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

Authors:
BRYANT Christina, JACKSON Henry, AMES David
Journal article citation:
Journal of Affective Disorders, 109(3), 2008, pp.233-250.
Publisher:
Elsevier

A systematic review of literature on anxiety in people over 60, published between 1980 and 2007, finds prevalence rates for anxiety disorders of 1.2% to 15% in community settings, and 1% to 28% in clinical settings. 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 conceptual and methodological inconsistencies in the literature. The review finds that Generalised Anxiety Disorder is the most common anxiety disorder among older people, but issues relating to co-morbidity and the nature of anxiety in old age remain unresolved. This hampers the design of interventions and highlights the need for further research with a primary focus on anxiety.

Extended abstract:
Author

BRYANT Christina; JACKSON Henry; AMES David;

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

Journal citation/publication details

Journal of Affective Disorders, 109(3), 2008, pp.233-250.

Summary

Forty nine observational studies are reviewed, and find that anxiety is widespread among people over 60, with anxiety symptoms much more common than diagnosed disorders. However, it is frequently unrecognised and untreated. Issues relating to the particular nature of anxiety in old age, and the comorbidity of anxiety and depression, remain to be resolved.

Context

There has been considerable research on anxiety in older people since the publication of the last comprehensive review in 1994, but there is still debate about its prevalence and nature; in particular, whether it is qualitatively different from anxiety in younger people, and whether it is, or is not, generally found in association with depression. This review therefore focuses on the epidemiology of anxiety in this population.

Methods

What sources were used?
Medline, PsycINFO and Web of Science were searched from 1980 to 2007. The references of relevant studies were checked and material was also ‘retrieved through publishers’ email alerting services’.

What search terms/strategies were used?
The terms ‘anxiety’ and ‘anxiety disorders’ were used, together with the names of specific disorders. The text indicates that these were: phobic disorder; agoraphobia; simple phobia; social phobia; generalised anxiety disorder; obsessive compulsive disorder; panic disorder; post-traumatic stress disorder; fear of falling.

The authors also report that they restricted their search to studies of participants aged 60 or more, although it is not clear whether this was applied during the search or manually once the searches had been completed.

What criteria were used to decide on which studies to include?
Eligible studies reported the prevalence of anxiety disorder in general, individual anxiety disorders or anxiety symptoms in people aged 60 or over.

Who decided on their relevance and quality?
The searches yielded some 2,500 studies, the majority clinical guidelines, descriptive studies or case studies. The process of filtering to arrive at a set of studies for review is not reported.

How many studies were included and where were they from?
Forty nine studies in total are reviewed and summarised in a series of tables. However, it is clear that the tables overlap to some degree in that some studies cover more than one disorder. Geographical origins are reported and are widespread among North America, Europe (including the UK) and Australasia.

How were the study findings combined?
‘In view of the heterogeneity in the study methodologies and measures used, it was not possible to pool data and provide summary prevalence figures.’ Prevalence data from each study are tabulated and conclusions drawn in relation to four key themes that emerge.

Findings of the review

Prevalence rates
The data show that both symptoms of anxiety and anxiety disorders ‘are relatively common in older adults’, especially among clinical populations (e.g. those with rehabilitation needs, or suffering from dementia or other neurodegenerative conditions). Prevalence rates for disorders vary widely in community settings from 1.2% to 14%, and in clinical settings from 1% to 28%. This variability is also evident in some studies that focus on specific disorders such as phobic disorders. Higher prevalence rates for anxiety disorders are reported among women than men, and where generalised anxiety disorder is included in surveys, it is often the most common disorder detected. However, the authors note that this remains a controversial diagnosis. Prevalence rates for anxiety symptoms are much higher than for disorders, ranging from 15% to 52.3% in community samples and 15% to 56% in clinical samples.

The variability in findings may reflect real differences in prevalence but they are more likely to be a product of differences in how anxiety is defined or measured. For example, the Geriatric Mental Schedule (GMS) does not permit the diagnosis of anxiety in the presence of a ‘higher order’ condition such as depression, and studies employing this scale typically report very low prevalence rates. Studies that use different approaches, or which take into account ‘sub-syndromal’ cases, report much higher rates.

Is anxiety qualitatively different in older people?
Most of the studies use checklists or diagnostic criteria that were not designed specifically for use with older people: an exception is the GMS which, as already noted, delivers very low prevalence rates for anxiety disorders. Some authors argue that commonly used self-report instruments such as the Fear Questionnaire have good internal reliability when used with older people, while others claim that many studies produce ‘spuriously low’ findings in the absence of a true understanding of what constitutes ‘normal’ anxiety among this population. The high levels of physical and psychological comorbidity experienced by many older people also make it difficult to distinguish between physical symptoms, anxiety and somatoform (psychosomatic) disorders. The development of instruments specifically designed and validated for use with older people might help in resolving these problems but would make comparison with younger age groups more difficult.

Overall, the review suggests that symptoms of anxiety are more common in older people than anxiety disorders, and that these symptoms are more common than depression. They are also different from those typically reported by younger people, with an increasing focus on somatic symptoms and a decreasing focus on worrying thoughts. This may suggest the concept of ‘geriatric anxiety’ that arises from cumulative age-related cognitive and physical impairment.

Do anxiety symptoms decline with age?
Most studies that investigate samples across the age ranges report that anxiety disorders are rarer among older than younger groups, and that very few new cases appear in old age. However, this is not the case for those with dementia and other neurodegenerative diseases, who are commonly not included in ‘community’ samples. The authors also note that the picture of declining anxiety in old age may be a consequence in some cases of the sampling methods used in studies.

Comorbidity of anxiety and depression
The neglect of anxiety as a condition in its own right may be a consequence of the view that anxiety rarely occurs in the absence of depressive symptoms. However, there are several barriers to teasing out the anxiety-depression relationship. Studies that use hierarchical case definition approaches such as the GMS cannot provide any enlightenment because people with depression cannot also be deemed cases of anxiety (because it is a ‘lower order’ condition). Older people may also under-report anxiety, and it may be less well recognised by medical practitioners. Most of the studies reviewed are cross-sectional and although they support an association between depression and anxiety, they cannot provide any information about the direction of the relationship. Further longitudinal studies are needed to answer the question of comorbidity.

Authors' conclusions

‘There appear to be relatively few unequivocal conclusions to be drawn from the literature on anxiety in older people, and these are rather broad.’ ‘Anxiety symptoms are highly prevalent among older people, frequently do not conform to current diagnostic criteria, and consequently go unrecognised and untreated.’ The review suggests that they are not simply an ‘understandable’ part of aging but ‘conditions that contribute to a spiral of interacting physical decline and mood disturbance.’

Further, hypothesis-driven research that focuses specifically on late-life anxiety is needed to clarify the picture.

Implications for policy or practice

The significant prevalence rates of anxiety among clinical samples of older people indicates ‘the potential of physical health settings as an important arena for mental health intervention in older people’. People with dementia and other neurodegenerative conditions, as well as their carers, are also ‘obvious target groups for prevention and early treatment’.

Subject terms:
older people, anxiety;
Content type:
systematic review
Link:
Journal home page
ISSN print:
0165-0327

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