Flint Alastair J, Gagnon Nadine
Departments of Psychiatry, University Health Network and University of Toronto, Toronto, Ontario, Canada.
Drugs Aging. 2003;20(12):881-91. doi: 10.2165/00002512-200320120-00002.
Panic disorder occurs less frequently in the elderly than in younger adults and rarely starts for the first time in old age. Panic attacks that begin in late life should prompt the clinician to conduct a careful search for a depressive disorder, physical illness or drugs that could be contributing to their presence. When panic attacks do occur in the elderly, the symptoms are qualitatively similar to those experienced by younger people. The elderly, however, may have fewer and less severe symptoms and exhibit less avoidant behaviour. As panic disorder is typically a chronic or recurrent condition, its management requires a long-term approach. With the exception of one descriptive pilot study, there have been no randomised controlled trials of the treatment of panic disorder in later life. Therefore, recommendations regarding the management of this disorder in the elderly must be extrapolated from research pertaining to younger patients. Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors, benzodiazepines and cognitive behavioural therapy are efficacious treatments for panic disorder. There are no consistent differences in efficacy between classes of medications or between pharmacotherapy and cognitive behavioural therapy. Furthermore, there are no reliable predictors of response to one type of treatment compared with another. Treatment selection, therefore, depends on an individual assessment of the risks and benefits of each type of treatment (taking into account comorbid psychiatric and physical conditions), patient preference, cost and the availability of therapists skilled in cognitive behavioural techniques. As a general rule, antidepressant medication is preferable to a benzodiazepine as a first-line treatment for panic disorder in the elderly, especially given the high level of comorbidity between panic disorder and depressive disorders. Of the antidepressants, an SSRI is recommended as the initial choice of treatment in older patients. Anxious patients frequently misattribute somatic symptoms of anxiety to adverse effects of medication. Adherence with treatment, therefore, can be enhanced by starting antidepressant medication at a low dosage so as to avoid initial exacerbation of anxiety (but then gradually increasing the dosage to the therapeutic range), frequent follow-up during the first few weeks of treatment, discussion about potential adverse effects and addressing any other concerns the patient may have about taking medication. Given the delayed onset of action of antidepressant medication, the short-term use of adjunctive lorazepam in the first few weeks of treatment may be helpful in selected patients.
惊恐障碍在老年人中比在年轻人中出现得更少，且很少在老年时首次发作。在晚年开始的惊恐发作应促使临床医生仔细寻找可能导致其出现的抑郁症、躯体疾病或药物。当老年人确实出现惊恐发作时，其症状在性质上与年轻人经历的症状相似。然而，老年人可能症状较少且不太严重，回避行为也较少。由于惊恐障碍通常是一种慢性或复发性疾病，其管理需要长期方法。除了一项描述性的试点研究外，尚无针对晚年惊恐障碍治疗的随机对照试验。因此，关于老年人这种疾病管理的建议必须从针对年轻患者的研究中推断得出。选择性5-羟色胺再摄取抑制剂（SSRI）、三环类抗抑郁药、单胺氧化酶抑制剂、苯二氮䓬类药物和认知行为疗法是治疗惊恐障碍的有效方法。不同类别的药物之间或药物治疗与认知行为疗法之间在疗效上没有一致的差异。此外，与另一种治疗相比，没有可靠的反应预测指标。因此，治疗选择取决于对每种治疗的风险和益处的个体评估（考虑到合并的精神和躯体状况）、患者偏好、成本以及具备认知行为技术技能的治疗师的可用性。一般来说，抗抑郁药物作为老年人惊恐障碍的一线治疗比苯二氮䓬类药物更可取，特别是考虑到惊恐障碍和抑郁症之间的高共病率。在抗抑郁药物中，推荐SSRI作为老年患者治疗的初始选择。焦虑患者经常将焦虑的躯体症状归因于药物的不良反应。因此，通过以低剂量开始使用抗抑郁药物以避免最初的焦虑加重（但随后逐渐增加剂量至治疗范围）、在治疗的头几周频繁随访、讨论潜在的不良反应以及解决患者可能对服药存在的任何其他担忧，可以提高治疗依从性。鉴于抗抑郁药物起效延迟，在治疗的头几周短期使用辅助性劳拉西泮可能对部分患者有帮助。
