Perspectives to the Management of Anxiety and Irritability in the Medically Ill and Geriatric Patients

Vernon M Neppe MD, PhD

Educational Objectives

1. To educate in the area of anxiety and to discuss the clinical implications with regard to management options and problems.

Abstract

The current classification of anxiety of a separation of panic and generalized anxiety disorder has historical and epidemiologic limitations. We review alternative perspectives of anxiety viewed along the normal - abnormal continuum , as well as the frameworks of somatic and psychic anxiety. Similarly, subdivisions into adjustment disorder, anxiety states, mixed anxiety / depression and organic anxiety disorder lead to a more fruitful approach as to the patient’s pharmacologic needs. Classification of irritability and aggression is limited by the lack of diagnoses in DSM3R, terminology confusion and unavailability of marketed drugs for aggression. Drugs for these indications should preferably be non-sedative, not induce dependence, be safe and have limited drug interactions, particularly in specialized groups such as addicts, medically ill and geriatric patients. Irritability is an especially difficult and common problem in the elderly, yet there are no approved agents for aggression or irritability.

One approach to anxiety involves a re-evaluation of past management to eliminate side-effects and develop customized treatment. Alcohol, bromides, barbiturates, meprobamate and the benzodiazepines have all had their problems. The benzodiazepines have benefits with selected but limited indications in anxiety because of amnesic effects and impairments of psychomotor responses (potential risks with driving and falls in the elderly). Benzodiazepines have no place in irritability. Legitimate alternatives exist such as antidepressant in anxiety, and beta-adrenergic blockers and azapirones in both anxiety and irritability.

Psychopharmacology is rapidly approaching the age of specialized receptorology and serotonin subtypes play a major role in management of both anxiety and depression. The advent of the azapirones has been a significant advance and may exemplify the neuromodulating roles played by varying doses of drug impinging on a specific receptor, in this instance serotonin 1A. The azapirones are potent anti-aggressive and anti-anxiety agents in animal models probably via components of their specific serotonin 1A effects. Irritability is an early target symptom of response with low-dose buspirone in generalized anxiety disorder. Moreover, preliminary open experience suggests a low doses of buspirone (15-25 mg per day) is effective after a few days in alleviating irritability, anger and hostility without associated significant anxiety in three studies by the author - all statistically significant. This data requires adequate controlled studies as buspirone as the only marketed azapirone is approved for use only in anxiety and mixed anxiety depressive states.