroxetine and fluoxetine in older adults due to higher rates of adverse effects and problematic drug interactions 1
Psychotherapy as First-Line Treatment
- Cognitive behavioral therapy (CBT) is the psychotherapy with the highest level of evidence for anxiety disorders in all age groups 4, 1
- Individual CBT sessions are preferred over group therapy due to superior clinical effectiveness 1
- Self-help CBT with professional support is a viable alternative if face-to-face therapy is not feasible 1
Dosing Principles for Elderly Patients
- Start low and go slow: Begin SSRIs at lower doses than in younger adults and titrate gradually 4
- Monitor closely during the first few weeks, as anxious patients may misattribute somatic symptoms to medication side effects 5
- Consider short-term adjunctive lorazepam (0.25-0.5 mg, maximum 2 mg in 24 hours) only during the initial weeks while waiting for SSRI onset of action, then discontinue 1, 5
Alternative First-Line Options
- Buspirone is an option for relatively healthy older adults when avoiding sexual side effects is a priority 2
- SNRIs (venlafaxine or duloxetine) are appropriate alternatives if SSRIs are ineffective or not tolerated 4, 2, 6
Treatment Duration
- For a first episode of anxiety, continue treatment for at least 4-12 months after symptom remission 1
- For recurrent anxiety, longer-term or indefinite treatment may be beneficial 1
Medications to Avoid
- Benzodiazepines should generally be avoided as first-line treatment due to increased risk of cognitive impairment, falls, and fractures in the elderly 6, 7
- Tricyclic antidepressants have suboptimal safety profiles and are not recommended 6
- Beta blockers lack evidence for efficacy in geriatric anxiety 6
Common Pitfalls
- The most common adverse effects of SSRIs in older adults include fatigue/somnolence (41%), sleep disturbance (14%), and urinary symptoms (9%) 3
- Many elderly patients with anxiety may already be on benzodiazepines started at a younger age; these should be continued with regular observation for whether harms are exceeding benefits, at which point switching to recommended agents is justified 2
- Always conduct a careful search for underlying depression, physical illness, or medications that could be contributing to anxiety symptoms, as anxiety in late life is often secondary 7, 5