Mohammed T. Abou-Saleh

560 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYincluding benzodiazepines, b-blockers and buspirone. For benzodiazepines,the net effect of these changes is usually a relativelyhigher level of active medication or its metabolites compared toyounger people. In addition, an increase in the proportion of bodyfat with aging may mean that a strongly lipophilic benzodiazepine,such as diazepam, will lead to a much higher accumulationin tissues, compared to less lipophilic drugs such as lorazepam andoxazepam, which are preferable in the elderly 4 . Of the b-blockers,propranolol is the most frequently used. One should note,however, that its adverse side effects are most common in patientsover the age of 60, including its potential to cause depression andworsen cardiac failure and bronchial asthma, and its potentiallytroublesome interactions with various other drugs, such ascalcium channel blockers, cimetidine and chlorpromazine 5 .Aging does not seem to significantly alter the pharmacokineticsof buspirone 6 . Appropriate usage of these agents in specificsituations will be discussed in later sections.PSYCHOLOGICAL MANAGEMENTFrom a cognitive-behavioral perspective, anxiety can be understoodto have three core components: psychological (e.g.cognitions and affects), physiological (e.g. increased heart rate,dizziness) and behavioral (e.g. ruminations, compulsions andavoidance behaviors). When unfounded, severe anxiety initiatesand maintains maladaptive functioning and psychological disturbance.How an individual perceives, understands and functionswith anxiety can be shaped by such factors as coping mechanisms,personality, social and environmental influences and past trauma.Cognitive-behavioral principles are very effective with a variety ofpsychiatric symptoms 7–8 . For example, breathing and musclerelaxation training, guided imagery, systematic desensitization,relabeling of anxiety reactions, insight into irrational beliefs andsystematic homework assignments are effective interventions thatmay be utilized during acute presentations of anxiety. Duringacute management, elders may need a greater amount ofreassurance and doctor/therapist contact time than their youngercounterparts. Maintenance of such techniques through follow-upsessions will increase the internal support strategies of the patientand decrease the risk for future crises.Diagnostic Categories Most CommonlyRequiring ManagementPanic DisorderThere are several management strategies that have shown somedegree of success in panic disorder 9 . The therapeutic efficacy ofantidepressants in panic disorder and agoraphobia is quite wellestablished. Particularly effective are the tricyclic antidepressantimipramine, the monoamine oxidase inhibitor (MAOI) phenelzine,and the selective serotonin reuptake inhibitor (SSRI)sertraline 10–12 . Due to their rapid onset of therapeutic action,however, benzodiazepines should be considered the mainstay ofacute management, as antidepressants usually take approximately2–3 weeks for their therapeutic effects to take place. Althoughalprazolam is the most commonly used benzodiazepine in panicdisorder 13 , clonazepam 14 and lorazepam 13 have reportedly beeneffective.Cognitive and behavioral therapies are inextricably intertwinedin the acute treatment of panic disorder, with or withoutagoraphobia. Panic disorder may be managed acutely withbreathing and muscle relaxation techniques, examination ofcognitive beliefs and a series of progressive behavioral exercises.With therapist-assisted graded exposure beginning even duringthe acute management phase of treatment, frequent exposuresessions may facilitate the lessening of the anxiety symptoms.Social Phobia(Fear of Public Speaking, Eating in Public, etc.)b-Blockers have been shown to be superior to a placebo fortreatment of a fear of public speaking or performance anxiety inthe general population 15,16 . The espoused mechanism of suchtherapeutic response is the suppression of peripheral responses ofanxiety (e.g. palpitations). We know of no studies or clinicalreports that address the effectiveness of b-blockers in the sociallyphobic elderly; thus, it is hard to say whether this treatment willbe equally effective in the elderly. It is also not clear whether abenzodiazepine in low dose (e.g. 0.5 mg lorazepam) will be helpfulin encountering the phobic situations.Office-based social skills training as well as exposure in vivo(individual or group treatment) can be very effective 17 . For acutemanagement purposes, teaching a single, generally acceptable‘‘coping strategy’’ is most useful to patients and can beimplemented quite easily in a variety of situations. A skilledclinician may also consider the use of paradoxical intention,visualization and systematic desensitization in acute managementinterventions.Specific Phobia(Crime, Medical and Dental Procedures, etc.)A minority of individuals seek psychiatric treatment for simplephobias, and clinically significant improvement is usuallyobtained in 75–85% of specific phobias treated 18 . Common fearsof older adults include being a crime victim and fears aboutmedical and dental procedures. Although crime rates decreasewith age, medical and dental procedures increase, thereforesuccessful management strategies are warranted. We find thatlow-dose benzodiazepines before the medical or dental procedurein very fearful patients may be helpful in alleviating anxiety andproducing better compliance with treatment.Acute management of most simple phobias can be treatedeffectively, and with therapy gains maintained, with one (2–3 h)office-based, therapist-assisted exposure session 18 . Effective treatmentrequires focusing on one phobia-related avoidance behaviorper session. Breathing and muscle relaxation techniques can alsobe quite effective in suppressing anxiety responses in older adults.Generalized AnxietyIn certain instances, the symptomatology of patients with ageneralized anxiety disorder can become extremely severe andmay require immediate intervention with benzodiazepines. Werecommend replacing benzodiazepines with buspirone and/orcognitive-behavioral interventions, including the range of relaxationexercises, until the acute symptomatology is under control.CONCLUSIONPrinciples for the acute management of anxiety in the elderlyremain more or less consistent over the range of anxiety disorders,although the contexts in which one is asked to evaluate andmanage such cases may vary greatly. The importance of a goodhistory, empathy to the patient’s psychosocial situation, andawareness of a possibility of an underlying medical conditioncannot be overemphasized. Finally, one needs to be cognizant of