The Silent Geriatric Giant: Anxiety Disorders in Late Life

Keri-Leigh Cassidy, MD; Neil A. Rector, PhD

Disclosures

Geriatrics and Aging. 2008;11(3):150-156. 

In This Article

Treatment of Late-Life Anxiety Disorders

Research on pharmacological treatment of anxiety disorders in late life is sparse, and guidelines are generally not based on randomized controlled trials of older adults but on extrapolation from research with younger age groups.[17] Benzodiazepines are frequently overprescribed for older individuals with anxiety, often with serious side effects in this age group including cognitive impairment, rebound withdrawal symptoms, dependence, incontinence, and falls leading to hip fractures and fall-related death.[18]

The general principles for the use of medications for older adults are to start low and go slow but also aim high and treat long. These principles are especially useful in the treatment of older persons with anxiety, who worry about taking medications, are acutely aware of and sensitive to side effects, and have high dropout rates. Taking time to titrate, beginning with one-half or one-quarter of the usual starting dose of an antidepressant and increasing slowly, with regular follow-up and reassurance, is often necessary for success. A summary of the evidence for various medications in treating anxiety disorders, based on mixed-age population studies, is provided in Table 6 .

Some prospective controlled trials with older adults support the use of selective serotonin reuptake inhibitors for late-life anxiety, such as citalopram for GAD.[19] There is also one meta-analysis of five controlled trials (136 subjects, 47 controls) that supports the use of the serotonin norepinephrine reuptake inhibitor venlafaxine for treating late-life GAD.[20] There is evidence for the use of citalopram to treat anxiety in Alzheimer's dementia,[21] and cholinesterase inhibitors, such as donepezil[22] and galantamine[23] have been shown to improve anxiety, irritability, or aberrant nighttime behaviour among persons with Alzheimer's dementia.

Other medication options for late-life GAD include buspirone, trazodone, mirtazapine, atypical neuroleptics, and mood stabilizers such as topiramate, which are effective as augmentation strategies in younger persons with anxiety. Avoid the use of activating antidepressants such as bupropion and stimulants such as methylphenidate, which may worsen anxiety symptoms. If benzodiazepines are used, they should be used for a short term on regular intervals rather than as needed to avoid psychological dependence and withdrawal anxiety between doses.

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