What is the appropriate use of Buspar (buspirone) for an elderly patient with dementia, impaired mobility, and a complex medical history?

Buspar (Buspirone) Indications

Buspirone is FDA-approved exclusively for generalized anxiety disorder (GAD) in adults, and should not be used for behavioral and psychological symptoms of dementia (BPSD), agitation, or aggression in elderly patients with dementia, as it lacks evidence for these conditions and contributes to unnecessary polypharmacy with increased fall risk. 1

FDA-Approved Indication

• Generalized Anxiety Disorder (GAD): Buspirone is indicated for the management of anxiety disorders or short-term relief of anxiety symptoms in adults 1
• The typical dosing is 15-60 mg/day in divided doses, with most patients responding to 15-30 mg/day 1, 2
• Onset of anxiolytic effect is gradual, requiring 2-4 weeks for therapeutic benefit, making it unsuitable for acute anxiety or immediate symptom relief 2, 3

Use in Elderly Patients with GAD

• Buspirone demonstrates similar efficacy and safety in elderly patients (≥65 years) compared to younger adults for treatment of GAD 4
• In elderly patients with GAD, buspirone 5-30 mg/day (mean dose 18 mg/day) produces significant improvement on Hamilton Anxiety Scale without requiring dose adjustment 5
• Both sertraline and buspirone show efficacy for GAD in elderly patients, with buspirone demonstrating faster onset (superior at 2-4 weeks) but similar efficacy by 8 weeks 6
• No special dose adjustments are required for elderly patients based on pharmacokinetic studies, though greater sensitivity in some older patients cannot be ruled out 1

What Buspirone Should NOT Be Used For

Behavioral Symptoms in Dementia

• Buspirone has limited evidence for BPSD management and contributes to polypharmacy without clear benefit 7
• For agitation in dementia, SSRIs (citalopram 10-40 mg/day or sertraline 25-200 mg/day) are the preferred first-line pharmacological treatment after non-pharmacological interventions fail 7
• Buspirone takes 2-4 weeks to become effective and is useful only in patients with mild to moderate agitation, making it inappropriate for acute behavioral crises 7

Panic Disorder

• Studies in panic disorder have been inconclusive, and buspirone is not recommended for routine treatment of panic disorder 2

Acute Agitation or Emergency Situations

• The delayed onset of action (2-4 weeks) makes buspirone completely inappropriate for acute agitation requiring immediate intervention 3
• For acute severe agitation in elderly patients, low-dose haloperidol (0.5-1 mg) is preferred when non-pharmacological interventions fail and there is imminent risk of harm 7

Critical Safety Considerations in Elderly Patients

Polypharmacy Risk

• The combination of multiple psychotropics (including buspirone) increases risk of adverse effects including cognitive impairment, falls, and QTc prolongation without demonstrated additive benefit 7
• In elderly patients with dementia already on other psychotropics, buspirone should be gradually tapered and discontinued over 2-3 weeks as it lacks strong evidence for BPSD 7

Falls Risk

• All psychotropics, including buspirone, increase fall risk in elderly patients and require falls risk assessment at each visit 7

Hepatic and Renal Impairment

• Buspirone is metabolized by the liver and excreted by the kidneys, with increased plasma levels and lengthened half-life in patients with impaired hepatic or renal function 1
• Administration to patients with severe hepatic or renal impairment cannot be recommended 1

Drug Interactions

• Buspirone can interfere with urinary catecholamine assays and should be discontinued at least 48 hours prior to urine collection 1

Pregnancy and Lactation

• Pregnancy Category B: No fertility impairment or fetal damage observed in animal studies, but adequate human studies have not been performed; use only if clearly needed 1
• Buspirone and its metabolites are excreted in rat milk; administration to nursing women should be avoided if clinically possible 1

Appropriate Patient Selection

• Best candidates: Patients with GAD who do not require immediate symptom relief and can tolerate gradual onset of anxiolytic effect over 2-4 weeks 2
• Advantages over benzodiazepines: Increased safety profile, lack of dependency-producing properties, no sedation, and no cognitive impairment 2, 5
• Elderly patients with chronic anxiety: Particularly appropriate for elderly patients with chronic medical conditions receiving multiple medications, as buspirone was well-tolerated in studies where 70% of patients were receiving two or more non-psychotropic drugs 5