Benzodiazepines About half of elderly patients with a diagnosis of anxiety disorder are treated by a pharmacological intervention [11]. The benzodiazepines are the most frequently prescribed class of drug therapy [11]. Despite the common use of benzodiazepines in the treatment of geriatric anxiety, few randomized controlled trials exist to substantiate their use. The common consensus is that benzodiazepines are effective medications in the elderly, but should be used with a degree of caution. The benzodiazepines have a sedative effect that may worsen cognition in the elderly. The use of lower doses and a frequent reassessment of elderly patients being treated with benzodiazepines are recommended. There are numerous benzodiazepines available on the market for the treatment of anxiety symptoms. A general recommendation is that shorter half-life benzodiazepines be used when treating the elderly. Longer acting benzodiazepines may not clear from the system as quickly in geriatric patients and, hence, tend to accumulate, causing oversedation. Table 15.8 lists several benzodiazepines that are useful in treating anxiety symptoms [21]. Selective Serotonin Reuptake Inhibitors Despite reports that the selective serotonin reuptake inhibitors (SSRIs) may cause a slight increased initial risk of suicide in the elderly [20], there is considerable recognition that this class of medication is quite helpful in the management of anxiety disorders. The effect of SSRI treatment is not as immediate as that seen with benzodiazepine therapy. An SSRI may require 7 to 30 days to reach a desired effect [21]. Starting with a low dose is recommended in the elderly, perhaps half of the usual staring dose for a younger adult patient [21]. In general, these medications have a relatively long half-life and may take as long as 30 days to reach steady state [21]. Long-term use of SSRIs in the elderly has been shown to be effective and safe [3]. Side effects are usually mild at lower doses. The elderly patient may be more sensitive to medications in general, and the SSRIs are no exception. Side effects of SSRI use in the geriatric patient are listed in Table 15.9 [22]. A discontinuation syndrome is possible following long-term treatment with this class of medicine. The syndrome is manifested by several symptoms including increased agitation, multiple somatic sensations such as tingling and electrical shocks, and a general feeling of illness. The SSRIs with shorter half-lives are more likely to cause this problem. Tapering of the dose over 1 to 2 weeks will reduce or prevent the discontinuation syndrome (Table 15.10).