What is the optimal medication regimen for an 81‑year‑old woman with persistent panic attacks and anxiety despite Buspar (buspirone) 15 mg twice daily, Xanax (alprazolam) 0.25 mg twice daily, and Lexapro (escitalopram) 15 mg daily?

Medication Optimization for Persistent Anxiety in an 81-Year-Old Woman

The best optimization is to increase escitalopram to 20 mg daily (the maximum safe dose for patients >60 years), discontinue alprazolam completely using a slow taper, and maintain buspirone at current dose. 1

Primary Recommendation: Optimize the SSRI First

• Escitalopram should be increased from 15 mg to 20 mg daily, as this is the maximum recommended dose for elderly patients and provides the best balance of efficacy and safety in this age group 1
• Escitalopram has the least effect on CYP450 isoenzymes compared to other SSRIs, resulting in the lowest propensity for drug interactions—a critical consideration in elderly patients often taking multiple medications 1
• The current dose of 15 mg is suboptimal; full therapeutic assessment requires 4-8 weeks at the optimized dose of 20 mg 1
• Do not exceed 20 mg daily in patients >60 years due to dose-dependent QT prolongation risk 2, 1

Critical Safety Issue: Discontinue Alprazolam

Alprazolam (Xanax) 0.25 mg BID must be discontinued in this 81-year-old patient due to the following evidence:

• The American Geriatrics Society strongly recommends avoiding benzodiazepines in older adults due to increased risk of cognitive impairment, delirium, falls, and fractures, as well as potential for dependence and withdrawal 1
• Regular benzodiazepine use leads to tolerance, addiction, depression, and cognitive impairment, with paradoxical agitation occurring in approximately 10% of elderly patients 2, 1
• Even at the low dose of 0.25 mg BID, elderly patients have enhanced sensitivity to benzodiazepines and face significantly elevated risks 1
• The 2019 AGS Beers Criteria explicitly warns against benzodiazepine use in the elderly 1

Safe Alprazolam Taper Protocol

Use the following gradual discontinuation schedule 3:

• Reduce by no more than 0.125 mg (half of one 0.25 mg tablet) every 3 days 3
• For this patient on 0.5 mg total daily: Week 1-2: 0.25 mg morning, 0.125 mg evening; Week 3-4: 0.125 mg BID; Week 5-6: 0.125 mg daily; Week 7-8: 0.125 mg every other day, then discontinue 3
• Some elderly patients may require an even slower taper—consider extending each step to 5-7 days if withdrawal symptoms emerge 3
• If significant withdrawal symptoms develop (anxiety, tremor, insomnia), reinstitute the previous dose, stabilize, then attempt a slower taper 3

Buspirone: Maintain Current Dose

Continue buspirone 15 mg BID (current regimen) for the following reasons:

• Buspirone is particularly appropriate for elderly patients with chronic anxiety and is generally better tolerated than benzodiazepines 2, 1
• The current dose of 15 mg BID (30 mg total daily) is within the therapeutic range and well-tolerated in elderly patients 4, 5
• Buspirone lacks the cognitive impairment, fall risk, and dependence issues associated with benzodiazepines 6, 5
• In elderly patients (≥65 years), buspirone 15 mg/day achieved similar anxiety relief as younger patients with minimal side effects (80% reported no side effects) 5
• Buspirone is NOT effective for panic attacks 7, 8, but may provide adjunctive benefit for persistent generalized anxiety when combined with the SSRI 8

Treatment Monitoring and Timeline

Assess response using the following schedule 1:

• Evaluate at 4 weeks and 8 weeks after escitalopram dose increase using standardized anxiety scales 1
• Monitor for symptom relief, side effects (especially nausea, initial anxiety/agitation), falls risk, and cognitive function 1
• Initial adverse effects of SSRIs (anxiety, agitation) typically resolve within 1-2 weeks 1
• Full therapeutic effect requires 4-8 weeks at the optimized dose 2, 1

If Symptoms Persist After 8 Weeks at Optimized Escitalopram

Consider the following algorithmic approach 1:

1. First alternative: Switch to sertraline (start 25 mg daily, increase to 50-100 mg daily over 2-4 weeks) as it has comparable efficacy with lower QT prolongation risk than citalopram 1
2. Second alternative: Switch to an SNRI (venlafaxine or duloxetine) if two SSRIs fail, though monitor blood pressure closely with venlafaxine due to dose-dependent hypertension risk 1
3. Augmentation strategy: Add pregabalin or gabapentin with renal dose adjustment for elderly patients 1

Critical Safety Monitoring

Obtain the following baseline and monitoring labs 1:

• Serum sodium level (SSRIs cause hyponatremia in 0.5-12% of elderly patients, typically within first month) 1
• Renal function to guide dosing decisions 1
• ECG if not done recently (to assess baseline QTc before maximizing escitalopram) 2, 1
• Review all current medications for CYP450 interactions 1

Common Pitfalls to Avoid

• Never discontinue escitalopram abruptly—taper gradually over 10-14 days to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, irritability) 1
• Never combine SSRIs with NSAIDs, aspirin, or anticoagulants without gastroprotection (PPI) due to increased GI bleeding risk (OR 1.2-1.5) 1
• Do not add another benzodiazepine or increase alprazolam dose—this worsens long-term outcomes 1
• Start low and go slow with any medication changes, using doses approximately 50% of standard adult starting doses 1