What are the causes and management of anxiety disorders in the geriatric population?

From the Guidelines

Anxiety in the elderly should be addressed through non-pharmacological approaches and careful medication management, prioritizing cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) over benzodiazepines due to their favorable side effect profiles and lower risk of adverse effects. When considering treatment options, it is essential to weigh the potential benefits and risks, particularly in older adults, where the risk of falls, cognitive impairment, and dependence is increased 1.

Non-Pharmacological Approaches

Non-pharmacological interventions such as CBT, relaxation techniques, and regular physical activity are recommended as first-line treatments for mild to moderate anxiety in the elderly. These approaches have been shown to be effective in reducing anxiety symptoms and improving quality of life, with minimal risk of adverse effects 1. CBT, in particular, has been found to be effective in reducing bad dream frequency and nightmare severity in older adults with generalized anxiety disorder (GAD) and post-traumatic stress disorder (PTSD) 1.

Medication Management

When medications are necessary, SSRIs such as sertraline (25-100mg daily) or escitalopram (5-10mg daily) are preferred due to their favorable side effect profiles in older adults. It is recommended to start at lower doses (half the typical adult starting dose) and increase gradually every 2-4 weeks as needed 1. Benzodiazepines, such as lorazepam (0.25-0.5mg), should be used sparingly and only short-term due to the increased risks of falls, cognitive impairment, and dependence in the elderly 1.

Screening and Monitoring

It is crucial to screen for underlying medical conditions that may cause or worsen anxiety, including thyroid disorders, cardiac issues, and medication side effects. Elderly patients often present with somatic symptoms of anxiety rather than psychological ones, so thorough assessment is essential. Regular monitoring for side effects, drug interactions, and treatment response is necessary, with follow-up appointments every 2-4 weeks initially. Treatment should be continued for at least 6-12 months after symptom resolution, with gradual tapering when discontinuing to prevent withdrawal symptoms.

Key considerations in managing anxiety in the elderly include:

• Prioritizing non-pharmacological approaches
• Careful selection and monitoring of medications
• Screening for underlying medical conditions
• Regular follow-up and monitoring for treatment response and side effects
• Gradual tapering of medications when discontinuing to prevent withdrawal symptoms.

From the FDA Drug Label

In 354 geriatric subjects treated with sertraline in placebo-controlled trials, the overall profile of adverse events was generally similar to that shown in Tables 2 and 3. SSRIs and SNRIs, including sertraline, have been associated with cases of clinically significant hyponatremia in elderly patients, who may be at greater risk for this adverse event No overall differences in the pattern of adverse reactions were observed in the geriatric clinical trial subjects relative to those reported in younger subjects (see ADVERSE REACTIONS), and other reported experience has not identified differences in safety patterns between the elderly and younger subjects. In one study of 6,632 patients who received buspirone for the treatment of anxiety, 605 patients were ≥ 65 years old and 41 were ≥ 75 years old; the safety and efficacy profiles for these 605 elderly patients (mean age = 70. 8 years) were similar to those in the younger population (mean age = 43. 3 years). Review of spontaneously reported adverse clinical events has not identified differences between elderly and younger patients, but greater sensitivity of some older patients cannot be ruled out.

Anxiety in the elderly can be treated with sertraline or buspirone.

• Sertraline has been studied in geriatric patients, with no overall differences in the pattern of adverse reactions observed compared to younger subjects 2.
• Buspirone has also been studied in geriatric patients, with similar safety and efficacy profiles compared to younger patients 3. It is essential to monitor elderly patients for potential adverse events, such as hyponatremia, when using SSRIs like sertraline 2. Greater sensitivity of some older patients to buspirone or sertraline cannot be ruled out 2 3.

From the Research

Anxiety in the Elderly

• Anxiety disorders are common in the elderly, often accompanied by depression, and can lead to worsening physical, cognitive, and functional impairments 4
• Antidepressants, such as SSRIs and SNRIs, are considered first-line treatment for anxiety in the elderly, with some SSRIs having more favorable pharmacokinetic profiles than others 4
• Mirtazapine and vortioxetine are also considered safe treatment options, while buspirone may have benefit but lacks studies in elderly populations 4
• Tricyclic/tetracyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be effective but have suboptimal side effect and safety profiles, and are not recommended in late-life 4
• Benzodiazepines and beta blockers should generally be avoided when treating anxiety in the elderly due to their potential for adverse effects 4

Treatment Options

• SSRIs are among the most commonly prescribed medications for anxiety disorders, with advantages including ease of titration and tolerability 5
• Long-term SSRI use can increase the risk of tachyphylaxis and discontinuation syndrome, and patients should have periodic monitoring to reassess the risk-benefit ratio of remaining on the SSRI 5
• SNRIs, such as venlafaxine, may also be effective in treating anxiety disorders, with similar efficacy to SSRIs 6, 7
• Other treatment options, such as azapirones (e.g., buspirone) and mixed antidepressants (e.g., mirtazapine), may also be considered, although their efficacy and safety in elderly populations may vary 6

Efficacy of Treatment Options

• A network meta-analysis found that most medications, including SSRIs, SNRIs, and benzodiazepines, are more effective than placebo in treating panic disorder, with diazepam, alprazolam, and clonazepam ranking as the most effective 8
• Another study found that SSRIs and SNRIs are effective in treating anxiety disorders, with higher doses of SSRIs associated with greater symptom improvement, although higher doses of both classes may increase the likelihood of dropout due to side effects 7