Here are a few factoids about anxiety disorders in older adults:
1. Start with SSRI. I like sertraline, but citalopram or escitalopram also good. Lower doses are better. Keep in mind that higher doses of any antidepressant can be overly activating, which worsens anxiety.
2. If no response, try a different SSRI
3. If still no response, try venlafaxine
4. Add buspirone.
5. If still no improvement, bail on the buspirone, keep the venlafaxine, and add gabapentin. Or sertraline + gabapentin. Or SSRI + pregabalin.
6. Do not use SGA until third trial. Then augment with quetiapine or risperidone. No olanzapine.
7. If all else fails, stabilize on clonazepam, with plan to slowly taper off. But first, raise your right hand and repeat after me: “I promise to taper off the benzo. I promise to taper off the benzo. I promise to taper off the benzo.” Now say it like you mean it.
Tidbit #1: Monitor for hyonatremia, as even the slightest dip in sodium can worsen anxiety in elders. New onset of hand-wringing anxiety in a pt that is not normally a Nervous Nellie is very frequently hyponatremia. Fix that first.
Tidbit #2: Also, hypoglycemia can induce anxiety d/t secretion of epinephrine. Fix that too.
Tidbit #3: Plain old acetaminophen has a very nice anxiolytic benefit. Truly. A little bit of APAP goes a long ways.
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