What is the recommended treatment for anxiety in an elderly patient with Parkinson's disease?

Treatment of Anxiety in Elderly Parkinson's Disease Patients

Cognitive Behavioral Therapy (CBT) specifically adapted for Parkinson's disease is the first-line treatment for anxiety in elderly PD patients, with strong evidence showing clinically significant reduction in situational anxiety and avoidance behaviors that is maintained at 6-month follow-up. 1

First-Line Treatment: Cognitive Behavioral Therapy

CBT should be offered as the primary intervention for anxiety in elderly PD patients, as it demonstrates both statistical and clinical superiority over monitoring alone, particularly for episodic (situational) anxiety and avoidance behavior. 1

• A randomized controlled trial demonstrated a 9.9-point reduction on the Parkinson Anxiety Scale with CBT versus 5.2-point reduction with clinical monitoring only (P = 0.012), with benefits maintained at 3- and 6-month follow-ups 1
• The CBT program should consist of 10 weekly sessions specifically adapted to address PD-specific anxiety symptoms 1
• CBT helps patients overcome behavioral avoidance associated with anxiety and challenge unhelpful negative cognitions, which are particularly relevant in the PD population 2
• Brief psychological interventions delivered in primary care settings show moderate to large effect sizes for reducing anxiety symptoms in elderly patients 3

Key CBT Components for PD Patients

• Psychoeducation describing the physiological process of anxiety and its physical impact on the body, including the concept of fight-or-flight response 4
• Breathing techniques and progressive muscle relaxation 4
• Grounding strategies to keep patients present in the moment and prevent dissociation 4
• Cognitive restructuring to address unhelpful negative thoughts 2
• Exposure techniques to reduce avoidance behaviors 3
• Integration of activities of enjoyment and regular cardiovascular exercise 4

Second-Line Treatment: Pharmacotherapy

If CBT is unavailable, not tolerated, or insufficient, selective serotonin reuptake inhibitors (SSRIs) are the preferred pharmacological option, though evidence in PD-specific populations is limited to uncontrolled studies. 5

SSRI Selection and Dosing

• Sertraline 25-50 mg/day (maximum 200 mg/day) is well-tolerated with less effect on metabolism of other medications 6
• Citalopram 10 mg/day (maximum 40 mg/day) is also well-tolerated, though some patients experience nausea and sleep disturbances 6
• Uncontrolled studies suggest SSRIs are effective for anxiety in PD, although anxiety outcomes were secondary measures in these trials 5
• SSRIs should be initiated at low doses and titrated to the minimum effective dose 6
• Response should be assessed within 4 weeks of adequate dosing using quantitative measures 6

Alternative Pharmacological Options

• Buspirone may be considered as an alternative anxiolytic, though no controlled studies exist specifically for anxiety in PD 7
• Buspirone is metabolized by the liver and excreted by the kidneys; administration to patients with severe hepatic or renal impairment cannot be recommended 7
• In elderly patients (≥65 years), buspirone safety and efficacy profiles were similar to younger populations in general anxiety disorder studies 7

What NOT to Use

• Benzodiazepines (including bromazepam) should be avoided despite one positive controlled trial, due to significant risk of confusion, falls, tolerance, addiction, cognitive impairment, and paradoxical agitation in 10% of elderly patients 5, 6
• Anticholinergic medications can worsen agitation and cognitive function in elderly PD patients and should be avoided 6
• Typical antipsychotics should not be used for anxiety, as they carry a 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 6

Multimodal Approach

A targeted combination of psychotherapeutic interventions along with pharmacologic therapies should be implemented when CBT alone is insufficient. 5

• Care partner involvement is important and should be integrated into treatment planning 8
• Remote delivery of psychotherapy interventions is increasingly feasible and should be considered for access barriers 8
• Regular cardiovascular exercise should be incorporated as it addresses both anxiety and motor symptoms 4

Critical Assessment Considerations

Before initiating any anxiety treatment, systematically rule out medical causes and medication-related factors that may be contributing to or exacerbating anxiety symptoms. 3

Medical Causes to Investigate

• Pain (a major contributor to behavioral disturbances in patients who cannot verbally communicate discomfort) 6
• Urinary tract infections, constipation, dehydration 6
• Medication side effects, particularly anticholinergic burden 6
• Sensory impairments (hearing or vision) that increase confusion and fear 6
• Hypoxia or other acute medical conditions 6

PD-Specific Anxiety Presentations

• Many PD patients experience physiological and somatic consequences of anxiety (racing heart rate, tight chest) without recognizing the experience emotionally, described as "panic without panic" or alexithymia 4
• Hypersensitivity to touch, light, sound, and movement is common in PD and can become a maintaining factor for anxiety 4
• Anxiety in PD often manifests as situational/episodic anxiety and avoidance behaviors, which respond particularly well to CBT 1

Common Pitfalls to Avoid

• Failing to offer CBT as first-line treatment when it has the strongest evidence base for anxiety in PD 1
• Using benzodiazepines despite their significant risks in elderly PD patients 5
• Neglecting to assess for medical causes of anxiety before initiating psychiatric treatment 3
• Excluding PD patients with cognitive concerns from anxiety interventions, when they should be included with appropriate adaptations 8
• Treating anxiety as a secondary concern rather than recognizing its significant impact on quality of life, functional performance, and caregiver burden 5
• Failing to involve care partners in treatment planning and implementation 8

Monitoring and Follow-Up

• Assess treatment response at 4 weeks using quantitative measures such as the Parkinson Anxiety Scale or Hamilton Anxiety Rating Scale 1, 6
• If no clinically significant response after 4 weeks at adequate dose, taper and withdraw the medication 6
• For CBT, benefits should be evident by end of 10-week program and maintained at 3- and 6-month follow-ups 1
• Periodically reassess the need for continued medication even with positive response 6