Evidence-Based Reviews

Most effective, least worrisome therapies for late-life anxiety

Current Psychiatry. 2008 March;7(3):83-93

References

1. de Beurs E, Beekman AT, van Balkom AJ, et al. Consequences of anxiety in older persons: its effect on disability, well-being, and use of health services. Psychol Med 1999;29:583-93.

2. Wadsworth EJK, Moss SC, Simpson SA, Smith AP. Psychotropic medication use and accidents, injuries, and cognitive failures. Hum Psychopharmacol 2005;20:391-400.

3. Beekman AT, Bremmer MA, Deeg DJ, et al. Anxiety disorders in later life: a report from the Longitudinal Aging Study Amsterdam. Int J Geriatr Psychiatry 1998;13:717-26.

4. Lindesay J, Briggs K, Murphy E. The Guy’s/Age Concern survey: prevalence rates of cognitive impairment, depression, and anxiety in an urban elderly community. Br J Psychiatry 1989;155:317-29.

5. Manela M, Katona C, Livingston G. How common are the anxiety disorders in old age? Int J Geriatr Psychiatry 1996;11:65-70.

6. Beekman AT, de Beurs E, van Balkom AJ, et al. Anxiety and depression in later life: co-occurrence and communality of risk factors. Am J Psychiatry 2000;157:89-95.

7. DeLuca AK, Lenze EJ, Mulsant BH, et al. Comorbid anxiety disorder in late life depression: association with memory decline over four years. Int J Geriatr Psychiatry 2005;29:848-54.

8. Blazer D, George LK, Hughes D. The epidemiology of anxiety disorders: an age comparison. In: Salzman C, Lebowitz BD, eds. Anxiety in the elderly: treatment and research. New York, NY: Springer; 1991:17-30.

9. Wetherell JL, Le Roux H, Gatz M. DSM-IV criteria for generalized anxiety disorder in older adults: distinguishing the worried from the well. Psychol Aging 2003;18:622-7.

10. van Balkom AJ, Beekman AT, de Beurs E, et al. Comorbidity of the anxiety disorders in a community-based older population in the Netherlands. Acta Psychiatr Scand 2000;101:37-45.

11. Jeste ND, Hays JC, Steffens DC. Clinical correlates of anxious depression among elderly patients with depression. J Affect Disord 2006;90:37-41.

12. Schuurmans J, Comijs HC, Beekman AT, et al. The outcome of anxiety disorders in older people at 6-year follow-up: results from the Longitudinal Aging Study Amsterdam. Acta Psychiatr Scand 2005;111:420-8.

13. Nordhus IH, Pallesen S. Psychological treatment of late-life anxiety: an empirical review. J Consult Clin Psychol 2003;71:643-51.

14. Lenze E, Pollock BG, Shear MK, et al. Treatment considerations for anxiety in the elderly. CNS Spectr 2003;8 (suppl 3):6-13.

15. Lenze E, Mulsant BH, Shear MK, et al. Efficacy and tolerability of citalopram in the treatment of late-life anxiety disorders: results from an 8-week randomized, placebo-controlled trial. Am J Psychiatry 2005;162(1):146-50.

16. Dannon PN, Iancu I, Lowengrub K, et al. Pharmacotherapy of panic disorder in the elderly: a naturalistic 12-month follow-up outcome study. Therapy 2005;2:249-54.

17. Schuurmans J, Comijs H, Emmelkamp PM, et al. A randomized, controlled trial of the effectiveness of cognitive-behavioral therapy and sertraline versus a waitlist control group for anxiety disorders in older adults. Am J Geriatr Psychiatry 2006;14:255-63.

18. Sheikh JI, Lauderdale SA, Cassidy EL. Efficacy of sertraline for panic disorder in older adults: a preliminary open-label trial. Am J Geriatr Psychiatry 2004;12:230.-

19. Wylie ME, Miller MD, Shear MK, et al. Fluvoxamine pharmacotherapy of anxiety disorders in later life: preliminary open-trial data. J Geriatr Psychiatry Neurol 2000;13:43-8.

20. Andreescu C, Lenze EJ, Dew MA, et al. Effect of comorbid anxiety on treatment response and relapse risk in late-life depression: controlled study. Br J Psychiatry 2007;190:344-9.

21. Steffens DC, McQuoid DR. Impact of symptoms of generalized anxiety disorder on the course of late-life depression. Am J Geriatr Psychiatry 2005;13:40-7.

22. Lenze E, Mulsant BH, Dew MA, et al. Good treatment outcomes in late-life depression with comorbid anxiety. J Affect Disord 2003;77:247-54.

23. Mohamed S, Osatuke K, Aslam M, Kasckow J. Escitalopram for comorbid depression and anxiety in elderly patients: a 12-week, open-label, flexible-dose, pilot trial. Am J Geriatr Pharmacother 2006;4:201-9.

24. Katz IR, Reynolds CF, Alexopoulos GS, Hackett D. Venlafaxine ER as a treatment for generalized anxiety disorder in older adults: pooled analysis of five randomized placebo-controlled clinical trials. J Am Geriatr Soc 2002;50:18-25.

25. Hanlon JT, Schmader KE, Boult C, et al. Benzodiazepine use and cognitive function among community-dwelling elderly. Clin Pharmacol Ther 1998;64:684-92.

26. Leipzig RM, Cummings RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: I. psychotropic drugs. J Am Geriatr Soc 1999;47:30-9.

27. Sheikh JI. Anxiety in older adults. Assessment and management of three common presentations. Geriatrics 2003;58:44-5.

28. Böhm C, Robinson DS, Gammans RE. Buspirone therapy for elderly patients with anxiety or depressive neurosis. J Clin Psychiatry 1990;51:309.-

29. Napoliello MJ. An interim multicentre report on 677 anxious geriatric out-patients treated with buspirone. Br J Clin Pract 1986;40:71-3.

30. Scogin F, McElreath L. Efficacy of psychosocial treatments for geriatric depression: a quantitative review. J Consult Clin Psychol 1994;62:69-74.

31. Stanley MA, Beck JG, Novy DM, et al. Cognitive-behavioral treatment of late-life generalized anxiety disorder. J Consult Clin Psychol 2003;71:309-19.

32. Stanley MA, Beck JG, Glassco JD. Treatment of generalized anxiety in older adults: a preliminary comparison of cognitive-behavioral and supportive approaches. Behav Ther 1996;27:565-81.

33. Wetherell JL, Gatz M, Craske MG. Treatment of generalized anxiety disorder in older adults. J Consult Clin Psychol 2003;71:31-40.

34. Swales PJ, Solfvin JF, Sheikh JI. Cognitive-behavioral therapy in older panic disorder patients. Am J Geriatr Psychiatry 1996;4:46-60.

35. Barrowclough C, King P, Colville J, et al. A randomized trial of the effectiveness of cognitive-behavioral therapy and supportive counseling for anxiety symptoms in older adults. J Consult Clin Psychol 2001;69:756-62.

36. Gorenstein EE, Kleber MS, Mohlman J, et al. Cognitive-behavioral therapy for management of anxiety and medication taper in older adults. Am J Geriatr Psychiatry 2005;13:901-9.

37. Doubleday EK, King P, Papageorgiou C. Relationship between fluid intelligence and ability to benefit from cognitive-behavioural therapy in older adults: a preliminary investigation. Br J Clin Psychol 2002;41:423-8.

38. Mohlman J, Gorman JM. The role of executive functioning in CBT: a pilot study with anxious older adults. Behav Res Ther 2005;43:447-65.

39. Mohlman J, Gorenstein EE, Kleber M, et al. Standard and enhanced cognitive-behavioral therapy for late-life generalized anxiety disorder: two pilot investigations. Am J Geriatr Psychiatry 2003;11:24-32.

40. Chen H, Coakley EH, Cheal K, et al. Satisfaction with mental health services in older primary care patients. Am J Geriatr Psychiatry 2006;14:371-9.

41. Hegel MT, Unützer J, Tang L, et al. Impact of comorbid panic and posttraumatic stress disorder in outcomes of collaborative care for late-life depression in primary care. Am J Geriatr Psychiatry 2005;13:48-58.

42. Stanley MA, Hopko DR, Diefenbach GJ, et al. Cognitive-behavior therapy for late-life generalized anxiety disorder in primary care. Am J Geriatr Psychiatry 2003;11:92-6.

Paroxetine, averaging approximately 28 mg/d, produced a similar response in older and younger adults with PD in terms of efficacy and tolerability in a naturalistic follow-up trial.¹⁶
Sertraline, started at 25 mg/d and titrated to 100 mg/d (maximum 150 mg/d), when combined with CBT was effective for treating older adults with anxiety disorders in a randomized, placebo-controlled trial¹⁷ and specifically for those with PD in an open-label trial.¹⁸
Fluvoxamine, median 200 mg/d, reduced anxiety symptoms in an open-label study of 12 older adults with various anxiety disorders. Most patients with GAD (57%) responded to fluvoxamine, but 3 patients with PD did not.¹⁹
We found no studies of fluoxetine for anxiety symptoms in older adults.

An important caveat to these findings is data suggesting older adults with mixed anxiety and depression (MAD) may take longer to respond to pharmacologic and psychotherapeutic interventions than older adults with anxiety or depression alone.^20,21 On the other hand, Lenze et al²² found no evidence of a lower or slower response to paroxetine in depressed older adults with or without anxiety. In an open-label, flexible-dose study, escitalopram, 10 to 20 mg/ d, reduced comorbid anxiety and depression symptoms and improved social functioning in 17 older outpatients.²³

SNRIs. In a retrospective, pooled analysis of 5 randomized, placebo-controlled trials²⁴ venlafaxine ER, 37.5 to 225 mg/d, was significantly more effective than placebo in treating older adults with GAD. Several studies suggest duloxetine may be effective for treating GAD in adults, but none examined efficacy specifically for older adults.

Clinical Point

SSRIs and SNRIs are considered first-line therapy for anxious older adults with panic disorder and generalized anxiety disorder

Benzodiazepines’ primary benefits are rapid onset and minimal cardiovascular effects. They remain the mainstay of pharmacologic therapy for acute anxiety and can be useful as initial, short-term adjunctive therapy with SSRIs and SNRIs.

Using benzodiazepines for more than a few weeks in older adults is not recommended, however.¹⁴ Potential complications of long-term benzodiazepine use in these patients include:

excessive daytime drowsiness
cognitive and psychomotor impairment
confusion
risk of falls
depression
paradoxical reactions
amnesic syndromes
respiratory problems
potential for abuse/dependence
breakthrough withdrawal reactions.^2,25,26

For older patients, short half-life benzodiazepines—such as lorazepam (maximum 1 to 3 mg/d divided bid or tid) or oxazepam (maximum 45 to 60 mg/d divided tid or qid)—are preferred because they require only phase II metabolism and are inactivated by direct conjugation in the liver, mechanisms minimally impacted by aging.²⁷

Buspirone. Investigations of anxious older adults have suggested that buspirone is effective for addressing anxiety symptoms.^28,29 Our experience, however, indicates that response to buspirone is inconsistent.

Recommendations. Based on this evidence and our clinical practice, we recommend using SSRIs or SNRIs as first-line treatment for most anxiety disorders in older adults (Table 3).

To minimize nonadherence associated with antidepressants’ delayed onset of action and initial transient “jitters”:

provide patient education about medication onset and side effects
add a short half-life benzodiazepine for the first few weeks of treatment only
start with small doses and increase gradually.

Table 2

Recommended dosages for treating anxiety in older adults

Medication	Starting dosage	Maximum dosage
Selective serotonin reuptake inhibitors
Citalopram	10 mg/d	30 mg/d
Escitalopram	5 mg/d	10 mg/d
Fluvoxamine	25 mg/d	100 mg/d
Paroxetine	10 mg/d	20 mg/d
Sertraline	12.5 mg/d	50 mg/d
Serotonin/norepinephrine reuptake inhibitors
Duloxetine	30 mg/d	60 mg/d
Venlafaxine	37.5 mg/d	150 mg/d
Benzodiazepines
Lorazepam	0.5 mg/d divided bid	1 to 3 mg/d, divided bid or tid
Oxazepam	30 mg/d divided tid	45 to 60 mg/d divided tid or qid
Azapirone
Buspirone	10 to 15 mg/d, divided bid or tid	30 to 60 mg/d divided bid or tid

Table 3

Anxiety in older adults: Recommended interventions

Disorder	First-line treatment(s)	Second-line treatment(s)
Generalized anxiety disorder	SSRIs, SNRIs, buspirone, and/or CBT	Other newer antidepressants*
Panic disorder, with or without agoraphobia	SSRIs, SNRIs, and/or CBT	Other newer antidepressants*
Mixed anxiety and depression	SSRIs or SNRIs	Buspirone, CBT
Anxiety and medical disorders	Identify and treat medical cause, use SSRIs or SNRIs for primary anxiety disorder	Benzodiazepines
* Novel agents such as mirtazapine
CBT: cognitive-behavioral therapy; SNRIs: serotonin/norepinephrine reuptake inhibitors; SSRIs: selective serotonin reuptake inhibitors

Psychotherapy as an alternative or adjunct

Researchers have compared the efficacy of CBT—which is effective for depression in older adults³⁰—with that of other psychotherapies for mixed and specific anxiety disorders, including GAD and PD.

For GAD. Multicomponent CBT for GAD typically includes:

psychoeducation
thought monitoring
cognitive restructuring
progressive muscle relaxation and similar techniques
breathing retraining
problem solving
exposure (imaginal, in vivo, worry)
time management
problem solving.

CBT treatment helps older adults with GAD improve on short-term measures of anxiety, worry, depression, and fear. In a clinical trial of 85 older patients with GAD who participated in 15 weekly CBT group sessions, Stanley et al³¹ rated 45% of CBT group patients as responders, compared with 8% of a control group that received minimal contact. Additionally, 55% of CBT participants met DSM-IV-TR diagnostic criteria for GAD, compared with 81% of control patients. CBT group patients maintained improvements across measures of worry, anxiety, depression, fears, and quality of life at 3-, 6-, and 12-month assessments.