Mohammed T. Abou-Saleh

564 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYTable 103.2 Medical disorders associatedwith anxiety as a symptomCardiopulmonaryAsthmaChronic obstructive pulmonary diseaseHypoxic statesAngina pectorisMitral valve prolapseCardiac arrhythmiasCongestive heart failureCerebral arteriosclerosisHypertensionPulmonary embolismNeurologicPartial complex seizuresEarly dementiaDeliriumPost-concussion syndromeCerebral neoplasmHuntington’s diseaseMultiple sclerosisVestibular dysfunctionEndocrineCarcinoid syndromeCushing’s syndromeHypoglycemia; hyperinsulinismHypo- or hyperthyroidismHypo- or hyperparathyroidismMenopausePheochromocytomaPremenstrual syndromeMedicationsAnticholinergic medicationsCaffeineCocaineSteroidsSympathomimeticsAlcoholNarcoticsSedative–hypnoticselderly patient, yet the clinician should be aware of the limitationsof the research, and sensitive to the developing research in thisarea.Special Adaptations for the Geriatric PatientBefore prescribing anti-anxiety agents for the elderly, thephysician should be aware of the several age-related physiologicchanges that may alter drug pharmacokinetics and contribute toincreased risk of adverse reactions. These include changes in drugabsorption, drug distribution, protein binding, cardiac output,hepatic metabolism and renal clearance 11–13 . In addition, changesin neurotransmitter and receptor function in the central nervoussystem (CNS) may make a patient more sensitive to psychotropicdrugs 14 . In general, the usual starting dose of psychotropic drugsfor geriatric patients is roughly one-half of the starting dose foryounger adult patients.PSYCHOPHARMACOLOGIC DRUGSDuring the past three decades, a variety of agents have been usedfor the treatment of anxiety and anxiety disorders with varyingdegrees of success. These include benzodiazepines, buspirone,tricyclic antidepressants (TCAs), monoamine oxidase inhibitors(MAOIs), serotonin selective reuptake inhibitors (SSRIs), newermixed-action antidepressants, antipsychotic neuroleptics, b-blockersand antihistamines. Despite the multiple medicationsavailable, none are completely safe or completely satisfactory inthe treatment of anxiety. Zimmer and Gershon’s 15 conclusion thatthe ‘‘ideal geriatric anxiolytic’’ has yet to be developed still holdstrue today. Therefore, effective methods of treating anxietydisorders are especially dependent upon thoughtful, comprehensiveand accurate assessment of psychiatric, social and medicalstatus, as well as a thorough knowledge of the patient’s drughistory and medication options.and flu medications, alcohol or nicotine withdrawal, and certainherbal remedies) may contribute to anxiety symptoms.Adult StudiesResearch in the treatment of anxiety disorders for elderly patientsis limited. A recent summary of the National Institute of MentalHealth Workshop on Late-life Anxiety 6 has highlighted thisproblem, noting three significant research gaps: (a) little consensuson the ‘‘best’’ approach to measure and count anxiety symptoms,syndromes or disorders in late life; (b) insufficient numbers ofstudies that examine anxiety among older adults; and (c) limitedknowledge of the differences in ‘‘early’’ and ‘‘later’’ onset ofvarious anxiety disorders. These limitations become especiallysignificant in treatment recommendations for elderly patients withanxiety. A recent review of the literature 5 indicated that there arevery few controlled clinical trials of medication or psychosocialinterventions for anxiety disorders in the elderly. Many of thefindings take the form of case reports, case series or open studies.Therefore, treatment decisions for elderly patients are usuallyextrapolated from the clinical studies of younger mixed-age adultpopulations and personal clinical experience. For the most part,there is little reason to doubt the applicability of the studies to theBENZODIAZEPINESSince the 1960s, the benzodiazepine class of compounds has beenthe mainstay of drug treatment for patients with situationalanxiety, GAD and panic disorder 16 . They are also frequentlyprescribed for other indications, such as insomnia, relaxationprior to certain medical procedures, seizures, or agitation indemented patients. In the last two decades, increased attention hasbeen given to the prescription pattern of benzodiazepines in theelderly. Benzodiazepines were prescribed at a much higher rateamong elderly patients than in the general population 17 .Epidemiologic data suggest that benzodiazepines may be overusedin the general elderly population 18 . This is significant because ofthe potential toxicity and side effects of benzodiazepines,especially common in the elderly.Despite their multiple uses, benzodiazepines are usuallyclassified in two groups: anxiolytics and sedative–hypnotics.Currently, seven benzodiazepines are available for the treatmentof anxiety. Listed in their order of introduction, they arechlordiazepoxide, diazepam, oxazepam, clorazepate, lorazepam,alprazolam and clonazepam 19 . Prazepam and halazepam, twobenzodiazepines previously used for the treatment of anxiety, areno longer available in the USA. The most common sedative–hypnotics are triazolam, temazepam and flurazepam. Commonlyused benzodiazepines in the elderly are listed in Table 103.3.