Symptoms of anxiety are one of the most common problems experienced by older adults (Rabins, 1992; Smyer, 1995). In fact, almost 20% of those older than age 65 have reported clinically relevant symptoms of anxiety (Blazer, George, & Hughs, 1991; Gatz, 1995; Himmelfarb & Murrell, 1984). Moreover, anxiety in elderly individuals is a growing public health concern for three important reasons. First, older adults tend to underreport, misidentify, and somaticize their symptoms of anxiety (Kahana, 1993). Second, research has shown 44% of older patients seek treatment from primary care physicians (Stanley & Beck, 1998), as opposed to mental health practitioners. Finally, anxiety in later life is often co-morbid with depression and physical health problems (Frazier & Waid, 1999; Himmelfarb & Murrell, 1984; Stanley & Beck, 1998).
As a consequence of these three factors, the prevalence of anxiety in clinical and non-clinical samples may be under-represented and the symptoms of anxiety often go untreated (Kastenbaum, 1994). For these reasons, it is crucial for gerontological nurses in particular, and health care practitioners in general, to be skilled at differentiating symptoms of anxiety and tailoring psychosocial intervention strategies to help older patients best manage their anxiety.
Despite the growing concern about anxiety in later life, anxiety remains a relatively undefined and understudied phenomenon in older adults (Shamoian, 1991; Sheikh, 1992). Although several decades of research have focused on coping and adjusting to physical problems in later life, few studies have examined how older adults cope with mental health problems such as anxiety. Moreover, most empirical work on anxiety does not differentiate among the somatic, cognitive, and affective symptoms (Frazier & Waid, 1999).
As a consequence, clinical assessment may not be as effective at identifying older adults in need of treatment. Treatments may, thus, be less than optimally effective because of lack of assessment of specific symptoms of anxiety. The purpose of the present study was, therefore, threefold:
* To examine the somatic, cognitive, and affective symptoms of anxiety among a non-clinical sample of older adults.
* To describe coping strategies used to manage anxiety.
* To describe the psychosocial interventions that can assist older adults to cope with anxiety.
A more general aim of this study was to focus attention on anxiety, a neglected issue in gerontology (Frazier & Waid, 1999; Gatz, 1995; Rabins, 1992; Shamoian, 1991; Sheikh, 1992; Smyer, 1995; Stanley & Beck, 1998), and to draw attention to the role of gerontological nurses in early assessment and intervention for successful treatment of anxiety in older adults.
Anxiety in Later Life
Anxiety has been conceptualized along a continuum from normal reactions to stress to maladaptive reactions to stress (Andrews, 1991; Barlow, 1988, 1991; Edelmann, 1992). The experience of anxiety under normal circumstances may be adaptive, preparing the individual to cope, whereas chronic anxiety is maladaptive and may lead to psychopathology in the form of anxiety disorders. Anxiety can be especially detrimental when it leads to feelings of helplessness, inadequacy, and perpetuates expectancies of negative outcomes and an inability to cope (Wolman & Strieker, 1994). Therefore, the focal point of psychosocial interventions designed to facilitate optimal anxiety management should identify specific coping strategies for interventions.
One potential factor that may influence coping is the way anxiety symptoms are experienced and interpreted by older adults. The etiology of anxiety in later life may be reactive (i.e., a response to age-related losses and changes) or endogenous (i.e., a correlate of medical morbidity [Busse & Pfeiffer, 1969; Gatz, 1995; Gatz, KaslGodley, & Karel, 1996; Gurian & Miner, 1991; Shamoian, 1991; Smyer, 1995]). The physical symptoms of anxiety derive from autonomic nervous system arousal and include
* Muscle aches.
Cognitive symptoms include impaired attention, poor concentration, anxiety-focused thoughts, repetitive or obsessive thoughts, and memory problems (Gurian & Miner, 1991).
Symptoms of anxiety can lead to generalized beliefs about the aversive consequences of the symptoms and the interpretation of physiological arousal as threatening - a condition referred to as anxiety sensitivity (Reiss, Peterson, Gursky, & McNally, 1986; Stanley & Beck, 1998). In older adults, anxiety is also often accompanied by an increased likelihood of somaticization and hypochondriacal concerns (Busse, 1982; Gurian & Miner, 1991; Salzman, 1982). Symptoms of anxiety may present as physiological reactivity, cognitive distortions, affective, and behavioral responses.
Regardless of presenting symptomology, the experience of these symptoms has been found to be quite common in elderly individuals (Gurian & Miner, 1991; Kastenbaum, 1994). Therefore, identifying and differentiating among the somatic, cognitive, and affective components of anxiety is an important first step toward improved assessment and targeting interventions to be most effective. Because older adults most often seek treatment from health care providers, nurses are often in the best position to assess and encourage treatment for anxiety. Early intervention by nurses who work with aging populations is extremely important because the symptoms can often be treated successfully and lead to improved quality of life.
Anxiety and Coping
A second step in targeting psychosocial interventions is to determine the behavioral responses, in the form of efforts at coping, by older adults to manage specific symptoms. Despite the interplay between anxiety and coping, little research has examined how people manage their anxious symptoms. Whereas clinicians have viewed an individual's coping skills as a mediator of psychopathology (i.e., defense mechanism [Vaillant, 1977]), researchers often have conceptualized coping as a response to psychological distress.
Although the concepts of defense mechanisms and coping styles have been used interchangeably, theory and research in the fields of coping and psychopathology have developed in relative isolation (Summerfeldt & Endler, 1996). Nevertheless, based on recent literature, it is clear some patterns of coping with anxiety have been found. For example, as mentioned previously, some anxious individuals experienced a heightened and acute sensitivity to their physiological symptoms. This anxiety sensitivity (Reiss et al., 1986), or "fear of fear" (Goldstein & Chambless, 1978), has been found to relate to increased likelihood of misguided and ineffective emotional regulation strategies (Watson, Clark, & Harkness, 1994).
Within the coping literature, emotional regulation traditionally has been viewed in coping research as an attempt to manage one's affective response to distress, as opposed to active, or problem-focused, attempts to manage the environmental sources of distress (Billings & Moos, 1981; Lazarus & Folkman, 1984; Pearlin & Schooler, 1978). Although studies show emotional regulation is useful, most research shows this strategy is less effective at relieving distress (Carver & Scheier, 1994). Within the context of anxiety, an inability to effectively self-regulate emotions may lead to habitual responses to anxiety and serve to amplify its effects (Summerfeldt & Endler, 1996).
Emotional regulation in response to anxiety takes the form of attentional deployment (i.e., distancing), cognitive avoidance, and withdrawal (Summerfeldt & Endler, 1996). However, behavioral (or active) avoidance is a chief behavioral component of anxiety and a diagnostic consideration (American Psychiatric Association [APA], 1994; Barlow, 1991; Ingram & Kendall, 1987). An important distinction was made by Rachman and Hodgson (1980) between passive avoidance (i.e., distancing oneself from the threatening stimulus) and active avoidance (i.e., sleeping, drinking, using substances, using other strategies to avoid thinking about the situation). Both forms of avoidance may be learned responses and are viewed as maladaptive strategies for coping with symptoms of anxiety (Zeidner & Saklofske, 1996).
Despite these findings that illuminate possible patterns of coping with anxiety, no empirical research has systematically examined how the particular strategies are used to manage symptoms of anxiety. Determining how older adults allocate their psychosocial resources to cope with symptoms of anxiety is crucial to planning successful interventions. Thus, it is important to identify specific coping strategies used to address specific symptoms of anxiety and measure their effectiveness at managing anxiety.
Until recently, little empirical interest in anxiety in later life beyond prevalence rates existed (Frazier & Waid, 1999; Shamoian, 1991). The present study was designed to fill this gap by investigating anxiety in a relatively healthy, non-clinical sample of older adults. Examining anxiety in this sample provided baseline data about symptoms of anxiety and the differential allocation of psychosocial resources to cope with anxiety prior to diagnosis or treatment. In addition, these community-dwelling older adults may be more likely to experience transient, reactive forms of anxiety and may represent the population of older adults never diagnosed or treated for anxiety.
Measurement of Components of Anxiety
As previously mentioned, anxiety is comprised of somatic, cognitive, and affective components (Barlow, 1991). Therefore, for the purposes of this study, anxiety was conceptually divided into three components (Frazier & Waid, 1999). One component reflects somatic aspects of anxiety - a heightened awareness of physiological arousal and discomfort (i.e., anxiety sensitivity). The second component reflects cognitive distortions or unrealistic worry or fear (i.e., hypochondriasis). The third component reflects global affective aspects of anxiety (i.e., distress).
Anxiety sensitivity can be used to assess the physiological component of anxiety as somewhat separable from the psychological component of anxiety. Anxiety sensitivity reflects the purely physiological experience of anxious symptomology as opposed to the cognitive or behavioral reactions. Individuals with high anxiety sensitivity tend to amplify and misrepresent bodily sensations and symptoms of anxiety (Barlow, 1991). Anxiety sensitivity is also important because it can be a precursor of more severe psychopathology and because it is thought to arise from prior experiences in which the individual perceived an inability, unpreparedness, or unsuccessful attempt to cope with distress (Barlow, 1991). Therefore, anxiety sensitivity is important as an identifiable risk factor and a focal point for intervention.
PEARSON PRODUCT-MOMENTCORRELATIONS AMONG THE THREE ANXIETY INDICES AND COPING (N = 91)
The assessment of hypochondriasis is important because it is a common comorbid symptom with anxiety in later life (Kahana, 1993). Hypochondriasis has been conceptualized as excessive or distorted concern about disease, an unreasonable preoccupation or unrealistic interpretation of health problems, when no underlying medical illness is present. In older adults, worry, a critical feature of generalized anxiety disorder, is focused on exaggerated concern for health (Powers, Wisocki, & Whitbourne, 1992). The third component of anxiety, distress, was selected to assess a normal (i.e., non-pathological) reactive affective-behavioral response to stress, and to avoid the conceptual confusion (or potential confounding) between stress and anxiety.
In this study, two research questions were proposed. The first question was: "Do the components of anxiety (i.e., anxiety sensitivity, hypochondriasis, distress) differentially relate to global coping strategies as measured by the COPE scale (i.e., active coping, emotional regulation, cognitive and behavioral disengagement)?" The second research question was: "Do anxious older adults use specific coping efforts (i.e., items on the COPE scale that represent specific activities, cognitive, affective, and behavioral responses) to address specific anxious symptoms? Based on prior literature on coping with anxiety (Carver & Scheier, 1994; Lazarus & Folkman, 1984; Summerfeldt & Endler, 1996), the authors hypothesized greater anxiety levels would be associated with less effective coping strategies (e.g., distancing, denial).
A sample of 91 older adults was recruited for participation from a larger study on mental health in later life (Frazier & Waid, 1999). Participants ranged in age from 60 to 92, with a mean of 72.3 (SD = 6.2). The sample was 46% men and 54% women, 39% were still married, 40% were widowed, 13% were divorced or separated, and 8% had never been married. The sample was White (89%), Hispanic (6%), Black (2%), and Native American (3%). Fortythree percent of the sample had a college or post-graduate degree, 27% had had some college or technical education, and 30% had a high school degree or less. Socioeconomic status, as measured by the Hollingshead Index (Hollingshead, 1975), indicated this sample of community-dwelling older adults was middle-class (range 16 to 66; M- 46.3, SD = 11.4).
Potential participants were recruited from local senior centers and residential communities in the South Florida area. Participants were screened using the Short Portable Mental Status Questionnaire (Pfeiffer, 1975), and excluded if they demonstrated memory impairments. Research assistants conducted interviews either in the participants' homes or in a quiet location at the senior center. Completion of interviews took approximately 90 minutes. Participants were not compensated for their time.
All participants provided demographic information including age, gender, race and ethnicity, marital status, length of marriage, education, employment status, socioeconomic status, and a question on selfreported health.
Anxiety Sensitivity. The Anxiety Sensitivity Index [ASI] (Reiss et al, 1986) was used to assess the degree of fear, concern, or anxiety experienced in response to one's own physiological, somatic sensations, or anxiety symptoms (i.e., rapid heart rate, difficulty breathing). The ASI is a 16-item Likert-type scale with answers ranging from very little (0) to very much (4). A higher score indicates greater anxiety sensitivity. Mean scores on the ASI in the present study were relatively low (M = 14.2, SD = 10.7). In the present study, the Cronbach's alpha was .84.
Hypochondriasis. A modified 21item version of the Kellner's (1986) Illness Attitudes Scale (IAS) was used to assess the degree of hypochondriasis, or exaggerated concerns related to health and illness. Each question is answered yes or no, indicating agreement with the statement. The original scale has different components of hypochondriacal concern (i.e., worry about illness, concern with pain, disease and death phobias, bodily preoccupations, symptoms interference, health habits). However, in the present study an overall IAS score was computed, and higher scores indicate greater hypochondriacal beliefs. In this sample of older adults, the scores on the IAS ranged from 21 to 39 (M = 27.9, SD = 3.5). Cronbach's alpha was .76.
Distress. The 14-item Perceived Stress Scale [PSS] (Cohen, Kamarck, & Mermelstein, 1983) was used to assess the degree to which current situations in one's life are appraised as stressful and cause distress. Answer choices range from never (0) to very often (4), and following item reversals, a high score indicates greater distress. Scores on the PSS ranged from 19 to 60 (M = 35.6, SD = 8.1). Cronbach's alpha was .82 for this scale.
Coping. A 28-question Likert-type scale based on the COPE scale (Carver, Scheier, & Weintraub, 1989) was used to determine the coping strategies usually used in response to health problems (Frazier, 2000). Participants were asked to think about a recently stressful health-related event, and asked to respond to questions regarding how they managed the event. The COPE scale yielded six different coping strategies:
* Active coping, including planning, suppression of competing activities, and restraint.
* Emotional regulation, including venting emotions, acceptance, and positive reinterpretation.
e Disengagement, including both behavioral and emotional strategies.
* Social support, including both instrumental and emotional.
After item reversal, a high score indicates greater endorsement of the coping strategy. Cronbach's alphas for the six dimensions of the COPE scale, respectively, were .76, .72, .67, .55, .6, and .66.
Anxiety and Coping
To examine if greater levels of anxiety were related to less effective coping strategies, a series of correlational analyses were performed. As the Table shows, anxiety sensitivity was significantly correlated with emotional regulation (r = .29, p = .006) and distancing (r = .26, p = .01). Those with higher anxiety sensitivity are more likely to try to regulate their emotional responses to stress, or to try and mentally or behaviorally distance from them. Distress was negatively correlated with active coping (r = -.21, ? = .05), and positively correlated with distancing (r - .34, ? = .0009). As distress increases, one is less likely to use active problem-solving strategies and more likely to distance or disengage from the problem. Hypochondriasis was not significantly correlated with any coping strategies. Results show the three components of anxiety were differentially related to coping strategies
To determine how older adults with symptoms of anxiety allocate their psychosocial resources to particular coping activities, and cognitive, affective, and behavioral responses, a series of correlations among the anxiety indices and specific items on the COPE scale were examined. Results show anxiety sensitivity was positively correlated with mental disengagement statements such as, "I turn to other activities to stop thinking about it" (r - .21, ? - .05), and "I go to movies or watch TV to think about it less" (r-. 25, ? = .02).
Anxiety sensitivity was also positively correlated with behavioral disengagement strategies such as, "I admit to myself I can't deal with it and quit trying" (r = .24, ? = .02). Anxiety sensitivity was also positively correlated with positive emotional regulation strategies (i.e., "trying to see things in a more positive light" [r = .30, p = .01]), and negative emotion regulation strategies (i.e., "I let my feelings out" [r = .29, p = .01]). Finally, anxiety sensitivity was significantly correlated with seeking emotional support, (i.e., "I try to get emotional support from family and friends" [r = .24,/» = .02]).
Distress was negatively correlated with active strategies (i.e., "taking additional action to remedy the problem" [r = -.25, p = .02], "I concentrate my efforts on doing something about it" [r = -.26, ? = .01]) and items related to planning strategies to manage problems (i.e., "I try to come up with a strategy about what to do" [r = -.24, p = .02]). In addition, distress was positively correlated with both behavioral disengagement (i.e., "I give up the attempt to get what I want" [r = .23, ? = .03]), and mental disengagement (i.e., "I turn to work to get my mind off things" [r = .33, ? = .002]). Distress was also positively correlated with restraint coping (i.e., "I hold off doing anything about it until the situation permits" [r = 31, p = -003]), and negatively correlated with positive reinterpretation or growth (i.e., "I look for something good in what is happening" [r = -.21, ? = .05]).
Hypochondriasis was only correlated with one mental disengagement strategy, "I go to movies or watch TV to think about it less" (r = .22, ? = .05). Taken together, these analyses demonstrate the complex ways in which different forms of anxiety influence coping strategies.
Results demonstrate global coping efforts (i.e., active coping, emotional regulation, disengagement) are differentially allocated to address the different components of anxiety. In addition, results show older adults use specific strategies or activities to address specific symptoms or stressful aspects of the experience of anxiety.
In this study, relatively healthy, community-dwelling older adults experienced symptoms of anxiety such as distress, heightened physiological reactivity, and exaggerated concerns and fears related to their health. These findings are consistent with prior research (Frazier & Waid, 1999). Anxious older adults used less effective coping strategies, such as emotion regulation, disengagement, and denial to manage their anxiety than did less anxious older adults. These findings are consistent with earlier work (Carver OC Scheier, 1994; Lazarus & Folkman, 1984; Summerfeldt & Endler, 1996). Moreover, anxious older adults tailored their coping activities to anxious symptoms, suggesting they differentially allocate psychosocial resources to cope with anxiety, but this allocation may not be adaptive in anxious elderly individuals.
Specifically, findings show an interesting pattern of coping with anxiety in which increased distress was related to a reduction in positive aspects of coping (i.e., active coping), coupled with an increase in negative coping strategies (i.e., disengagement). However, increased anxiety sensitivity and increased hypochondriasis were associated only with increased use of negative forms of coping. These findings are consistent with prior research on coping (Summerfeldt & Endler, 1996).
One possible explanation of this trend is that distress may arise from real, tangible, everyday environmental threats and challenges. This, in turn, may compromise an older adult's resources, making active coping more difficult. Conversely, anxiety sensitivity and hypochondriasis may arise from internal, cognitive-affective responses more likely to promote feelings of loss of control and a need to regulate emotions (Barlow, 1991; Frazier & Waid, 1999). Further research could suggest interventions to promote sense of control and teach effective coping.
Findings shed light on both global patterns of coping, and more finegrained strategies of managing stressful experiences that may illuminate possible points for psychosocial intervention. In this study, older adults experiencing distress and anxiety sensitivity were more likely to mentally or behaviorally disengage. Other studies show behavioral disengagement perpetuates stress, rather than reduces it (Carver & Scheier, 1994; Lazarus, 1993).
Although behavioral avoidance has been considered a chief behavioral component of anxiety (Summerfeldt & Endler, 1996), if the purpose of coping is to alleviate anxiety, then this feature of anxious behavior may be especially detrimental because it does not accomplish its goal. Moreover, this sample of older adults with anxiety sensitivity were more likely to attempt to regulate their emotions - a coping strategy shown in other studies to be less effective at alleviating stress (Carver et al., 1989; Lazarus & Folkman, 1984; Zeidner & Saklofske, 1996). Misguided emotional regulation strategies may actually maintain or amplify anxiety symptoms by focusing attention on them (Summerfeldt & Endler, 1996).
Individual item analyses revealed distressed older adults were less likely to try and find something positive in the situation, and more likely to get upset and express their emotions, hold off or give up trying to cope, and admit defeat. Similarly, older adults with anxiety sensitivity were more likely to vent or turn to distracting activities to get their mind off their physiological reactions. Over time, these patterns become habitual responses which contribute to feelings of being out of control, perpetuate maladaptive cycles of coping, and may lead in the future to more exaggerated panic attacks and anxiety disorders (Barlow, 1991).
These findings suggest the importance of identifying older adults who are experiencing a wide range of anxious cognitions, physiological reactions, and behavioral responses and to tailor psychological treatment to those specific mental health parameters. As older adults present with anxietyrelated symptoms in health care settings, nurses can make early differential diagnoses, and provide psychosocial and educational interventions to enable older adults to better manage their symptoms.
When symptoms are severe, nursing staff may be in the best position to encourage older adults to seek treatment from mental health professionals. Early intervention by health care professionals is critical because anxiety in later life, whether it is co-morbid with other health problems or a reactive response to age-related loss, often is treated successfully.
Research on treatment of anxiety has shown the utility of multidimensional assessment of symptomology, an issue especially important for older adults (Gurian & Miner, 1991; Sheikh, 1992; Stanley & Beck, 1998). The assessment tools used in this study to distinguish among the somatic, cognitive, and affective components of anxiety are available and can be modified for use in health care settings via an interview format. Intervention research has also generated models for treatment of anxiety focusing on teaching patients how to:
* Identify environmental triggers and recognize their physiological reactions to those triggers.
* Identify their maladaptive cognitions that perpetuate anxiety.
* Use strategies that facilitate "thought-stopping" and other strategies for cognitively refraining the stressor (Silverman & Kurtines, 1996).
Other cognitive-behavioral interventions also employ systematic desensitization and biofeedback to enhance control of environmental antecedents and psychological responses (Stanley & Beck, 1998). These models highlight the importance of enhancing perceptions of control (Barlow, 1991; Frazier & Waid, 1999), and focus on providing anxious patients with active strategies to manage their anxiety and positive emotional regulation strategies such as positive reframing and self-confidence.
In a therapeutic setting, an older patient would be assessed to determine the source and presentation of the anxious cognitions. A treatment protocol would be based on teaching the patient to identify potential anxiety-producing thoughts and stimuli, and to be aware of the physiological response to those stimuli. The patient would be trained to master thought processes while experiencing anxiety. Over time, the patient would gain more control over the therapeutic process, and develop a sense of mastery and control over anxiety.
Several studies have been successful at teaching coping skills for managing anxiety (Adler, Craske, Kirshenbaum, & Barlow, 1989). Yet, to date these interventions have not been modified for older adults (Knight & Satre, 1999). The findings reported in this article suggest how coping skills training programs might be best tailored to meet the needs of older patients. For example, patients could be trained to selfreflect on their responses to anxiety producing situations as opposed to mentally or behaviorally disengaging.
The goal of this study was to determine how older adults cope with three forms of anxiety, and potential avenues for applied interventions. Although the findings shed light on some interesting findings with potential psychosocial applications, several limitations need to be noted.
First, this study was based on two assumptions. The assumption, based on earlier work (Carver et al., 1989; Lazarus & Folkman, 1984; Zeidner & Saklofske, 1996), that certain coping strategies are more effective than others, and an assumption of the direction of influence in which anxiety is a precursor of coping strategies. Because this was an exploratory study, the research questions did not directly test these assumptions.
Second, this study is correlational in nature. Therefore, conclusions cannot be drawn about the causality of these associations.
Third, as with any self-report data and self-selected sample, one needs to interpret the findings with caution. Similarly, for the purposes of the study, a non-clinical sample of older adults was examined using three distinct conceptualizations of anxiety.
Suggestions for future research include:
* Replication of this study using a multidimensional measure of anxiety appropriate for clinical samples.
* A longitudinal replication of this study identifying patterns of coping that facilitate adjustment over time.
Finally, a more general purpose of this study was to focus attention on a neglected issue in gerontology - the experience of anxiety in later life (Frazier & Waid, 1999; Gatz, 1995; Rabins, 1992; Shamoian, 1991; Sheikh, 1992; Smyer, 1995; Stanley & Beck, 1998), and, most importantly, the role of gerontological nurses in early assessment and intervention for successful treatment of anxiety in older adults.
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PEARSON PRODUCT-MOMENTCORRELATIONS AMONG THE THREE ANXIETY INDICES AND COPING (N = 91)