Interactions between anxiety, social support, health status and buspirone efficacy in elderly patients

Pharmacological treatment of anxiety in older adults: a systematic review and meta-analysis

BACKGROUND

Anxiety and its disorders are common in later life. Given the known risks of psychopharmacological treatments in older adults, clinical decision making for anxiety management should be guided by the strongest available evidence. This study aimed to comprehensively synthesise evidence on the pharmacological treatment of anxiety in older adults.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Cochrane Central, Embase, PsycINFO, and CINAHL from database inception to April 23, 2024, for randomised controlled trials on pharmacological treatments for anxiety in older adults (aged 60 years or older, mean age 65 years or older, or subgroup analyses meeting these criteria). Primary outcomes included reduction in anxiety symptoms, or treatment response, or remission. Standardised mean differences (SMD) were calculated for continuous variables and absolute difference and risk ratio (RR) for dichotomous variables. The risk of bias was assessed using the Cochrane Risk of Bias tool, and the certainty of evidence rated using GRADE. People with lived experience were involved in conducting this research. This trial is registered with PROSPERO (CRD42023407837).

FINDINGS

We identified 19 eligible studies, including 2336 participants, 1592 (68·15%) of whom were women and 722 (30·91%) men, and sex was not reported for the other 22 (0·94%) participants. Only eight of 19 studies reported on race or ethnicity, and study participants were predominantly White (1309 [91·6%] of 1428), and no studies reported outcomes related to gender. Antidepressants were more effective than placebo or waitlist control in reducing anxiety symptoms (SMD -1·19 [95% CI -1·80 to -0·58), with moderate certainty of evidence and substantial heterogeneity (I2 92·34%; p<0·0001). Antidepressants were also more effective than placebo or waitlist control in response or remission (RR 1·52 [95% CI 1·21 to 1·90]; absolute difference 146 per 1000 [95% CI 59 to 252]); with a low certainty of evidence and low heterogeneity (I2 8·09%; p=0·36). Planned subgroup analysis indicated selective serotonin reuptake inhibitors led to a greater reduction in anxiety symptoms (SMD -1·84 [95% CI -2·52 to -1·17]) compared with serotonin-norepinephrine reuptake inhibitors (SMD -0·46 [95% CI -0·65 to -0·27]), and there was no difference in response or remission. Benzodiazepines might reduce anxiety symptoms compared with placebo, but the evidence is very uncertain with high risk of bias. Meta-analyses for other drug classes for primary outcomes were not possible.

INTERPRETATION

Antidepressants are more effective than placebo or waitlist for reducing anxiety symptoms, with evidence supporting their safety and tolerability in older adults. Evidence for the efficacy and safety of benzodiazepines is weak. These findings can guide evidence-based practice.

FUNDING

Public Health Agency of Canada.

A Proposed Algorithm for the Pharmacological Treatment of Generalized Anxiety Disorder in the Older Patient

BackgroundThis is a new algorithm from the Psychopharmacology Algorithm Project at the Harvard South Shore Program, focused on generalized anxiety disorder (GAD) in older adults. Pertinent articles were identified and reviewed.ResultsSelective serotonin reuptake inhibitors (SSRIs) are considered to be first-line medications, with a preference for sertraline or escitalopram. If avoiding sexual side effects is a priority, buspirone is an option for the relatively healthy older adult. If response is inadequate, the second recommended trial is with a different SSRI or one of the serotonin-norepinephrine update inhibitors (SNRIs), venlafaxine or duloxetine. For a third medication trial, additional alternatives added to the previous options now include pregabalin/gabapentin, lavender oil, and agomelatine. If there is an unsatisfactory response to the third option chosen, quetiapine may be considered. We recommend caution with the following for acute treatment in this population: benzodiazepines and hydroxyzine. Other agents given low priority but having some supportive evidence were vilazodone, vortioxetine, mirtazapine, and cannabidiol. Acknowledging that the median age of onset of GAD is in early adulthood, many patients with GAD will have been started on benzodiazepines (or other medications that require caution in the elderly) for GAD at a younger age. These medications may be continued with regular observation to see if the potential harms are starting to exceed the benefits and a switch to other recommended agents may be justified.

The efficacy, safety, and adverse events of azapirones in anxiety disorders: A systematic review and meta-analysis of randomized controlled trials

Azapirones have been proposed as anxiety and mood modulators. We assessed azapirones' viability in anxiety disorders via systematic review and random-effects meta-analysis, inquiring PubMed/MEDLINE/CENTRAL/WHO-ICTRP/WebOfScience/VIP up-to 05/01/2023. We conducted sensitivity, and subgroup analyses assessing heterogeneity, publication bias, risk of bias, and confidence in the evidence within the GRADE framework. Symptom reduction (mean difference/MD), study-defined response (risk ratios/RRs), and acceptability were co-primary outcomes. Adverse events and withdrawal were secondary. Seventy studies were included. In generalized anxiety disorder (GAD), azapirones largely outperformed placebo (MD=-4.91, 95%C.I.[-5.91, -3.90], Hedges'g -1.37 [-1.02, -0.73]), k = 22, n = 2,567; RR=1.64, 95%C.I.[1.45, 1.86], k = 9, n = 1,346). While azapirones overlapped benzodiazepines in symptom reduction (MD=-0.12, 95%C.I.[-0.70, 0.45], k = 34, n = 3,160), they were slightly outperformed in response rate (RR=0.94, 95%C.I.[0.90, 0.99], k = 18, n = 2,423). Azapirones overlapped SRIs (MD=0.09, 95%C.I.[-0.49, 0.67], k = 8, n = 747; RR=0.97, 95%C.I.[0.89, 1.07], k = 7, n = 737). Confidence in estimates was high/moderate vs. placebo, moderate/low vs. benzodiazepine, very-low vs. SRIs. Azapirones failed to outperform the placebo in panic and social anxiety disorders. Azapirones overlapped placebo and SRIs in drop-out rates, while they showed higher treatment discontinuation rates than benzodiazepines (RR=1.33, 95%C.I.[1.16, 1.53], k = 23, n = 2,768). Azapirones caused less sedation/fatigue/drowsiness/weakness/cognitive issues than benzodiazepines, resembling placebo. They caused more nausea and dizziness than placebo, more headache and nausea than benzodiazepines, and less nausea and xerostomia than SRIs. Azapirones proved effective and relatively well-tolerated for GAD. They should be preferred over benzodiazepines, especially in the long-term, considering their lower sedation and addiction potential, representing a potential SRI alternative. Further research is warranted to prove efficacy in panic and social anxiety.

Predictors and moderators of treatment outcome in late-life anxiety: A systematic review

BACKGROUND

The aim of this review was to identify and critically appraise predictors and moderators of outcomes of psychological and pharmacological treatments for late-life anxiety disorders. Their identification may guide the development of personalised treatments for older people with anxiety disorders.

METHODS

Web of Science, PsychINFO, CINAHL, Embase, and Pubmed were searched for studies published up to 12 May 2022. Randomised controlled trials and observational studies reporting treatment predictors and moderators were included. Participants with a diagnosis of any anxiety disorder who were aged over 60 years were included. Treatment outcomes included response, remission, and change in anxiety score.

RESULTS

Thirteen studies met the inclusion criteria. Twenty-three out of 49 predictors or moderators assessed at post-treatment, and 14 out of 33 predictors or moderators assessed at follow-up were statistically significant. Only one predictor, baseline worry severity at post-treatment, was reported in at least three studies. Most studies were rated as having a low risk of bias in at least three areas and satisfied important quality criteria for predictor and moderator analyses.

LIMITATIONS

Samples were predominantly white, female and highly educated, and most studies were secondary analyses.

CONCLUSIONS

There is evidence that baseline worry severity appears to predict treatment outcome in late-life anxiety disorders. However, this was only explored in psychological intervention studies and therefore its predictive ability in pharmacotherapy remains unknown. Future research should explore predictors and moderators in a range of anxiety disorders and design methodologically-strong and adequately-powered studies with the primary aim of assessing predictors of treatment outcomes.

The relationship between anxiety and social support in male and female students in high schools in the southeast of Iran

INTRODUCTION

Adolescence is associated with physical, social and personality changes. Adolescents usually face some fears during this period, the removal and adjustment of which requires family and teachers' support and the lack of attention to the issues of maturity will have negative effects on their health, awareness and self-esteem. The aim of this study was to investigate the relationship between anxiety and social support among male and femaille students in high schools in the southeast of Iran.

MATERIALS AND METHODS

In this cross-sectional study that was conducted as a descriptive comparison, 452 students who were studying in the first period of high school in Kerman (junior high schools) were selected as the entire population by the cluster sampling method and the data collection instruments were: a demographic questionnaire, Philips Social Support Scale and the Cattle Anxiety Scale. As well as descriptive statistics, to test the hypothesis of this study by SPSS software, and in the case of abnormal distribution of each variable, non-parametric tests were used.

RESULTS

The results showed that anxiety in girls is great than in boys, also data analysis through Pearson's test showed that there is a negative and significant relationship between anxiety and social support in girls (r = -0.428, n = 226, p < 0.001) and boys (r = -0.378, n = 226, p < 0.001).

CONCLUSION

The results of research showed that by increasing perceptions of social support in students, their anxiety decreases. Therefore, paying attention to the social determinants of health such as social support is important and necessary to reduce the anxiety of students.

The moderating effect of social support on the relationship between physical health and suicidal thoughts among Chinese rural elderly: A nursing home sample

Suicide rate is relatively high among Chinese rural elderly. While there has been some exciting work on reporting and preventing suicide among community-dwelling elderly, only a few published studies have addressed the issues of rural nursing homes in China. This study aimed to investigate the relationship among perceived social support, physical health, and suicidal thoughts of the elderly living in Chinese rural nursing homes. It also examined the moderating effects of social support on the path from physical health to suicidal thoughts of the rural institutional elderly in China. This study investigated 205 participants aged 60 years and above in Chinese rural nursing homes. Participants' suicidal thoughts, perceived social support, and physical health were assessed. This study conducted descriptive analysis, Student's t-test, and Pearson's chi-square test to test how physical health and social support predicted suicidal thoughts, as well as the moderating effects of family's, friends', and others' social support on physical health and suicidal thoughts. Both physical health and perceived social support were significantly related to suicidal thoughts. Perceived social support from family, friends, and significant others moderated the relationship between physical health and suicidal thoughts. Findings of this study suggested that increasing social support and improving physical health would be effective in both suicide prevention and intervention for the residents in Chinese rural nursing homes.

Anxiety disorders in older people

This article reviews the research into anxiety disorders in adults aged 65 years and older that has been published over the past ten years. The topics covered include: the construct of anxiety and its disorders in this age group; epidemiology, including prevalence, incidence, course, outlook, and risk factors; assessment scales; co-morbidity and differential diagnosis (depression, dementia, physical illness); and management, both pharmacological and non-pharmacological. There has been a significant improvement in our understanding of these disorders in older adults over this period, but evidence to support their treatment and prevention is still quite sparse.

Interventions for generalized anxiety disorder in older adults: systematic review and meta-analysis

INTRODUCTION

Generalized anxiety disorder (GAD) is one of the most common anxiety disorders in later life, with widespread consequences for individuals and society.

OBJECTIVE

To perform a systematic review of the efficacy of controlled interventions for GAD in adults aged 55 years and older.

METHOD

Direct search of digital databases and the main publications on aging and iterative searches of the references from retrieved articles.

RESULTS

Twenty-seven trials (14 pharmacological, 13 psychotherapeutic) fulfilled the inclusion criteria, reporting results from 2373 baseline participants. There were no differences between trials in their overall quality. Pooled treatment effects for pharmacological (OR=0.32, 95% CI: 0.18, 0.54) and psychotherapeutic (OR=0.33, 95% CI: 0.17, 0.66) trials were similar, with findings in each case favoring active interventions over control conditions.

CONCLUSIONS

Older adults with GAD benefited from both pharmacological and psychotherapeutic interventions. Future studies should investigate combined treatment with medication and psychotherapy.

The roles of social support and self-efficacy in physical health's impact on depressive and anxiety symptoms in older adults

Physical illness may precipitate psychological distress among older adults. This study examines whether social support and self-efficacy moderate the associations between physical health and depression and anxiety. Predictions were tested in 222 individuals age 60 or older presenting for help with worry. Physical health was assessed through self-report (subjective) and physical diagnoses (objective). Objective physical health did not have a significant association with depression or anxiety. Worse subjective physical health was associated with increased somatic anxiety, but not with depression or worry. The relationship between subjective physical health and depressive symptoms was moderated by self-efficacy and social support. As predicted, when self-efficacy was low, physical health had its strongest negative association with depressive symptoms such that as physical health improved, depressive symptoms also improved. However, the moderation effect was not as expected for social support; at high levels of social support, worse physical health was associated with increased depressive affect.

Randomized, single-blind, trial of sertraline and buspirone for treatment of elderly patients with generalized anxiety disorder

AIM

Generalized anxiety disorder (GAD) in elderly people is common, but few systematic studies regarding the best treatments have been performed. The aim of the present study was to evaluate the efficacy and safety of sertraline and buspirone in the treatment of elderly patients with GAD.

METHODS

Based on selection criteria, 46 patients were recruited who met DSM-IV criteria for GAD. Patients were randomly assigned to sertraline (50-100 mg/day) or buspirone (10-15 mg/day) for 8 weeks in a single-blind trial. The primary outcome measure used in the present study was the Hamilton Rating Scale for Anxiety (HRSA).

RESULTS

Both sertraline and buspirone had significant anxiolytic efficacy. A steady decrease in the total HRSA scores for both groups was observed throughout the study period. After 2 and 4 weeks, buspirone was found to be significantly superior to sertraline (P < 0.001), but at the end of study period this difference did not reach statistical significance (P = 0.16). The mean HRSA score after 8 weeks significantly decreased in subjects treated with sertraline (P < 0.001), and buspirone (P < 0.001). No clinically adverse events or changes in laboratory test results were observed during the study period.

CONCLUSION

Both sertraline and buspirone appear to be efficacious and well tolerated in the treatment of GAD in elderly patients. Further studies with larger sample size, evaluating the effect of medical illness, cognitive impairment, depression, and combined therapy with support and psychotherapy are needed.

Treatment of anxiety disorders in older adults: a meta-analytic comparison of behavioral and pharmacological interventions

OBJECTIVE

To reduce the morbidity attributable to anxiety disorders in old age and to improve the quality of care, data on the effectiveness of current treatments are needed.

METHODS

A comparative meta-analysis of 32 studies of treatments focused on anxiety disorders in older adults (N = 2,484) receiving behavioral interventions or pharmacotherapy was conducted.

RESULTS

In separate analyses of the effects of interventions, stronger improvements of anxiety symptoms are found in pharmacotherapy than in behavioral interventions (d = 1.76 versus d = 0.81 SD units). This difference disappears when computing effect sizes that control for nonspecific change in the control group (d = 0.80 and d = 0.83 SD units) because effect sizes are greater in pill-placebo controls of pharmacological studies than in control groups (e.g., wait list) of behavioral interventions (d = 1.06 versus d = 0.10 SD units). Both interventions also yield moderate reductions in depressive symptoms (d = 0.59 versus d = 0.61 SD units), and dropout rates were comparable.

CONCLUSIONS

Available pharmacotherapy and behavioral interventions are reasonably effective. Given the higher average treatment effects of pharmacological interventions, pharmacotherapy may be the first choice of treatment as long as medical conditions and patients' preferences do not preclude this form of treatment.