Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0103Psychopharmacological Treatment of AnxietyJohn L. Beyer and K. Ranga KrishnanDuke University Medical Center, Durham, NC, USAEven though the prevalence of anxiety disorders declines as peopleage, anxiety disorders still remain the most common psychiatricillness in the elderly 1 . This statistic represents not only thecontinuation of chronic anxiety disorders into later life for manypeople, but also the development of new anxiety disorders forothers. Loneliness and fear of isolation, diminished sensory andgeneral functional capacities, increased incidence of illness,financial limitations and the prospect of dying often generateconsiderable anxiety 2 . Elderly patients who recover from a mooddisorder often develop persistent anxiety, especially in themorning. An estimated 10–20% of older patients experienceclinically significant symptoms of anxiety 3 . Unfortunately, manyindividuals may never seek treatment, or their anxiety may not berecognized. The result has been a significant undertreatment of avery treatable illness.This chapter reviews the pharmacologic treatment of anxietydisorders in the elderly. At this time, there is no ‘‘perfect’’anxiolytic drug for treating the elderly 4,5 . Further, there aresignificant gaps in the research of anxiety disorders in the elderly,which makes the choice of treatment difficult 6 . This chapter willtherefore begin with a review of general considerations a physicianmust make prior to selecting and starting pharmacologictreatment. A discussion of current pharmacologic options willfollow. Classes of medication, rather than specific recommendationsfor each anxiety disorder, will be reviewed, since researchhas not clarified primary treatments for most anxiety disorders.Finally, guidelines for the evaluation and selection of pharmacologictreatments are suggested.GENERAL CONSIDERATIONSWhen to TreatThe decision to treat the anxious older patient with medicationdepends on the severity of the anxiety and the degree to which itinterferes with the patient’s functioning 7,8 . Anxiety may interferewith social and interpersonal activity in the older patient, resultingin a breakdown of support systems or coping skills. It may worsencognitive function by decreasing a patient’s concentration.Anxiety may also exacerbate physical illnesses or may be anunrecognized consequence of a medical disorder. Anxiety hasbeen related to blood pressure variability and, by extension, toincreased cardiovascular risk 9 . The DSM-IV has identified severalsubtypes of anxiety disorders (Table 103.1) for the general adultpopulation. They are based on the presence of a cluster ofsymptoms with a characteristic course and treatment. However,anxiety may also present as a symptom of another disorder.Therefore, the first task is to assess the impact of the anxietysymptoms on social and emotional functioning or the severity of acoexisting physical illness.Differential DiagnosisThe diagnosis of anxiety, as either a disorder or a symptom, is notalways apparent. This is especially true in the elderly patient.Elderly patients are often less willing to discuss ‘‘anxiety’’, butmay report ‘‘anxiety-equivalent’’ complaints and physical illnesses.Thus a patient may deny being ‘‘anxious’’, but admit tobeing ‘‘jittery’’, ‘‘sick’’, ‘‘uneasy’’, ‘‘flustered’’, ‘‘hot’’, ‘‘restless’’,‘‘ill’’, ‘‘achy’’, ‘‘agitated’’ or ‘‘bad’’. Alternatively, the patient mayverbalize physical symptoms, such as being ‘‘sick to my stomach’’,or having ‘‘heart pain’’ or ‘‘insomnia’’. These complaints mayobscure the true diagnosis or complicate another. The physicianmust therefore be attuned to what the patient is actually saying.Further complicating the differential diagnosis is the fact thatanxiety may present as a primary disorder (panic disorder,generalized anxiety disorder, obsessive–compulsive disorder, etc.)or a symptom of another primary diagnosis (such as depression,thyroid disease, cardiovascular disease or dementia). There aremany conditions that may cause anxiety as a symptom (see Table103.2); thus, differentiating the source or sources may be difficult.Common medical disorders associated with anxiety as a symptomin the elderly include chronic obstructive pulmonary disease,coronary artery disease, early dementia, major depressiveepisodes, and medication interactions or withdrawal. Environmentalstressors, bereavement or anniversary reactions andexperience of medical illness or hospitalizations are also commonlyassociated with anxiety in late life 10 . Non-prescriptionmedications (especially caffeine-containing products, certain coldTable 103.1DSM-IV anxiety disordersPanic disorder without agoraphobiaPanic disorder with agoraphobiaAgoraphobia without a history of panic disorderSpecific phobiaSocial phobiaObsessive–compulsive disorder (OCD)Post-traumatic stress disorder (PTSD)Acute stress disorderGeneralized anxiety disorder (GAD)Anxiety disorder due to . . . [a general medical condition]Substance-induced anxiety disorderAnxiety disorder, NOSPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd