What are the recommended medications for treating anxiety in the elderly?

Recommended Medications for Anxiety in the Elderly

For first-line treatment of anxiety in elderly patients, start with sertraline 25 mg daily or escitalopram 10 mg daily, as these SSRIs offer the best balance of efficacy and safety with minimal drug interactions. 1, 2

First-Line Pharmacotherapy: SSRIs

Sertraline and escitalopram are the preferred initial agents due to their favorable safety profiles and reduced potential for drug-drug interactions—a critical consideration given polypharmacy in this population. 1, 2

Specific Dosing for Elderly Patients

• Sertraline: Start at 25 mg daily (half the standard adult dose), titrate at 1-2 week intervals based on tolerability 1
• Escitalopram: Start at 10 mg daily, which is the recommended dose for elderly patients given the 50% increase in AUC and half-life in those ≥65 years 3
• Escitalopram has the least effect on CYP450 isoenzymes compared to other SSRIs, resulting in the lowest propensity for drug interactions 1

Important Monitoring Considerations

• Initial adverse effects (anxiety, agitation) typically resolve within 1-2 weeks 1
• Assess treatment response at 4 and 8 weeks using standardized instruments 1
• If symptoms are stable or worsening after 8 weeks despite good adherence, switch to a different SSRI or SNRI 1

Alternative First-Line Option: Buspirone

Buspirone (starting 5 mg twice daily, maximum 20 mg three times daily) is appropriate for relatively healthy elderly patients, particularly when avoiding sexual side effects is a priority. 4, 2

• Useful only in patients with mild to moderate anxiety 4
• May take 2-4 weeks to become effective 4
• Well tolerated in elderly patients with no significant adverse events reported 5
• Critical caveat: Cannot be recommended in patients with severe hepatic or renal impairment due to increased plasma levels and prolonged half-life 6

Second-Line Options: SNRIs

If SSRIs are ineffective or not tolerated, switch to venlafaxine or duloxetine. 1, 2

These serotonin-norepinephrine reuptake inhibitors are appropriate alternatives with demonstrated efficacy in elderly populations. 7

SSRIs to AVOID in the Elderly

Paroxetine and fluoxetine should generally be avoided in older adults. 1

• Paroxetine: Significant anticholinergic properties and increased risk of suicidal thinking compared to other SSRIs 1
• Fluoxetine: Very long half-life and extensive CYP2D6 interactions make it problematic in elderly patients 1

Benzodiazepines: Use with Extreme Caution

Benzodiazepines should generally be avoided for routine anxiety treatment in the elderly due to increased risk of cognitive impairment, falls, and fractures. 7, 8

If absolutely necessary for acute management:

• Lorazepam: Reduce dose to 0.25-0.5 mg in elderly patients (maximum 2 mg in 24 hours) 4
• Short half-life benzodiazepines are least problematic if use is unavoidable 4
• High-potency compounds (lorazepam, alprazolam) may cause more intense dependence, rebound symptoms, and memory impairment than low-potency options like oxazepam 9

Important Caveat for Long-Term Benzodiazepine Users

Many patients started benzodiazepines at younger ages may continue them into elderly years. These should be continued with regular observation to assess if harms are exceeding benefits, at which point switching to recommended SSRIs is justified. 2

Treatment Duration and Discontinuation

• For a first episode of anxiety, continue treatment for at least 4-12 months after symptom remission 1
• For recurrent anxiety, longer-term or indefinite treatment may be beneficial 1
• Never discontinue SSRIs abruptly—taper gradually over 10-14 days to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 4, 1

Special Monitoring Requirements

• Review all current medications for potential interactions, particularly with CYP450 substrates 1
• Monitor for QT prolongation if using citalopram (avoid doses >20 mg daily in patients >60 years old) 1
• Assess for sexual side effects, gastrointestinal disturbances, and activation symptoms 4

Third-Line Options (If First Two Trials Fail)

Additional alternatives include pregabalin/gabapentin, lavender oil, and agomelatine, with quetiapine reserved for refractory cases. 2 However, these carry additional risks in elderly populations and should be used under specialist guidance.

Common Pitfalls to Avoid

• Do not use standard adult starting doses—elderly patients require 50% dose reductions for most SSRIs 1, 3
• Do not rush titration—increase doses at 1-2 week intervals minimum 1
• Do not prescribe benzodiazepines for chronic anxiety management given cumulative toxicity and cognitive risks 9, 8
• Do not use tricyclic antidepressants or MAOIs despite potential efficacy, as their side effect and safety profiles are suboptimal in late-life 7