Dr. Smith, Mr. Ingram, and Ms. Brighton are Assistant Professors, The University of Iowa College of Nursing, Iowa City, Iowa. Dr. Adams is Associate Director, Research Translation and Dissemination Core, Gerontological Nursing Interventions Research Center, The University Iowa College of Nursing, Iowa City, Iowa.
Guidelines in this series were produced with support provided by grant P30 NR03979 (PI: Toni Tripp-Reimer, The University of Iowa College of Nursing), National Institute of Nursing Research, National Institutes of Health. Copyright © 2008 The University of Iowa Research Translation and Dissemination Core, Gerontological Nursing Interventions Research Center. All rights reserved.
Address correspondence to Marianne Smith, PhD, RN, Assistant Professor, The University of Iowa College of Nursing, 50 Newton Road, Iowa City, IA 52242; e-mail: email@example.com.
Anxiety symptoms and disorders are both common and disabling in older adults. Anxiety, which is widely defined as apprehensive expectation and excessive worry, exists on a continuum from normal reactions to everyday stress to disabling levels categorized as anxiety disorders. Diverse psychological and behavioral symptoms are regularly associated with anxiety, including irritability, uncertainty, fearfulness, restlessness, and fidgeting. (The Sidebar on page 10 lists these and other common symptoms of anxiety in late life.) Anxiety symptoms often occur in conjunction with other health problems that cluster in late life, including a wide variety of medical problems (e.g., cardiovascular, gastrointestinal, and respiratory diseases) (Katon, Lin, & Kroenke, 2007) and psychiatric disorders such as depression (Löwe et al., 2008) and dementia (Mantella et al., 2007).
- Anticipation that something bad is about to happen (e.g., fear of dying, fainting, falling, losing control; fear that family members are ill or injured)
- Apprehensive expectation
- Body aches and pains
- Diaphoresis, sweating
- Difficulty concentrating
- Difficulty falling asleep
- Dry mouth
- Easy to startle
- Eyelid twitch
- Fatigue on awakening
- Feeling “on edge”
- Frequent urination
- Furrowed brow
- Heart pounding
- Hot or cold spells
- Inability to relax
- Interrupted sleep
- Muscle aches
- Nausea, upset stomach
- Pulse increased at rest
- Strained face
- Worry that is excessive, unrealistic, or out of proportion
Anxiety Symptoms in Late Life
Sources.American Psychiatric Association (2000); Dada, Sethi, and Grossberg (2001); Dugue and Neugroschl (2002); and Small (1997).
The frequency with which anxiety occurs among older adults varies by the definition used and the setting in which the study is conducted. Anxiety symptoms are reported by more than 50% of community-dwelling older adults (Schaub & Linden, 2000). Estimates of subthreshold anxiety, which is generally defined as a cluster of clinically significant symptoms that do not meet criteria for an anxiety disorder (Papassotiropoulos & Heun, 1999), range from 17% to 25% among older adults (Areán & Alvidrez, 2001; Szádóczky, Rózsa, Zámbori, & Füredi, 2004). The prevalence of anxiety disorders among community-dwelling older adults ranges from 5.5% to 15% in epidemiological studies (Manela, Katona, & Livingston, 1996; Regier et al., 1988) but is reported to be 20% in primary care settings (Kroenke, Spitzer, Williams, Monahan, & Löwe, 2007). Terms and definitions related to anxiety disorders are listed in the Table.
Table: Anxiety Disorders Terms and Definitions
Negative outcomes and experiences are highly associated with anxiety symptoms in older adults and underscore the importance of accurate assessment, referral, and treatment. Anxiety is regularly associated with reduced quality of life and lower life satisfaction (Smith, Gomm, & Dickens, 2003); impaired physical and social function (Löwe et al., 2008; Mehta et al., 2007; Schultz, Hoth, & Buckwalter, 2004); and self-perceived worthlessness, decreased health, and functional disability (Allsup & Gosney, 2002; de Beurs, Beekman, Deeg, Van Dyck, & van Tilburg, 2000; Mehta et al., 2007). When anxiety occurs comorbidly with depression, the person is more likely to experience a longer duration of symptoms and greater physical and social disability than if anxiety or depression occurred alone (Lenze et al., 2001; Smalbrugge et al., 2006; Steffens & McQuoid, 2005).
A variety of factors regularly confounds the detection and treatment of late-life anxiety. An important first consideration is that older adults and health professionals alike fail to recognize subthreshold anxiety disorders as clinically significant and worthy of assessment, treatment, and monitoring (Penninx et al., 2008; Rickels & Rynn, 2001). In addition, the ways in which older adults describe their anxiety experiences, including their focus on somatic symptoms and complaints, may distract health care providers from identifying anxiety as a key causal factor in symptom presentation (Kogan, Edelstein, & McKee, 2000). In tandem, problems that cause or contribute to anxiety symptoms, particularly depression (Katon et al., 2007), dementia (Mantella et al., 2007), physical health problems (Bair, Wu, Damush, Sutherland, & Kroenke, 2008; Kroenke et al., 2007), and challenges such as falling (Gagnon, Flint, Naglie, & Devins, 2005), may lull nurses and other health providers into thinking the problematic symptoms are just “understandable” consequences of aging. Detection and assessment are essential to accurately identify and treat clinically significant anxiety and to simultaneously address factors that cause or contribute to anxiety-related symptoms, distress and discomfort, and functional limitations.
The purpose of this evidence-based practice guideline is to improve the detection and assessment of anxiety symptoms in older adults. The guideline and associated assessment methods may be used by all levels of health care practitioners, including advanced practice and generalist nurses; nursing assistants; physicians; physician assistants; medical assistants; social workers; and occupational, recreational, activity, and physical therapists and their assistants. Likewise, this guideline is appropriate for use in the diverse settings where older adults receive health-related services, including their homes, adult day services, community-based programs, residential and assisted living centers, nursing homes and other long-term care facilities, and outpatient and acute care services.
Individuals at Risk
Two primary groups of risk factors must be considered to promote optimal detection and assessment of late-life anxiety: (a) factors that reduce the likelihood that anxiety will be recognized as anxiety—by the older person himself or herself, family members, and the health care team, and (b) factors that increase the risk that anxiety will occur.
An important first step in anxiety detection and assessment is recognition of attitudes and beliefs that may interfere with recognizing anxiety symptoms. One set of barriers is associated with the characteristics, beliefs, and behaviors of older adults (Beck & Averill, 2004; Carmin, Wiegartz, & Scher, 2000). For example, the stigma associated with mental illness, such as fear of being labeled as “crazy” and being shunned, often interferes with help-seeking behaviors for mental disorders among older adults. Interpretation of psychological symptoms as physical ailments increases the risk that symptoms are attributed to medical causes or to being a hypochondriac. Of equal importance, physical symptoms, such as pain, headaches, nausea, heartburn, and diarrhea, are significantly associated with anxiety (Haug, Mykletun, & Dahl, 2004).
Underreporting and denial of problems are common among older adults (Levy, Conway, Brommelhoff, & Merikengas, 2003); examples include when family members observe and report symptoms and when a family member says anxiety does not exist in a loved one who self-reports otherwise. Labels used for anxiety, such as complaining of feeling nervous, fretful, worked up, or worried about their physical health or safety, may contribute to underestimation of and misunderstandings about the problems. Somatic complaints, such as pain and physical distress for which no cause can be identified, may represent psychological problems in older adults (Carmin et al., 2000; Roy-Byrne & Wagner, 2004).
Another set of challenges relates to health providers and care settings. Ageist attitudes and beliefs, such as the mistaken belief that anxiety and depression are “natural reactions” to aging, reduce the likelihood that problems are identified and treated. For example, anxiety may be regarded as an understandable reaction to life stress and, as a result, may not be fully assessed or treated. Diagnostic difficulties, such as distinguishing “unrealistic” and “excessive” worry from worry that is grounded in real-life fear associated with recent experiences (e.g., fear of victimization, injury, falling) or anxiety that is related to medical problems, often challenge older adults and clinicians alike (Kogan & Edelstein, 2004; Szádóczky et al., 2004). Setting-specific deficits, particularly in primary care where most older adults seek help for psychological problems, may also create barriers to detection. For example, both anxiety and depression are regularly unrecognized and untreated in primary care settings (Bartels et al., 2004; Kroenke et al., 2007; Lecrubier, 2007).
Risk Factors for Anxiety
In addition to the attitudinal barriers that interfere with anxiety recognition and assessment, a number of socioeconomic and health-related problems also confound detection. Factors that are highly associated with anxiety symptoms in later life and that may interfere with recognizing anxiety as a contributing problem include:
- Physical illness (Beekman et al., 1998; Beyer, 2004; Kogan et al., 2000).
- Psychosocial stress, including death or illness of family members and traumatic events such as falling or being victimized (Beekman et al., 1998; Gagnon et al., 2005).
- Depression, including undiagnosed depression (Löwe et al., 2008; Penninx et al., 2008; Steffens & McQuoid, 2005).
- Cognitive impairment, including both dementia and mild cognitive impairment (Bierman, Comijs, Jonker, & Beekman, 2007; Lyketsos et al., 2002; Mantella et al., 2007).
- Personal characteristics, including female gender, advanced age, lower educational or professional levels, family history of anxiety disorder, alcohol or drug use, and Latino ethnicity (Beekman et al., 1998; Cohen, Magai, Yaffee, & Walcott-Brown, 2006; Diefenbach, Robison, Tolin, & Blank, 2004; Hettema, Neale, & Kendler, 2001).
Any person age 60 and older who expresses worry or fear and who is identified as being at risk (e.g., physical illness, recent psychosocial stress, depression, cognitive impairment, somatic complaints for which no cause can be identified) should be evaluated for anxiety.
Description of the Practice
The scales recommended in this guideline are designed to screen for anxiety, not to make clinical diagnoses. Detection of clinically significant anxiety should trigger a diagnostic assessment by a qualified health or mental health provider, preferably one with expertise in geriatric psychiatry. The anxiety scales recommended in the decision-making algorithm (Figure) were selected on the basis of their ease of administration, documented use with older adults, and focus on general anxiety detection (not diagnosis or detection of change related to treatment), and are included in the full guideline (Smith, Ingram, & Brighton, 2008).
Figure. Algorithm for Detection of Anxiety in Older Adults.
Because different anxiety assessment methods are recommended for older adults with and without cognitive impairment, the guideline begins with using the Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975). The anxiety screening tools incorporated in the algorithm include the Geriatric Anxiety Inventory, Short Anxiety Screening Test, Hospital Anxiety and Depression Scale, and Rating Anxiety in Dementia scale.
Geriatric Anxiety Inventory (GAI). The GAI (Pachana et al., 2007) measures anxiety symptoms across a range of anxiety disorders and symptoms and may be used in a variety of settings. The 20-item scale is scored 1 (yes) or 0 (no) for a total score ranging from 0 to 20. The scale can be self-administered or may be rated by a clinician during an interview. A score of 8 correctly classified 78% of patients with any anxiety disorder in a group of older adults with psychiatric disorders, with a sensitivity of 78% and specificity of 80%.
Short Anxiety Screening Test (SAST). The SAST (Sinoff, Ore, Zlotogorsky, & Tamir, 1999) was designed to detect clinically significant symptoms of anxiety. Somatic symptoms were intentionally incorporated into the scale because they are a common manifestation of anxiety in older adults. The scale can be self-administered or scored by a clinician during an interview. Ten questions are answered never, rarely, sometimes, often, and always, generating a total score of 10 to 40. Scores of less than 21 are considered “negative” for anxiety disorder, 22 to 23 “borderline,” and greater than 24 “positive.”
Hospital Anxiety and Depression Scale (HADS). The HADS (Zigmond & Snaith, 1983) was designed as a brief rating scale for medically ill patients. The scale purposefully omits physical signs and symptoms characteristic of anxiety and depression and instead focuses on psychological ones. The HADS is designed to be self-administered. Anxiety and depression subscales each consist of 7 items that are rated 0 to 3 using narrative anchors specific to the item, resulting in total subscale scores of 0 to 21. Cut-off points by subscale include: scores of less than 8 = disorder not present; 8 to 10 = disorder is doubtful; 11 or higher = disorder is definite (Spinhoven et al., 1997; Wetherell, Birchler, Ramsdell, & Unützer, 2007; Zigmond & Snaith, 1983).
Rating Anxiety in Dementia (RAID) Scale. The RAID scale was specifically developed to measure anxiety in individuals with dementia (Shankar, Walker, Frost, & Orrell, 1999). The scale is scored based on a combination of caregiver interview, direct observation, and information in the medical record. A caregiver who knows the person with dementia well (e.g., family member, nurse, daily care provider) is asked to rate items on the basis of their observations during the past 2 weeks. Following caregiver interview, the person with dementia is interviewed, and additional information in the medical record is reviewed. Symptoms likely due to physical illness or medications are not scored. Scores of 11 and higher indicate significant anxiety.
Step 1: Consider Cognitive Function
If cognitive impairment is suspected (which may interfere with accurate self-report), use the MMSE (Folstein et al., 1975) to assess level of function. If the person scores 23 or below (of 30 points) on the MMSE, the RAID scale may be more suitable for assessing anxiety symptoms. If the person scores 24 or above on the MMSE, administer the SAST or another alternative, as outlined in Step 2.
Step 2: Assess Anxiety
The next step in assessing anxiety in cognitively intact older adults is to use a scale that best addresses that person’s needs and abilities. Using the SAST is a good starting point. Individuals scoring greater than 21 (of 40 points) should be referred for further evaluation of their increased risk for anxiety. If the person has difficulty using the SAST, which is scored on a 4-point scale, substitute the GAI, which is scored yes or no. Individuals scoring greater than 7 should be referred for further evaluation. If the person has both anxious and depressed symptoms, the HADS should be administered. A score of 8 or above on either subscale should trigger further evaluation.
Step 3: Monitor Subthreshold Symptoms
If the person scores below 22 on the SAST, below 8 on the GAI, or below 8 on either subscale of the HADS, he or she should continue to be monitored for anxiety-related symptoms. Three main groups of anxiety-related symptoms demand attention:
- Mood disturbance, including visible signs (e.g., grimacing, worried facial expression or vocal inflection, sighing, jitteriness) and symptoms expressed as worries, fears, apprehensions, and ruminations.
- Behavioral symptoms, including restlessness, fidgeting, repetitive behaviors (e.g., rubbing, twisting hair, questioning and/or commenting), irritability, pacing, and vigilance.
- Physical symptoms, including diaphoresis, dizziness, dry mouth, dyspnea, flushing, insomnia (i.e., difficulty getting to sleep, difficulty staying asleep, early awakening), headaches, palpitations, or trembling.
It must be remembered that sub-threshold anxiety (i.e., anxiety that does not meet criteria for an anxiety disorder) is often clinically significant, causing distress, discomfort, and disability that interferes with quality of life. The severity and persistence of anxiety signs and symptoms should be monitored at least weekly, if not more often, to assure that steps are taken to determine or rule out other causes of distress.
Outcome indicators are those expected to change or improve from consistent use of this guideline. Use of this guideline will result in improved detection of clinically significant anxiety in older adults. The major outcome indicators that should be monitored over time are:
- Primary Outcome: Identification of symptomatic older adults who have risk factors for clinically significant anxiety and who may benefit from timely detection and treatment of distressing symptoms.
- Secondary Outcomes: Improved quality of life, overall health, and functional status; more effective use of health resources.
Although the kind of outcomes selected for monitoring may vary by the setting in which the guideline is implemented, some important examples include:
- Patient record indicates that (SAST, GAI, HADS) was completed, or that the MMSE and RAID were completed.
- Patient record indicates that psychiatric evaluation was requested/ordered and completed.
- Patient record indicates that the nursing care plan included appropriate symptom monitoring criteria.
- Patient record indicates that discharge/transfer information includes appropriate scale scores and need for ongoing assessment.
Anxiety is common among older adults but is underdiagnosed and undertreated (Kroenke et al., 2007; Sadavoy & LeClair, 1997), leading to unnecessary suffering for the anxious older person. The most important first steps in facilitating appropriate treatment involve recognition of anxiety and unrealistic and excessive worry, and understanding that older adults may worry about real-life problems. In addition, nurses and other health care providers have many opportunities to observe physical and psychological symptoms that accompany anxious mood and worry, such as restlessness, fidgeting, irritability, and difficulty concentrating. Presence of one or more risk factor for anxiety (e.g., physical illness, recent psychosocial stress, depressed mood, cognitive impairment, somatic complaints for which no cause can be identified, select personal characteristics) should trigger assessment.
Use of the full anxiety guideline (Smith et al., 2008) increases the probability that anxiety is accurately identified and quantified in a way that guides decision making. Referral for comprehensive assessment of anxiety and related symptoms is essential to determine diagnoses and, in turn, initiate therapeutic interventions and treatment to restore function and comfort. Just as for other health-related factors (e.g., vital signs, weight), ongoing monitoring of individuals at risk is essential to ensure optimal outcomes for anxious older adults.
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Anxiety Disorders Terms and Definitions
|Anxiety disorders||Anxiety disorders are a group of mental disorders in which the primary symptoms are unrealistic and excessive anxiety and/or fear. The focus of anxiety/fear, specific symptoms, and other characteristic features of individual anxiety disorders vary considerably from one disorder to another (APA, 2000). In general, symptoms may be considered a disorder if they are persistent, excessive, and life altering (Rabins, 2005).|
|Generalized anxiety disorder||Important distinguishing characteristics of generalized anxiety disorder are unrealistic and excessive worry that is difficult to control, causes significant distress and/or functional impairment, persists for 6 months, and includes three of the following additional symptoms: restlessness, feeling keyed up or on edge, fatigue, concentration problems, mind going blank, irritability, muscle tension, or sleep disturbance (APA, 2000).|
|Phobias||Unrealistic and excessive fears of specific objects or situations are called phobias. Phobias cause anxiety symptoms and may result in avoidance behaviors (APA, 2000).|
|Specific phobias||These are phobias that fall into four broad categories: fear of animals or insects, fear of things in the natural environment (e.g., storms, heights, water), fear of events related to blood or injury, and fear of particular situations (e.g., bridges, elevators, driving) (APA, 2000).|
|Social phobias||These are phobias provoked by certain kinds of social or performance situations, such as giving a speech or attending a large gathering (APA, 2000).|
|Agoraphobia||Anxiety and fear about being in places or situations from which escape may be difficult or embarrassing. This anxiety leads to pervasive avoidance of a variety of situations, such as being alone or in crowds (APA, 2000).|