What is the starting dose of buspirone (anxiolytic medication) for an elderly patient with anxiety who wants to trial it instead of a Selective Serotonin Reuptake Inhibitor (SSRI)?

Starting Dose of Buspirone in Elderly Patients with Anxiety

Start buspirone at 5 mg twice daily (10 mg/day total) in elderly patients with anxiety, then titrate gradually every 5-7 days based on tolerability and response. 1, 2

Initial Dosing Strategy

• Begin with 5 mg twice daily as the conservative starting dose specifically recommended for elderly patients to minimize adverse effects while establishing tolerability 1, 2
• This lower starting dose is appropriate even though elderly patients ultimately respond to similar total daily doses as younger patients (mean effective dose around 18 mg/day) 3
• The 5 mg twice daily starting dose has been validated in controlled trials of elderly patients with anxiety disorders 3, 4

Titration Schedule

• Increase by 5 mg increments every 5-7 days based on clinical response and tolerability 1, 2
• Most elderly patients respond well to doses between 15-18 mg per day in divided doses 2, 3
• Maximum dose is 20 mg three times daily (60 mg/day total), though most elderly patients achieve therapeutic benefit at lower doses 1, 2
• The typical therapeutic range studied in elderly patients is 15-30 mg/day 3, 5

Critical Counseling Points

• Buspirone requires 2-4 weeks to become effective - this is essential to communicate upfront to prevent premature discontinuation 1, 2
• A full therapeutic trial requires 4-8 weeks at adequate doses before determining treatment failure 2
• Unlike benzodiazepines, buspirone provides no immediate anxiolytic effect, which can be a source of patient dissatisfaction if not properly explained 1, 2
• The delayed onset of action (1-2 week "lagtime") has been consistently noted in clinical trials 6

Safety Profile in Elderly Patients

• Buspirone demonstrates excellent tolerability in elderly patients, with no need for dose adjustment based solely on age 4
• The side effect profile in elderly patients (≥65 years) is similar to younger patients, with 80% reporting no side effects in large trials 4
• Buspirone is well-tolerated even in elderly patients taking multiple medications for chronic medical conditions (70% on ≥2 concomitant drugs in controlled trials) 3
• No withdrawal syndrome occurs with abrupt discontinuation, even after prolonged use 5

Comparative Efficacy Considerations

• In head-to-head trials, buspirone showed faster initial response than sertraline in elderly GAD patients (superior at 2 and 4 weeks), though both were equally effective by 8 weeks 7
• This early superiority over SSRIs may be relevant for your patient's preference, though the 2-4 week delay to onset still applies 7
• Buspirone lacks the sedation, cognitive impairment, and fall risk associated with benzodiazepines - important advantages in elderly patients 4, 6