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

Journal of Affective Disorders 109 (2008) 233–250www.elsevier.com/locate/jad

Special review article

The prevalence of anxiety in older adults: Methodological issuesand a review of the literature

Christina Bryant a,⁎, Henry Jackson a, David Ames b

a School of Behavioural Science, University of Melbourne, Victoria 3010, Australiab National Ageing Research Institute, P.O. Box 31, Parkville, Victoria, 3052, Australia

Received 16 August 2007; received in revised form 21 November 2007; accepted 21 November 2007Available online 26 December 2007

Abstract

Background: Despite the relative neglect of anxiety in older adults, the growing literature on its prevalence suggests that anxiety ishighly prevalent and associated with considerable distress and morbidity in this age group. This review provides a comprehensiveoverview of this literature and discusses some unresolved controversies in the field.Methods: A systematic search of articles published from 1980–2007was performed. Articles were included for review if they reported theprevalence of anxiety symptoms, anxiety disorder or specified anxiety disorders in adults aged N60 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%. Theprevalence of anxiety symptoms is much higher, ranging from 15% to 52.3% in community samples, and 15% to 56% in clinicalsamples. These discrepancies are partly attributable to the conceptual and methodological inconsistencies that characterise thisliterature. 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 comorbidityand the nature of anxiety in old age remain unresolved. This hampers the design of intervention programmes, and highlights theneed for further research with a primary focus on anxiety.© 2007 Elsevier B.V. All rights reserved.

Keywords: Anxiety; Aged 65 and older; Prevalence

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2342. Method. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2363. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

3.1. The prevalence of anxiety disorder and symptoms of anxiety in community samples . . . . . . . . . . . . . 2363.1.1. The prevalence of anxiety disorder in community samples . . . . . . . . . . . . . . . . . . . . . . 2363.1.2. The prevalence of anxiety symptoms in community samples . . . . . . . . . . . . . . . . . . . . . 236

3.2. The prevalence of specific disorders in community samples. . . . . . . . . . . . . . . . . . . . . . . . . . . 2373.2.1. The prevalence of phobic disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

⁎ Corresponding author.E-mail address: [email protected] (C. Bryant).

0165-0327/$ - see front matter © 2007 Elsevier B.V. All rights reserved.doi:10.1016/j.jad.2007.11.008

http://dx.doi.org/10.1016/j.jad.2007.11.008

234 C. Bryant et al. / Journal of Affective Disorders 109 (2008) 233–250

3.2.2. The prevalence and nature of Generalised Anxiety Disorder . . . . . . . . . . . . . . . . . . . . . . 2383.2.3. Less prevalent anxiety disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2383.2.4. Fear of falling — an age-specific anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

3.3. The prevalence of anxiety in clinical samples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2413.3.1. Anxiety and physical health in clinical populations . . . . . . . . . . . . . . . . . . . . . . . . . . 243

3.4. The impact of anxiety on well functioning individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2444. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

4.1. The prevalence of anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2444.2. Is anxiety qualitatively different in older adults? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2444.3. Do anxiety disorders become less prevalent as people age? . . . . . . . . . . . . . . . . . . . . . . . . . . 2454.4. The comorbidity of anxiety and depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245

5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246Role of funding source. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

1. Introduction

It has become almost commonplace to express theview that the study of anxiety in older people has beenneglected. In 1998, Beekman et al. stated that epide-miological studies of psychopathology in later lifehave concentrated on depression and dementia, whileanxiety disorders have received far less attention(Beekman et al., 1998). Recent articles by Flint(2005) and Wetherell et al. (2005a,b) have made asimilar point. However, there has, in fact, been consi-derable research on the prevalence, nature andconsequences of anxiety in older people in the13 years since the literature was last comprehensivelyreviewed by Flint (1994). Research output in the areahas increased significantly from an average of 215 pub-lications per year being cited in the PsycINFO databasein the early 1990s, to an average of 434 per year from2002–2007.

Despite this increasing research output, key contro-versies as to the prevalence and nature of anxietyremain unresolved (Ayers et al., 2007; Schuurmans etal., 2005; Wetherell et al., 2005a). The viewsexpressed in two recent editorials (Flint, 2005;Wetherell et al., 2005a) highlight the lack of consensusthat persists in relation to key issues in the literature.Firstly, debate surrounds the nature of anxiety in olderadults, with some commentators, such as Flint (2005),suggesting that it is qualitatively different fromanxiety in younger persons, while others downplaythese differences (Wetherell et al., 2005a,b). Secondly,there is controversy regarding the comorbidity ofanxiety with depression. Flint (2005) advocated theview that most anxiety co-occurs with depression;

Wetherell et al. (2005a) stated that the prevalence ofmixed anxiety and depression is lower than that ofeither disorder alone. Resolving this issue, and thequestion of whether anxiety becomes less prevalent aspeople get older, is complicated by the likelihood thatcurrent diagnostic criteria do not adequately capture thenature of anxiety in older adults (Flint, 2002; Jeste etal., 2005; Krasucki et al., 1999). Finally, the study ofanxiety remains particularly neglected in the context ofdementia and neurodegenerative disease.

These debates are not merely academic: Recentcommunity surveys suggest that symptoms of anxietyare nearly twice as common as symptoms of depres-sion — in the UK 2000 Survey of PsychiatricMorbidity, 3% of adults aged 70–74 met criteria forGeneralised Anxiety Disorder, while 1.7% weredeemed depressed (Singleton et al., 2000). Otherstudies have found that around 10% of community-dwelling older adults have a diagnosable anxietydisorder (Beekman et al., 1998), a rate that rises to23.5% in caregivers of people with dementia (Maho-ney et al., 2005). Prevalence rates are even higher inclinical populations — up to 18% in older adults withchronic pulmonary disease (Yohannes et al., 2000) and24% in Puerto Rican primary care patients (Tolin et al.,2005). Anxiety causes considerable subjective distress(Ayers et al., 2007), reduces life satisfaction (Brenes et al.,2005) and increases the risk for the onset of disability,even in high-functioning older adults (Seeman et al.,1995). It also increases the risk of mortality, both fromsuicide (Allgulander and Lavori, 1993) and physical,especially cardiovascular diseases, with males being atparticularly high risk (van Hout et al., 2004). Yet anxietycontinues to be under-recognised, and therefore, under-

Table 1Epidemiological studies: community samples

Authors N Age Measureused

Design Prevalence Comments

Beekman et al.(1998)

3107 55–85 CES-D Longitudinal communitybased (Amsterdam)

Overall prevalenceof anxiety disorder10.2%

No clear association with age per se.Men reported a prevalence of 7% andwomen 13%

HADS

Bland et al.(1988)

358 65+ DIS Cross-sectional study incommunity-dwelling olderadults (Edmonton, Canada)

Overall prevalenceof anxiety 3.5%;5% in institutions

Institutionalised women had a higherrate of anxiety at 7.1%, while therate for men was 1.4% — the latterfinding possibly due to a lowrecruitment level in that group

Cohen et al.(2006)

1074 55+ ASIS Cross-sectional sample(Brooklyn, New York)

2.3% syndromalanxiety

Sub-syndromal anxiety: 13.3%. Oneof the few studies to include asignificant number of non-Caucasianparticipants

Copeland et al.(1987a)

1070 65–90+ GMS-AGECAT

Cross-sectional sample fromGP's lists (Liverpool, UK)

Prevalence ofneurosis 2.4% (cases)

Much more common in women.Prevalence increases to 26.7% ifsub-cases included

Copeland et al.(1987b)

841 65–90+ GMS-AGECAT

Community sample(New York and London)

Cases 1.2% (NewYork); 1.4%(London)

Sub-cases: New York=18%;London=28.9%

Forsell andWinblad(1998)

966 78+ CPRS Cross-sectional communitybased (Stockholm, Sweden)

Anxiety disorder3.2%

24.4% reported anxiety feelings

Hunt et al.(2002)

10,641 18–65+ CIDI Nationwide householdsurvey (Australia)

1.3% in 65+(GAD) GAD less prevalent in older age groups.Strong association with depression,but not other anxiety disorders

Heun(2000)

286 60+ CIDI Cross-sectional study ofcommunity-dwelling olderpeople (Mainz, Germany)

Anxiety disorder6.6%

Sub-threshold depression and anxietyfound to be highly prevalent in olderpeople; 18.5% a sub-threshold disorder

RBD

Lindesay et al.(1989)

890 65–85+ DSM-III Cross-sectional community-dwelling older people(London, UK)

13.7% (total);3.7% GAD 10.0%phobic disorders

Both GAD and phobic disordersassociated with depression scoresGMS

PDSManela et al.

(1996)694 65–100 ADS Cross-sectional survey of all

persons 65+ in local area(Islington, UK)

Anxiety disorders15%

Phobic disorder the most common andusually in the absence of depression orother anxiety disorder

DIS

Mehta et al.(2003)

3041 70–79 HSC Cross-sectional study as partof Health ABC cohort study(Pittsburgh, Pennsylvania/Memphis, Tennessee)

Anxiety symptomsin 15% of sample

Self-report of two or more anxietysymptoms

Regier et al.(1988)

65+=5071

18–65+ DIS Multi-site EpidemiologicalCatchment Area Study (USA)

Overall prevalence5.5%

4.8% of anxiety accounted forby phobic disorders

Ritchie et al.(2004)

1873 65+ DSM-IV Cross-sectional communitysurvey (France)

14% prevalence ofany anxiety disorder

Prevalence for males: 8.7%; forfemales: 18.1%

Schaub andLinden(2000)

516 70–103 GMS Part of the Berlin Aging Study Anxiety disorder4.3% in 70–80-yearolds and 2.3% in85+ group

52.3% of sample reported N1symptom of anxietyDSM-III

Schoevers et al.(2003)

4051 65–84 GMS Longitudinal, communitydwelling (Amsterdam)

Anxiety 2.9%,mixed anxiety/depression 1.8%

Singleton et al.(2000)

8800 18–74 CIS-R Cross-sectional nationalsurvey (UK)

GAD=3.7%in 65–69-year oldsand 3% in 70–74

Prevalence of GAD peaked in50–54-year old age group and declinedthereafter. Mixed anxiety–depressionthe most prevalent neurotic disorder —8.3% in 65–69-year olds

Tuohy et al.(2005)

1334 34–94 HADS Cross-sectional sampleof retired police officers(Scotland)

10.3% scored N11on HADS

Early retirement associated with higheranxiety levels; anxiety decreasedwith age

(continued on next page)

235C. Bryant et al. / Journal of Affective Disorders 109 (2008) 233–250

Table 1 (continued )

Authors N Age Measureused

Design Prevalence Comments

Uhlenhuth et al.(1983)

442 65+ HSC National Survey ofPsychotropic Drug Use (USA)

10.2% (7.1% GAD,3.1% phobic disorder)

Higher prevalence of anxiety than ECAstudy because of inclusion of GAD

Zilber et al.(2001)

2001 18–65 CIDI-S Sub-sample of larger randomsample of migrants to Israel

1-monthprevalence 3.9%

Immigration found to contribute toincrease in psychopathology includinganxiety in older migrants to Israel

Note: ADS = Anxiety Disorder Schedule; ASIS = Anxiety Status Inventory Scale; CES-D = Center for Epidemiological Studies Depression Scale;CIDI = Composite International Diagnostic Interview; CIS-R = Clinical Interview Schedule – Revised; CPRS = Comprehensive PsychopathologicalRating Scale; DIS = Diagnostic Interview Schedule; DSM III = Diagnostic and Statistical Manual, 3rd edition; GMS-AGECAT = Geriatric MentalSchedule with AGECATcomputer programme; HADS = Hospital Anxiety and Depression Scale; HSC = Hopkins Symptom Checklist; PDS = PhobicDisorder Screen; RBD = Recurrent Brief Depressive Episode.


treated (Forsell &Winblad, 1998; (van Hout et al., 2004),and is likely to be chronic and unremitting (Livingston etal., 1997).

It is, therefore, timely to review the growing literatureon anxiety in older people. While there have been anumber of \recent reviews of the literature on the treat-ment of anxiety in older adults (Ayers et al., 2007;Nordhus and Pallesen, 2003; Wetherell et al., 2005b),there has been no recent systematic review of theepidemiology of anxiety. The objective of this review isto provide a comprehensive survey of the literature onthe prevalence of anxiety, in both community and clini-cal settings, with a view to evaluate the current status ofthe literature, and its implications for clinical practiceand future research. A further aim is to examine thekey conceptual andmethodological issues regarding thepresentation and nature of anxiety in older adults.

2. Method

This systematic review is based on literature pub-lished between 1980 and 2007, using the Medline, Webof Science and PsycINFO databases, entering the keyterms ‘anxiety’, ‘anxiety disorders’, the names ofspecific disorders and restricting the search to articleson participants aged 60 and older. Articles were alsoretrieved through publishers' email alerting services andby following up references listed in articles. Althougharound 2500 articles were published in this time, themajority are clinical treatment guidelines, descriptivestudies of anxiety or case studies. Articles were selectedfor this review if they reported the prevalence of anxietydisorder in general, or of anxiety symptoms, or of in-dividual anxiety disorders. This yielded 49 articles forinclusion. In view of the heterogeneity in the studymethodologies and measures used, it was not possible topool data and provide summary prevalence figures.

3. Results

3.1. The prevalence of anxiety disorder and symptomsof anxiety in community samples

3.1.1. The prevalence of anxiety disorder in communitysamples

Table 1 provides a summary of the epidemiologi-cal studies of anxiety in old age conducted since thelate 1980s. A number of studies have reported on theoverall prevalence of anxiety disorders, for example,Beekman et al. (1998),Copeland et al. (1987a,b),Lindesay et al. (1989), Manela et al. (1996), Riedel-Heller et al. (2006), and Regier et al. (1988). There iswide variation in the prevalence of anxiety disorderreported in these studies — from 1.2% in New York(Copeland et al., 1987a,b) to 14% in a study conductedin France (Riedel-Heller et al., 2006).

3.1.2. The prevalence of anxiety symptoms in com-munity samples

Clearly, the prevalence of anxiety disorder is muchlower than that of anxiety symptoms (Beekman et al.,1998). As part of the Health Aging and Body Com-position study (Mehta et al., 2003), participants wereasked about three key anxiety symptoms. These, takenfrom the Hopkins Symptoms Checklist, were feelingfearful, tense/keyed up or shaky/nervous. Participantswere considered to have anxiety symptoms if theyreported at least two anxiety symptoms “a little” or onesymptom “quite a bit” in the previous week. Forsell andWinblad (1998) reported on a study from Stockholm,Sweden of 966 very elderly people (78+), of whom24.4% reported feeling anxious either “now and then” or“most of the time”. The authors also used DSM-IV(APA, 1994) criteria to diagnose anxiety disorders andnoted that all of the persons with anxiety disorders


(n=25) had visited a physician in the previous month,but only five of them were receiving any treatment fortheir condition.

3.2. The prevalence of specific disorders in commu-nity samples

The literature reviewed here is based on searchesusing Medline and PsycINFO. Key terms were thenames of specific anxiety disorders. Articles were alsoretrieved through publishers' email alerting services andby following up references listed in articles.

3.2.1. The prevalence of phobic disorderTable 2 gives details of studies that report the

prevalence of phobic disorder. Where these studies giveseparate figures for agoraphobia, simple phobia andsocial phobia, these too are summarised below. It canbe seen that the reported prevalence ranges enormouslyfrom 1.4% (Copeland et al., 1987a,b) to 25.6%(Lindesay and Banerjee, 1993). These differencesundoubtedly reflect the differences in the instrumentsused, and, in particular, the application of hierarchical

Table 2The prevalence of phobic disorder in community samples

Study Instrument Prevalence of phobic disorder in th

Beekman et al. (1998) DIS 3.1% (males 1.6%; females 4.4%)Bland et al. (1988) DIS 3.0% in community (males1.8%; fe

1.0% in institutions (males 0.0%; feCohen et al. (2005) Scale derived

from the PDS8.9% (multi-racial sample, BrooklyDifferences between racial groups a

Copeland et al.(1987a,b)

GMS 1.4% (New York)1.8% (London)

Gretarsdottir et al.(2004)

SPAI

Lindesay andBanerjee (1993)

GMS 3.6% (males 0.0%; females 4.7%)PDS 25.6% (males 5%; females 32%)DSM-III 25.6% (males 5%; females 32%)DSM-III a 16.4% (males 0%; females 13.7%)

McCabe et al. (2006) CIDI

Manela et al. (1996) ADS 12% (males 4.7%; females 16.1%)Regier et al. (1988) DIS 4.8% (males 2.9%; females 6.1%)Singleton et al. (2000) CIS-R 1.3% (females, 65–69); 0.4%

(females, 69–70); 0% (males)Tolin et al. (2005) CIDI-SF

Uhlenhuth et al. (1983) HSC 3.1%

Note: ADS = Anxiety Disorder Scale; CIDI = Composite InternatiDiagnostic Interview — Short Form; CIS-R = Clinical Interview SchedDiagnostic and Statistical Manual, 3rd edition; GMS = Geriatric MenDisorder Screen; SPAI = Social Phobia and Anxiety Inventory.a DSM-III diagnosis made using hierarchical exclusion rules.

case ascertainment rules. Lindesay and Banerjee (1993)compared the performance of the GMS, DSM-IIIand the Phobic Disorder Screen, and demonstratedthat there was a very large variation between rates ofphobic disorder depending on the instrument used.

Some studies report that phobic disorder is the mostcommon anxiety disorder in people of all ages,including older age groups (Regier et al., 1988; Blandet al., 1988). However, neither of those studies surveyedGeneralised Anxiety Disorder, which other studies havefound to be more prevalent than phobic disorder(Uhlenhuth et al., 1983; Beekman et al., 1998). Alsoof note are the large variations between the prevalencerates for males and females.

The generally low prevalence of social phobiadeserves some comment. One reason for it may bethat it is easy for older people to avoid social situationsthat provoke anxiety. This could involve relying onothers; moreover, the lifestyle of some older people maynot include challenges commonly faced by youngerpeople who are exposed to a greater variety of profes-sional and social situations. An alternative explanationmight lie in the personality maturation that some people

ose b65 Agoraphobia Specificphobia

Social phobia

males 3.8%)males 1.6%)n, NY).re non-significant

18.7%

20% 8.3% 0.0%14.9% 13.1% 1.2%6.5% 8.9% 0.6%0.4% (12-monthprevalence)

Numbers toosmall to report

7.9% 5.9% 0.6%

5.7% males;7.1% females

8% males;13.1% females

4.7% males3.8% (females)

onal Diagnostic Interview; CID-SF = Composite Internationalule — Revised; DIS = Diagnostic Interview Schedule; DSM-III =tal Schedule; HSC = Hopkins Symptom Checklist; PDS=Phobic


believe leads to lower levels of neuroticism and self-consciousness in older people (McCrae et al., 2000).The figure of 18.7% in the study by Gretarsdottir et al.(2004) needs to be interpreted with caution as it isderived from a highly self-selected sample in a studythat had as its primary objective the psychometric eval-uation of the Social Phobia and Anxiety Inventory.

3.2.2. The prevalence and nature of Generalised AnxietyDisorder

When Generalised Anxiety Disorder is included insurveys, it is often, but not always, the commonest anxietydisorder detected. Beekman et al. (1998) found it to bemore than twice as prevalent as phobic disorder, whereasManela et al. (1996) reported a prevalence of 4.7%,compared with 12% for phobic disorder, a similar findingto that of the Guy's/Age Concern Study (Lindesay et al.,1989). Further details of the prevalences reported aregiven in Table 1.

Considerable controversy surrounds GAD as a diag-nostic entity. Some authors favour the view that GAD isbest conceptualised as a disorder in its own right, andseparate from depression (Lenze et al., 2005). In aretrospective review of 103 older people in a clinicalsample, Lenze et al. found that most of the patients withbothGAD and depression had different times of onset andremission from the two disorders, with GAD typicallypreceding the major depressive episode. Lenze et al.conclude from this that GAD is best characterised as adisorder distinct from depression. However, it could beargued that these results could be interpreted asdemonstrating that GAD and depression are merely twosides of the same coin.

Evidence supporting this view includes the high co-morbidity of this disorder with depression (Manela et al.,1996; Blazer, 2003). Moreover, Copeland et al. (1987a)found that generalised anxiety symptoms were muchmore likely to be manifested as symptoms than as syn-drome disorders and that they frequently occurred indiagnostic categories other than Generalised AnxietyDisorder itself. More recently, it has been reported thateven if GAD was not associated with depression at first,up to 40% of those diagnosed with the disordersubsequently developed depression or mixed anxiety–depression, leading to the conclusion that GeneralisedAnxiety Disorder probably lies on a continuum withdepression (Schoevers et al., 2003). Of all the anxietydisorders, GADmay perhaps best correspond to the broaddimensional concept of neurosis (Lindesay, 1996; Tyrer,1990). Flint (2002) has advocated the use of a dimensionalapproach to the study of affective disorder as this can“provide a framework for studying the complex interac-

tions that exist between depression, anxiety, medicalillness, cognitive impairment, personality and adversepsychosocial conditions” (Flint, 2002, p. 231).

3.2.3. Less prevalent anxiety disordersObsessive compulsive disorder, panic disorder and

post-traumatic stress disorder are the least prevalent ofthe anxiety disorders in older people. This is reflected inthe small number of studies generated by Medline andPsycINFO searches when using the terms obsessivecompulsive disorder (17), panic disorder (23) and post-traumatic stress disorder (38), restricting the search tothe 65+ age group.

There has been a significant level of clinical interestin post-traumatic stress disorder, because the survivorsof the Second World War and the Holocaust are nowwell into old age. However, prevalence data on data onpost-traumatic stress disorder are very limited (Sadavoy,1997; van Zelst et al., 2003) — the ECA study did notassess this, and it is not included in the symptom clustersof the GMS-AGECAT. This situation has been partiallyremedied by data collected as part of the LongitudinalAging Study Amsterdam (van Zelst et al., 2003; 2006).The authors reported 6-month prevalences of PTSD andsub-threshold PTSD of 0.9% and 13.1% respectively.Adverse events in early childhood and neuroticismemerged as the strongest predictors for both PTSD andsub-threshold PTSD. Female gender and poor self-ratedhealth also increased the risk for PTSD.

Studies of Holocaust survivors have found that up to46% meet criteria for PTSD (Sadavoy, 1997). Beekmanet al. found that “extreme experiences during World WarII” (Beekman et al., 1998, p. 723) were a significant riskfactor for anxiety in the Longitudinal Aging StudyAmsterdam. Weintraub and Ruskin's (1999) review ofthis area does not give prevalence figures and empha-sises the similarities between PTSD in older and young-er groups. In a more general review of the effects ofprior trauma, Sadavoy suggests that, overall, Holocaustsurvivors have effected better adaptations to their expe-riences than combat veterans (Sadavoy, 1997).

Table 3 summarises findings to date with respect tothe prevalence of obsessive compulsive disorder (OCD)in older people. Of the 17 studies yielded by PscyhInfoand Medline searches using OCD as keyword, 7 are casestudies, 6 are treatment guidelines, 1 describes the clini-cal features of OCD in older people and, of 3 articlesreferring to the epidemiology of OCD, only 2 report theprevalence of OCD in old age (Horwath and Weissman,2000; Nestadt et al., 1998). However, these studies arein agreement about the low prevalence of OCD and thegreater numbers of women with this diagnosis. The

Table 3Prevalence of obsessive compulsive disorder in community samples

Study Instrument Prevalence of OCD Comments

Beekman et al.(1998)

DIS Overall prevalence0.6%

LongitudinalAging StudyAmsterdamMales 0.0%,

females 1.2%Copeland et al.

(1987a)GMS-AGECAT

2.44% of femalesample and 1.36%sub-cases of OCD;0.15 prevalence ofcases of OCD

Liverpool,UK

Copeland et al.(1987b)

GMS-AGECAT

New York=0.7%sub-cases

London andNew York

London=9.3%sub-cases;0.6% cases of OCD

Horwath andWeissman(2000)

DSM-IIIcriteria

1%–1.8% prevalence;no decline with age

Cross-nationalsample

Nestadt et al.(1998)

DIS 32 new casessince 1988

1920participants(65+ n=178)followed upfrom ECAStudy

Incidence 1.21 per1000 person years;peak of new cases inwomen 65+

Regier et al.(1988)

DIS Overallprevalence 0.8%

ECA Study

Males 0.7%,females 0.9%

Tolin et al.(2005)

CIDI-SF 1.6% males;2% females

Puerto Ricansample (US)


GMS-AGECAT/DSM-IIIcriteria

1 case of OCD insample of 516

Berlin AgingStudy

Singleton et al.(2000)

CIS-R 0.5% (females,65–69); 0.4%(females, 69–70);0% (males)

Cross-sectionalnationalsurvey (UK)

Note: CIDI-SF = Composite International Diagnostic Interview —Short Form; CIS-R = Clinical Interview Schedule — Revised; DIS =Diagnostic Interview Schedule; DSM-III = Diagnostic and StatisticalManual, 3rd edition; GMS = Geriatric Mental Schedule.

Table 4Prevalence of panic disorder in community samples

Study Instrument Prevalence ofpanic disorder

Comments

Beekmanet al.(1998)

DIS 1% overall.Females 2%,males 0.3%

LongitudinalAging StudyAmsterdam

Bland et al.(1988)

0.3% incommunity; 1%in institutions

Edmonton,Canada

Deer andCalamari(1998)

ASI 27% of samplereported a panicattack in theprevious year

Small,unrepresentativesample, US

Depp et al.(2005)

ASI 26.2% of sampleendorsed “non-clinical” panic

42.7% of youngerparticipantsendorsed “non-clinical” panic

Lindesay et al.(1989)

DSM-III 0.0% Guy's AgeConcern Study

Regier et al.(1988)

DIS Females 0.2%,males 0.0%

ECA Study

Tolin et al.(2005)

CIDI-SF 10.5% overall;9.4% males;11.2% females

Puerto Ricanprimary carepatients


GMS-AGECAT/DSM-IIIcriteria

1 case of panicdisorder insample of 516

Berlin AgingStudy

Singletonet al. (2000)

CIS-R 0.7% (females,65–69); 0.7%(females, 69–70);0% (males)

Cross-sectionalnational survey(UK)

Note: ASI = Anxiety Sensitivity Index; CIDI-SF = CompositeInternational Diagnostic Interview — Short Form; CIS-R = ClinicalInterview Schedule— Revised; DIS = Diagnostic Interview Schedule;DSM-III = Diagnostic and Statistical Manual, 3rd edition; GMS =Geriatric Mental Schedule.


condition tends to manifest itself in early life to mid-lifeand then run a chronic course, with relatively few newcases manifesting themselves after the age of 55 (Kra-sucki et al., 1999).

The ECA study (Regier et al., 1988) found that theprevalence of OCD declined with age, but subsequentfollow up of that sample has suggested an age–genderinteraction (Nestadt et al., 1998). Studies using theGMS-AGECAT, for example, Copeland et al. (1987b)reported a very low prevalence. The exception to this isthe rather high figure for sub-case levels of what theAGECAT terms obsessional neurosis, found in London.

The authors reported that this is a statistically significantdifference (Copeland et al., 1987b), but did not offer anysuggestions as to why this might be.

Panic disorder is reported to be extremely rare inolder persons (Flint et al., 1996) but it has been notedthat the data on this condition are sparse (Blazer, 1997).Only 12 of the articles generated by the current literaturesearch specifically addressed panic disorder in olderpeople, of which 5 discussed the phenomenology ofpanic in older adults, 5 were either case studies orreviews of treatment and only one addressed the issue ofepidemiology. This does not include general epidemio-logical studies of psychiatric disorder, which, asdiscussed below, may or may not encompass panicdisorder. A number of authors have commented on theassociation of panic disorder with health factors (Deppet al., 2005; Raj et al., 1993; Sheikh and Salzman,


1995), while others have reported that panic disordercan present de novo in old age (Hassan and Pollard,1994; Raj et al., 1993).

The GMS-AGECAT does not generate a diagnosticcategory of panic disorder, but a number of studies fromthe ECA study onwards have reported prevalence ratesfor this disorder. These results are summarised in Table4. The study by Deer and Calamari (1998) and its recentreplication by Depp et al. (2005) stand out from theothers by the high levels of panic symptoms and attacksreported by their participants. However, none of theirparticipants met diagnostic criteria for panic disorder.They used a self-report instrument designed specificallyto elicit information about panic attack; such instruments

Table 5Anxiety in people with dementia

Authors N Age Measure used Design

Ballardet al.(1996)

158 73.5 (mean),range notstated

DSM-III-Rcriteria

Cross-sectioreferrals toclinic, (UK

Ballardet al.(2000)

184 VaD: 79.1(mean)

DSM-IVsymptomchecklist

Consecutivfrom demenregister, (UAD: 82.1

(mean), rangenot stated

Chemerinskiet al.(1998)

398 65+ SCID Out patientAD (Argen

Ferretti et al.(2001)

137 65+ DSM-III-Rcriteria;HARS

Geriatric cloutpatientsdiagnosed A

Forsell andWinblad(1997)

966 (of whom180 withdementia)

84.2 (mean) DSM-III-Rcriteria

Population-sample (Sw

Porter et al.(2003)

231 AD: 77.2(mean)

NPI (elicitsinformationfrom caregivers)

UCLA ADdatabase (U

VaD: 75.1FTD: 65.8

Skoog(1993)

478 (29.8%had dementia)

85 DSM-III-Rcriteria

Populationdemented ademented 8olds (Swed

Starksteinet al.(2007)

552 72.7 (mean) DSM-IV andICD-10 criteria

Consecutivpatients wit(Argentina)

Twelvetreeand Qazi(2006)

40 79.4 (mean) RAID; STAI;CMAI

Communitysample (UK

Note 1: CMAI = Cohen–Mansfield Agitation Inventory; DSM-III-R = Diagnand Statistical Manual, 4th edition; HARS = Hamilton Anxiety Rating ScaleNeuropsychiatric Inventory; RAID = Rating for Anxiety in Dementia; SCIAnxiety Inventory.Note 2: AD = Alzheimer's Disease; FTD = Fronto-temporal dementia: VaD

have been demonstrated to over-estimate rates ofsymptoms (Deer and Calamari, 1998). The concept of“non-clinical panic” must surely be questioned — if itinterferes with functioning it is significant; if it does not,then it is meaningless to talk of a non-clinical entity. Ofnote is the over-representation of women, in keepingwith the data for younger age groups.

3.2.4. Fear of falling — an age-specific anxietyThere has been a strong interest in fear of falling

recently because of its now well documented associa-tions with physical and social activity restriction (How-land et al., 1993; Tennstedt et al., 2001), resulting inpoorer quality of life (Arfken et al., 1994) and loss of

Prevalence Comments

nala memory)

29.4% any anxietysymptom

No difference in association withVaD or AD

e patientstia caseK)

VaD: N2symptoms in71% of patients;AD: N2 symptomsin 38% of patients

Statistically significant differencein anxiety prevalence in VaDcompared with AD

s withtina)

7% prevalence ofanxiety (5% GAD,2% panic disorder)

SCID adapted to use informationform patient and their carers

inicwithD (US)

5%–6%prevalence ofGAD

66% of sample had 2+ moderateto severe symptoms; strongassociation with depression andbehavioural disturbances

basededen)

3.3% in group withdementia; 3.2% innon-dementedgroup

No difference in anxiety betweengroups as a whole, but anxietyonly present in mild dementia

patientS)

AD: 26.1% Anxiety symptoms in AD morecommon in those with earlierAD onsetVaD: 51.2%

FTD: 54.5%sample ofnd non-5-yearen)

31.1% anxietysyndrome, GAD mostcommon (21%)

No significant difference inprevalence between dementedand non-demented group

e series ofh AD

10% met revisedDSM criteria forGAD

26% experienced “excessiveanxiety and worry”; restlessness,irritability, tension, fears andrespiratory symptoms importantsymptoms of anxiety in AD

-dwelling)

40% above clinicalcut-off on RAID

CMAI and RAID correlated, butauthors distinguish agitation fromanxiety

ostic and Statistical Manual, 3rd edition revised; DSM-IV = DiagnosticICD-10 = International Classification of Diseases, 10th edition; NPI =D = Structured Clinical Interview for DSM-III-R; STAI = State Trait

= Vascular dementia.


independence (Cumming et al., 2000). Prospectivestudies have suggested that poor balance and reducedactivity levels are the pathways by which fear falling canitself raise the risk of future falls which, in turn, can haveserious health consequences, such as hip fracture (Cum-ming et al., 2000).

Fear of falling remains rather poorly defined. Initiallyidentified as the “Post Fall Syndrome” (Murphy andIsaacs, 1982), it is said to be the anxiety most frequentlyreported by older people (Howland et al., 1993), withestimates of its prevalence in community samplesranging from 29%–54% (Arfken et al., 1994; Tinettiet al., 1994). It is characterised by many features com-mon to anxiety disorders, namely physiological arousalwhen confronted with ambulation and a phobic avoid-ance of such situations (Yardley and Smith, 2002), al-though Gagnon et al. (2005) also reported a strongassociation with depressive symptoms.

However, its assessment has been largely based on theuse of the Falls Efficacy Scale (Tinetti et al., 1994),which measures beliefs about personal capacity to carryout daily activities without falling, rather any psycholo-gical constructs of fear or physiological arousal. Earlier

Table 6The prevalence of anxiety in clinical samples

Study N Ages Instruments Methodology

Ames et al. (1994a,b) 81 61–96 GMS-AGECAT

Cross-sectional samhospital (Australia

Ames and Tuckwell (1994) 167 65+ GMS-AGECAT

Cross-sectional samhospital (Australia

Bland et al. (1988) 358 65+ DIS Cross-sectional studwelling and institolder adults (Cana

Cheok et al. (1996) 107 65+ GMS Cross-sectional; nuresidents without mimpairment (Austr

GAS

Kay et al. (1987) 189 65+ ICDcriteria

Cross-sectional; nuresidents (Australia

Kvaal et al. (2001) 166 70–96 STAI Cross-sectional; geand home-dwelling(Norway)

Parmalee et al. (1998) 65+ Symptomchecklist

Cross-sectional; nuresidents (US)

Smallbrugge et al. (2005) 33 55+ SCAN Cross-sectional; nuresidents (Netherla

Tolin et al. (2005) 303 50+ CIDI-SFSpanishversion

Cross-sectional samPuerto Ricans in incare setting (US)

Note: CIDI-SF = Composite International Diagnostic Interview — Short FoGeriatric Mental Schedule; ICD = International Classification of Diseases;STAI = State Trait Anxiety Inventory.

reports tended to emphasise the physical manifestationsof fear of falling — for example, Murphy and Isaacs(1982) described the marked tendency to “clutch andgrab” and other gait disturbances they observed. Anexception to this was a series of four case reports (Marksand Bebbington, 1976). They described four olderwomen who had intense fear of falling “when therewas no visible support at hand” and concluded that thisfear was different from agoraphobia and characterised byits late-life onset. Only very recently has there been areturn of interest in the psychiatric aspects of fear offalling (Gagnon et al., 2005; Kennedy and Tannenbaum,2000). Gagnon et al. examined the affective correlates offear of falling in 48 older people. Although many hadmoderate avoidance, only one believed their fear to beexcessive, so the remainder failed to meet diagnosticcriteria for a DSM-IV(APA, 1994) phobia.

3.3. The prevalence of anxiety in clinical samples

This literature can be considered in two groups —studies of the prevalence of anxiety undertaken inclinical settings or with particular diagnostic groups, and

Prevalence Comments

ple in geriatric)

15% (sub-cases) 1 diagnostic case ofphobic disorder

ple in general)

56% (sub-cases) 1% cases of anxietydisorder

dy in community-utionalisedda)

Overallprevalence ofanxiety 3.5%;

Lower than all other agegroups surveyed in samestudy

rsing homeajor cognitive

alia)

14% (phobicdisorders)

Strong association betweenanxiety and depression

rsing home)

7% (anxiety orphobic states/OCD)

riatric inpatientscontrols

44% in patients(significantanxiety symptoms)

Home-dwelling controls hadmuch lower scores

rsing home 4.5% (anxietydisorders); 19%anxiety symptoms

rsing homends)

5.7% (anxietydisorders); 29.4%anxiety symptoms

Significant association withstroke

ple of low SESner city primary

24% met criteriafor any anxietydisorder

No significant differencesbetween males and females

rm; DSM-III = Diagnostic and Statistical Manual, 3rd edition; GMS =SCAN = Schedules for the Clinical Assessment in Neuropsychiatry;


studies examining the effect of anxiety on the onset oroutcome of particular physical conditions or syndromes.

Clinical populations are of considerable interest toboth the clinician and the researcher. This is becauseelevated levels of anxiety and depression are associatedwith increased rates of mortality (Allgulander andLavori, 1993; Ashby et al., 1991; Cameron, 1996;Shah et al., 1994), morbidity (Kennedy and Frazier,1999; Koenig et al., 1998), and disability (Lenze et al.,2001). While this is true of community populations, itis more marked in clinical populations (Brenes et al.,2005). Moreover, there is some recognition that psy-chiatric disorder is highly prevalent in geriatric andrehabilitation settings (Lichtenberg and MacNeill,2003; Sood et al., 2003). This has important implica-tions for service provision, with Lichtenberg suggest-ing that “geriatric medical rehabilitation is one of thebest settings in which the mental health problems ofolder adults can be detected and treated” (Lichtenbergand MacNeill, 2003, p. 56). Yet there is a low level ofrecognition of mental health issues by rehabilitationstaff (Dorra and Lenze, 2002), which, compoundedby lack of information on the prevalence of anxi-

Table 7Association of anxiety with physical health outcomes in clinical populations


Astrom (1996) 80 44–100

DSM-III-based diagnosticinterview

3-year prospective stuadmissions to stroke uassessed 5 days afteradmission (Sweden)

Bond et al. (1998) 642 65+ HADS 6-month prospective sof patients admitted togeneral hospitals withstroke or hip fracture

Dorra and Lenze(2002)

137 60+ Clinical recordreview

Review of clinical recrehabilitation wards (U

Salaffi et al.(1991)

61 51–79 Zung AnxietyInventory

Cross-sectional studywomen with kneeosteoarthritis (Italy)

Shimoda andRobinson (1998)

142 59.5(mean)

Present StateExamination

2-year prospective stuconsecutive acute stroadmissions (US)

Sullivan et al.(1997)

198 45–79(65+=89)

HAM-AHAM-D

1-year prospective stucardiac catheterisationpatients (US)

Yohannes et al.(2000)

137 60–89 GMS-AGECAT Cross-sectional studyoutpatients with chronobstructive airwaysdisease (UK)

MADRSBASDEC

Note: BASDEC = Brief Assessment Schedule Depression Cards; DSM-III = DSchedule; HAM-A = Hamilton Anxiety Rating Scale; HAM-D = Hamilton DRating Scale.

ety disorders in rehabilitation settings, limits knowl-edge as to the relevance of anxiety for rehabilitationoutcomes.

An issue of specific relevance to the mental health ofolder adults is the prevalence of anxiety in patients withdementia and other neurodegenerative diseases, such asParkinson's disease. There have been very few studiesof anxiety in people with dementia (Ballard et al., 2000;Porter et al., 2003), perhaps because of the lack of validcriteria for diagnosing anxiety in people with severelyimpaired cognition (Starkstein et al., 2007), and thedifficulty of distinguishing anxiety from agitation(Twelvetree and Qazi, 2006). Of the studies summarisedin Table 5, two found a significantly higher prevalenceof anxiety in vascular dementia than Alzheimer'sdementia (Ballard et al., 2000; Porter et al., 2003),suggesting that vascular pathology may play anaetiological role in this subset of anxiety presentations.Neurobiological factors may also contribute to anxietyin people with Parkinson's disease (PD) (Erdal, 2001),which has received little attention until recently (Marsh,2000; Walsh and Bennett, 2001), despite reports that upto 40% of patients with PD experience significant

Main findings Comments

dy ofnit

28% of samplehad GAD

No significant decrease after 3 years;high comorbidity with depression

urvey6

(UK)

48% had anxietysymptoms

Strong association between anxiety andsevere disability for women but not men

ords inS)

No difference inoutcome betweenanxious and non-anxious patients

Study relied on reports of anxiety withoutformal assessment

of ZAI score 35.96(S.D. 8.59)

Anxiety and depression more importantthan radiographic score as predictors ofpain and disability

dy ofke

GAD n=15,MDD n=9,GAD+MDDn=18

GAD and MDD had strong interactiveeffect on physical impairment andrecovery. No effect of anxiety oncognitive functioning

dy of Levels of anxietynot reported

Anxiety severity more stronglyassociated with function thandisease severity

ofic

18% clinicallyanxious 42%depressed

Anxiety a strong predictor of hospitaladmission for exacerbation of COPD

iagnostic and Statistical Manual, 3rd edition; GMS = Geriatric Mentalepression Rating Scale; MADRS = Montgomery Asberger Depression


anxiety (Starkstein et al., 1993). Little attention has beenpaid to anxiety in caregivers of people with dementia,but Mahoney et al. (2005) found that anxiety was morethan twice as prevalent as depression in a group of 153people caring for a family member with Alzheimer'sdisease.

3.3.1. Anxiety and physical health in clinical populationsCompared with the literature on depression, there is a

paucity of evidence in relation to the implications ofanxiety and anxiety disorders for physical health. Acomprehensive review of studies examining the associa-tion between late-life depression and anxiety withphysical disability by Lenze et al. (2001) highlightedthe dearth of literature on anxiety. Of the 66 studiesreviewed by Lenze, only 5 assessed symptoms ofanxiety or anxiety disorder (Astrom, 1996; Kroenkeet al., 1997; Salaffi et al., 1991; Shimoda and Robinson,1998; Sullivan et al., 1997; Yohannes et al., 2000). Noneof these was able to assess whether anxiety was a riskfactor for increased disability independent of depres-

Table 8Association of anxiety with health outcomes in community samples


Bruce et al.(2002)

1005 70–85 Self-report Cross-sectional communityliving women (Australia)

Delbaereet al. (2004)

225 61–92 Modified 3point fear offalling scale

1-year prospective study ofcommunity living older peopl(Belgium)

de Beurset al. (1999)

659 55–85 DIS Cross-sectional comparison oanxiety disorder, anxietysymptom and control groupwithout anxiety (Netherlands)

HADS

Breneset al. (2005)

1002 65+ HopkinsSymptomChecklist

3-year prospective observatiostudy of functionally limitedpeople (US)

Kawachiet al. (1994)

33,999 42–77 Crown-Crisp Index

Longitudinal Health ProfessioFollow-Up Study (US)

Mehtaet al. (2003)

3041 70–79 HopkinsSymptomChecklist

Cross-sectional community liwell functioning older people

Tinettiet al. (1995)

927 72+ STAI 1-year prospective study ofcommunity living older peopl

Note: DIS = Diagnostic Interview Schedule; HADS = Hospital Anxiety and

sion, a gap in the literature that was also highlighted byMehta et al. (2003).

The studies reviewed here and summarised in Tables 6,7, and 8 are thus of two types— their objective is either toascertain the prevalence of anxiety in a clinical setting, orto ascertain the association of anxiety with particularillnesses or conditions and their outcome. Amongst thesestudies are several that are not specific to people over theage of 65, but included a significant number of olderparticipants. The studies are tabulated separately, sincemany of the investigations of specific conditions donot include prevalence figures as such. Rather, anxietyis treated as a risk factor for poorer outcomes in thatcondition.

Overall, these studies point to high levels of anxietysymptoms in clinical, especially hospitalised, popula-tions, and suggest that anxiety is both a source ofsignificant distress for older adults with physical ill-nesses, and also a potential risk factor for a pooroutcome. The few studies that have examined the latterissue all found anxiety to be an important predictor of a

Main findings Comments

33.9% reported fear of falling Fear of falling a risk factorfor non-participation inphysical activity

eFear-related avoidance ofactivities predictive ofincreased falls

Avoidance of physicalactivity part of a pathwayof decreased musclestrength and frailty

f Anxiety associated withincreased disability and healthservice use, but use of mentalhealth services very low

Findings applied to anxietydisorder and symptomgroups equally

nal 19% of women reported 2+symptoms of anxiety atbaseline

Presence of anxietypredicted the developmentof ADL disability

nals Phobic anxiety increased riskof sudden fatal CHD (RR 2.5)

Wide confidence intervals;all male sample;no association withnon-fatal heart disease

ving(US)

19% of sample had N2 anxietysymptoms; 43% of thosewith depression had anxietysymptoms; 15% anxiety withoutdepression

Anxiety correlated withchronic health conditions,e.g. incontinence, hearingimpairment andhypertension

e (US)Anxiety as well as physicalimpairment increased risk offalling, incontinence anddependency

Authors highlight needfor an approach to geriatricsyndromes that integratesphysical and affectiverisk factors

Depression Scale; STAI = State Trait Anxiety Inventory.


range of outcome variables. These included increasedrisk of hospitalisation in people with chronic obstructiveairways disease (Yohannes et al., 2000), increased riskof social isolation after stroke (Astrom, 1996), and poormobility after knee replacement surgery (Salaffi et al.,1991). This adds further evidence to the argument thatanxiety is not a minor matter, and reinforces the need forfurther research that can elucidate the relationshipsbetween anxiety and physical health in older adults.

3.4. The impact of anxiety on well functioning individuals

A final aspect of the literature on anxiety as it affectsphysical health comes from studies of community-dwelling, well functioning older people. Although fewin number, they are significant for a number of reasons.Firstly, community-dwelling older people represent themajority of older people and thus, the findings of suchstudies have potential relevance to large numbers ofpeople. Secondly, these results indicate that even wellfunctioning individuals may be at risk of compromisedphysical health as a result of potentially treatableconditions, such as anxiety. For example, it has beenfound that fear of falling in well functioning olderpeople can lead to avoidance of physical activities suchas walking (Bruce et al., 2002), and a subsequentdownward spiral of activity avoidance, increased like-lihood of falling, and disability (Delbaere et al., 2004).

4. Discussion

The studies reviewed indicate that both symptoms ofanxiety and anxiety disorders are relatively common inolder adults. Although only rarely the primary presentingproblem in psychiatric settings (Flint, 1994), anxiety ishighly prevalent in medical settings, where up to 65% ofolder adults experience anxiety symptoms (Ames et al.,1994a,b). In community-dwelling populations, there arestriking differences in reported prevalences, which rangefrom 2.4% (Copeland et al., 1987a,b) to 15% in the studyby Manela et al. (1996). This discussion examines fourkey themes that emerge from this literature. These are:inconsistencies in the reported prevalence of anxiety inolder adults, the nature of anxiety in this population,whether anxiety does become less common as peopleage, and comorbidity with depression.

4.1. The prevalence of anxiety

Although discrepancies between studies samplingsimilar populations may reflect real differences inprevalence, it is more likely that they reflect differences

in how anxiety is defined or measured (Jeste et al.,2005). A fundamental distinction concerns whetheranxiety is measured dimensionally, or in terms ofcategorical disorders. At one extreme, the GeriatricMental Schedule (GMS) and its computerised diagnos-tic classification employs a hierarchical system in whichan anxiety disorder cannot be diagnosed in the presenceof a “higher” level disorder, such as depression ordementia. As a result, studies using the GMS/AGECATtypically report very low rates of anxiety disorder, e.g.,2.4% of a community sample in the study by Copelandet al. (1987a,b).

In contrast, Copeland et al. noted that, although caseswere rare, “high proportions of neurotic symptoms,particularly anxiety, are often present” (Copeland et al.,1987(b), p.821) at a sub-syndromal level. When theseso-called ‘sub-cases’ are included, the overall preva-lence rises to 26.7%. Given that sub-syndromal levels ofpsychiatric disorder, notably depression, in older peopleare now being recognised as clinically significant (Juddand Akiskal, 2002; Lavretsky and Kumar, 2002), it isarguable that sub-case levels of anxiety and anxietysymptoms should be of concern.

4.2. Is anxiety qualitatively different in older adults?

If symptoms of anxiety are important, this hasimplications for a second issue, namely, what constitutesan anxiety disorder in older people, and how to measureit. A number of authors have addressed this issue.Fuentes and Cox (1997) argued that much of theexisting literature on anxiety was premature because ithad been carried out using instruments that had not beenvalidated for use in older populations. It can be seenfrom Table 1 that most of the studies use checklists ordiagnostic criteria that were not designed specificallyfor use in an older population — the GMS being asignificant exception. However, in a later study, Fuentesand Cox (2000) compared the psychometric propertiesof a number of scales in samples of older (n=84) andyounger (n=48) people and showed that commonlyused self-report instruments such as the STAI and theFear Questionnaire had good internal reliability whenused in older people. While acknowledging the limita-tions of a small sample, they concluded that anxiety inolder people was more similar to, than different from,anxiety in their younger sample.

However, Krasucki et al. (1999) suggested that manystudies may have produced “spuriously low” figuresbecause of their use of diagnostic hierarchies andarbitrary caseness criteria at a time when little is knownabout what constitutes “normal” anxiety in the elderly


and thus, how much anxiety constitutes a case (p. 26).Palmer et al. (1997) argued that the DSM-IV (APA,1994) criteria are inappropriate for late-life anxiety andthat the application of these diagnostic criteria devel-oped for younger populations results in the under-diagnosis of anxiety. Flint (2005) reiterated the latterpoint, stating that the problem is not just one of duration,i.e., not meeting sufficient criteria for long enough, but,rather that anxiety may be experienced differently inolder people, in whom it is characterised by anxiousmood, tension, and diffuse somatic complaints, such asdizziness, shakiness and nausea.

The high level of physical and psychiatric comor-bidity frequently experienced by older people wasidentified by Jeste et al. (2005) as one of a number ofpotential causes of diagnostic confusion in older adults.Older people do actually experience more physicalillness than younger age groups and it can be verydifficult to tease out physical symptoms, anxiety andsomatoform disorders (Wijeratne and Hickie, 2001).Although somatisation in older people decreases whenanxiety and depression are treated (Sheehan et al.,2002), it remains the case that individuals almost in-variably experience their somatic and psychologicaldistress as intertwined (Simon et al., 1996). Oneapproach to this issue may be to use instruments spe-cifically designed for older adults, with criteria validatedfor use in this population — which would, however,have the drawback of making comparisons with youn-ger age groups harder to make.

4.3. Do anxiety disorders become less prevalent aspeople age?

Thirdly, the question arises as to whether anxietydisorders become less prevalent in older populations(Jorm, 2000). The ECA study, reported by Regier at al.(1983) used the Diagnostic Interview Schedule (DIS) tomake diagnoses in accordance with DSM-III (APA,1980) criteria, except that they did not have to conformto the usual hierarchical constraints. The ECA study didreport that anxiety disorders were less common in theolder age groups. In contrast, the study of Uhlenhuthet al. (1983) found marginally higher levels of anxietyamong older people than younger age groups. A morerecent study reported a curvilinear relationship betweenage and anxiety symptoms, with increases observed inanxiety and negative affect after the mid 70s (Teachman,2006).

In theBerlinAgingStudy (BASE) (Schaub andLinden,2000), data were analysed in two age brackets — 70–84(n=258) and 85–103 (n=258) and the prevalence of

anxiety was found to be lower in the older age group (2.3%as compared to 4.5% in those below 85). Although this isconsistent with other reports that rates of anxiety decreasewith age (Flint, 1994), it should also be borne in mind thatthese lower rates may reflect the sampling method in thisstudy, which resulted in only 27% of the eligibleparticipants taking part in the full assessment protocol,leading to definite positive selection bias in the sample.These sampling issues have been discussed in relation tothe Australian National Survey of Mental Health andWellbeing (O'Connor, 2006), which reported that olderAustralians were less anxious and depressed than theiryounger counterparts. However, the survey omitted agedcare facilities and people in hospital, probably resulting inspuriously low estimates of psychiatric morbidity.

4.4. The comorbidity of anxiety and depression

Comorbidity is an important issue, because it may bethat the neglect of anxiety in its own right has been aconsequence of the view that anxiety disorders rarelyoccur in the absence of depressive symptoms (Manelaet al., 1996). There are a number of barriers to teasingout this relationship. Firstly, studies using hierarchicalcase definition (for example, the GMS) cannot informthis issue, because participants who are cases of de-pression are, ipso facto, not deemed cases of anxiety.Secondly, it is possible that older people under-reportanxiety to a greater extent than they do depression, orthat symptoms are under-recognised by medical practi-tioners (Lindesay, 1990). The use of avoidance caneffectively prevent an older person from experiencinganxiety symptoms.

Thirdly, most studies have been cross-sectional.While the majority of these tend towards supportingthe association between anxiety and depression, they areunable to address the directionality of the relationship. Itis clear that the prevalence of anxiety disorders in peoplewith depression is much higher than would be expectedby chance. Lenze et al. (2001) reported that an estimated85% of adults with depression have significant symp-toms of anxiety, while Jeste et al. (2006) found that 42%of their depressed sample endorsed comorbid anxiety.The Guy's/Age Concern Survey (Lindesay et al., 1989),using the semi-structured Anxiety Disorder Scale, foundthat 39% of phobic participants also had depressioncompared with only 11% of their participants who werenot phobic. Comorbidity was highest in those diagnosedwith Generalised Anxiety Disorder, of whom 91% alsohad a diagnosis of depression.

The same instrument was used by Manela et al.(1996). Consistent with the Guy's/Age Concern Study


(Lindesay et al., 1989) was the finding of a high level ofcomorbidity between Generalised Anxiety Disorder anddepression. However, a notable aspect of their findingswas the lack of such a relationship for phobic disorder.This led the authors to challenge the view that anxietypresents most commonly in association with depression.They suggested that phobic disorder, in particular,should be regarded as a disorder that is both commonand distinct from depression and Generalised AnxietyDisorder. This view may be consistent with the threedimensions of psychopathology advocated by Ormelat al. (1995).

Therefore, longitudinal designs are needed to answerthe question of comorbidity. One such study is that ofde Beurs et al. (2001). The Longitudinal Aging StudyAmsterdam, used data from participants who werehealthy at baseline to investigate risk factors for be-coming anxious and/or depressed 3 years later. AtTime 2, 4% of the sample had become depressed, 2.4%became anxious and 2.9% were both depressed andanxious. The authors found that the vulnerability factorsfor depression and anxiety were similar (namely, highneuroticism and low mastery), but stressful life eventshad differential effects: The onset of depression waspredicted by the loss of a partner or relative, whileanxiety was predicted by conflict with or illness in apartner or relative. Events that contributed to a dualdiagnosis were death of a family member and being avictim of crime. These findings were interpreted by theauthors as suggesting that there are different pathwaysleading to anxiety and depression, and that the distinc-tion between these symptom clusters is a valid one.

A different picture emerges from data reported bySchoevers et al. (2003) from the Amsterdam Study ofthe Elderly (AMSTEL). Using the GMS on a sample of4051 community living persons, they found that theseverity of anxiety or depression symptoms increasedthe likelihood of having mixed anxiety and depression,which they conceptualised as a more severe form ofpsychopathology. In their sample, it was almost entirelyspecific to women.

In summary, the findings thus far are equivocal:While anxiety clearly often presents with depression,quite significant rates of anxiety are present in theabsence of depression. Mehta et al. (2003) found thatalthough anxiety occurred in 43% of their sample whowere depressed, 15% of their non-depressed participantsalso reported anxiety symptoms. Beekman et al. (2000)reported that 25% of older people with anxiety suf-fered from major depression, while 50% of those withdepression had symptoms of anxiety. Perhaps theimportant message is for clinicians to be alert to the

possibility of anxiety, even in the absence of depression,but not overlook symptoms of anxiety when a diagnosisof depression has been made. One implication for re-search is that further longitudinal studies are needed.

5. Conclusion

There appear to be relatively few unequivocalconclusions to be drawn from the literature on anxietyin older people, and these are rather broad: In communitysamples, feelings of anxiety are quite common —reported by up to 24% of participants, but anxietydisorders, however defined, are much rarer. Overallprevalence rates of anxiety disorder vary from 2.4% inthe study of Copeland et al. (1987a,b) in Liverpool to 15%in the work of Manela et al. (1996). These differences canbe largely accounted for by the use of differentmethods ofcase ascertainment. The prevalence of anxiety (howevervariably defined) is much higher in clinical samples, withreported prevalence of anxiety symptoms as high as 44%in geriatric settings (Kvaal et al., 2001). This highlightsthe potential of physical health settings as an importantarena for mental health intervention in older people.Women continue to have an elevated risk for anxietydisorders in late life and most studies that use samplesacross the adult age span report that anxiety disorders arerarer in older age groups, with very few new cases ofanxiety presenting in old age. However, old age ischaracterised by a number of unique features, includingthe increasing prevalence of neurodegenerative diseases,associated dementias, frailty and the need for institutionalcare. It is clear that these groups, and their carers, are atmuch higher risk of anxiety than their physically well,cognitively intact counterparts, often not included in“community samples”, and, yet, may be important targetgroups for prevention and early treatment.

Perhaps one of the most intriguing questions concernsthe nature of anxiety in older adults. Consistent withsuggestions regarding depression and other psychiatricdisorders, this reviewwould suggest that anxiety tends topresent as a sub-threshold disorder in older people. Inother words, there are fewer cases of anxiety, but morepeople with symptoms of anxiety, which are, in fact,more common than symptoms of depression. Moreover,these symptoms themselves are different from thosetypically endorsed by younger adults, with an increasingfocus on somatic symptoms, and reduced prominenceof worrying thoughts. One way of conceptualisingthis might be that anxiety in older adults divergesincrementally from that in younger age groups ascumulative age-related physical and cognitive impair-ments lead to what might be termed ‘geriatric anxiety’.

R


Anxiety symptoms are highly prevalent among olderpeople, frequently do not conform to current diagnosticcriteria, and consequently go unrecognised and untreated.The evidence is that these are not an “understandable” partof aging, but rather conditions that contribute to a spiral ofinteracting physical decline andmood disturbance (Bruce,2001; Bruce et al., 1994). Some variables known to be riskfactors for poor physical functioning, such as older ageand female gender (Seeman et al., 1995) are not mod-ifiable. In contrast, anxiety and mood disorders arepotentially treatable. The public health and quality oflife benefits that could flow from greater awareness,detection and treatment of these disorders are considerable(Kennedy, 2001; Smit et al., 2007). A recent editorial(Flint, 2005) highlighted the need for clinically relevant,“hypothesis-driven research where late-life anxiety is thea priori focus.” (p.4). Such research is needed to resolvethe issues and controversies that currently impedeprogress towards the effective treatment and preventionof anxiety in older adults.

Role of funding sourceThe funding source had no say in the carrying out of the review or

the subsequent writing of the paper.

Conflict of interestNo conflict declared.

Acknowledgements

This work was supported in part by NHMRC Grantnumber 310655.

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

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