Late-Life Anxiety Requires Modified Approach: Lower Profile for Drug Interactions Makes Citalopram, Escitalopram, and Sertraline Attractive

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Anxiety seems to be as prevalent in older as in younger adults--data are inconsistent on this point--but may look different in each group. "The DSM criteria were developed for anxiety disorders in younger patients and don't always identify them in this age group," said Javaid I. Sheikh, M.D., professor of psychiatry at Stanford (Calif.) University.

Older patients tend to focus less on nervousness and worry than on somatic manifestations of anxiety, he said. Memory deficits and other cognitive difficulties are frequently part of the picture, possibly reflecting the neurotoxic effects of chronic anxiety on the hippocampus and other brain centers.

Anxiety also exacerbates the age-linked decline in restful sleep. Complaints of severe insomnia are "very common," Dr. Sheikh said.

More prominent than the distinct anxiety syndromes of early adulthood is a mix of anxiety and depression symptoms. "These appear together frequently enough to constitute a separate diagnostic category," said Carl Salzman, M.D., professor of psychiatry at Harvard Medical School, Boston.

Anxiety associated with medical disorders, medication, and mild to moderate dementia is frequently encountered as well, Dr. Sheikh said.

The possible contribution of medical factors should be considered, particularly if anxiety is of recent onset. Thyroid function, for example, may influence both mood and anxiety disorders. "I've found that thyroid status is askew in about 10% of the patients I see, and needs to be addressed for effective management," said Eric Lenze, M.D., of the Western Psychiatric Institute and Clinic in Pittsburgh.

"In my experience, people with chronic obstructive pulmonary disease have particularly high rates of comorbid anxiety," said Peter V. Rabins, M.D., professor of psychiatry at Johns Hopkins University, Baltimore. "Air hunger and anxiety are so intertwined that you can't simply treat one or the other. I empathize with the distress caused by air hunger as part of psychoeducation, and help people make lifestyle changes to minimize shortness of breath," he said.

Although there is little literature to guide treatment of late-life anxiety, serotonergic antidepressants are commonly the first choice, particularly when the patient exhibits depressive symptoms.

Dr. Lenze's group recently published what he believes to be the first prospective controlled trial validating the use of a selective serotonin reuptake inhibitor (SSRI)--citalopram (Celexa)--for late-life anxiety (Am. J. Psychiatry 2005;162:146-50). Another study, which retrospectively examined industry data, found venlafaxine (Effexor) equally effective for older and younger patients (J. Am. Geriatr. Soc. 2002;50:18-25).

In the choice among SSRIs, a lower potential for drug interactions makes citalopram, escitalopram (Lexapro), and sertraline (Zoloft) attractive, Dr. Lenze and Dr. Sheikh said.

Enhanced sensitivity to side effects--including exacerbations of anxiety--suggests initiation at low dosage and cautious titration. Dr. Sheikh may start at one-fourth the full therapeutic dosage and go to one-half after 2 weeks, go to three-fourths 2 weeks later, and then wait 4 more weeks to evaluate the need for further increases.

Although some may require a larger dosage, many elderly patients respond to SSRIs at even one-half the usual dosage for young adults, he said.

To Dr. Lenze, "management is more important than the choice of drug," in view of the high dropout risk. …