What are the considerations for using anxiolytics (anxiety-reducing medications) in the elderly population?

From the Guidelines

Anxiolytics should be used cautiously in elderly patients, with benzodiazepines generally avoided when possible due to increased risk of falls, cognitive impairment, and paradoxical reactions. When anxiety treatment is necessary in older adults, start with non-pharmacological approaches like cognitive behavioral therapy, relaxation techniques, and addressing underlying medical conditions 1. If medication is required, consider starting with SSRIs like sertraline (25-50mg daily) or escitalopram (5-10mg daily), which have better safety profiles in the elderly 1. For short-term anxiety management, use lower doses of shorter-acting benzodiazepines such as lorazepam (0.25-0.5mg) or oxazepam (5-10mg) at half the usual adult dose, limiting duration to 2-4 weeks when possible. Buspirone (5mg twice daily, gradually increased) is another option with fewer cognitive and psychomotor effects. Hydroxyzine (10-25mg) may help with mild anxiety but can cause anticholinergic effects.

Elderly patients metabolize medications more slowly, have increased sensitivity to side effects, and often take multiple medications that can interact with anxiolytics 1. Regular monitoring for effectiveness, side effects, and continued need is essential, with gradual tapering when discontinuing to avoid withdrawal symptoms. The American Geriatrics Society Beers Criteria for potentially inappropriate medication is a useful resource to assess the safety of medications in older adults 1.

Some key points to consider when prescribing anxiolytics to elderly patients include:

• Avoiding benzodiazepines when possible due to increased risk of falls, cognitive impairment, and paradoxical reactions
• Starting with non-pharmacological approaches like cognitive behavioral therapy and relaxation techniques
• Using SSRIs or buspirone as first-line medication options
• Monitoring for effectiveness, side effects, and continued need, with gradual tapering when discontinuing to avoid withdrawal symptoms
• Considering the potential for drug-drug interactions and polypharmacy in elderly patients 1

From the FDA Drug Label

Clinical studies of lorazepam generally were not adequate to determine whether subjects aged 65 and over respond differently than younger subjects; however, the incidence of sedation and unsteadiness was observed to increase with age In general, dose selection for an elderly patient should be cautious, and lower doses may be sufficient in these patients For elderly or debilitated patients, an initial dosage of 1 mg/day to 2 mg/day in divided doses is recommended, to be adjusted as needed and tolerated

The use of lorazepam in the elderly should be done with caution, as the incidence of sedation and unsteadiness increases with age.

• Initial dosage for elderly or debilitated patients should be 1 mg/day to 2 mg/day in divided doses, adjusted as needed and tolerated 2.
• Dose selection should be cautious, and lower doses may be sufficient in these patients 2.
• The dosage of lorazepam should be increased gradually when needed to help avoid adverse effects 2.

From the Research

Anxiolytics in the Elderly

• The use of anxiolytics in the elderly requires caution due to altered pharmacokinetics 3.
• Benzodiazepines with a relatively short half-life, such as lorazepam, are considered appropriate anxiolytics for elderly patients 3.
• Non-benzodiazepines, such as barbiturates and pseudobarbiturates, have a higher toxic potential and are less useful for treating sleep disturbances in the elderly 4.
• A balanced medical and psychological approach to sleep disturbance and anxiety in the elderly, including behavioral techniques, can be effective 4.

Factors Influencing Anxiolytic Use

• The use of sedatives/hypnotics in the elderly is associated with factors such as consumption of other drugs, presence of established depression, multiple comorbidities, being female, and dependence on basic activities of daily living 5.
• The prevalence of self-reported anxiety/hypnotics use in adults 65 years and older is estimated to be around 16.6% 5.
• Benzodiazepines, mainly lorazepam, account for the majority of anxiolytics/hypnotics used by the elderly 5.

Treatment Principles

• General treatment principles for anxiety disorders in older adults include the use of anxiolytic medications and non-pharmacologic treatment approaches 6.
• Selective serotonin reuptake inhibitors (SSRIs) are frequently recommended as a first-line treatment for depression in elderly patients, but their benefits and risks must be carefully considered 7.