What is the first-line treatment for geriatric anxiety?

First-Line Treatment for Geriatric Anxiety

Cognitive Behavioral Therapy (CBT) is the first-line treatment for anxiety in elderly patients, with SSRIs (specifically escitalopram or sertraline) as the preferred pharmacological option when psychotherapy is unavailable, ineffective, or when symptoms are severe. 1

Non-Pharmacological Approaches (Preferred Initial Treatment)

• CBT has the strongest evidence for efficacy in treating anxiety disorders in older adults and should be considered first when available. 1
• Brief psychological interventions delivered in primary care settings demonstrate moderate to large effect sizes for reducing anxiety symptoms. 1
• Psychoeducation combined with cognitive therapy, exposure techniques, and relapse prevention strategies show effectiveness that persists at 12-month follow-up. 1
• For patients aged 60 and older, motivational interviewing combined with psychoeducation and breathing techniques demonstrates significant anxiety reduction at 3-month follow-up. 1
• Relaxation training alone appears as effective as CBT in older adults, though this finding requires cautious interpretation given study limitations. 2

Pharmacological Treatment (When Psychotherapy Insufficient or Unavailable)

First-Line Medications: SSRIs

• Escitalopram is FDA-approved for generalized anxiety disorder with a recommended starting dose of 10 mg once daily, increased to 20 mg after a minimum of one week if needed. 3
• Sertraline (starting 25-50 mg/day, maximum 200 mg/day) is well-tolerated with fewer drug-drug interactions, making it particularly suitable for elderly patients on multiple medications. 4
• Citalopram (starting 10 mg/day, maximum 40 mg/day) is well-tolerated though some patients experience nausea and sleep disturbances. 4
• Venlafaxine (SNRI) has demonstrated efficacy in older adults with GAD and represents an alternative when SSRIs are not tolerated. 5

Dosing Considerations for Elderly Patients

• 10 mg/day is the recommended dose for most elderly patients taking escitalopram, with hepatic impairment requiring the same reduced dosing. 3
• Start at the lowest effective dose and titrate slowly, as elderly patients are more sensitive to both therapeutic and adverse effects. 3
• Monitor for at least 4 weeks at an adequate dose before determining treatment failure. 4

What NOT to Use

• Benzodiazepines should be avoided as first-line treatment due to unfavorable risk-benefit ratio in elderly patients, including risks of cognitive impairment, falls, fractures, tolerance, addiction, and paradoxical agitation in 10% of elderly patients. 6, 7
• If a benzodiazepine is absolutely necessary for short-term use, lorazepam or oxazepam are preferred due to favorable pharmacokinetics, but this should be exceptional rather than routine. 5
• Buspirone has a more limited role than antidepressants in treating late-life GAD. 5

Critical Pre-Treatment Assessment

• Always rule out underlying medical causes of anxiety symptoms before initiating treatment, including hyperthyroidism, cardiac arrhythmias, hypoxia, infections (especially UTI and pneumonia), pain, urinary retention, and constipation. 1, 4
• Review all medications for drug toxicity or adverse effects that may be contributing to anxiety symptoms, particularly anticholinergic medications. 1, 4
• Screen for bipolar disorder prior to initiating antidepressant treatment, as antidepressants can precipitate manic episodes. 3
• Assess for comorbid major depression, as generalized anxiety frequently occurs during depressive episodes and treating the depression may resolve the anxiety. 5
• Address sensory impairments (hearing, vision) that may exacerbate anxiety symptoms. 1

Treatment Monitoring and Duration

• Assess treatment response within 4 weeks of initiating pharmacotherapy at an adequate dose. 4
• If no clinically significant response after 4 weeks, taper and withdraw the medication and consider alternative treatments. 4
• Monitor for suicidal ideation and symptom changes throughout treatment. 7
• When discontinuing SSRIs, use gradual dose reduction rather than abrupt cessation to minimize discontinuation symptoms. 3
• Periodically reassess the need for continued medication, as acute anxiety episodes may not require indefinite treatment. 3

Common Pitfalls to Avoid

• Failing to identify and treat underlying medical causes of anxiety before initiating psychiatric treatment is a critical error. 1
• Using high doses without appropriate adjustments for elderly patients increases adverse effect risk without improving efficacy. 1
• Neglecting non-pharmacological approaches and jumping directly to medications misses the safest, most effective first-line option. 1
• Prescribing benzodiazepines for chronic anxiety management in elderly patients creates more problems than it solves. 6, 7
• Starting multiple medications simultaneously makes it impossible to determine which intervention is effective or causing adverse effects. 1