What to do for an elderly patient with persistent anxiety despite being on buspirone (anxiolytic) 30mg daily and sertraline (selective serotonin reuptake inhibitor) 125mg daily?

Management of Persistent Anxiety in an Elderly Patient on Buspirone 30mg and Sertraline 125mg Daily

For an elderly patient with persistent anxiety despite adequate doses of buspirone and sertraline, augment the current SSRI with cognitive-behavioral therapy (CBT) as the next step, which has been shown to significantly improve response rates and reduce worry in older adults with generalized anxiety disorder. 1

Immediate Assessment Priorities

Before escalating treatment, verify:

• Medication adherence and timing of doses 2
• Reversible causes of anxiety: hypoxia, urinary retention, constipation, pain, delirium 2
• Drug interactions: Sertraline at 125mg may interact with other medications metabolized by CYP2D6; buspirone metabolism can be affected by CYP3A4 inhibitors/inducers 3
• Adequate trial duration: Both medications require 4-8 weeks for full therapeutic effect 2
• Comorbid depression or cognitive impairment that may be contributing to anxiety symptoms 2, 4

Evidence-Based Treatment Algorithm

Step 1: Augmentation with CBT (Preferred)

• Add 16 weeks of modular CBT to current escitalopram/sertraline regimen 1
• This combination increased response rates on worry measures compared to medication alone in elderly patients (mean age >60 years) 1
• CBT augmentation allows for potential medication discontinuation later while maintaining remission 1

Step 2: Switch SSRI Strategy

If CBT augmentation is unavailable or ineffective:

• Switch from sertraline to escitalopram 10-20mg daily 5, 1
• Escitalopram is preferred in elderly patients due to minimal CYP450 interactions and favorable tolerability profile 5, 4
• Alternative: Switch to venlafaxine or duloxetine (SNRI) 5, 4
• Discontinue sertraline gradually over 10-14 days to avoid discontinuation syndrome 2

Step 3: Additional Augmentation Options

If response remains inadequate after SSRI switch:

• Pregabalin or gabapentin as third-line augmentation 5
• Mirtazapine 7.5-30mg at bedtime if insomnia or appetite loss are prominent features 2, 4
• Quetiapine may be considered as fourth-line, though carries black box warning for increased mortality in elderly with dementia 5, 4

Medications to AVOID in Elderly Patients

Benzodiazepines should be avoided despite their efficacy, due to:

• Risk of tolerance, addiction, cognitive impairment, and falls 2
• Paradoxical agitation in ~10% of elderly patients 2
• If already prescribed, consider very cautious use of lorazepam 0.25-0.5mg (maximum 2mg/24 hours in elderly) only for acute breakthrough anxiety 2

Hydroxyzine and beta-blockers should generally be avoided in elderly anxiety treatment 4

Buspirone Considerations

The current buspirone dose of 30mg daily is at the upper end of typical dosing:

• Buspirone 10-20mg three times daily (maximum 60mg/day) is the FDA-approved range 2
• Buspirone may take 2-4 weeks to become effective and is most useful for mild-moderate agitation 2
• Consider discontinuing buspirone if switching SSRIs, as evidence shows SSRIs/SNRIs are more effective first-line agents in elderly 5, 4
• One trial showed buspirone had faster onset (superior at 2-4 weeks) but equivalent efficacy to sertraline at 8 weeks in elderly GAD 6

Sertraline Dose Optimization

At 125mg daily, sertraline is within therapeutic range (maximum 200mg/day) 2:

• Sertraline is well-tolerated and has less effect on metabolism of other medications compared to other SSRIs 2
• However, it can cause discontinuation syndrome 2
• Before increasing beyond 125mg, consider switching to escitalopram which may have superior efficacy in elderly 5

Maintenance Strategy

Once remission is achieved:

• Continue treatment for minimum 9 months before considering dose reduction 2
• Continued SSRI prevents relapse compared to placebo in elderly patients 1
• CBT allows sustained remission without requiring long-term pharmacotherapy in many individuals 1
• Reassess need for medication after 9 months using gradual dose reduction 2

Critical Safety Monitoring

• Monitor for serotonin syndrome if combining multiple serotonergic agents 2, 3
• Check for QT prolongation if using higher SSRI doses, especially with citalopram 2
• Assess fall risk regularly, as anxiety medications increase this risk in elderly 4
• Screen for suicidal ideation, particularly when changing antidepressants 2