Anxiety in medically ill older patients: a review and update

Illness burden and symptoms of anxiety in older adults: optimism and pessimism as moderators

BACKGROUND

We assessed the association between medical illness burden and anxiety symptoms, hypothesizing that greater illness burden would be associated with symptoms of anxiety, and that optimism would buffer, while pessimism would exacerbate, this relationship.

METHODS

We recruited 109 older adults, aged 65 years and older, from primary care and geriatric clinics to participate in this cross-sectional, interview-based study. Participants completed the Snaith Clinical Anxiety Scale and the Life Orientation Test - Revised, a measure of optimism/pessimism. A physician-rated measure of illness burden, the Cumulative Illness Rating Scale, was also administered.

RESULTS

Supporting our hypotheses, greater levels of overall optimism weakened, and pessimism strengthened, the association between illness burden and anxiety symptoms, after accounting for the effects of demographic, cognitive, functional, and psychological covariates.

CONCLUSIONS

Bolstering positive and reducing negative future expectancies may aid in the prevention of psychological distress in medically ill older adults. Therapeutic strategies to enhance optimism and reduce pessimism, which may be well-suited to primary care and other medical settings, and to which older adults may be particularly amenable, may contribute to reduced health-related anxiety.

A randomized controlled study of paroxetine and cognitive-behavioural therapy for late-life panic disorder

OBJECTIVE

To examine the effectiveness of paroxetine and cognitive-behavioural therapy (CBT) in elderly patients suffering from panic disorder with or without agoraphobia (PD(A)).

METHOD

Forty-nine patients aged 60+ years with confirmed PD(A) were randomly assigned to 40 mg paroxetine, individual CBT, or to a 14-week waiting list. Outcomes, with avoidance behaviour and agoraphobic cognitions being the primary measures, were assessed at baseline and at weeks 8, 14 (conclusion CBT/waiting list), and at week 26 (treated patients only) and analysed using mixed models.

RESULTS

All outcome measures showed that the patients having received CBT and those treated with paroxetine had significantly better improvement compared with those in the waiting-list condition. With one patient (1/20, 5%) in the CBT and three (3/14, 17.6%) in the paroxetine condition dropping out, attrition rates were low.

CONCLUSION

Patients with late-life panic disorder respond well to both paroxetine and CBT. Although promising, the outcomes warrant replication in larger study groups.

A pilot study on perceived stress and PTSD symptomatology in relation to four dimensions of older women's physical health

OBJECTIVES

The authors examined whether selected demographic and psychological factors would predict physical health dimensions in a sample of 53 cognitively high-functioning and ethnically diverse women (age 65-105 years).

METHOD

Predictors encompassed posttraumatic stress disorder (PTSD) symptomatology and perceived stress (of a nontraumatic nature and beyond health status) in relation to four dimensions of physical health. Age and income, well-known correlates of health in the target population, were included as potential predictors. The authors first tested the relationship between potential predictors and health dimensions via a canonical correlation analysis, and then employed full multiple regression analyses to simultaneously test the predictors in each health dimension model.

RESULTS

Perceived stress was a significant predictor of lower levels of general health (GH), but not of physical role limitations or physical functioning (PF). Conversely, PTSD symptomatology predicted more limitations in role fulfillment (and, to a lesser extent, impaired PF), but not lower levels of GH. As expected, age and income were predictive of some physical health dimensions. The hypothesized predictors failed to account for a significant portion of variance in pain scores.

CONCLUSION

PTSD symptomatology and perceived stress might influence older women's physical health dimensions differentially; additional research on larger samples is needed to corroborate these findings.

A pilot study on perceived stress and PTSD symptomatology in relation to four dimensions of older women's physical health

OBJECTIVES

The authors examined whether selected demographic and psychological factors would predict physical health dimensions in a sample of 53 cognitively high-functioning and ethnically diverse women (age 65-105).

METHOD

Predictors encompassed posttraumatic stress disorder (PTSD) symptomatology and perceived stress (of a nontraumatic nature and beyond health status) in relation to all dimensions of physical health of the Medical Outcome Study 36-item Short Form Health Survey (MOS SF-36); (Ware, J.E., & Sherbourne, C.D., 1992). The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical Care, 30(6), 473-483). Age and income, well-known correlates of health in the target population, were included as potential predictors. The authors first tested the relationship between potential predictors and health dimensions via a canonical correlation analysis, and then employed full multiple regression analyses to simultaneously test the predictors in each health dimension model.

RESULTS

Perceived stress was a significant predictor of lower levels of general health (GH), but not of role limitations or physical functioning (PF). Conversely, PTSD symptomatology predicted more limitations in role fulfillment (and, to a lesser extent, impaired PF), but not lower levels of GH. As expected, age and income were predictive of some physical health dimensions. The hypothesized predictors failed to account for a significant portion of variance in pain scores.

CONCLUSION

PTSD symptomatology and perceived stress might influence older women's physical health dimensions differentially; additional research on larger samples is needed to corroborate these findings.

Integration of religion into cognitive-behavioral therapy for geriatric anxiety and depression

Religion is important to most older adults, and research generally finds a positive relationship between religion and mental health. Among psychotherapies used in the treatment of anxiety and depression in older adults, cognitive-behavioral therapy (CBT) has the strongest evidence base. Incorporation of religion into CBT may increase its acceptability and effectiveness in this population. This article reviews studies that have examined the effects of integrating religion into CBT for depression and anxiety. These studies indicate that improvement in depressive and anxiety symptoms occurs earlier in treatment when CBT incorporates religion, although effects are equivalent at follow-up. The authors present recommendations for integrating religious beliefs and behaviors into CBT based on empirical literature concerning which aspects of religion affect mental health. A case example is also included that describes the integration of religion into CBT for an older man with cognitive impairment experiencing comorbid generalized anxiety disorder and major depressive disorder. It is recommended that clinicians consider the integration of religion into psychotherapy for older adults with depression or anxiety and that studies be conducted to examine the added benefit of incorporating religion into CBT for the treatment of depression and anxiety in older adults.

Symptoms of depression and anxiety (MHI) following acute medical/surgical hospitalization and post-discharge psychiatric diagnoses (DSM) in 839 geriatric US veterans

OBJECTIVE

We addressed the relatively unexplored use of screening scores measuring symptoms of depression and/or anxiety to aid in identifying patients at increased risk for post-discharge DSM-IV Axis I diagnoses. We were unable to find such studies in the literature.

METHOD

Elderly veterans without recent psychiatric diagnoses were screened for depression and anxiety symptoms upon admission to acute medical/surgical units using the Mental Health Inventory (MHI). Following discharge, those who had exceeded cut-off scores and had been randomized to UPBEAT Care (Unified Psychogeriatric Biopsychosocial Evaluation and Treatment, a clinical demonstration project) were evaluated for DSM diagnoses. We report on 839 patients, mostly male (96.3%; mean age 69.6 +/- 6.7 years), comparing three groups, i.e. those meeting screening criteria for symptoms of (i) depression only; (ii) anxiety only; and (iii) both depression and anxiety.

RESULTS

Despite absence of recent psychiatric history, 58.6% of the 839 patients received a DSM diagnosis post-discharge (21.8% adjustment; 15.4% anxiety; 7.5% mood; and 14.0% other disorders). Patients meeting screening criteria for both depression and anxiety symptoms received a DSM diagnosis more frequently than those meeting criteria for anxiety symptoms only (61.9% vs 49.0%, p = 0.017), but did not differ significantly from those meeting criteria for depressive symptoms only (61.9% vs 56.8%, p = 0.174). Although exceeding the MHI screening cut-off scores for depression, anxiety, or both helped to identify patients with a post-discharge DSM diagnosis, the actual MHI screening scores failed to do so.

CONCLUSION

Screening hospitalized medical/surgical patients for symptoms of depression, anxiety, and particularly for the combination thereof, may help identify those with increased risk of subsequent DSM diagnoses, including adjustment disorder.

Promoting communication with older adults: protocols for resolving interpersonal conflicts and for enhancing interactions with doctors

In this paper, we review the importance of effective communication in older adulthood, and ideas for promoting it. We focus on theoretical and applied work in two communicative encounters that have particular relevance for older adult health, i.e., interpersonal conflict and visits with a healthcare provider. Little applied work has aimed to adapt training protocols for older adults in these two areas. We will present training protocols we have developed in constructive conflict resolution for older adults, and on enhancing doctor-patient communication. We present these protocols to stimulate ideas on the part of the reader on how to further develop and refine training efforts for older adults in effective communication.

Anxiety disorders and disability secondary to urinary incontinence among adults over age 50

OBJECTIVE

No previous research has investigated whether there is an association between anxiety disorders and urinary incontinence. We hypothesized that anxiety disorders would be associated with increased urinary incontinence related disability.

METHOD

Continuing participants who were aged 50 years and older in a longitudinal study of community-dwelling adults who were initially living in East Baltimore in 1981 (n = 787). Participants were classified as incontinent if any uncontrolled urine loss within the 12 months prior to the interview was reported. Urinary incontinence related functional loss was further assessed based on a series of questions relating directly to participants' inability to engage in certain activities due to their urinary incontinence. Anxiety disorders were assessed with standardized interviews.

RESULTS

Persons meeting criteria for an anxiety disorder were no more likely to have urinary incontinence than were persons without anxiety disorders (unadjusted odds ratio (OR) = 1.36,95 percent confidence interval (CI) [0.96, 1.93]). Among people with urinary incontinence (n = 159), persons meeting criteria for anxiety disorders in 1981 and in 1994 were much more likely to report urinary incontinence relatedfunctional impairment in 1994(adjusted OR = 6.51, 95 percent CI [1.42, 29.86]).

CONCLUSIONS

Individuals with changes in day-to-day routines or activities secondary to urinary incontinence were more likely to meet criteria for an anxiety disorder than were other older adults. Further studies must tease out the temporal relationship and whether early detection of urinary incontinence and associated anxiety improves quality of life and 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 and Panic Disorders in Older Adults Sharon

Despite the growing numbers of older adults in the home health care system, those who suffer from anxiety disorders often are not detected or effectively treated. Untreated anxiety disorders reduce the patient's quality of life, activities of daily living, and compliance with treatment. In worse cases, the patient may decide that life is not worth living and may contemplate suicide. Untreated anxiety accounts for costly visits for medical care (3.5 million visits in 1995) and unnecessary visits for emergency care when the patient mistakes anxiety for a heart attack. Careful assessment by the nurse is the key to detection and evaluation of anxiety disorders among older adults receiving home care. This article presents a case study to illustrate evaluation, identification of risk factors, diagnosis, and management of panic disorder.

Anxiety and its treatment in the elderly

A search for references relating to the treatment of anxiety disorders in the elderly was made using the BIDS computerized database back to 1981, the Medline computerized database back to 1983, and the PsycLIT computerized database back to 1974, together with a search of relevant citations. The profusion of clinical recommendations was found to contrast with the lack of adequate supporting controlled clinical trials. There was evidence of a trend away from the benzodiazepine class of anxiolytics and an upsurge in interest in agents active at the serotonin receptor, although with the possible exception of buspirone, there is so far little research evidence for advocating use of the new agents in the elderly. Psychological therapies may be useful for many types of anxiety in the elderly, but their efficacy is also as yet unproven. Rational prescribing recommendations for anxiety in this age group will require controlled clinical trials incorporating a multiaxial approach to anxiety assessment, quality-of-life measures, psychological and placebo controls, and adequate follow-up intervals.

Anxiety disorders and insomnia in geriatric patients

Anxiety and insomnia are among the more frequently encountered problems in geriatric cases. The effective clinical approach identifies underlying diagnostic syndromes or general medical conditions. An integrated approach to management combines pharmacotherapy and behavioral interventions as appropriate. Overall the prognosis for most patients is excellent.