ANTIDEPRESSANTS FOR ANXIETY DISORDERS IN LATE-LIFE: A SYSTEMATIC REVIEW

Introduction Anxiety disorders are encountered frequently in late life, and contribute to distress, disability, and increased mortality. Late-life GAD has been linked to increased risk of incident stroke [3]. Anxiety is associated with an increased risk for cognitive impairment and dementia in community dwelling older adults independent of psychosocial risk factors [6]. Despite these impairments, late-life anxiety disorders are largely untreated in primary care, with only 36.3% of recurrent cases in a community sample receiving treatment [7]. Antidepressants are considered to be first-line pharmacological treatment for anxiety disorders [8]. Current evidence for the treatment of anxiety disorders in the elderly is extrapolated from studies on younger adults. However, older adults suffer from medical conditions that affect renal, hepatic, and cardiac function. Pharmacokinetic considerations such as variable drug absorption and decreased volume of distribution may also contribute to reduced safety and tolerability of antidepressants in the elderly [5]. To date, there has not been a systematic review on the use of antidepressants for anxiety disorders in older adults. The aim of this systematic review is to provide updated information on the efficacy and tolerability of antidepressants in treatment of anxiety disorders among older adults from randomized controlled studies. Methods This systematic review was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The objective of this review is to summarize the results from published randomized controlled clinical trials of antidepressants for late-life anxiety. We performed a literature search of PubMed, MEDLINE, EMBASE, PsychINFO, and Cochrane collaboration databases through October 18th, 2018, using the following keywords: “late life”, “elderly”, aged, “senior citizen”, or “geriatric” combined with the keywords “anxiety” or “anxiety disorder”, and “antidepressant” or “antidepressive agents” or their pharmaceutical names. The search was restricted to English-language studies conducted in human subjects. We reviewed the bibliographic databases of the published articles for additional studies. Results Our search yielded a total of 12 randomized controlled trials. Two of these studies [14, 15] were pooled analyses of randomized controlled trials, which have been included as they fulfilled our selection criteria. We found 8 trials of selective serotonin reuptake inhibitors (SSRIs): 3 studies on sertraline [16, 17, 18], 2 each on citalopram [19, 20] and escitalopram [21, 22], and 1 trial of paroxetine [23]. We found 3 studies on serotonin-norepinephrine reuptake inhibitors (SNRIs), including 1 study on duloxetine [24], and 1 study each on duloxetine [14] and venlafaxine [15] reporting pooled analyses. There was 1 study of a tricyclic antidepressant (TCA), namely imipramine [25]. Three studies were rated “good”, 8 were rated “fair” and 1 was rated “poor” according to our quality appraisal criteria. Conclusions This systematic review supports the use of antidepressants as an efficacious and well-tolerated treatment option for late-life anxiety. Future research should focus on other anxiety disorders such as phobias and post-traumatic stress disorders, and should include older adults as well as those with cognitive impairment to increase their generalizability to community settings. Long term trials are needed to assess the efficacy of antidepressants in maintenance and prevention of relapse of anxiety, and provide necessary data on long-term tolerability. Head-to-head trials of antidepressants and other agents used for anxiety such as gabapentin and quetiapine are needed to compare their efficacy and safety. Future studies should include treatment modalities commonly used in the elderly such as problem-solving therapy, as well as newer modes of service delivery such as tele-psychiatry and home-visits to conceptualize efficacious treatment options for anxiety disorders in late-life that are commonly encountered in clinical settings. This research was funded by The authors did not receive any funding for this study