What is the best practice for managing excessive anxiety in a geriatric patient in their late 60s with generalized anxiety disorder (GAD) and insomnia, currently taking escitalopram (Selective Serotonin Reuptake Inhibitor - SSRI) 10mg and pregabalin (Anticonvulsant) 75mg, with a history of taking lorazepam (Benzodiazepine) 2mg?

Managing Excessive Anxiety in a Late-60s Patient on Escitalopram and Pregabalin

The escitalopram dose should be increased to 20 mg daily, as the current 10 mg dose is subtherapeutic for most older adults with GAD, and pregabalin should be titrated upward to 150-300 mg daily in divided doses while avoiding reinitiation of lorazepam. 1, 2

Optimize Current SSRI Therapy First

• Escitalopram 10 mg is likely an inadequate dose for this patient's GAD, as the therapeutic range in older adults extends to 20 mg daily, though 10 mg is the FDA-recommended starting dose for elderly patients 3, 1
• The patient has only been on escitalopram for "a few weeks," which is insufficient time to assess full therapeutic response, as SSRIs typically require 4-8 weeks to achieve maximal anxiolytic effects 1, 4
• Increase escitalopram to 15 mg daily now, then to 20 mg daily after one week if tolerated, as older adults in clinical trials received doses between 10-20 mg with the higher doses showing greater efficacy 1
• Monitor specifically for fatigue/somnolence (41% incidence), sleep disturbance (14%), and urinary symptoms (9%) as these are the most common adverse effects in elderly patients 1

Optimize Pregabalin Augmentation

• Pregabalin 75 mg daily is a subtherapeutic dose for GAD, as effective doses typically range from 150-600 mg daily in divided doses, with most patients requiring at least 150 mg daily 2
• The patient has only been on pregabalin for approximately one week, which is at the lower end of the typical onset window (≤1 week), so inadequate time has elapsed to judge efficacy at even this low dose 2
• Increase pregabalin to 150 mg daily (75 mg twice daily) immediately, then titrate to 300 mg daily (150 mg twice daily) after 3-7 days if anxiety remains uncontrolled and the medication is well-tolerated 2
• Pregabalin specifically addresses both psychic and somatic symptoms of GAD and improves common comorbidities including insomnia, making it an ideal augmentation agent for this patient 2
• Monitor for dizziness, somnolence, and weight gain, which are the most common adverse effects, though pregabalin has low abuse potential and low risk of withdrawal symptoms when discontinued gradually 2

Why Not Restart Lorazepam

• Benzodiazepines including lorazepam should be avoided in elderly patients due to increased risk of falls, cognitive impairment, dependence, and potential acceleration of dementia 5, 6
• The 2 mg lorazepam dose this patient previously took is particularly concerning in a late-60s individual, as even low-dose benzodiazepines are associated with increased dementia risk with longer-term use 5
• Benzodiazepines have a limited role in geriatric GAD treatment and should only be considered for very short-term use (days to weeks) in crisis situations, not as ongoing therapy 6

Add Cognitive Behavioral Therapy

• CBT should be initiated immediately as an adjunct to optimized pharmacotherapy, as combined treatment with escitalopram plus modular CBT resulted in full remission for most older adults with GAD in clinical trials 7
• CBT augmentation of SSRI therapy significantly reduced anxiety symptoms and pathological worry beyond medication alone, with some patients maintaining response even after medication discontinuation 7
• The American Academy of Sleep Medicine recommends CBT for insomnia (CBT-I) as first-line treatment, which can be integrated with GAD-focused CBT to address both conditions simultaneously 8, 5

Timeline for Reassessment

• Reassess anxiety symptoms in 2 weeks after escitalopram dose increase to 20 mg and pregabalin increase to 150-300 mg daily 8
• If anxiety remains problematic at 4 weeks on optimized doses, consider adding a sedating antidepressant specifically for insomnia (mirtazapine 15 mg at bedtime or low-dose doxepin 3-6 mg at bedtime) rather than returning to benzodiazepines 9, 10, 5
• Do not add quetiapine or other antipsychotics, as these are explicitly not recommended in elderly populations due to increased mortality risk and lack of systematic evidence for effectiveness in anxiety or insomnia 9

Critical Monitoring Parameters

• Assess for serotonin syndrome given the combination of escitalopram and pregabalin, watching for mental status changes, autonomic instability, neuromuscular symptoms, or gastrointestinal symptoms 3
• Monitor for hyponatremia, as SSRIs including escitalopram are associated with clinically significant hyponatremia in elderly patients who may be at greater risk 3
• Check for suicidal thoughts or worsening depression, particularly during the initial weeks after dose adjustments, though risk decreases with age (6 fewer cases per 1000 patients ≥65 years) 3
• Escitalopram half-life is increased by approximately 50% in elderly subjects, necessitating careful monitoring for accumulation effects with dose increases 3