Treating Anxiety Disorder in an Older Woman

To the Editor,

I read Dr. Lantz’s article titled “Agoraphobia: When an Older Woman Refuses to Leave Home”¹ with interest. It is always a pleasure when the dangers of chronic benzodiazepine prescription are discussed, as well as utility restricted to that of a tertiary option relative to selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) in the treatment of anxiety disorders.

I also appreciated the mention of antihistamines as an option in the treatment of anxiety disorder, and Dr. Lantz’s commenting on the adverse anticholinergic properties of this class was appropriate. However, it should not have been neglected when mentioning the utility of tricyclics, as the inclusion of nortriptyline in the Table without noting caution with respect to acetylcholine receptor blockade is unfortunate; it is quite profound with even second-generation agents of this class, predisposing to confusion, falls, etc.

The elderly often suffer from comorbid pain, and opioids at low doses may offer dual utility as analgesics as well as anxiolytics,² such that inclusion of this fact may be of value to readers. In particular, efficacy with tapentadol may be appreciated as a newer opioid with less adverse sedating cognitive impact in the elderly given its concomitant noradrenergic-stimulating properties.

The unfortunate absence of discussion of GABA neurotransmitter analogues is also of importance. Agents such as baclofen,³ gabapentin,⁴ and gabapentin’s nearly identical twin,⁵ pregabalin,⁶ have considerable utility in the pharmacologic management of anxiety disorders.

Regular participation in exercise for three weeks or longer also decreases anxiety symptoms,⁷ and the endorphin- and enkephalin-mediated sense of wellness needs to be appreciated relative to potential adverse cognitive effects of pharmacologic management.

As the patient in Dr. Lantz’s article appreciated a less than favorable clinical outcome, providing additional options is of value to optimize patient care.

Aaron S. Geller, MD Assistant Professor, Tufts University School of Medicine New England Medical Center Boston, MA President, Nashua Pain Management Corporation Nashua, NH Dr. Geller reports no relevant financial relationships.

References

1. Lantz MS. Agoraphobia: When an older woman refuses to leave home. Clinical Geriatrics 2010;18(1):13-16.

2. Tenore PL. Psychotherapeutic benefits of opioid agonist therapy. J Addict Dis 2008;27(3):49-65.

3. Drake RG, Davis LL, Cates ME, et al. Baclofen treatment for chronic posttraumatic stress disorder. Ann Pharmacother 2003;37(9):1177-1181.

4. Kong VK, Irwin MG. Gabapentin: A multimodal perioperative drug? Br J Anaesth 2007;99(6):775-786.

5. Pregabalin: New drug. Very similar to gabapentin. Prescrire Int 2005;14(80):203-206.

6. Marks DM, Patkar AA, Masand PS, Pae CU. Does pregabalin have neuropsychotropic effects? A short perspective. Psychiatry Investig 2009;6(2):55-58. Published Online: June 30, 2009.

7. Herring MP, O’Connor PJ, Dishman RK. The effect of exercise training on anxiety symptoms among patients: A systematic review. Arch Intern Med 2010;170(4):321-331.
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Dr. Lantz responds:

Thank you for the thoughtful reply regarding the evaluation and treatment of agoraphobia in an older woman.¹ It is always important to consider and screen for treatable comorbid conditions, including chronic pain in older adults who have restricted activity and mobility. The prevalence of anxiety disorders and chronic pain is quite high, and treatment of both conditions should be pursued following a thorough evalution.² The specific recommendation for use of tapentadol is interesting. Tapentadol, a dual-action opioid agonist and norepinephrine reuptake inhibitor, is approved by the FDA for the treatment of acute moderate-to-severe pain. While it may be useful in the elderly, published data are very limited, and the potential for drug-drug interactions with antidepressants may be problematic.³

The case patient continues to refuse all medications but has accepted home services, including nursing and social work. When dealing with the frail elderly, quality of life must be considered a goal. While this patient refused medications, her quality of life improved when she was able to trust her clinicians enough to accept home-based care.

It is always important to consider the adverse events and side effects associated with medications in the elderly. While nortriptyline is a very effective medication for the treatment of depression and anxiety, its anticholinergic, hypotensive, and cardiac side effects should not be overlooked. Of note is the doctor’s suggestion regarding the use of gabapentin, pregabalin, and baclofen for the treatment of anxiety. While some studies have shown improvement in anxiety with pregabalin, none of these three agents is FDA-approved for the treatment of anxiety.⁴ Any off-label use should always be discussed with patients prior to initiation of the medication.

Melinda S. Lantz, MD
Chief of Geriatric Psychiatry
Beth Israel Medical Center
New York, NY

Dr. Lantz reports no relevant financial relationships.

References

1. Lantz MS. Agoraphobia: When an older woman refuses to leave home. Clinical Geriatrics 2010;18(1):13-16.

2. Asmundson GJ, Katz J. Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art. Depress Anxiety 2009;26(10):888-901.

3. Wade WE, Spruill WJ. Tapentadol hydrochloride: A centrally acting oral analgesic. Clin Ther 2009;31(12): 2804-2818.

4. Montgomery S, Chatamra K, Pauer L, et al. Efficacy and safety of pregabalin in elderly people with generalised anxiety disorder. Br J Psychiatry 2008;193(5):389-394.