Prevalence of anxiety disorders in elderly adults: a critical analysis

Detecting Anxiety in Long-Term Care Residents: A Systematic Review

Anxiety is common in long-term care (LTC), but it is unclear which anxiety detection tools are accurate when compared to a reference standard for residents of LTC. Four databases and grey literature sources were searched using the search concepts "anxiety" and "LTC". Included studies evaluated the diagnostic accuracy of an anxiety detection tool compared to a reference standard in LTC residents. Diagnostic accuracy measures were extracted. Four articles out of 4,620 met the inclusion criteria. Despite limited evidence and poorly reported study procedures and characteristics, the Geriatric Anxiety Inventory (sensitivity: 90.0%, specificity: 86.2%) and the Hospital Anxiety and Depression Scale-Anxiety (sensitivity: 90.0%, specificity: 80.6%) had the best performance when detecting generalized anxiety disorder. We identified four anxiety detection tools appropriate for use in LTC; a critical first step to diagnosing and managing anxiety in residents of LTC. Non-generalized anxiety disorders and tool feasibility must be further evaluated.

The association between chronic pain conditions and subclinical and clinical anxiety among community-dwelling older adults consulting in primary care

OBJECTIVE

To examine associations between chronic pain conditions, pain level, and subclinical/clinical anxiety in community-dwelling older adults.

DESIGN

Cross-sectional associations were analyzed using multinomial logistic regression to compare the odds of having subclinical/clinical anxiety by painful condition and pain level, controlling for confounders.

SETTING

Participants were recruited in primary care waiting rooms to take part in the first wave of the Étude sur la Santé des Aînés (ESA)-Services study.

SUBJECTS

1608 older adults aged 65+.

METHODS

Clinical anxiety was assessed using DSM-IV criteria. Subclinical anxiety was considered present when participants endorsed symptoms of anxiety but did not fulfill clinical diagnostic criteria for an anxiety disorder. Painful chronic conditions included arthritis, musculoskeletal conditions, gastrointestinal problems, and headaches/migraines. Presence of painful conditions was assessed using combined self-report and health administrative data sources. Pain level was self-reported on an ordinal scale. Physical comorbidities were identified from ICD-9/10 diagnostic codes and depression was evaluated based on the DSM-IV.

RESULTS

Sixty-six percent of home-living older adults suffer from a chronic pain condition. Older adults with clinical anxiety are more likely to experience musculoskeletal pain, gastrointestinal problems, headaches/migraines, and higher pain levels compared to those with no anxiety. Also, those with ≥3 painful conditions are at greater risk for subclinical and clinical anxiety compared to those with no painful condition.

CONCLUSIONS

These results emphasize the need for assessing anxiety symptoms in older adults with chronic pain conditions. Comprehensive management of comorbid chronic pain and psychopathology might help reduce the burden for patients and the healthcare system.

Odorants: a tool to provide nonpharmacological intervention to reduce anxiety during normal and pathological aging

Anxiety disorders represent 1 of the most common classes of psychiatric disorders. In the aging population and for patients with age-related pathology, the percentage of people suffering of anxiety is significantly elevated. Furthermore, anxiety carries with it an increased risk for a variety of age-related medical conditions, including cardiovascular disease, stroke, cognitive decline, and increased severity of motor symptoms in Parkinson's disease. A variety of anxiolytic compounds are available but often carry with them disturbing side effects that impact quality of life. Among nonmedicinal approaches to reducing anxiety, odor diffusion and aromatherapy are the most popular. In this review, we highlight the emerging perspective that the use of odorants may reduce anxiety symptoms or at least potentiate the effect of other anxiolytic approaches and may serve as an alternative form of therapy to deal with anxiety symptoms. Such approaches may be particularly beneficial in aging populations with elevated risk for these disorders. We also discuss potential neural mechanisms underlying the anxiolytic effects of odorants based on work in animal models.

A precision medicine approach to pharmacological adjuncts to extinction: a call to broaden research

There is a pressing need to improve treatments for anxiety. Although exposure-based therapy is currently the gold-standard treatment, many people either do not respond to this therapy or experience a relapse of symptoms after treatment has ceased. In recent years, there have been many novel pharmacological agents identified in preclinical research that have potential as adjuncts for exposure therapy, yet very few of these are regularly integrated into clinical practice. Unfortunately, the robust effects observed in the laboratory animal often do not translate to a clinical population. In this review, we discuss how age, sex, genetics, stress, medications, diet, alcohol, and the microbiome can vary across a clinical population and yet are rarely considered in drug development. While not an exhaustive list, we have focused on these factors because they have been shown to influence an individual's vulnerability to anxiety and alter the neurotransmitter systems often targeted by pharmacological adjuncts to therapy. We argue that for potential adjuncts to be successfully translated from the lab to the clinic empirical research must be broadened to consider how individual difference factors will influence drug efficacy.

A cross-sectional study on clinical correlates of anxiety disorders in 613 community living older adults in Hong Kong

OBJECTIVES

Previous studies have reported that the prevalence of late life anxiety disorders varies between 3.2% and 15.3%. Despite its high prevalence, anxiety disorders are still under-recognized in old age. This study evaluated the association among health, psychosocial factors, lifestyle choices, cognitive function and anxiety disorders in the older population in Hong Kong.

METHODS

Six hundred and thirteen volunteer participants aged 60 years or above were interviewed for their socio-demographic background, physical and mental health statuses, social network, cognitive function and their activity engagement style. Ascertainment of diagnosis of anxiety disorders was based on the use of ICD-10 diagnostic criteria generated by the Revised Clinical Interview Schedule (CIS-R) algorithms.

RESULTS

According to the ICD-10 diagnostic criteria generated by the CIS-R algorithms, 4.4% (N = 27) had mixed anxiety and depressive disorder, 2.5% (N = 15) had generalized anxiety disorders and 0.2% (N = 1) had other anxiety disorders (Phobia). Individuals with anxiety disorders had more gastrointestinal conditions (OR = 2.66, 95% CI 1.48-4.76) and genitourinary problems (OR = 1.96, 95% CI 1.05-3.65), poor 10-min delayed recall (OR = 0.68, 95% CI 0.56-0.83), worse abstract thinking (OR = 0.65, 95% CI 0.49-0.85) and poor social networking in confidante relationship (OR = 0.88, 95% CI 0.79-0.98). Lifestyle activity engagement was not associated with the presence of anxiety disorders.

CONCLUSIONS

Older adults with anxiety disorders appeared to have greater medical comorbidity and lower cognitive function. While anxiety may affect memory performance, future studies are needed to explore if anxiety symptom may reflect early neurodegeneration that easily escapes clinical attention. Copyright © 2016 John Wiley & Sons, Ltd.

DETECTION OF ANXIETY DISORDERS IN PRIMARY CARE: A META-ANALYSIS OF ASSISTED AND UNASSISTED DIAGNOSES

BACKGROUND

Evidence suggests that general practitioners (GPs) fail to diagnose up to half of common mental disorder cases. Yet no previous research has systematically summarized the evidence in the case of anxiety disorders. The aim of this review was to systematically assess and meta-analyze the diagnostic accuracy of GPs' assisted (i.e., using severity scales/diagnostic instruments) and unassisted (without such tools) diagnoses of anxiety disorders.

METHODS

Systematic review (PROSPERO registry CRD42013006736) was conducted. Embase, Ovid Journals--Ovid SP Medline, Pubmed, PsycINFO, Scopus, Web of Science, and Science Direct were searched from January 1980 through June 2014. Seven investigators, working in pairs, evaluated studies for eligibility. The quality of included studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool version 2 (QUADAS-2). The main outcome measures were sensitivity and specificity of clinical diagnoses of any anxiety disorder. We pooled sensitivity and specificity levels from included studies using bivariate meta-analyses.

RESULTS

Twenty-four studies were included in the meta-analysis with a total sample of 34,902 patients. Pooled sensitivity and specificity were estimated at 44.5% (95% CI 33.7-55.9%) and 90.8% (95% CI 87-93.5%). GPs' sensitivity was higher when diagnoses were assisted (63.6%, 95% CI 50.3-75.1%) than when unassisted (30.5%, 95% CI 20.7-42.5%) to the expense of some specificity loss (87.9%, 95% CI 81.3-92.4% vs. 91.4%, 95% CI 86.6-94.6%, respectively). Identification rates remained constant over time (P-value = .998).

CONCLUSIONS

The use of diagnostic tools might improve detection of anxiety disorders in "primary care."

Anxiety among community-dwelling U.S. Chinese older adults

BACKGROUND

This study aimed to explore the prevalence and correlates of anxiety disorders and any anxiety symptoms among community-dwelling U.S. Chinese older adults.

METHODS

Guided by a community-based participatory research approach, 3,159 community-dwelling Chinese older adults in the Greater Chicago area were interviewed in person between 2011 and 2013.

RESULTS

Of 3,159 older adults surveyed, 8.5% had anxiety disorders and 65.0% reported having any anxiety symptoms. Being female, unmarried, poorer health status, lower quality of life, and worsening health over the past year were positively correlated with anxiety disorders and any anxiety symptoms. Living with fewer people and having fewer children were only correlated with any anxiety symptoms and lower income was only correlated with anxiety disorders.

CONCLUSIONS

This study emphasizes that interventions for anxiety among Chinese older adults should give special attention to older women, those who are unmarried, with impaired health status, and poorer quality of life. Further longitudinal studies should be conducted to better understand risk factors and outcomes associated with anxiety among U.S. Chinese older adults.

Illness conceptualizations among older rural Mexican-Americans with anxiety and depression

Research on barriers and utilization of mental health services in older ethnic minorities has been productive. However, little is known about the characterization and beliefs about anxiety and depression symptoms among older Mexican-Americans. Exploration of these conceptualizations will lead to better detection and provision of care to this large, yet underserved group. The present study used a mixed methods approach to explore conceptualizations of anxiety and depression in a group of rural older Mexican-Americans. Twenty-five Spanish-speaking participants (mean age 71.2) responded to flyers that solicited individuals who felt “tense or depressed.” Participants completed a structured diagnostic interview as well as self-report questionnaires about medical health, anxiety and depressive symptoms, and cognitive functioning. Qualitative interviews included questions about how participants describe, conceptualize, and cope with anxiety and depression symptoms. Sixty-eight percent of the sample met criteria for at least one anxiety or mood disorder with high comorbidity rates. Self-reported symptoms of depression, anxiety, and somatization were below clinical ranges for all participants. Medical illness, cognitive impairment, age, education, and acculturation were not associated with distress. Qualitative analyses revealed that nearly half of the terms used by the sample to describe distress phenomena deviated from Western labels traditionally used to indicate anxious and depressive symptomatology. Multiple methods of symptom endorsement demonstrated that older Mexican-Americans may report distress differently than detected by traditional self-report measures or common Western terminology. Understanding these additional illness conceptualizations may have implications for improving the detection of mental illness and increasing service use among this growing population.

Mood and anxiety disorders across the adult lifespan: a European perspective

BACKGROUND

The World Mental Health Survey Initiative (WMHSI) has advanced our understanding of mental disorders by providing data suitable for analysis across many countries. However, these data have not yet been fully explored from a cross-national lifespan perspective. In particular, there is a shortage of research on the relationship between mood and anxiety disorders and age across countries. In this study we used multigroup methods to model the distribution of 12-month DSM-IV/CIDI mood and anxiety disorders across the adult lifespan in relation to determinants of mental health in 10 European Union (EU) countries.

METHOD

Logistic regression was used to model the odds of any mood or any anxiety disorder as a function of age, gender, marital status, urbanicity and employment using a multigroup approach (n = 35500). This allowed for the testing of specific lifespan hypotheses across participating countries.

RESULTS

No simple geographical pattern exists with which to describe the relationship between 12-month prevalence of mood and anxiety disorders and age. Of the adults sampled, very few aged ≥ 80 years met DSM-IV diagnostic criteria for these disorders. The associations between these disorders and key sociodemographic variables were relatively homogeneous across countries after adjusting for age.

CONCLUSIONS

Further research is required to confirm that there are indeed stages in the lifespan where the reported prevalence of mental disorders is low, such as among younger adults in the East and older adults in the West. This project illustrates the difficulties in conducting research among different age groups simultaneously.

Clinical issues in the treatment of anxiety and depression in older adults with Parkinson's disease

A significant proportion of persons affected by Parkinson's disease (PD) are over age 65 years. Mental health issues are often less a focus of treatment in this population than physical manifestations of the illness. Anxiety or depression alone, as well as comorbid depression and anxiety, are underrecognized in patients with PD and are associated with deleterious effects on physical and interpersonal functioning, negatively impacting quality of life and well-being. We offer a brief overview of salient clinical points with respect to assessment and treatment approaches to enhance efficacy of the treatment of mental health symptoms in older adults with PD. Cognitive behavior therapy involves the patient learning to overcome behavioral avoidance associated with anxiety and challenge unhelpful negative cognitions. It is suggested that cognitive behavior therapy is an effective approach to treatment of anxiety and depression in PD and should be offered as a treatment to patients.

The prevalence of mental disorders in older people in Western countries - a meta-analysis

OBJECTIVE

To conduct a meta-analysis assessing the prevalence of mental disorders in older people in Europe and North America.

METHOD

Studies that reported prevalence rates of mental disorders in older people from the general population were identified through MEDLINE, PsycINFO, Web of Science, and reference lists for the period between January 2000 and December 2011. Studies were included if they reported prevalence rates of mental disorders in older people (50+ years) from the community. The final sample comprised 25 studies. Prevalence rates were extracted, and effect sizes were transformed into logits. Random-effects models were calculated due to significant heterogeneity. In meta-regression analyses possible sources of bias, including age of onset, gender distribution, and risk of bias were examined. To analyze the robustness of the results, sensitivity analyses were performed. Publication bias was assessed with funnel plots and the Egger method.

RESULTS

Disorders with the highest prevalence estimates were dimensional depression (19.47%), lifetime major depression (16.52%), and lifetime alcohol use disorders (11.71%). Disorders with the lowest estimates were current and lifetime drug use disorders (0.34% and 0.19%, respectively), and current bipolar disorder and current agoraphobia (both 0.53%).

CONCLUSION

The majority of studies investigated major depression, panic disorder and social phobia. Future research requires a larger database on the epidemiology of mental disorders in the elderly. Furthermore, an improvement to the methodology that addresses the challenges of older age and produces comparable data, including the use of instruments tailored to the needs of older people, is required.

Frequency of anxiety after stroke: a systematic review and meta-analysis of observational studies

BACKGROUND AND PURPOSE

Negative psychological outcomes occur frequently after stroke; however, there is uncertainty regarding the occurrence of anxiety disorders and anxiety symptoms after stroke. A systematic review of observational studies was conducted that assessed the frequency of anxiety in stroke patients using a diagnostic or screening tool.

SUMMARY OF REVIEW

Databases were searched up to March 2011. A random effects model was used to summarize the pooled estimate. Statistical heterogeneity was assessed using the I(2) statistic. Forty-four published studies comprising 5760 stroke patients were included. The overall pooled estimate of anxiety disorders assessed by clinical interview was 18% (95%confidence interval 8-29%, I(2)  = 97%) and was 25% (95% confidence interval 21-28%, I(2)  = 90%) for anxiety assessed by rating scale. The Hospital Anxiety and Depression Scale-Anxiety subscale 'probable' and 'possible' cutoff scores were the most widely used assessment criteria. The combined rate of anxiety by time after stroke was: 20% (95% confidence interval 13-27%, I(2)  = 96%) within one-month of stroke; 23% (95% confidence interval 19-27%, I(2)  = 84%) one to five-months after stroke; and 24% (95% confidence interval 19-29%, I(2)  = 89%) six-months or more after stroke.

CONCLUSION

Anxiety after stroke occurs frequently although methodological limitations in the primary studies may limit generalizability. Given the association between prevalence rates and the Hospital Anxiety and Depression Scale-Anxiety cutoff used in studies, reported rates could in fact underrepresent the extent of the problem. Additionally, risk factors for anxiety, its impact on patient outcomes, and effects in tangent with depression remain unclear.

Assessment of anxiety in older adults: a systematic review of commonly used measures

OBJECTIVES

The authors set out to systematically review the research literature in order to identify the anxiety measures most commonly used in the assessment of older adults. Once identified, the literature was reviewed to determine the extent to which these instruments had age-relevant norms and psychometric data supporting their use with older adults.

METHOD

Literature searches were conducted in PsycINFO and PubMed to identify research articles in which anxiety measures were completed by older adults. After screening for suitability, a total of 213 articles were reviewed to determine the most commonly used anxiety measures with older adults to examine the psychometric properties of these instruments and to evaluate whether the instruments are appropriate for use with older adults.

RESULTS

A total of 91 different anxiety measures were used in the 213 included articles. Twelve anxiety measures were most commonly used in the literature and of those three were specifically developed for older adults.

CONCLUSIONS

Of the most commonly used measures, the majority lacked sufficient evidence to warrant their use with older adults. Based on psychometric evidence, three measures (Beck Anxiety Inventory, Penn State Worry Questionnaire, and Geriatric Mental Status Examination) showed psychometric properties sufficient to justify the use of these instruments when assessing anxiety in older adults. In addition, two measures developed specifically for older adults (Worry Scale and Geriatric Anxiety Inventory) were also found to be appropriate for use with older adults.

Évaluation de l’usage à risque des benzodiazépines chez les personnes âgées : facteurs de risque et impacts

L’usage à risque de la benzodiazépine (BZD), fréquent chez les aînés, est un problème souvent sous-estimé. Cet article présente une recension des écrits qui explore ce profil de consommation problématique sur les plans biologique, psychologique et environnemental. Les auteurs constatent qu’il y un manque de consensus et de validité quant à la description du phénomène. Ils discutent de certains facteurs qui contribuent à l’usage à risque des BZD chez les aînés : des habitudes de prescriptions et des attitudes parfois laxistes des médecins ; les attitudes des aînés envers la maladie mentale et la façon dont se manifestent leurs symptômes ; les difficultés dans l’évaluation de l’anxiété et de la dépression des aînés. En conclusion, les auteurs proposent que la recherche s’intéresse à des méthodes intégratives pour l’évaluation de l’usage à risque de la BZD chez les aînés.

Psychometric properties of a structured interview guide for the rating for anxiety in dementia

OBJECTIVES

The Rating Anxiety in Dementia (RAID; Shankar, K.K., Walker, M., Frost, D., & Orrell, M.W. (1999). The development of a valid and reliable scale for rating anxiety in dementia (RAID). Aging and Mental Health, 3, 39-49.) is a clinical rating scale developed to evaluate anxiety in persons with dementia. This report explores the psychometric properties and clinical utility of a new structured interview format of the RAID (RAID-SI), developed to standardize administration and scoring based on information obtained from the patient, an identified collateral, and rater observation.

METHOD

The RAID-SI was administered by trained master's level raters. Participants were 32 persons with dementia who qualified for an anxiety treatment outcome study. Self-report anxiety, depression, and quality of life measures were administered to both the person with dementia and a collateral.

RESULTS

The RAID-SI exhibited adequate internal consistency reliability and inter-rater reliability. There was also some evidence of construct validity as indicated by significant correlations with other measures of patient-reported and collateral-reported anxiety, and non-significant correlations with collateral reports of patient depression and quality of life. Further, RAID-SI scores were significantly higher in persons with an anxiety diagnosis compared to those without an anxiety diagnosis.

CONCLUSION

There is evidence that the RAID-SI exhibits good reliability and validity in older adults with dementia. The advantage of the structured interview format is increased standardization in administration and scoring, which may be particularly important when RAID raters are not experienced clinicians.

Psychiatric disorders in ageing

The ageing of the population brings particular challenges to psychiatric practice. Although the clinical presentation of common psychiatric disorders such as mood and psychotic disorders is largely similar to those in younger adults, late life presentations tend to be more complex as co-morbidity with dementia and physical illness is common. Suicide tends to increase with age in most countries. In this chapter we argue that the aetiology of disorders may be best understood within a stress vulnerability model in which neurobiological and psychosocial factors interplay. We further present that management strategies need to be comprehensive, incorporating physical, social, pharmacological, and psychological treatments appropriate to each case. We close with a call for the use of specialised multi-disciplinary services to improve the overall quality of care.

The epidemiology of specific phobia and subthreshold fear subtypes in a community-based sample of older adults

BACKGROUND

Specific phobias have received little attention among older adults. This study is aimed at determining the 12-month prevalence rates of fear subtypes in older adults with a full or subthreshold DSM diagnosis of specific phobia as well as to examine differences among these conditions according to health and health behavior characteristics potentially associated with the severity of anxious symptoms.

METHODS

Data came from a representative sample of community-dwelling older adults aged 65 years and older (N = 2784). Diagnoses were established by in-home semi-structured interviews. DSM-IV criteria for specific phobia were slightly modified in line with recommendations for DSM-V.

RESULTS

The 12-month prevalence rates of specific phobias and subthreshold fears were, respectively, 2.0 and 8.7%. More than half of the respondents with a specific phobia did not recognize the "excessiveness" of their fears. Situational and natural environment fears were the most frequent subtypes. Compared to respondents with no symptoms of anxiety, older adults with a full- or subthreshold-specific phobia reported more chronic physical health problems, more comorbid depressive disorders and a higher use of benzodiazepines. However, older adults with specific phobia reported more comorbid anxiety disorders than respondents with subthreshold fears.

CONCLUSIONS

The present study provides evidence for the fact that subthreshold fears have a high prevalence among older adults. Since several older people with specific phobia do not recognize the "excessiveness" of their fears, it is recommended that DSM-V criteria allow clinicians to rely on their own judgment to assess whether the perceived danger is out of proportion.

The impact of DSM-IV symptom and clinical significance criteria on the prevalence estimates of subthreshold and threshold anxiety in the older adult population

OBJECTIVES

Subthreshold anxiety refers to a condition where individuals do not meet the full symptom criteria (i.e., the number of symptoms required for a formal diagnosis is not reached) and/or do not report significant impairment or distress in functioning (i.e., the clinical significance criterion is not met). The purpose of this study was to examine how the symptom and the clinical significance criteria may affect the prevalence estimates of anxiety problems in the older adult population and whether applying these criteria results in an identifiable older group showing more severe anxiety.

SETTING AND PARTICIPANTS

Data came from a large representative sample of community-dwelling older adults age 65 years and older (N = 2,784).

RESULTS

Results showed that the 12-month prevalence rate of any anxiety problem varied from 5.6% when DSM-IV criteria for anxiety disorders were used to 26.2% when all subthreshold manifestations of anxiety were considered. Findings also indicated that when compared with respondents without anxiety, older adults presenting different manifestations of subthreshold or threshold anxiety appear to be more similar than different in their health and health behavior characteristics.

CONCLUSIONS

Subthreshold anxiety has a high prevalence and may cause significant impairment. Both symptom and clinical significance criteria do not perfectly discriminate between older adults with or without a severe anxiety problem presenting comorbid disorders and needing psychiatric help.

Validity and reliability of the Geriatric Anxiety Inventory in Parkinson's disease

AIM

To examine the psychometric properties of a novel anxiety rating scale, the Geriatric Anxiety Inventory (GAI) in Parkinson's disease (PD).

METHOD

The predictive validity of the GAI was tested against the presence of any DSM-IV anxiety disorders in 58 PD patients using receiver operating curve analysis. The concurrent validity of this scale was also studied against the state half of the Spielberger State Trait Anxiety Inventory (STAI). The internal consistency and test-retest reliability of the GAI were also examined.

RESULTS

The GAI displayed good concurrent validity against the STAI and the DSM-IV. It also showed good internal consistency and test-retest reliability.

CONCLUSIONS

This study suggested that the GAI is an appropriate scale to use in non-demented PD patients.

Anxiety disorders in Parkinson's disease: prevalence and risk factors

Anxiety disorders are common in Parkinson's disease (PD) patients, yet are poorly studied. We examined the prevalence of anxiety disorders in PD, investigated the association between anxiety, and presentation and progression of PD, and studied for the first time the contribution of putative risk factors for anxiety in PD. A case-series of 79 PD patients recruited from neurology out-patient clinics was examined for anxiety disorders using the DSM-IV criteria. The Unified Parkinson's Disease Rating Scale and the Hoehn and Yahr Staging of PD were employed to understand the relationship between anxiety disorders, and the clinical presentation and severity of PD. A validated survey assessed putative risk factors for anxiety in PD. Twenty-five percent of PD patients were diagnosed with anxiety. Panic disorder, generalised anxiety disorder and social phobia were prevalent anxiety disorders. Comorbid depression with anxiety was observed (14%). The severity but not the duration of PD was positively related to anxiety. PD patients with postural instability and gait dysfunction symptom clustering were more likely to experience anxiety than tremor-dominant patients. While levodopa dosage had no relationship to anxiety, experience of dyskinesias or on/off fluctuations increased the risk. Lateralisation of PD had no association with anxiety. Anxiety disorders decreased with age and young onset PD patients were more likely to experience anxiety than the late onset subjects. Anxiety adds to the complexity of PD, lowering patients' quality of life. Future research can be directed to identify reactive and organic nature of anxiety in PD.

Specific phobias in older adults: characteristics and differential diagnosis

BACKGROUND

Differential diagnosis implies identifying shared and divergent characteristics between clinical states. Clinical work with older adults demands not only the knowledge of nosological features associated with differential diagnosis, but also recognition of idiosyncratic factors associated with this population. Several factors can interfere with an accurate diagnosis of specific phobia in older cohorts. The goal of this paper is to review criteria for specific phobia and its differential diagnosis with panic disorder, agoraphobia, post-traumatic stress disorder and obsessive compulsive disorder, while stressing the specific factors associated with aging.

METHODS

A literature search regarding specific phobia in older adults was carried out using PubMed. Relevant articles were selected and scanned for further pertinent references. In addition, relevant references related to differential diagnosis and assessment were used.

RESULTS

Etiologic factors, specificity of feared stimulus or situation, fear predictability and the nature of phobic situations are key points to be assessed when implementing a differential diagnosis of specific phobia.

CONCLUSIONS

First, age-related sensory impairments are common and interfere both with information processing and communication. Second, medical illnesses create symptoms that might cause, interfere with, or mimic anxiety. Third, cohort effects might result in underreporting, through the inability to communicate or recognize anxiety symptoms, misattributing them to physical conditions. Finally, diagnostic criteria and screening instruments were usually developed using younger samples and are therefore not adapted to the functional and behavioral characteristics of older samples.

Effect of age on the frequency of anxiety disorders in major depression with psychotic features

OBJECTIVE

To compare the frequency of anxiety disorders in older and younger persons with major depressive disorder with psychotic features.

DESIGN

Cross-sectional.

SETTING

University medical centers.

PARTICIPANTS

Two hundred fifty-nine persons (N = 117 aged 18-59 years and N = 142 aged > or =60 years) with major depressive disorder with psychotic features who were enrolled in the Study of the Pharmacotherapy of Psychotic Depression (STOP-PD).

MEASUREMENTS

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) defined anxiety disorders were determined by Structured Clinical Interview for DSM-IV interview at baseline assessment. Younger and older participants were compared on the frequencies of any current anxiety disorder and any lifetime anxiety disorder, as well as the frequencies of individual anxiety disorders.

RESULTS

Older persons had significantly lower frequencies of any current anxiety disorder and any lifetime anxiety disorder, even after controlling for relevant demographic and clinical variables. With respect to specific anxiety disorders, older persons had significantly lower frequencies of current and lifetime panic disorder, current and lifetime social anxiety disorder, and current and lifetime posttraumatic stress disorder.

CONCLUSION

The findings of this study are consistent with those of community-based epidemiologic surveys that anxiety disorders are less prevalent in older than younger adults. Because of the rigorous assessment used in STOP-PD, our findings suggest that the age-related decline in the prevalence of anxiety disorders is not simply due to a failure to detect cases in older people, as has been previously suggested.

Anxiety and the aging brain: stressed out over p53?

We propose a model in which cell loss in the aging brain is seen as a root cause of behavioral changes that compromise quality of life, including the onset of generalized anxiety disorder, in elderly individuals. According to this model, as stem cells in neurogenic regions of the adult brain lose regenerative capacity, worn-out, dead, or damaged neurons fail to be replaced, leaving gaps in function. As most replacement involves inhibitory interneurons, either directly or indirectly, the net result is the acquisition over time of a hyper-excitable state. The stress axis is subserved by all three neurogenic regions in the adult brain, making it particularly susceptible to these age-dependent changes. We outline a molecular mechanism by which hyper-excitation of the stress axis in turn activates the tumor suppressor p53. This reinforces the loss of stem cell proliferative capacity and interferes with the feedback mechanism by which the glucocorticoid receptor turns off neuroendocrine pathways and resets the axis.

Prevalence of anxiety disorders among elderly people

OBJECTIVES

The objectives of this study are to determine current and lifetime prevalence of anxiety disorders and also to explore the relationship, if any, between possible risk factors and anxiety disorders, amongst elderly people living in the Sivas province of Turkey.

METHODS

The research sample consisted of 462 persons. A Socio-demographic Data Form was given to the participants and the Anxiety Module of SCID-I was applied. Chi-square and Fischer's exact tests were used to evaluate the data obtained.

RESULTS

The current prevalence for all types of anxiety disorder was found to be 17.1% overall and the lifetime prevalence was found to be 18.6%. The current prevalence rates for particular disorders were found to be 0.4% for panic disorder, 3.2% for obsessive-compulsive disorder, 1.9% for post-traumatic stress disorder, 2.8% for social phobia, 11.5% for specific phobia, 6.9% for generalized anxiety disorder (GAD). Lifetime prevalence rates for these disorders (except GAD) were 1.1%, 3.2%, 3.0%, 2.85%, 11.5% respectively.

CONCLUSIONS

Anxiety disorders are more common among elderly people than was previously thought. The lifetime prevalence of specific phobia amongst the elderly is higher than that of general population; the lifetime prevalence ratios of obsessive-compulsive disorder and social phobia are similar to that of the general population in Sivas. In order to improve the delivery of health services, it is recommended that further studies should be conducted among elderly people, both by applying standardized diagnostic tools, but also taking into account socio-economic factors and using convenient therapy methods developed specifically for this group.

Anxiety symptoms in mild cognitive impairment

INTRODUCTION

Anxiety disorders are less well studied in elderly people than other disorders such as depression. In particular the diagnosis of anxiety is more difficult in patients with Mild Cognitive Impairment (MCI) since the current definition of MCI does not mention neuropsychiatric symptoms.

OBJECTIVES

To validate the Italian version of Geriatric Anxiety Inventory (GAI), an instrument that measures dimensional anxiety in elderly people, and assess whether MCI subjects with anxiety symptoms show different neuropsychological profiles in comparison with MCI without anxiety symptoms.

METHODS

Fifty-seven outpatients with MCI were consecutively recruited. All patients were assessed using a complete neuropsychological battery to detect the cognitive impairment, and the GAI for the presence of anxiety symptoms.

RESULTS

Anxiety + patients (GAI >or= 10) show more behavioral and psychological disturbances than patients with Anxiety- (GAI < 10); in particular they had more agitation, anxiety, depression and more sleep disorders. Moreover, Anxiety + patients are more compromised on instrumental daily functions and on executive functions evaluated with Trail Making B test (TMB). Linear Regression analysis was completed to estimate the coefficients of the linear equation, involving neuropsychological, psychobehavioural and functional characteristics: the executive functions (TMB) are the only variable independently related to the presence of anxiety disturbances.

CONCLUSIONS

Executive functions are independently related to anxiety disorders in MCI patients. We hypothesized that the strict interaction between anxiety symptoms and executive functions could depend on specific pathological features at the level of caudate nucleus characterizing early phases of dementia.

The prevalence of anxiety in older adults: methodological issues and a review of the literature

BACKGROUND

Despite the relative neglect of anxiety in older adults, the growing literature on its prevalence suggests that anxiety is highly prevalent and associated with considerable distress and morbidity in this age group. This review provides a comprehensive overview of this literature and discusses some unresolved controversies in the field.

METHODS

A systematic search of articles published from 1980-2007 was performed. Articles were included for review if they reported the prevalence of anxiety symptoms, anxiety disorder or specified anxiety disorders in adults aged >60 in either community or clinical settings.

RESULTS

The prevalence of anxiety in community samples ranges from 1.2% to 15%, and in clinical settings from 1% to 28%. The prevalence of anxiety symptoms is much higher, ranging from 15% to 52.3% in community samples, and 15% to 56% in clinical samples. These discrepancies are partly attributable to the conceptual and methodological inconsistencies that characterise this literature. Generalised Anxiety Disorder is the commonest anxiety disorder in older adults.

LIMITATIONS

The methodologies used in the studies are so variable as to make comparisons difficult.

CONCLUSIONS

Although anxiety disorder, particularly Generalised Anxiety Disorder is common, issues in relation to comorbidity and the nature of anxiety in old age remain unresolved. This hampers the design of intervention programmes, and highlights the need for further research with a primary focus on anxiety.

Co-occurrence of anxiety and depressive disorders in a community sample of older people: results from the MRC CFAS (Medical Research Council Cognitive Function and Ageing Study)

BACKGROUND

Few population-based studies have examined the whole range of subthreshold syndromes and disorders of anxiety and depression in older people.

AIMS

To investigate the co-occurrence of anxiety and depressive syndromes in older people. Associations between these conditions and personal and environmental factors are examined.

METHOD

MRC CFAS included 13,004, age 65 years and above, who completed the initial screening interview. A stratified random subsample of 2,640 participated in the assessment interview where the Geriatric Mental State Examination (GMS) was administered. The AGECAT diagnostic system was used to generate subthreshold and disorder-level of anxiety and depression as well as the combination of these into eight syndromes categories plus a group without any of the syndromes categories. Prevalences, unadjusted and adjusted odds ratios are calculated for the syndrome categories in relation to cross-sectional personal and environmental factors, and odds ratios of subthreshold and disorders level are estimated.

RESULTS

The overall prevalence of anxiety and depressive disorders are 3.1% and 9.7% respectively. The overall prevalence of either anxiety or depressive disorder (anxiety disorder with subthreshold depression, mixed anxiety and depressive disorder with subthreshold anxiety) where they overlapped is 8.4%. The highest Odds Ratios unadjusted and adjusted for age and gender, of anxiety and depressive disorders and significant for trend are found for increasing disability. Disability has a strong relationship with all the co-morbid syndrome categories. In all analyses women showed significant higher estimates than men.

CONCLUSIONS

Our study demonstrated high estimates where anxiety and depression occurred in parallel both as disorders and as subthreshold syndromes.

Distinguishing worry from rumination in older people: a preliminary investigation

Anxiety and depression are common mental health problems in later life. Since worry and rumination are thought to underpin the respective primary cognitive processes in anxiety and depression, we developed a measure to distinguish worry from rumination in later life. The Ruminative Response Scale was adapted to include items that characterise the cognitive features of worry. We examined its properties using 92 clinical and non-clinical participants, aged over 65. Factor analysis demonstrated a three-factor structure: brooding, reflection and worry with internal consistencies of alpha = 0.72, alpha = 0.67 and alpha = 0.55 respectively. We found no evidence for concurrent validity of these factors using the Penn State Worry Questionnaire. Modest but significant associations between reflection and brooding (r = 0.36) and reflection and worry (r = 0.2) were found. Brooding and worry sub-scales remained unrelated. We suggest that it is possible to distinguish worry from rumination in older people and that differentiating between their key underlying characteristics in the assessment of mood problems may enhance the targeting and evaluation of cognitive-behavioural therapy for anxiety and depression in later life. Future research with a substantial clinical sample is needed to explore the underlying dimensions and correlates of worry in later life.

Development and validation of the Geriatric Anxiety Inventory

BACKGROUND

Anxiety symptoms and anxiety disorders are highly prevalent among elderly people, although infrequently the subject of systematic research in this age group. One important limitation is the lack of a widely accepted instrument to measure dimensional anxiety in both normal old people and old people with mental health problems seen in various settings. Accordingly, we developed and tested of a short scale to measure anxiety in older people.

METHODS

We generated a large number of potential items de novo and by reference to existing anxiety scales, and then reduced the number of items to 60 through consultation with a reference group consisting of psychologists, psychiatrists and normal elderly people. We then tested the psychometric properties of these 60 items in 452 normal old people and 46 patients attending a psychogeriatric service. We were able to reduce the number of items to 20. We chose a 1-week perspective and a dichotomous response scale.

RESULTS

Cronbach's alpha for the 20-item Geriatric Anxiety Inventory (GAI) was 0.91 among normal elderly people and 0.93 in the psychogeriatric sample. Concurrent validity with a variety of other measures was demonstrated in both the normal sample and the psychogeriatric sample. Inter-rater and test-retest reliability were found to be excellent. Receiver operating characteristic analysis indicated a cut-point of 10/11 for the detection of DSM-IV Generalized Anxiety Disorder (GAD) in the psychogeriatric sample, with 83% of patients correctly classified with a specificity of 84% and a sensitivity of 75%.

CONCLUSIONS

The GAI is a new 20-item self-report or nurse-administered scale that measures dimensional anxiety in elderly people. It has sound psychometric properties. Initial clinical testing indicates that it is able to discriminate between those with and without any anxiety disorder and between those with and without DSM-IV GAD.

Age differences in the presentation of anxiety

The research on anxiety and age has produced inconsistent findings. One reason for this may be that the manifestation of anxiety symptoms is age-related. The purpose of this study was to determine if there are age-related differences in the presentation of affective, cognitive, and somatic symptoms of anxiety. Primary care patients ranging in age from 19-87 years completed three self-report measures of anxiety. Results indicate that older adults report less worry than younger adults. There were no age differences in the report of somatic and affective symptoms. Thus, worry appears to play a less prominent role in the presentation of anxiety in older adults. These findings suggest that older adults do experience anxiety differently than younger adults.

Aging and negative affect: The rise and fall and rise of anxiety and depression symptoms

The relationship between aging and negative affect is dynamic and complex. Although prior studies have often cited lower prevalence rates of anxiety and mood disorders among older individuals, these studies may miss the dynamic relationship between symptoms and aging. To evaluate a nonlinear model of the relationship between aging and negative affect, the author examined measures of neuroticism, anxiety, and depression symptoms in a cross-sectional, community sample (N = 335), ages 18 to 93. Results indicated a curvilinear relationship, with mean symptom levels increasing during early adulthood (until the mid-30s) and then showing a small decline until older adulthood (the mid-70s), when symptoms again increase with age.

Psychological interventions for late-life anxiety: a review and early lessons from the CALM study

The authors review the literature on psychological treatment for anxiety in older adults, focusing on randomized, controlled trials. Evidence exists for the efficacy of relaxation training for subjective anxiety symptoms and cognitive-behavioral therapy for generalized anxiety disorder and miscellaneous anxiety syndromes, including panic disorder. The authors also present the rationale for the CALM Study (Controlling Anxiety in Later-life Medical Patients), an ongoing randomized trial in which a modular psychotherapeutic intervention for anxiety in older primary care patients is compared with treatment as usual. Data are presented from 2 pilot patients in the CALM Study, and preliminary lessons are discussed.

Correlates of anxiety symptoms in physically disabled older women

OBJECTIVE

The authors describe characteristics that are associated with chronic anxiety symptoms and examine the use of anxiolytic and antidepressant medications in physically disabled women with and without symptoms of anxiety.

METHODS

Participants were 791 physically disabled women age 65+ years who participated in the Women's Health and Aging Study for 2-3 years. Anxiety symptoms were measured with four questions from the Hopkins Symptom Checklist, and women were categorized as having no anxiety, intermittent anxiety, and chronic anxiety symptoms. Health-related characteristics, medications, physical functioning, physical activity, and psychosocial variables were also measured.

RESULTS

Forty-nine percent of women reported no anxiety symptoms; 41% reported intermittent symptoms; and 10% reported chronic symptoms of anxiety. Depressive symptoms and lack of emotional support were significant correlates of intermittent anxiety symptoms, whereas depressive symptoms, negative life events, and lack of emotional support were significant correlates of chronic anxiety symptoms. Over the course of 3 years, 20.3% of women with no anxiety, 33.0% of women with intermittent anxiety, and 48.7% of women with chronic anxiety symptoms took anxiolytic and/or antidepressant medications.

CONCLUSION

Anxiety symptoms are common among disabled older women. Psychosocial variables were significantly different in women with intermittent or chronic anxiety symptoms, versus women without anxiety.

Stability and change of emotional functioning in late life: modelling of vulnerability profiles

BACKGROUND AND AIMS

The present study investigated stability and change in emotional well-being in a prospective study of a large sample of community-dwelling older adults (> or = 55 years). Emotional functioning was conceptualized according to the tripartite model distinguishing three aspects: general negative affect (NA), depression, and anxiety. The study tested models for the decline of mental health in late life based on the diathesis-stress model. In previous studies, support has been found for the diathesis-stress model (for an overview, see [Goldberg, D.P., Huxley, P., 1992. Common mental disorders: a biosocial model. Routledge, London; Zuckerman, M., 1999. Vulnerability to psychopathology. American Psychological Association, Washington, DC.]). The predictive ability of vulnerability factors (the personality characteristics mastery and neuroticism) and stressful life events and their interaction was tested for an increase in general negative affect, decreased positive affect (PA), and increased anxiety. More specifically, we tested the hypothesis that loss leads to decreased positive affect in subjects with low mastery, whereas threat leads to anxiety in subjects with high neuroticism.

METHODS

Data from the Longitudinal Aging Study Amsterdam (LASA) were used. LASA is a longitudinal study in a large representative sample of adults aged 55 to 85 (N=1837). Self-report data on depression, anxiety, and negative affect were collected from adults over a 6-year period in three waves. The data were analyzed using multilevel analysis.

RESULTS

The findings revealed an association between low mastery, high neuroticism, and an increase in negative affect, lack of positive affect, and anxiety. Furthermore, high mastery protected against the negative impact of loss events, but neuroticism did not augment the negative impact of threat events on emotional health.

CONCLUSION

Partial support was found for a diathesis-stress model of change in emotional functioning in late life. Furthermore, support was found for distinguishing between symptoms of negative affect, depression, and anxiety.

Effects of Age on Symptoms of Anxiety and Depression in a Sample of Retired Police Officers

This study addressed the effects of age on anxiety and depressive symptoms. The analysis was based on the responses of 1,334 retired male Scottish police officers (34-94 years old) to the Hospital Anxiety and Depression Scale. Multiple regression analysis was used to determine the partialed linear and curvilinear effects of symptoms of, separately, anxiety and depression on age and retirement variables. Significant partialed effects of retirement type and present age were found. Early retirement was a vulnerability factor for both disorders. The authors found a consistent linear reduction in anxiety across age and a U-shaped function for depression across age. The differing profiles and independent effects of age on anxiety and depression are consistent with their status as separate entities. Respondents were increasingly susceptible to depression from the mid-50s onward, whereas susceptibility to anxiety was reduced with age.

Social anxiety in older adults: phenomenology, prevalence, and measurement

Although phobias represent the most common anxiety disorders among the elderly, little is known about their social nature. The present study provides information about the prevalence, measurement, and phenomenology of social anxiety in older adults (n = 283) and compares results to those of younger adults (n = 318). Analyses revealed that social anxiety is less prevalent in old age than it is within younger cohorts and is associated with different symptomatology. The psychopathological profile of those who reach clinical levels of social anxiety is however similar, irrespective of age. Results regarding the psychometric properties of the SPAI when used for the elderly were promising, but the questionnaire appears to be difficult for some older adults to complete. Results are discussed in terms of explanations for age differences in social anxiety, initial psychometrics of the SPAI in an older adult sample, and suggestions for future research.

Quality of life in geriatric patients with mood and anxiety disorders

This article reviews the impact of depressive and anxiety disorders on quality of life (QOL), disability, and economic burden in the lives of older individuals. Distinctions between the terms QOL, disability, and burden are important in understanding the extent of improvement needed in treatment for elderly patients with depression or anxiety. Treatment efforts should be extended to remediate not only signs and symptoms of psychiatric syndromes but QOL and disability as well; increased understanding toward this end is evolving, yet it is clear that these issues need to be the focus of more investigation.

Anxiety and well-being in older people after discharge from hospital

BACKGROUND

A previous study using the State-Trait Anxiety Inventory (STAI) has documented a very high prevalence of anxiety symptoms among older inpatients. The STAI produced two main concepts on factor analysis -'Nervousness' and 'Well-being'- and high scores on both caused the high overall score in these patients.

AIM

To investigate how the scorings on the STAI evolve after discharge in older patients in order to understand better the reasons for their high scorings while in hospital.

METHODS

Sixty-three patients who had been scored on the STAI during their stay in an elder care department were followed up at 1-3 and 12 months after discharge. Data were analysed by ancova for unbalanced designs.

RESULTS

The mean STAI sum score increased significantly (3.5 points adjusted for the baseline scoring, age and gender, P < 0.001) from the first follow-up while in hospital to 1-3 months after discharge, with no significant change between the second and the last follow-up. This increase resulted primarily from a significant worsening of the score on 'well-being'. The score on 'nervousness' remained unchanged. Age did not influence the scores, while females scored higher. No interaction effects were observed, indicating that the evolvement of nervousness and anxiety after discharge is independent of gender and age. Item analysis showed that the worsening of the score on 'well-being' in these patients during the first 1-3 months after discharge was primarily caused by a lower score on the item 'I feel secure'.

CONCLUSION

The study does not support the hypothesis that a high level of nervousness and lack of well-being among hospitalized older patients results from acute illness and hospitalization. The worsening in the score on well-being after discharge of such patients is primarily caused by low levels of feelings of security. This represents a challenge to nurses providing home-based care.

A randomized trial of the effectiveness of cognitive-behavioral therapy and supportive counseling for anxiety symptoms in older adults

The authors used a randomized trial to compare cognitive-behavioral therapy (CBT) and supportive counseling (SC) in the treatment of anxiety symptoms in older adults who met Diagnostic and Statistical Manual of Mental Disorders (4th ed.: American Psychiatric Association, 1994) criteria for anxiety disorders. Both conditions had a 6-week baseline no-treatment phase. Treatment was delivered primarily in patients' own homes and in an individual format. Outcomes were assessed at posttreatment and at 3-, 6-, and 12-month follow-ups. There was no spontaneous improvement during the baseline phase. Both groups showed improvement on anxiety measures following treatment, with a better outcome for the CBT group on self-rating of anxiety and depression. Over the follow-up period, the CBT group maintained improvement and had significantly greater improvement than the SC group on anxiety and 1 depression measure. Treatment response for anxiety was also superior for the CBT group, although there was no difference between groups in endstate functioning.

High prevalence of anxiety symptoms in hospitalized geriatric patients

OBJECTIVE

To examine the prevalence of anxiety symptoms in hospitalized geriatric patients.

DESIGN

Controlled cross-sectional study.

SUBJECTS

Ninety-eight geriatric in-patients and 68 healthy home-dwelling controls of similar age recruited from senior citizen centres.

OUTCOME MEASURE

Anxiety measured as a current emotional state by Spielberger's State-Trait Anxiety Inventory (STAI).

RESULTS

The geriatric patients scored significantly higher than the controls. Applying Spielberger's recommended cut-off of 39/40 on the STAI sumscore, 41% of the female and 47% of the male geriatric patients might be suspected of suffering from significant anxiety symptoms. Patients with chronic obstructive pulmonary disease tended to score higher; otherwise no relationship was found between the STAI sumscore and type of chronic somatic disease, nor between the STAI sumscore and number of drugs in regular use.

CONCLUSIONS

STAI proved feasible for use in the elderly. The scoring on the STAI is high in geriatric in-patients. Further studies are needed to clarify to what extent this relates to a high prevalence of anxiety disorders.

Anxiety disorders

Research has only recently begun to address the nature and treatment of anxiety in later life. Prevalence rates suggest that anxiety disorders occur more than twice as frequently as depression among older adults, with the highest rates reported for generalized anxiety disorder and phobias. However, relatively little is known about the psychopathology and treatment of these and other anxiety disorders. In this review, recent clinical advances in this area are summarized. Particular attention is given to the prevalence and nature of late-life anxiety and its overlap with related conditions, psychometric properties of assessment tools for evaluating anxiety in older adults, and treatment outcome literature in both pharmacological and psychosocial domains. Directions for future research are provided throughout and summarized in a final section with the goal of stimulating additional empirical work in the area.

Anxiety disorders in the elderly

Although the epidemiology, neurobiology, and treatment of anxiety disorders have received considerable attention in the child and adult literature, they have not received the same consideration in the geriatric population. This disparity is remarkable given the prevalence and associated costs of these disorders that can persist into late life. Further, although a considerable amount is known about these disorders in younger age groups, it is unclear whether the phenomenology of anxiety evolves over the course of the aging process. Thus, conclusions drawn based on younger populations of anxious adults may not hold true for older cohorts. This article reviews issues of epidemiology, phenomenology, neurobiology, and medical comorbidity, as well as pharmacologic and psychotherapeutic treatments in older adults.