Pharmacological Management of Anxiety Disorders in the Elderly

Abstract

Opinion Statement Anxiety disorders are common in the elderly. Additionally, anxiety symptoms often accompany co-morbid psychiatric, medical, as well as neurodegenerative diseases in the older population. Anxiety in the elderly, often accompanied by depression, can lead to worsening physical, cognitive and functional impairments in this vulnerable population. Antidepressants are considered first line treatment. Both SSRIs and SNRIs are efficacious and well-tolerated in the elderly. Some SSRIs are strong inhibitors of the cytochrome P450 hepatic pathway whereas others have less potential for drug interaction. Those antidepressants with more favorable pharmacokinetic profiles should be considered first-line in the treatment of anxiety. Mirtazapine and vortioxetine are also considered safe treatment options. Buspirone may have benefit, but lacks studies in elderly populations. Although tricyclic/tetracyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be effective in the elderly, their side effect and safety profiles are suboptimal and thus are not recommended in late-life. Benzodiazepines and beta blockers should generally be avoided when treating anxiety in the elderly. There is not enough evidence to support the use of antipsychotics or mood stabilizers given their risk of problems in both the long and short term. In addition, antipsychotics have a black box warning for increased mortality in elderly patients with dementia.

Long-Term Treatment with Fluvoxamine Decreases Nonmotor Symptoms and Dopamine Depletion in a Postnatal Stress Rat Model of Parkinson’s Disease

“…This explained why we found that maternally separated treated rats spent more time in the open arms of the EPM than nonseparated treated (NSF) rats. The long-term treatment with Fluvoxamine produced noticeable behavioral relief in agreement with previous studies that showed that psychological disorders including anxiety and depression are relieved with prolonged and consistent antidepressant treatment [27,64]. Fluvoxamine may have activated the HPA axis resulting in neuroendocrine responses via specific serotonergic neurons [65].…”

The role of beta-adrenolytic drugs in treating anxiety disorders

“…One of the reasons behind it is the fact that beta blockers such as metoprolol and propranolol are lipophilic and can cross the bloodbrain barrier [84]. Lipophilic adrenolytic drugs are also metabolized by the liver, which is an important aspect as far as elderly patients affected by heart or liver diseases are concerned [85]. Moreover, there is a number of other psychoactive drugs which can influence the effectiveness of beta blockers and their side effects.…”

“…Drugs from the SSRI group may increase the concentration of beta-adrenolytic drugs in blood plasma. However, tricyclic antidepressants can increase their antihypertensive effect [85]. For this reason, beta blockers are not recommended to be used in anxiety disorders in geriatric patients.…”

“…Jedną z przyczyn wyjaśniających jest to, że beta-blokery, takie jak metoprolol i propranolol, są lipofilne i dlatego mogą przenikać przez barierę krew-mózg [84]. Lipofilneadrenolityki są również metabolizowane przez wątrobę, co jest ważnym aspektem u starszych pacjentów obciążonych chorobami serca lub wątroby [85]. Ponadto istnieje kilka innych leków psychoaktywnych, które mogą wpływać na skuteczność beta-blokerów oraz na ich działania niepożądane.…”

“…Leki z grupy SSRI mogą zwiększać stężenie beta-adrenolityków w osoczu. Tymczasem trójcykliczne leki przeciwdepresyjne mogą zaostrzyć ich działanie hipotensyjne [85]. Z tego względu beta-blokery nie są zalecane do stosowania w zaburzeniach lękowych u pacjentów geriatrycznych.…”