What is the recommended treatment for anxiety and depression in the elderly?

Treatment of Anxiety and Depression in the Elderly

For elderly patients with depression, initiate treatment with sertraline (starting at 25 mg daily) or escitalopram as first-line pharmacotherapy, combined with cognitive behavioral therapy when accessible, while strictly avoiding paroxetine and fluoxetine due to their unfavorable side effect profiles in this population. 1

First-Line Pharmacological Treatment for Depression

Preferred Agents

• Sertraline and citalopram receive the highest ratings for both efficacy and tolerability in older adults according to the American Academy of Family Physicians 1
• Escitalopram is equally preferred, having the least effect on CYP450 isoenzymes among SSRIs, resulting in minimal drug interaction risk—critically important given polypharmacy common in elderly patients 2
• Venlafaxine (SNRI) is equally preferred as first-line therapy, particularly when cognitive symptoms are prominent, as it has dopaminergic/noradrenergic effects with lower rates of cognitive side effects 1
• Bupropion is particularly valuable when cognitive symptoms are prominent due to its dopaminergic/noradrenergic effects with lower rates of cognitive side effects 1

Critical Dosing Strategy

• Start at approximately 50% of standard adult doses due to slower metabolism and increased sensitivity to adverse effects in older adults 1
• For sertraline specifically: Start at 25 mg daily (half the standard adult starting dose of 50 mg) 3
• Increase doses at 1-2 week intervals for shorter half-life SSRIs (sertraline) to 3-4 week intervals for longer half-life SSRIs, monitoring for tolerability 3
• For venlafaxine: The recommended starting dose is 75 mg/day in two or three divided doses, with increases up to 75 mg/day at intervals of no less than 4 days 4
• No dose adjustment is recommended for elderly patients on the basis of age alone for venlafaxine, though caution should be exercised when increasing the dose 4

Medications to Strictly Avoid

• Paroxetine should not be used in older adults due to significantly higher anticholinergic effects, sexual dysfunction rates, and increased risk of suicidal thinking compared to other SSRIs 1, 2
• Fluoxetine should be avoided due to greater risk of agitation and overstimulation in this age group, very long half-life, and extensive CYP2D6 interactions 1, 2
• Tertiary-amine TCAs (amitriptyline, imipramine) are potentially inappropriate per Beers Criteria due to severe anticholinergic effects 1

First-Line Pharmacological Treatment for Anxiety

Preferred Agents

• Sertraline and escitalopram are the preferred first-line options for older adults with anxiety due to their favorable safety profiles and low potential for drug interactions 2
• SNRIs (venlafaxine or duloxetine) are appropriate alternatives if SSRIs are ineffective or not tolerated 2

Dosing for Anxiety

• Start SSRIs at lower doses than in younger adults and titrate gradually 2
• For sertraline: Begin at 25 mg daily 2
• Increase at 1-2 week intervals, monitoring for tolerability 3

Combined Depression and Anxiety

When both depression and anxiety symptoms are present, prioritize treatment of depressive symptoms first, or use a unified protocol combining CBT treatments for both conditions 5, 3

Non-Pharmacological Interventions (Essential Component)

• Cognitive Behavioral Therapy (CBT) is the psychotherapy with the highest level of evidence for both anxiety and depression disorders in all age groups 2
• Individual therapy sessions are generally preferred over group therapy due to superior clinical effectiveness 2
• Exercise programs can alleviate depressive symptoms and improve mental health in older adults 1
• Address social isolation and loneliness through referral to local social assistance programs 1
• Optimize nutrition and encourage social engagement as essential components of treatment 1

Treatment Monitoring Requirements

Initial Assessment and Follow-up

• Assess treatment response at 4 weeks and 8 weeks using standardized validated instruments 5, 2
• Monitor for symptom relief, side effects, adverse events, and patient satisfaction 5
• Initial adverse effects of SSRIs can include anxiety or agitation, which typically resolve within 1-2 weeks—reassure patients about this transient phenomenon 3

Safety Monitoring

• Check for bleeding risk, especially if patient takes NSAIDs or anticoagulants, as upper GI bleeding risk increases substantially with age when using SSRIs (4.1 hospitalizations per 1,000 adults aged 65-70 years and 12.3 hospitalizations per 1,000 octogenarians) 1
• Risk multiplies dramatically (adjusted OR 15.6) when SSRIs are combined with NSAIDs 1
• Monitor blood pressure regularly to assess for orthostatic hypotension 3
• Review all current medications for potential interactions, particularly with CYP450 substrates, before initiating treatment 3
• Monitor for QT prolongation if using citalopram (avoid doses >20 mg daily in patients >60 years old) 3

Treatment Duration

• Continue treatment for 4-12 months after first episode of major depressive disorder 1, 2
• For recurrent depression or anxiety, longer-term or indefinite treatment may be beneficial 2
• Residents with a first or second episode of major depression responding well to antidepressant treatment should be continued on full-dose treatment for at least 6 months after significant improvement is noted 5

Treatment Adjustment Algorithm

If symptoms are stable or worsening after 8 weeks despite good adherence, adjust the regimen by: 5, 2

1. Adding a psychological or pharmacologic intervention to single treatment
2. Switching to a different SSRI or SNRI 3
3. Changing from group to individual therapy if applicable 5
4. Considering vortioxetine, agomelatine, or bupropion as superior alternatives if SSRIs prove ineffective 3

Efficacy Evidence Supporting These Recommendations

• Antidepressants double the likelihood of remission compared to placebo (OR 2.03,95% CI 1.67-2.46), with 36% achieving remission versus 21% on placebo 1
• Psychotherapy is equally effective, with treated older adults more than twice as likely to achieve remission compared to no treatment (OR 2.47-2.63) 1
• Second-generation antidepressants show no differences in efficacy based on age, with elderly patients responding as well as younger patients 1
• Antidepressants appear protective against suicidal behavior in adults over 65 years (OR 0.06,95% CI 0.01-0.58), contrasting sharply with increased risk in younger adults 1

Special Populations and Comorbidities

Patients with Dementia and Frailty

• Provide treatments considering risk of adverse effects, comorbidities, and behavioral/psychological symptoms 1
• Among SSRIs, fluoxetine is generally not recommended for patients with dementia and frailty due to its long half-life and side effects 1
• Venlafaxine, vortioxetine, and mirtazapine are safer options in terms of drug interactions for patients with dementia and frailty 1

Selection Criteria for Antidepressant Choice

Base selection on: 5

• Previous treatment history 5
• Other affective features 5
• Other medical comorbidities 5
• Side-effect profiles of the antidepressants 5
• Potential drug-drug interactions 5

Critical Pitfalls to Avoid

• Do not use standard adult starting doses—always reduce by approximately 50% 1
• Do not prescribe paroxetine or fluoxetine as first-line agents in older adults 1, 2
• Do not combine SSRIs with NSAIDs without gastroprotection given the 15-fold increased bleeding risk 1
• Do not use tertiary-amine TCAs (amitriptyline, imipramine) due to severe anticholinergic burden 1
• Never discontinue SSRIs abruptly—taper gradually to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 3
• Do not overlook benzodiazepines in medication reconciliation—many patients started on these at younger ages may need gradual transition to recommended agents 6

Nursing Home Residents Specific Considerations

• Selective serotonin-reuptake inhibitors are the most appropriate for first-line treatment of depression in nursing home residents 5
• Tertiary tricyclics and psychostimulants are NOT first-line treatment 5
• Monitor effectiveness at approximately 6 weeks and 12 weeks of treatment using validated depression instruments 5