Summary
Although the incidence of anxiety disorders diminishes with age, the prevalence of anxiety symptoms among older patients is substantial. These symptoms, which include cognitive and somatic manifestations, are a source of diminished quality of life. The many potential sources of illness- and medication-induced anxiety must be excluded before instituting treatment. The general principles of antianxiety medication treatment in older patients include: (i) symptom relief with minimum sedation; (ii) improvement in sleep; (iii) freedom from autonomic and cognitive toxicities; and (iv) freedom from physical dependence and drug interactions. Older compounds such as the tricyclic antidepressants should be avoided, since more modern agents (e.g. benzodiazepines and buspirone) are well tolerated and effective. Modern antidepressants have also been used to reduce anxiety symptoms, although there is a potential for the opposite effect to occur. The selective serotonin reuptake inhibitors appear to be better suited to treating syndromes such as panic and obsessive-compulsive disorder, whereas nefazodone would be a better choice for generalised anxiety complicated by depression.
Similar content being viewed by others
References
Leon AC, Portera L, Weissman MM. The social costs of anxiety disorders. Br J Psychiatry Suppl 1995 Apr; 27: 19–22
Blazer DG, George L, Hughes D. The epidemiology of anxiety disorders: an age comparison. In: Salzman C, Lebowitz B, editors. Anxiety disorders in the elderly. New York: Springer, 1991: 17–30
Flint AJ. Epidemiology and comorbidity of anxiety disorders in the elderly. Am J Psychiatry 1994 May; 151: 640–9
Cloninger CR. Comorbidity of anxiety and depression. J Clin Psychopharmacol 1990 Jan; 10: 43–6
Fogelson D, Bystritsky A, Sussman N. Inter-relationships between major depression and anxiety disorders. Psychiatr Ann 1988 Mar; 18: 158–67
Stein MB, Kirk P, Prabhu V, et al. Mixed anxiety-depression in a primary-care clinic. J Affect Disord 1995 May 17; 34(2): 79–84
Lish JD, Zimmerman M, Farber NJ, et al. Psychiatric screening in geriatric primary care: should it be for depression alone? J Geriatr Psychiatry Neurol 1995 Jul; 8(3): 141–53
WHO. International statistical classification of diseases and related health problems. 10th rev. ed. (ICD-10). Geneva: WHO, 1992
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. (DSM-IV). Washington, DC: American Psychiatric Association, 1994
Smith SL, Sherrill KA, Colenda CC. Assessing and treating anxiety in elderly persons. Psychiatr Serv 1995 Jan; 46(1): 36–42
Smith SL, Colenda CC, Espeland MA. Factors determining the level of anxiety state in geriatric primary care patients in a community dwelling. Psychosomatics 1994 Jan–Feb; 35(1): 50–8
Weiss KJ. Management of anxiety and depression syndromes in the elderly. J Clin Psychiatry 1994 Feb; 55Suppl. 2: 5–12
Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959; 32: 50–5
Rankin EJ, Gfeller JD, Gilner FH. Measuring anxiety states in the elderly using the State-Trait Anxiety Inventory for Children. J Psychiatr Res 1993 Jan–Mar; 27(1): 111–7
Parkerson GR, Broadhead WE, Tse CK. Anxiety and depressive symptom identification using the Duke Health Profile. J Clin Epidemiol 1996 Jan; 49(1): 85–93
Tueth MJ. Anxiety in the older patient: differential diagnosis and treatment. Geriatrics 1993 Feb; 48(2): 51–4
Wise MG, Griffies WS. A combined treatment approach to anxiety in the medically ill. Louisiana State University School of Medicine, New Orleans. J Clin Psychiatry 1995; 56Suppl. 2: 14–9
Bercsi SJ, Brickner PW, Saha DC. Alcohol use and abuse in the frail, homebound elderly: a clinical analysis of 103 persons. Drug Alcohol Depend 1993 Sep; 33(2): 139–49
Egbert AM. The older alcoholic: recognizing the subtle clinical clues. Geriatrics 1993 Jul; 48(7): 63–6, 69
Whelan G. Alcohol-related health problems in the elderly. Med J Aust 1995 Mar 20; 162(6): 325–7
Serfaty M, Masterton G. Fatal poisonings attributed to benzodiazepines in Britain during the 1980s [see comments]. Br J Psychiatry 1993 Sep; 163: 386–93
Conwell Y. Suicide among elderly persons. Psychiatr Serv 1995 Jun; 46: 563–4
Massion AO, Warshaw MG, Keller MB. Quality of life and psychiatric morbidity in panic disorder and generalized anxiety disorder. Am J Psychiatry 1993 Apr; 150(4): 600–7
Warshaw MG, Fierman E, Pratt L, et al. Quality of life and dissociation in anxiety disorder patients with histories of trauma or PTSD. Am J Psychiatry 1993 Oct; 150(10): 1512–6
McLeod JD. Anxiety disorders and marital quality. J Abnorm Psychol 1994 Nov; 103(4): 767–76
Hocking LB, Koenig HG. Anxiety in medically ill older patients: a review and update. Int J Psychiatry Med 1995; 25(3): 221–38
Paul SM. Anxiety and depression: a common neurobiological substrate? J Clin Psychiatry 1988 Oct; 49 Suppl.: 13–6
Reiman EM. The quest to establish the neural substrates of anxiety. Psychiatr Clin North Am 1988 Jun; 11: 295–307
Teicher MH. Biology of anxiety. Med Clin North Am 1988 Jul; 72: 791–814
Baldwin D, Rudge S. The role of serotonin in depression and anxiety. Int Clin Psychopharmacol 1995 Jan; 9Suppl. 4: 41–5
Martin LM, Fleming KC, Evans JM. Recognition and management of anxiety and depression in elderly patients. Mayo Clin Proc 1995 Oct; 70(10): 999–1006
Steinberg JR. Anxiety in elderly patients: a comparison of azapirones and benzodiazepines. Drugs Aging 1994 Nov; 5(5): 335–45
Hoehn-Saric R, Borkovec TD, Nemiah JC. Generalized anxiety. In: American Psychiatric Association. Treatment of psychiatric disorders. 2nd ed. Washington, DC: American Psychiatric Press, 1995
Boulenger JP, Lavallee YJ. Mixed anxiety and depression: diagnostic issues. J Clin Psychiatry 1993 Jan; 54 Suppl.: 3–8
Shorr RI, Robin DW. Rational use of benzodiazepines in the elderly. Drugs Aging 1994 Jan; 4(1): 9–20
Cadieux RJ. Geriatric psychopharmacology: a primary care challenge. Postgrad Med 1993 Mar; 93(4): 281–2, 285–8, 294–301
Fernandez F, Levy JK, Lachar BL, et al. The management of depression and anxiety in the elderly. J Clin Psychiatry 1995 Feb; 56Suppl. 2: 20–9
Wise MG, Rieck SO. Diagnostic considerations and treatment approaches to underlying anxiety in the medically ill. J Clin Psychiatry 1993 May; 54 Suppl.: 22–6
Simington JA, Laing GP. Effects of therapeutic touch on anxiety in the institutionalized elderly. Clin Nurs Res 1993 Nov; 2(4): 438–50
Rankin EJ, Gilner FH, Gfeller JD, et al. Efficacy of progressive muscle relaxation for reducing state anxiety among elderly adults on memory tasks. Percept Mot Skills 1993 Dec; 77 (3 Pt 2): 1395–402
Hanser SB, Thompson LW. Effects of a music therapy strategy on depressed older adults. J Gerontol 1994 Nov; 49(6): P265–9
Andersson G, Green M. Anxiety in elderly hearing impaired persons. Percept Mot Skills 1995 Oct; 81(2): 552–4
Salzman C. Practical considerations in the pharmacologic treatment of depression and anxiety in the elderly. J Clin Psychiatry 1990 Jan; 51 Suppl.: 40–3
Salzman C. Medication compliance in the elderly. J Clin Psychiatry 1995 Jan; 56Suppl. 1: 18–22
Murray MD, Birt JA, Manatunga AK, et al. Medication compliance in elderly outpatients using twice-daily dosing and unit-of-use packaging. Ann Pharmacother 1993 May; 27(5): 616–21
Isaac LM, Tamblyn RM. Compliance and cognitive function: a methodological approach to measuring unintentional errors in medication compliance in the elderly. Gerontologist 1993 Dec; 33(6): 772–81
Salzman C. Clinical geriatric psychopharmacology. 2nd ed. Baltimore (MD): Williams & Wilkins, 1992
Boyer W. Serotonin uptake inhibitors are superior to imipramine and alprazolam in alleviating panic attacks: a meta-analysis. Int Clin Psychopharmacol 1995 Mar; 10(1): 45–9
Andrews N, File SE. Increased 5-HT release mediates the anxiogenic response during benzodiazepine withdrawal: a review of supporting neurochemical and behavioural evidence. Psychopharmacology (Berl) 1993; 112(1): 21–5
Barrett JE, Vanover KE. 5-HT receptors as targets for the development of novel anxiolytic drugs: models, mechanisms and future directions. Psychopharmacology (Berl) 1993; 112(1): 1–12
Rickeis K, Downing R, Schweizer E, et al. Antidepressants for the treatment of generalized anxiety disorder: a placebo-controlled comparison of imipramine, trazodone, and diazepam. Arch Gen Psychiatry 1993 Nov; 50(11): 884–95
Stoudemire A, Moran MG. Psychopharmacologic treatment of anxiety in the medically ill elderly patient: special considerations. J Clin Psychiatry 1993 May; 54 Suppl.: 27–33
Markovitz PJ. Treatment of anxiety in the elderly. J Clin Psychiatry 1993 May; 54 Suppl.: 64–8
Sakauye K. Behavioral disturbances: pharmacologic therapies. Psychiatr Ann 1995 Jul; 25: 425–31
Naranjo CA, Herrmann N, Mittmann N, et al. Recent advances in geriatric psychopharmacology. Drugs Aging 1995 Sep; 7(3): 184–202
Ashton H. Guidelines for the rational use of benzodiazepines: when and what to use. Drugs 1994 Jul; 48(1): 25–40
Ray WA, Griffin MR, Schaffner W, et al. Psychotropic drug use and the risk of hip fracture. N Engl J Med 1987; 316: 363–9
Wysowski DK, Baum C, Ferguson WJ, et al. Sedative-hypnotic drugs and the risk of hip fracture. J Clin Epidemiol 1996 Jan; 49(1): 111–3
Herings RM, Stricker BH, de Boer A, et al. Benzodiazepines and the risk of falling leading to femur fractures: dosage more important than elimination half-life. Arch Intern Med 1995 Sep 11; 155(16): 1801–7
Buckley NA, Dawson AH, Whyte IM, et al. Relative toxicity of benzodiazepines in overdose. BMJ 1995 Jan 28; 310(6974): 219–21
Sussman N. The uses of buspirone in psychiatry. J Clin Psychiatry Monogr 1994 May; 12: 3–19
Goldberg RJ. The use of buspirone in geriatric patients. J Clin Psychiatry Monogr 1994 May; 12: 31–5
Rickeis K, Amsterdam J, Clary C, et al. Buspirone in major depression: a controlled study. J Clin Psychiatry 1991; 52: 34–8
Littman AB, Fava M, McKool K, et al. Buspirone therapy for Type A behavior, hostility, and perceived stress in cardiac patients. Psychother Psychosom 1993; 59(2): 107–10
Sakauye KM, Camp CJ, Ford PA. Effects of buspirone on agitation associated with dementia. Am J Geriatr Psychiatry 1993; 1: 82–4
Hohagen F, Kappler C, Schramm E, et al. Prevalence of insomnia in elderly general practice attenders and the current treatment modalities. Acta Psychiatr Scand 1994 Aug; 90(2): 102–8
Nierenberg AA, Adler LA, Peselow E, et al. Trazodone for antidepressant-associated insomnia. Am J Psychiatry 1994 Jul; 151(7): 1069–72
Oehrberg S, Christiansen PE, Behnke K, et al. Paroxetine in the treatment of panic disorder: a randomised, double-blind, placebo-controlled study. Br J Psychiatry 1995 Sep; 167(3): 374–9
Pecknold JC, Luthe L, Iny L, et al. Fluoxetine in panic disorder: pharmacologic and tritiated platelet imipramine and paroxetine binding study. J Psychiatry Neurosci 1995 May; 20(3): 193–8
Schweizer E, Feighner J, Mandos LA, et al. Comparison of venlafaxine and imipramine in the acute treatment of major depression in outpatients. J Clin Psychiatry 1994; 55: 104–8
Rudorfer MV, Potter WZ. Antidepressants: a comparative review of the clinical pharmacology and therapeutic use of the ‘newer’ versus the ‘older’ drugs. Drugs 1989; 37: 713–38
Fawcett J, Marcus RN, Anton SF, et al. Response of anxiety and agitation symptoms during nefazodone treatment of major depression. J Clin Psychiatry 1995 Jun; 56Suppl. 6: 37–42
Preskorn SH, Janicak PG, Davis JM, et al. Advances in the pharmacotherapy of depressive disorders. Princip Pract Psychopharmacother 1995; 1: 1–24
Rickeis K, Schweizer E, Clary C, et al. Nefazodone and imipramine in major depression: a placebo-controlled trial. Br J Psychiatry 1994; 164: 802–5
Fontaine R, Ontiveros A, Elie R, et al. A double-blind comparison of nefazodone, imipramine, and placebo in major depression. J Clin Psychiatry 1994; 55: 234–41
Ware JC, Rose FV, McBrayer RH. The acute effects of nefazodone, trazodone and buspirone on sleep and sleep-related penile tumescence in normal subjects. Sleep 1994 Sep; 17(6): 544–50
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Weiss, K.J. Optimal Management of Anxiety in Older Patients. Drugs & Aging 9, 191–201 (1996). https://doi.org/10.2165/00002512-199609030-00005
Published:
Issue Date:
DOI: https://doi.org/10.2165/00002512-199609030-00005