What can be added to Lexapro (escitalopram) 20 mg for ongoing anxiety in an elderly patient?

Augmentation Strategy for Persistent Anxiety on Lexapro 20 mg in Elderly Patients

For an elderly patient with ongoing anxiety despite Lexapro 20 mg, add buspirone starting at 5 mg twice daily, titrating up to a maximum of 20 mg three times daily as tolerated, as this provides anxiolytic benefit without the risks of benzodiazepines in this vulnerable population. 1

Primary Augmentation Approach

Buspirone as First-Line Add-On

• Buspirone is specifically recommended for anxiety management in elderly patients, with an initial dose of 5 mg twice daily and a maximum of 20 mg three times daily 1
• This agent is useful for mild to moderate agitation and anxiety, though it requires 2-4 weeks to become fully effective 1
• Buspirone avoids the significant risks associated with benzodiazepines in elderly populations, including cognitive impairment, falls, paradoxical agitation (occurring in ~10% of patients), tolerance, and addiction 1

Why Not Benzodiazepines

• Benzodiazepines should be avoided as routine treatment in elderly patients despite their rapid anxiolytic effects 1
• In elderly or debilitated patients, if benzodiazepines are absolutely necessary for severe acute anxiety, lorazepam should be reduced to 0.25-0.5 mg (maximum 2 mg in 24 hours) rather than the standard 0.5-1 mg dosing 1
• Regular benzodiazepine use leads to tolerance, addiction, depression, cognitive impairment, and increased fall risk in older adults 1
• Agents with short half-lives (lorazepam, oxazepam, temazepam) are least problematic if use is unavoidable 1

Alternative Augmentation Strategies

Low-Dose Antipsychotics for Severe Anxiety

If anxiety is severe with significant agitation:

• Quetiapine 25 mg orally at bedtime can be considered, as it is sedating and less likely to cause extrapyramidal symptoms 1
• Reduce doses in elderly patients and those with hepatic impairment 1
• Use only at the lowest effective dose for the shortest duration, with daily reassessment 1

Mirtazapine Switch or Addition

• Mirtazapine 7.5 mg at bedtime (maximum 30 mg) is well-tolerated and effective, particularly for patients with associated anxiety 1
• This agent promotes sleep and appetite, which may benefit elderly patients with comorbid insomnia or poor oral intake 1

Critical Considerations for Elderly Patients

Medication-Specific Cautions

• Escitalopram itself is effective for anxiety disorders and may simply need more time (4-8 weeks for full therapeutic effect) 2, 3, 4
• Before adding medications, confirm adequate duration of treatment at 20 mg (at least 8-12 weeks) 3, 5, 6
• Elderly patients have reduced renal function and medication clearance, creating a smaller therapeutic window and increased risk of accumulation 1

Drug Interaction Monitoring

• Escitalopram has relatively low potential for drug interactions compared to other SSRIs, but still monitor for serotonin syndrome when combining with other serotonergic agents 1, 2
• Avoid combining with MAOIs, tramadol, or other serotonergic medications without careful monitoring 1

Common Pitfalls to Avoid

• Do not use tricyclic antidepressants (desipramine, nortriptyline) despite their anxiolytic properties, as their anticholinergic, cardiotoxic, and hypotensive effects make them suboptimal in elderly patients 1, 2
• Avoid paroxetine as an alternative SSRI due to its strong anticholinergic effects and higher risk of suicidal thinking compared to other SSRIs 1
• Monitor for falls, cognitive impairment, and orthostatic hypotension with any augmentation strategy 1

Monitoring Parameters

• Assess anxiety symptoms using validated scales (GAD-7) at 2-4 week intervals 1
• Monitor for adverse effects including sedation, dizziness, and orthostatic hypotension at each visit 1
• Evaluate for drug-drug interactions, particularly if the patient takes multiple medications 1, 2
• Reassess need for augmentation after 9 months of combined therapy 1