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Diagnosis and Management of Panic Disorder in Older Patients

  • Therapy In Practice
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Abstract

Panic disorder occurs less frequently in the elderly than in younger adults and rarely starts for the first time in old age. Panic attacks that begin in late life should prompt the clinician to conduct a careful search for a depressive disorder, physical illness or drugs that could be contributing to their presence. When panic attacks do occur in the elderly, the symptoms are qualitatively similar to those experienced by younger people. The elderly, however, may have fewer and less severe symptoms and exhibit less avoidant behaviour. As panic disorder is typically a chronic or recurrent condition, its management requires a long-term approach.

With the exception of one descriptive pilot study, there have been no randomised controlled trials of the treatment of panic disorder in later life. Therefore, recommendations regarding the management of this disorder in the elderly must be extrapolated from research pertaining to younger patients. Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors, benzodiazepines and cognitive behavioural therapy are efficacious treatments for panic disorder. There are no consistent differences in efficacy between classes of medications or between pharmacotherapy and cognitive behavioural therapy. Furthermore, there are no reliable predictors of response to one type of treatment compared with another. Treatment selection, therefore, depends on an individual assessment of the risks and benefits of each type of treatment (taking into account comorbid psychiatric and physical conditions), patient preference, cost and the availability of therapists skilled in cognitive behavioural techniques.

As a general rule, antidepressant medication is preferable to a benzodiazepine as a first-line treatment for panic disorder in the elderly, especially given the high level of comorbidity between panic disorder and depressive disorders. Of the antidepressants, an SSRI is recommended as the initial choice of treatment in older patients. Anxious patients frequently misattribute somatic symptoms of anxiety to adverse effects of medication. Adherence with treatment, therefore, can be enhanced by starting antidepressant medication at a low dosage so as to avoid initial exacerbation of anxiety (but then gradually increasing the dosage to the therapeutic range), frequent follow-up during the first few weeks of treatment, discussion about potential adverse effects and addressing any other concerns the patient may have about taking medication. Given the delayed onset of action of antidepressant medication, the short-term use of adjunctive lorazepam in the first few weeks of treatment may be helpful in selected patients.

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Acknowledgements

Dr Flint receives a salary from the University of Toronto, Toronto General Hospital and the Toronto Rehabilitation Institute. Dr Gagnon is supported by the Research Institute of the Toronto Rehabilitation Institute. The authors have no conflicts of interest that are directly relevant to the content of this manuscript.

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Authors and Affiliations

  1. Departments of Psychiatry, University Health Network and University of Toronto, Toronto, Ontario, Canada

    Alastair J. Flint & Nadine Gagnon

  2. Geriatric Program, Toronto Rehabilitation Institute, Toronto, Ontario, Canada

    Alastair J. Flint & Nadine Gagnon

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  1. Alastair J. Flint
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  2. Nadine Gagnon
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Correspondence to Alastair J. Flint.

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Flint, A.J., Gagnon, N. Diagnosis and Management of Panic Disorder in Older Patients. Drugs Aging 20, 881–891 (2003). https://doi.org/10.2165/00002512-200320120-00002

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