Optimal management of anxiety in older patients

Although the incidence of anxiety disorders diminishes with age, the prevalence of anxiety symptoms among older patients is substantial. These symptoms, which include cognitive and somatic manifestations, are a source of diminished quality of life. The many potential sources of illness- and medication-induced anxiety must be excluded before instituting treatment. The general principles of antianxiety medication treatment in older patients include: (i) symptom relief with minimum sedation; (ii) improvement in sleep; (iii) freedom from autonomic and cognitive toxicities; and (iv) freedom from physical dependence and drug interactions. Older compounds such as the tricyclic antidepressants should be avoided, since more modern agents (e.g. benzodiazepines and buspirone) are well tolerated and effective. Modern antidepressants have also been used to reduce anxiety symptoms, although there is a potential for the opposite effect to occur. The selective serotonin reuptake inhibitors appear to be better suited to treating syndromes such as panic and obsessive-compulsive disorder, whereas nefazodone would be a better choice for generalised anxiety complicated by depression.