Anxiety in elderly patients. A comparison of azapirones and benzodiazepines

The onset of primary generalised anxiety or other anxiety disorders during old age is unusual. However, these disorders are often chronic and may persist into old age, so that their occurrence in the elderly population is not rare. Secondary anxiety is also very common and may be related to endogenous stimuli, such as concomitant medical illness, or exogenous events such as loss of friends, change in life status or financial concerns. As the elderly constitute the most rapidly growing segment of the population of many developed nations, this is a problem of significant proportion. Anxiety disorders cause considerable morbidity and dysfunction and have even been shown to increase mortality rates. Nonetheless, the disorders are readily diagnosable if symptoms are properly interpreted. Failure to do so, dramatically and unnecessarily inflates healthcare costs. Certain presentations are more typical in the elderly. For example, somatisation and generalised anxiety are more common, and panic disorder is seen less often, in elderly than in younger patients. Once diagnosed, both nondrug and drug interventions may be effective. Benzodiazepines, although well recognised as useful, have been excessively criticised in terms of general use in the past. Extreme caution is warranted when these agents are used in geriatric patients as they may exacerbate cognitive impairment and cause psychomotor effects that may lead to adverse events and outcomes. Newer agents, such as the azapirones, have a lag-time to onset of action and require patient education for efficient use. They are, however, very effective in elderly patients and have been shown to be remarkably free of dangerous adverse effects. They have a very favourable risk to benefit profile in the elderly. Proper selection of therapeutic intervention allows clinicians to relieve symptoms with minimal risk of adverse effects in elderly patients.