geropsych pearls

anxiety disorders

Here are a few factoids about anxiety disorders in older adults:

  • They are really difficult to treat, especially once they become chronic.  Over time, it is not uncommon for worry and nervousness to be replaced by somatization and perseveration on physical conditions. Structural changes include enlargement of the amygdala and the dorsmedial prefrontal cortex. Full remission is uncommon, and improvement is going to be incremental. At best. 
  • So, HIT IT HARD. Summon your favorite football coach voice and bark "Hit 'em hard and hit 'em fast! And if they get up, hit 'em again!" NOW you're ready! 


  • First line tx is SSRI, best if started right away. Not as effective once anxiety becomes chronic. Stay the course for at least 4-6 weeks before bailing. 
  • Buspirone: SSRIs don’t make serotonin, they just help you hang onto it. It's like Hamburger Helper without hamburger. Get some buspirone in there.  I know folks like to poo-poo buspirone, but try it. Seriously, just try it. 
  • Gabapentin or pregabalin: decent adjunct for treatment-resistant anxiety. Theoretically, pregabalin has better anxiolytic benefit than gabapentin or other alpha-2-delta ligands because it’s cleaner, but folks can also get fat and tired. Plus it’s spendy. But they say it is Most Excellent for peeps with concurrent anxiety and fibromyalgia pain.
  •  When to start a benzo? Never. Ever. Unless you absolutely have to. The effect of benzos on GABA-receptors is the same as alcohol. Would you give Grandma a shot of Jack Daniels to calm down? Sure, she might liven up a little, but then she is going to be drunk and disorderly, dancing on the tables, digging thru the ashtrays for cigarette butts, and will eventually trip over the microphone cord. Benzos are all fun and games until someone breaks a hip.
  •  Hydroxyzine: helpful for young whippersnappers, but not geriatric peeps. Likely to cause delirium and memory probs.
  •  Diphenhydramine: also avoid like the plague. Makes 'em goofy, then they fall down. Plus, it is notorious for causing delirium.
  •  Second generation antipsychotics (SGA) are indicated in treatment-resistant anxiety. Risperidone is best, then quetiapine. Olanzapine, ziprasidone, and aripiprazole don’t have much of an anxiolytic benefit.
  • Exercise, particularly resistance training, is associated with increased rates of remission.
  • If you are fortunate enough to achieve remission, treat for at least 12 months, as anxiety disorders have very high rates of relapse.

Try this:
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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