Since most patients are seen in primary care and general medical settings, this is where the focus of management should be. The role of specialist old age psychiatry services should be to provide any advice and support that is necessary, which may include assuming responsibility for the most complex cases.

Psychological treatments

For the most part, the goals and techniques of cognitive-behavioural therapy are the same for elderly patients as they are for younger adults (see Ch§pter6.3:2.1). However, these may require some adaptation to accommodate limitations imposed by sensory impairment, physical illness and disability, and cognitive dysfunction. (l5 The need to tailor treatment approaches to the individual may limit the value of cognitive-behavioural therapy in a group setting, although this has to be set against the benefits of shared experience and peer support during and after the treatment. Group treatment is probably more straightforward with task-centred activities such as anxiety management.

The use of formal psychodynamic approaches to management is currently limited by economic constraints, and the lack of evidence regarding their effectiveness. However, health professionals should have some knowledge of the psychodynamics that underlie the concerns of elderly patients, and the mental defences that they use. They also need to be aware of their own preconceptions and cognitive distortions regarding the experience of old age, the psychological sophistication of elderly people, and their capacity for growth and change. ^J2

Physical treatments

The general principles of drug treatment in old age are set out in Chapter.8.6. None of the drugs used to treat anxiety symptoms in elderly people is entirely without problems or limitations, so they should be prescribed with care. Benzodiazepines are the most commonly used drugs, but they are often prescribed inappropriately. (l7 Prolonged use is associated with dependence, memory impairment, motor inco-ordination, depression of respiratory drive, and paradoxical excitement. Elderly patients are particularly sensitive to their effects, and drug accumulation may lead to delirium, incontinence, and falls and fractures. As a rule, compounds with short half-lives and no active metabolites, such as oxazepam, are least problematic, although patients may develop withdrawal symptoms if they are discontinued, or taken erratically. Long-term use of benzodiazepines should be avoided where possible, although it may be necessary for a minority of patients who are unresponsive to other forms of treatment.

Antidepressant drugs are also effective in disorders such as generalized anxiety and panic, particularly if depressive symptoms are prominent. The use of antidepressants in elderly patients is discussed in Chapter.8.5..4.. Drugs with serotonin-reuptake-inhibiting activity have a specific effect in obsessive-compulsive disorder. Neuroleptics have a limited role in the management of anxiety in elderly patients, in view of their potentially disabling extrapyramidal side-effects. However, a short course of low-dose treatment with a drug such as haloperidol or zuclopenthixol may be used in patients who are unable to tolerate benzodiazepines. Alternatively, sedative antihistamine drugs such as hydroxyzine may be useful. b-Blockers are used in younger adults to control the sympathetic somatic symptoms of anxiety, but contraindications such as chronic obstructive airways disease, sinus bradycardia, and heart failure limit their use in elderly patients. Buspirone is an azapirone anxiolytic that is well tolerated by elderly patients, but it takes about 2 weeks to become effective, so it is not useful for the management of acute episodes. It is indicated for severe chronic generalized anxiety and in patients where there is risk of dependence or abuse.

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