Do you consider using buspirone for the management of anxiety in older patients?

While buspirone has been FDA-approved for the treatment of generalized anxiety disorder (GAD) and for short-term relief of anxiety symptoms in general since the 1970s, it is not generally considered a first-line treatment, despite its low misuse potential as a non-benzodiazepine. There are no large studies of its use in the older patient with anxiety. One study in 2010 of 46 patients with a mean age of 66 found equivalent positive effects on GAD symptoms when compared with sertraline [1]. A Coch...

Hydroxyzine... everyone thinks it is anticholinergic since it is an antihistamine like Benadryl, which is anticholinergic. The Ki value for muscarinic receptors is >4000, which is clinically negligible.

End of the day - it's not anticholinergic and is safe to use in the elderly.

On another note, doxepin at low doses is selective for H1 receptors, so you can also use this in the elderly and not worry about anticholinergic effects or QTc prolongation.

I have found buspirone helpful for many patients, of all ages, but it has to be used correctly, and patient expectations have to be addressed early. It does not work quickly, and for people with anxiety, that is often translated to it not working at all. Before I start it, I explain that it will take about two months to reach full efficacy at any particular dose, so the patient knows that they have to be patient. I’ve also found it to be most effective at dosages between 30 mg and 60 mg (total) ...

Buspirone has been a drug looking for a home for a long time. The data in older adults are almost nonexistent, but I do see a real signal for anxiety when it’s used correctly. The bigger issue is that people rarely dose it high enough, and its short half‑life means patients often feel it fade.

I’ve had plenty of patients do fine on BID. What I’ve also noticed is that some people like having the option of an extra dose when their anxiety spikes. Whether that’s pharmacologic or supratentorial doesn...

I use Clonidine for GAD, with careful monitoring of blood pressure. I find it to be safe and effective, especially for insomnia, and easy to stop. Excellent results. The main side effect is tiredness, which some people don't tolerate well. For intermittent anxiety and panic attacks, I use propranolol, unless there is a history of asthma, which can be triggered by beta blockers. Again, good results. Some people will carry propranolol around for a sense of security.

It is impossible to study GAD with clinical trials and randomized studies, as the condition seems to be the end product of biological, psychological, social, and existential conflicts that surface especially in old age. With that said, buspirone is an excellent choice to weave into a psychotherapeutic alliance to address debilitating anxiety concerns. Setting proper expectations at the onset that “we will not just numb you as in benzodiazepines” allows the patients to allow themselves to work th...