Management of anxiety and depression syndromes in the elderly

Elderly patients are susceptible to disruptions in mood from a variety of sources: primary anxiety or mood disorders, medical illnesses and treatments, and psychosocial stressors. The goals of intervention are to discover reversible etiologies, treat in the least intrusive manner, and improve or restore quality of life. The clinical presentation may vary from typical anxiety or depression, to mixed symptoms, to a highly somatized or dementia-like picture. The most common disturbance is mixed anxiety/depression. Once the threshold is reached for drug therapy, there are safe and effective remedies, including azapirones, short-acting benzodiazepines, serotonin reuptake inhibitors, and others. Because elderly patients are more vulnerable to drug side effects such as sedation and orthostatic hypotension, selection of the therapeutic agent is crucial. Management strategies, therefore, tend to avoid sedating agents and those with strong autonomic effects. Antipsychotic drugs, unless specifically indicated--for example, in cases of delusional depression--are to be avoided in simple anxiety/depression syndromes. Prescribers for patients in nursing facilities must also observe Omnibus Budget Reconciliation Act (OBRA) regulations. These include preference for psychosocial over drug therapies, avoidance of physical and chemical restraint, and minimal use of any psychotropic medication.