” … left untreated, anxiety can lead to: A decline in an older person’s ability to carry out daily tasks; poorer health; and decreased life satisfaction … “
Although anxiety is one of the most common psychiatric conditions in later life1, it receives only limited attention in long-term care settings, such as nursing homes. In contrast, there is widespread awareness of the impact of depression among older people living in long-term care.
Late-life depression has been extensively studied by researchers, and many facility staff and visiting medical practitioners now screen for depression as part of their routine assessments. While this increased focus on depression is very much welcomed, the lack of attention paid to anxiety – a similarly common mental health condition – merits fresh focus and response. Unfortunately, the consequence of this poor awareness of anxiety is that many anxious older adults remain unrecognized and under-treated. This is particularly concerning given that when left untreated, anxiety can lead to:
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- a decline in an older person’s ability to carry out daily tasks;
- poorer health;
- decreased life satisfaction; and
- depression over time2,3.
How does anxiety present later in life?
While anxiety is a natural, future-oriented emotional response to anticipated danger4, it can become problematic when the sensations of doom, dread, or panic become overwhelming and overly frequent. In later life, anxiety can be harder to detect particularly among those older adults who find it difficult to communicate their symptoms, with many older people continuing to feel uncomfortable discussing issues related to mental health. Adding to this, it is common for health professionals to fail to recognize anxiety. For example, a symptom of avoidance may be put down to other factors, such as declining health and physical abilities, aging, or medication side-effects5.
Studies have found that late-life anxiety is often characterized by more worries about health and the future than is the case in younger adults, with fewer worries related to work, finances, and relationships. Older people with anxiety also appear to have more difficulty concentrating, sleeping, and controlling their worry than younger adults, as well as increased restlessness and muscle tension6,7.
To date, research suggests that specific phobias are one of the most common anxiety disorders among older adults, with the elderly often reporting anxiety related to specific situations (e.g., flying, being in an elevator) and the natural environment (e.g., storms, heights). In addition, there is also a unique geriatric anxiety subtype of fear of falling8, which can impact significantly on older people’s lives.
” … anxiety is more frequently experienced by long-term care residents than by the general community.”
Unfortunately, there are very few studies examining the rate of anxiety in long-term care, making it difficult to gain a clear picture of the extent of this problem. However, the few studies that are available suggest that anxiety is substantially more common in long-term care than among older people living in their own homes in the community. A recent review of nine studies published in the International Journal of Geriatric Psychiatry9 found that prevalence rates for anxiety disorders in long-term care settings ranged from 3.2% to 20% compared with 1.4% to 17% in the community.
This review also examined the number of older people in long-term care who experience anxiety symptoms that warrant intervention, but don’t meet strict criteria for a psychiatric diagnosis. Using this more liberal measure, the rate of anxiety symptoms in long-term care ranged from 6.5% to 58.4%, which is compared to 4.7% to 24.4% in the community. While the variation from study to study makes it difficult to pinpoint the precise prevalence, these findings suggest that anxiety is more frequently experienced by long-term care residents than by the general community.
It is also interesting to look at which types of anxiety are more common in the long-term care setting. Studies suggest that the most common anxiety disorders among long-term care residents are Generalized Anxiety Disorder (GAD) and Specific Phobias, which is consistent with community-based older adults. Currently, little is known about the other anxiety disorders in long-term care, but Obsessive Compulsive Disorder (OCD) and Panic Disorder are the next most common. Both Social Anxiety Disorder (SAD) and Agoraphobia appear to be rare.
Which long-term residents are most at risk of anxiety?
A number of research papers have examined demographic factors associated with anxiety in long-term care. These studies suggest that anxiety is more common among younger long-term care residents, women, and those with a higher level of education. The experience of pain and difficulty performing daily activities, such as dressing and self-care, were all also found to be significantly associated with higher levels of anxiety. Poor social support has also been linked to anxiety.
The relationship between higher levels of cognitive impairment or dementia and anxiety is inconclusive; some studies have found residents with better cognition/memory are more likely to experience anxiety, while other studies have found higher levels of anxiety in people with worse cognition/memory. Consistent with our understanding of anxiety in other groups, older people with anxiety are also more likely to develop symptoms of depression and report a reduced quality of life. All of these factors are common among residents of long-term care, and so may account for the higher prevalence of anxiety within this setting.
How do we address the problem of anxiety in long-term care?
Currently, while it appears that the majority of individuals who are recognized as anxious receive some treatment, the majority receive medications only and continue to experience anxiety. In a study currently being conducted by the authors, preliminary data suggests that only 3.5% of those recognized as anxious have received psychological support for their anxiety, while 68% are receiving some form of medication. This is in contrast to younger adults, who are more commonly offered a combination of both medication and psychological support, which has been shown in a key meta-analysis to be more effective than either treatment alone10.
To help address this gap:
- Further research into the prevalence and factors associated with anxiety in long-term care is needed, as this will help us better understand and characterize the extent of the issue, as well as aid in the development of strategies to support and treat anxious older people living in care.
- Long-term care staff and medical practitioners who work with older adults should receive more training about identifying and managing anxiety within this population.
- An easy-to-use screening tool for anxiety in long-term care settings should be implemented to increase the chances of anxious residents being detected and monitored early, which would help to ensure that they are appropriately and effectively treated as soon as possible.
Sources
1. Gonçalves, D.C., N.A. Pachana, and G.J. Byrne, Prevalence and correlates of generalized anxiety disorder among older adults in the Australian National Survey of Mental Health and Well-Being. Journal of Affective Disorders, 2011. 132(1–2): p. 223-230.
2. Lenze, E.J., et al., Generalized anxiety disorder in late life: Lifetime course and comorbidity with major depressive disorder. American Journal of Geriatric Psychiatry, 2005. 13(1): p. 77-80.
3. Smalbrugge, M., et al., The impact of depression and anxiety on well being, disability and use of health care services in nursing home patients. International Journal of Geriatric Psychiatry, 2006. 21(4): p. 325-332.
4. Cohen, D. and C. Eisdorfer, Integrated textbook of geriatric mental health. 2011, Baltimore, USA: The John Hopkins University Press.
5. Jeste, D.V., D.G. Blazer, and M. First, Aging-related diagnostic variations: Need for diagnostic criteria appropriate for elderly psychiatric patients. Biological Psychiatry, 2005. 58(4): p. 265-271.
6. Gonçalves, D.C. and G.J. Byrne, Who worries most? Worry prevalence and patterns across the lifespan. International Journal of Geriatric Psychiatry, 2013. 28(1): p. 41-49.
7. Wetherell, J.L., H. Le Roux, and M. Gatz, DSM-IV criteria for generalized anxiety disorder in older adults: Distinguishing the worried from the well. Psychology and Aging, 2003. 18(3): p. 622-627.
8. Grenier, S., et al., The epidemiology of specific phobia and subthreshold fear subtypes in a community-based sample of older adults. Depression and Anxiety, 2011. 28(6): p. 456-463.
9. Creighton, A.S., T.E. Davison, and D.W. Kissane, The prevalence of anxiety among older adults in nursing homes and other residential aged care facilities: A systematic review. International Journal of Geriatric Psychiatry, 2016. 31(6): p. 555-566.
10. Cuijpers, P., et al., Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. . World Psychiatry, 2014. 13(1): p. 56-67.
Alexandra Creighton (B.Psych(Hons)) is a clinical psychology doctorate student from Monash University, Australia. She received her Bachelor of Psychology (Honours) degree from Monash in 2014, with her honours thesis examining the effectiveness of a memory intervention for older adults with dementia. Alex has continued to pursue her interest in the field of ageing and older adults through her doctoral research, which is examining anxiety in long-term care settings.
Dr. Tanya Davison (DPsych(Clin) MAPS) is a Clinical Psychologist, based at the Institute for Health and Ageing at the Australian Catholic University. Dr. Davison has a long history of research and practice in long-term care settings, with a particular focus on improving the management of older people with dementia, depression, and anxiety. She has designed and evaluated several interventions to train staff to manage residents with depression, as well as those with behavioural symptoms associated with dementia. She is currently leading a large trial evaluating an intervention to assist newly admitted long-term care residents to adjust to their new environment.
David W. Kissane, MD is an academic psychiatrist and researcher in the fields of psycho-oncology and palliative care. He is currently the Head of the Department of Psychiatry for Monash University in Australia, was previously Chairman of the Department of Psychiatry and Behavioral Sciences at Memorial Sloan-Kettering Cancer Center in New York and, before that, the Foundation Chair of Palliative Medicine at the University of Melbourne.
His academic interests include group, couples and family psychotherapy trials, communication skills training, studies of existential distress, and the ethics of end-of-life care. He is best known for his model of family therapy delivered to ‘at risk’ families during palliative care, which prevents complicated grief and depression in bereavement. His work on demoralization as a variation of depression in the medically ill has preceded interventions to promote meaning-based coping.
His books include Bereavement Care for FamiliesHandbook of Psychotherapy in Cancer Care (Wiley-Blackwell, 2011), Handbook of Communication in Oncology and Palliative Care (Oxford University Press, 2010), Depression and Cancer (World Psychiatric Association/Wiley, 2011) and Family Focused Grief Therapy (Open University Press, 2002, 2008).
