What is the best treatment approach for a 74-year-old male with anxiety, panic attacks, and poor sleep, who has not responded to Xanax (alprazolam) and experiences increased blood pressure and heart rate during attacks?

Treatment Approach for Panic Disorder with Sleep Disturbance in a 74-Year-Old Male

This patient requires immediate discontinuation of alprazolam and initiation of an SSRI (sertraline or escitalopram) combined with cognitive behavioral therapy, as benzodiazepines are contraindicated in older adults and paradoxically increase sympathetic activity in panic disorder. 1, 2, 3

Critical Safety Concern: Benzodiazepine Use in Elderly

Alprazolam must be tapered and discontinued. The patient is experiencing treatment failure with alprazolam 0.25 mg, and continuing benzodiazepines in a 74-year-old poses significant risks 1:

• Benzodiazepines should be avoided in older patients due to decreased cognitive performance, falls risk, and cognitive impairment 1
• Paradoxically, alprazolam increases muscle sympathetic nerve activity and heart rate in panic disorder patients, which may explain his elevated blood pressure and heart rate during attacks 3
• The Beers Criteria explicitly recommends tapering benzodiazepines in elderly patients, with cognitive behavioral therapy as the safer alternative 1
• Benzodiazepines cause sedation, cognitive impairment, unsafe mobility with injurious falls, habituation, and withdrawal syndromes including sleep disruption 1

First-Line Pharmacotherapy

Initiate sertraline or escitalopram as first-choice SSRI 2, 4:

• These agents have the lowest potential for drug interactions and superior tolerability in older adults 2
• SSRIs are the primary pharmacological treatment for panic disorder with Level A evidence 4
• Avoid paroxetine and fluoxetine, especially in older adults, due to higher rates of adverse effects 2
• Alternative: Venlafaxine extended-release (SNRI) is equally effective as first-line treatment 2

Treatment duration: Continue for at least 6-12 months after symptom remission for first episode; longer-term treatment may be necessary given the recurrent nocturnal pattern 2, 4

First-Line Psychotherapy

Individual Cognitive Behavioral Therapy (CBT) specifically designed for panic disorder is the gold standard 1, 2, 4:

• CBT has the highest level of evidence for anxiety disorders and should be initiated immediately 4
• Individual CBT sessions are preferred over group therapy due to superior clinical effectiveness 2
• The American Academy of Sleep Medicine recommends CBT for insomnia (CBT-I) as the initial treatment intervention (strong recommendation, moderate quality evidence) 1
• If face-to-face CBT is not feasible, self-help CBT with professional support is a viable alternative 2

Addressing the Sleep Component

The nocturnal panic attacks and poor sleep require specific intervention 1, 5, 6:

• Sleep disturbance is a stronger predictor of anxiety than vice versa, making sleep treatment critical 6
• Implement sleep hygiene and stimulus control as part of CBT-I 1
• Progressive deep muscle relaxation training (Level B recommendation) can reduce anxiety and improve sleep 1
• Consider low-dose trazodone or mirtazapine for refractory insomnia if SSRI alone is insufficient 1
• Avoid zolpidem and other benzodiazepine-like hypnotics in this elderly patient due to cognitive impairment and fall risk 1

Cardiovascular Monitoring

The elevated blood pressure and heart rate during panic attacks require attention 7:

• Document baseline cardiovascular parameters before initiating SSRI 7
• Note that imipramine (tricyclic) significantly increases heart rate and blood pressure and should be avoided 7
• SSRIs do not cause the cardiovascular stimulation seen with tricyclics 7
• The patient's hypertension (157 mmHg) may improve with anxiety treatment, but coordinate with primary care for blood pressure management 1

Treatment Algorithm

1. Immediately begin alprazolam taper using the EMPOWER technique while initiating SSRI 1
2. Start sertraline or escitalopram at low dose, titrating as tolerated 2
3. Initiate individual CBT for panic disorder with integrated CBT-I components 1, 2, 4
4. Add progressive muscle relaxation training for both anxiety and sleep 1
5. If SSRI alone insufficient after 4-6 weeks, consider adding low-dose trazodone or mirtazapine specifically for sleep (not as primary anxiolytic) 1
6. If first SSRI fails, switch to another SSRI or venlafaxine rather than adding additional agents 2
7. Continue treatment for minimum 6-12 months after remission 2, 4

Common Pitfalls to Avoid

• Do not continue benzodiazepines "for breakthrough anxiety" in elderly patients—this perpetuates the problem 1
• Do not use antipsychotics (quetiapine, olanzapine) solely for sleep disturbances due to metabolic syndrome risk 1
• Do not add multiple medications simultaneously—this increases polypharmacy burden in elderly 1
• Do not expect immediate SSRI effects—therapeutic response typically requires 4-6 weeks, unlike the immediate (but problematic) effects of benzodiazepines 4, 7