They are really difficult to treat, especially once they become chronic. Over time, it is not uncommon for worry and nervousness to be replaced by somatization and perseveration on physical conditions. Structural changes include enlargement of the amygdala and the dorsmedial prefrontal cortex. Full remission is uncommon, and improvement is going to be incremental. At best.
So, HIT IT HARD. Summon your favorite football coach voice and bark "Hit 'em hard and hit 'em fast! And if they get up, hit 'em again!" NOW you're ready!
First line tx is SSRI, best if started right away. Not as effective once anxiety becomes chronic. Stay the course for at least 4-6 weeks before bailing. Sertraline is the workhorse.
What about buspirone? Try it, you might like it.
SSRIs don’t make serotonin, they just help you hang onto it. It's like Hamburger Helper without hamburger. Get some buspirone in there. I know folks like to poo-poo buspirone, but try it. Seriously, just try it.
Gabapentin or pregabalin: decent adjunct for treatment-resistant anxiety. Theoretically, pregabalin has better anxiolytic benefit than gabapentin or other alpha-2-delta ligands because it’s cleaner, but it’s spendy. Works well for folks with both anxiety and neuropathic pain.
Avoid hydroxyzine. It's helpful for young whippersnappers, but not geriatric peeps. Likely to cause delirium and memory probs.
When to start a benzo? Never. Ever. The effect of benzos on GABA-receptors is the same as alcohol. Would you give Grandma a shot of Jack Daniels to calm down? Sure, she might liven up a little, but then she is going to be drunk and disorderly, dancing on the tables, digging thru the ashtrays for cigarette butts, and will eventually trip over the microphone cord. Benzos are all fun and games until someone breaks a hip. And trying to wean them off is butt-ugly. Just.Don't.Do.It.
1. Start with sertraline. Lower doses are better. Keep in mind that higher doses of any antidepressant can be overly activating, which worsens anxiety.
2. If no response, try citalopram or escitalopram, but peek at the QT once in awhile.
3. If still no response, try venlafaxine
4. Add buspirone.
5. If still no improvement, bail on the buspirone, keep the venlafaxine, and add gabapentin. Or sertraline + gabapentin. Or SSRI + pregabalin.
6. Do not use SGA until third trial. Then augment with quetiapine or risperidone, which have decent data for augmentation.
7. If all else fails, stabilize on clonazepam, with plan to slowly taper off. But first, raise your right hand and repeat after me: “I promise to taper off the benzo. I promise to taper off the benzo. I promise to taper off the benzo.” Now say it like you mean it.
THE BOTTOM LINE:
Sertraline is well-tolerated in older adults: Start with 25mg daily, go as low as 12.5mg if they are in the 90/90 club (older than 90 or weigh less than 90). Higher doses can be overly activating. Think of sertraline as an upside-down U (kind of like your golf score when drinking). Your pt might start to look better when you push the dose, but it's easy to over-shoot your goal, and then it's all downhill. How do you know when you've gone too far? Watch for bad dreams, worsening of anxiety, they can look a bit tremulous.
Tidbit #1: Monitor for hyonatremia, as even the slightest dip in sodium can worsen anxiety in elders. New onset of hand-wringing anxiety in a pt that is not normally a Nervous Nellie is very frequently hyponatremia. Fix that first.
Tidbit #2: Also, hypoglycemia can induce anxiety d/t secretion of epinephrine. Fix that too.
Tidbit #3: Plain old acetaminophen has a very nice anxiolytic benefit. Truly. A little bit of APAP goes a long ways.
If your first episode of major depression is early in life, you actually do better with it as you age. You know what it’s like, you recognize it, etc. But if your first episode of MDD is in your 70s-90s, you are more likely to have very severe symptoms, including psychotic features. (So go get depressed NOW! Your mind will thank you later. J/K.)
Here’s another factoid: the most common depression-related psychotic feature is auditory hallucinations. If Grandma is hearing voices, rule out depression. If you are already treating depression, now is the time to add a pinch of antipsychotic.
And another factoid: Grandma hearing a bunch of voices, or a choir, may actually be SSRI-induced musical ear syndrome (MES), which is not a psychosis at all. Kind of like the auditory version of Charles Bonnet Syndrome. Tx is a referral to audiology for amplification. Scaling back the dose of the SSRI might also help.
1. Start with monotherapy, usually sertraline.
2. If no improvement, try a different SSRI. Watch for QT prolongation with citalopram or escitalopram. Avoid paroxetine (cognitive-blunting) and fluoxetine (higher fall risk).
3. If no improvement, AND if they have concurrent insomnia OR if you also want them to gain weight, add mirtazapine.
4. If partial response switch to venlafaxine or duloxetine (avoid duloxetine if kidney probs).
5. If depression severe, SI, or psychosis, add a second-generation antipsychotic (SGA) – best evidence supports quetiapine, olanzapine, aripiprazole.
6. If still no improvement, add buspirone, lithium, or lamotrigine.
For ANXIETY: Start with sertraline, escitalopram, citalopram. Avoid paroxetine.
For PANIC: Try half-doses of escitalopram
For anxiety with COPD: Sertraline can reduce episodes of breathlessness. Avoid benzos unless you wanna knock out their resp drive completely.
For OCD: Fluvoxetine best, followed by sertraline.
Bruxism: all SSRIs can contribute
Cognitive problems: Sertraline best. Paroxetine worse
Seizure disorders: Keep SSRI dose low, avoid bupropion.
Sexual dysfunction: Try bupropion.
Nightmares: All SSRIs. Keep the dose low and never take at HS.
Withdrawal symptoms:
· Worst: paroxetine> venlafaxine
· Intermediate: Sertraline > fluvoxetine > bupropion > mirtazapine
· Minimal: citalopram > escitalopram > fluoxetine
Activating:
· Most activating: bupropion > fluoxetine > sertraline
· Not too bad: paroxetine > venlafaxine > duloxetine
· Most sedating: mirtazapine >fluvoxetine > citalopram
Suicide rates are disproportionately elevated in older adults. Highest risk are white males with military service that own firearms.
Differentiate between "I've had a good life" and "Death would solve all my problems." Or to put it more bluntly, differentiate between "I am ready to meet my Maker" and "My kids need my life insurance policy."
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