What is the most appropriate first‑line pharmacologic treatment for anxiety in an 87‑year‑old long‑term care resident with marked anxiety?

Treatment of Anxiety in an 87-Year-Old Long-Term Care Resident

For an 87-year-old nursing home resident with marked anxiety, lorazepam 0.25-0.5 mg orally as needed (maximum 2 mg in 24 hours) is the most appropriate first-line pharmacologic treatment for acute symptom management, while addressing reversible causes and considering an SSRI such as sertraline for longer-term management if anxiety persists. 1

Immediate Management Approach

Address Reversible Causes First

Before initiating pharmacologic treatment, you must systematically evaluate and treat potential underlying causes 1:

• Explore the patient's specific concerns and anxieties through direct conversation 1
• Assess for medical causes: hypoxia, urinary retention, constipation, pain, and delirium 1
• Review current medications for agents that may worsen anxiety or cause delirium, particularly opioids 1
• Ensure adequate environmental support: proper lighting, effective communication, and orientation strategies 1

Acute Pharmacologic Management

For immediate anxiety or agitation in elderly patients able to swallow, the NICE guidelines specifically recommend:

• Lorazepam 0.25-0.5 mg orally four times daily as required (maximum 2 mg in 24 hours for elderly or debilitated patients) 1
• Oral tablets can be used sublingually if needed 1

This reduced dosing for elderly patients is critical—the standard adult dose is 0.5-1 mg (maximum 4 mg/24 hours), but elderly patients require half this dose to minimize risks of cognitive impairment, falls, and paradoxical agitation 1.

Longer-Term Pharmacologic Strategy

SSRIs as Preferred Agents

If anxiety persists beyond acute management, SSRIs are the preferred long-term treatment for elderly patients 1, 2, 3, 4:

• Sertraline is specifically recommended as a preferred agent for older patients due to its favorable side effect profile and low potential for drug interactions 1, 2, 3
• Citalopram and escitalopram are also appropriate first-line choices for elderly patients 1
• SSRIs have established efficacy for the full spectrum of anxiety disorders and are generally well-tolerated in geriatric populations 2, 3, 4, 5

Avoid paroxetine and fluoxetine in elderly patients due to higher rates of adverse effects in this population 1.

Dosing Considerations for SSRIs in the Elderly

• Start at lower doses than in younger adults 6
• Titrate slowly to recommended therapeutic doses 6
• Sertraline 50-200 mg/day has demonstrated efficacy in elderly patients with anxiety and depression 2, 3
• No dosage adjustments are required for sertraline based solely on age, though starting low is prudent 2, 3

Critical Safety Considerations

Benzodiazepine Cautions

While benzodiazepines like lorazepam are guideline-recommended for acute anxiety management, they carry significant risks in elderly patients 1:

• Increased risk of cognitive impairment, falls with injury, and motor skill impairment 1
• Risk of habituation and withdrawal syndromes including sleep disruption 1
• Use should be time-limited in accordance with psychiatric guidelines 1
• Avoid long-acting benzodiazepines like diazepam entirely in elderly patients 1

Monitoring Requirements

Monthly assessment is essential until symptoms subside 1:

• Assess compliance with treatment and satisfaction 1
• Monitor for adverse effects, particularly cognitive changes and falls 1
• Evaluate symptom relief and functional status 1
• Consider tapering benzodiazepines if symptoms are controlled 1

Agents to Avoid

Do not use the following in elderly patients with anxiety 1:

• Tertiary tricyclic antidepressants (marked anticholinergic effects) 1, 2, 3
• Long-acting benzodiazepines (diazepam) 1
• Antipsychotics for anxiety alone (increased mortality risk in elderly, particularly those with dementia) 1

Alternative Considerations

Buspirone may be considered as an alternative anxiolytic, though evidence is less robust in the very elderly 7, 4:

• No dosage adjustment required based on age alone 7
• Avoid in severe hepatic or renal impairment (common in this age group) 7
• Takes several weeks for full effect, making it unsuitable for acute management 4

Common Pitfalls to Avoid

• Do not prescribe benzodiazepines for routine long-term use without regular reassessment and attempts at tapering 1
• Do not overlook delirium as a cause of agitation—this requires different management with haloperidol, not benzodiazepines alone 1
• Do not use SSRIs and NSAIDs together without gastroprotection due to increased bleeding risk 6
• Monitor for hyponatremia when initiating SSRIs in elderly patients, as this can be life-threatening 6
• Assess fall risk regularly, as both anxiety and its treatments increase fall risk in this population 1, 6