Mohammed T. Abou-Saleh

568 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYorganic brain disease 65 . Although b-blockers decrease autonomicallymediated symptoms such as diaphoresis, palpitation, tremorand gastrointestinal upset, they usually do not reduce the innersubjective effects 2,4 .Propranolol in small doses (e.g. 5–10 mg one to four times aday) may be effective in elderly patients 20 . These drugs should notbe used in patients with chronic obstructive pulmonary disease,congestive heart failure, heart block, insulin-dependent diabetes,severe renal disease or peripheral vascular disease.AntihistaminesSedating antihistamines such as hydroxyzine and diphenhydraminehydrochloride are sometimes useful for anxiety or insomniain the elderly. They have been rarely recommended because theyare less effective than benzodiazepines, and their anticholinergicside effects are outweighed by their weak anxiolytic effects 4 . Theymay be used in patients with mild symptoms, in severe chronicobstructive pulmonary disease, addiction-prone personalities,alcoholics, or patients for whom more traditional drugs are noteffective 66 . However, physicians must be aware that the elderlypatient is much more susceptible to their anticholinergic properties,which may cause blurred vision, tachycardia, dry mouth,urinary urgency, constipation, restlessness, hallucinations andconfusion. Antihistamines have no potential for inducing drugdependency or addiction.GENERAL GUIDELINESDespite the limited data on treatment of anxiety disorders in theelderly, the clinician can successfully treat patients with aconservative and thoughtful use of medications. The followingguidelines have been adapted from Small 20 .1. Conduct a complete psychiatric evaluation. Listen specificallyfor expression of anxiety. Does this patient have anxiety thatsignificantly affects their quality of life or functioning?2. Consider the full differential diagnosis. Does the pattern ofanxiety identify itself as a formal anxiety disorder, or as asymptom of another psychiatric or medical disorder? Geriatricpsychiatry has been called ‘‘the specialty of co-morbidity’’.There may be several potential etiologies for anxiety symptomsthat should be considered before initiating treatment.3. Consider non-pharmacologic treatments first. Education andreassurance are invaluable in the treatment of anxiety, andmay themselves be adequate treatments. Specifically addresssocial stressors and evaluate the effectiveness of the supportsystems. Attention to family caregivers may facilitate thepositive response to other treatment. Remember, the ability tobenefit from therapy is not based on age.4. Minimize polypharmacy. In the geriatric population (especiallythose in the nursing care facilities), the use of multiplemedications is the rule rather than the exception. Mostclinicians stress the importance of reviewing the medicationlist for potential areas of reduction, prior to adding newtreatments. Reducing the number of medications may actuallytreat the anxiety symptoms 20 .5. When selecting an anxiolytic, consider the full presentationrather than just the anxiety when selecting an initialmedication. For example, use an antidepressant if depressivesymptoms are apparent. Avoid anticholinergic medications inpatients with dementia. Avoid benzodiazepines when thepatient’s ability to ambulate is compromised.6. As far as possible, make medication changes one at a time inorder to clarify whether a complaint results from a medicationside effect or an underlying illness.7. ‘‘Start low and go slow’’.REFERENCES1. Blazer DG, George LK, Hughes DC. The epidemiology of anxietydisorders: an age comparison. In Salzman C, Lebowitz BD, eds,Anxiety in the Elderly: Treatment and Research. New York: Springer,1991; 17–30.2. Shader RI, Greenblatt DJ. Management of anxiety in the elderly: thebalance between therapeutic and adverse effects. J Clin Psychiat 1987;42: 107–13.3. Hocking LB, Koenig HG. Anxiety in medically ill older patients: areview and update. Int J Psychiat Med 1995; 25: 221–38.4. Barbee JG, McLaulin JB. Anxiety disorders: diagnosis andpharmacotherapy in the elderly. Psychiat Ann 1990; 20: 439–45.5. Krasucki C, Howard R, Mann A. Anxiety and its treatment in theelderly. International Psychogeriat 1998; 11(1): 25–45.6. Pearson JL. Summary of a National Institute of Mental Healthworkshop on late-life anxiety. Psychopharmac Bull 1998; 34(2):127–38.7. Salzman C. Pharmacologic treatment of the anxious elderly patient.In Salzman C, Lebowitz BD, eds, Anxiety in the Elderly: Treatmentand Research. New York: Springer, 1991; 149–73.8. Schneider L. Overview of generalized anxiety disorder in the elderly. JClin Psychiat 1996; 57(suppl 7): 34–45.9. Watkins LL, Grossman P, Krishnan R, Blumenthal JA. Anxietyreduces baroreflex cardiac control in older adults with majordepression. Psychosom Med 1999; 61(3): 334–40.10. Corbett L. Anxiety in the elderly: current concepts. In Fawcett J, ed.,Anxiety and Anxiety in the Elderly in Contemporary Psychiatry.Chicago, IL: Pragmaton, 1983; 37–41.11. Jenike MA. Anxiety disorders of old age. In Rall TW, Nies A, TaylorP, Jenike MA, eds, Geriatric Psychiatry and Psychopharmacology: AClinical Approach. Chicago: Yearbook Medical Publishers, 1989;248–71.12. Thompson TL II, Moran MG, Nies AS. Psychotropic drug use in theelderly. N Engl J Med 1983; 308: 134–8.13. Ouslander JG. Drug therapy in the elderly. Ann Intern Med 1981; 95:711–22.14. Salzman C. Practical considerations in the pharmacologic treatmentof depression and anxiety in the elderly. J Clin Psychiat 1990; 51(suppl 1): 40–43.15. Zimmer B, Gershon S. The ideal late-life anxiolytic. In Salzman C,Lebowitz BD, eds, Anxiety in the Elderly: Treatment and Research.New York: Springer, 1991; 277–303.16. Hayes PE, Dommisse CS. Current concepts in clinical therapeutics.Anxiety disorders, Part 1. Clin Pharm 1987; 6(2): 140–47.17. American Psychiatric Association. Benzodiazepine Dependence,Toxicity, and Abuse. Washington, DC: American PsychiatricAssociation, 1990.18. Shorr RI, Robin DW. Rational use of benzodiazepines in the elderly.Drugs Aging 1994; 4: 9–20.19. Baldessarini RJ. Drugs and the treatment of psychiatric disorders. InGoodman-Gilman A, ed., The Pharmacological Basis of Therapeutics,8th edn. Oxford: Pergamon, 1990.20. Small GW. Recognizing and treating anxiety in the elderly. J ClinPsychiat 1997; 58(suppl 3): 41–7.21. Ray WA, Griffin MR, Downey W. Benzodiazepines of long and shortelimination half-life and the risk of hip fracture. J Am Med Assoc1989; 262: 3303–6.22. Dubovsky SL. Generalized anxiety disorder: new concepts andpsychopharmacologic therapies. 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