• Smith M, Ingram T, Brighton V. Evidence-based practice guideline. Detection and assessment of late life anxiety. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core; 2008 Nov. 51 p. [112 references]

This is the current release of the guideline.

The grades of evidence (A1, A2, B1, B2, C1, C2, D) are defined at the end of the "Major Recommendations" field.

Definition of Anxiety Symptoms

Diverse psychological, physical and behavioral symptoms are associated with anxiety in late life. Anxiety is often defined as the combination of apprehensive expectation, (the vague but nagging feeling that something bad is about to happen), and worries that are both unrealistic and excessive. Additional anxiety-related symptoms include irritability, uncertainty, fearfulness, unrealistic fears, rumination (e.g., preoccupation with repetitive negative thoughts), impaired concentration, restlessness, fidgeting, and repetitive behaviors. Autonomic nervous system arousal associated with anxiety may contribute to physical symptoms, including cardiac (e.g., heart beating out of the chest), respiratory (e.g., shortness of breath), gastrointestinal (e.g., butterflies in stomach, diarrhea), musculoskeletal (e.g., physical tension, headache) and other health-related signs and symptoms (American Psychiatric Association [APA], 2000). Common general symptoms of anxiety in late life are listed in Table 1 of the original guideline document.

Individuals/Patients at Risk for Late Life Anxiety

Two primary groups of risk factors must be considered to promote the optimal detection and assessment of late life anxiety:

• Factors that reduce the likelihood that anxiety will be recognized as anxiety—by the older person him/herself, family members, and the health care team
• Factors that increase the risk that anxiety will occur

Factors That Reduce the Likelihood That Anxiety Is Recognized

Attitudes and beliefs that influence the assessment of older adults with anxiety include the following points (Beck & Averill, 2004; Beck & Stanley, 2001; Beyer, 2004; Carmin, Wiegartz, & Scher, 2000; Dada, Sethi, & Grossberg, 2001; Flint, 1994; Fuentes & Cox, 1997; Gorman, 2001; Kogan, Edelstein, & McKee, 2000; Lenze, et al., 2001. Evidence Grade = C1).

• Stigma associated with mental illness, such as fear of being labeled as "crazy" and being shunned, continue to interfere 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 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. Evidence Grade = C1).
• Under-reporting and denying problems, including anxiety symptoms that are observed and reported by family members and saying anxiety does not exist in a family member who self-reports anxiety, is common among older adults (Levy, et al., 2003. Evidence Grade = C1).
• Labels used for anxiety, such as denying anxiety but complaining of feeling nervous, fretful, worked up, or worried about their physical health or safety, may contribute to under-estimation of problems and misunderstandings.
• Ageist attitudes and beliefs, like 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, 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), often challenge older adults and clinicians alike.
• Setting-specific deficits, particularly in primary care where most older adults seek help for their psychological problems, may contribute to problems. For example, unrecognized and untreated anxiety and depression are both common in primary care settings (Bartels, et al., 2004; Bogner, et al., 2005; Cole, Bellavance, & Mansour, 1999; Colenda, et al., 2003; Edlund, Unutzer, & Wells, 2004; Harman, et al., 2002; Katon & Roy-Byrne, 2007; Wilheim, et al., 2008; Kroenke, et al., 2007; Lecrubier, 2007. Evidence Grade = C1).
• Somatic complaints, such as pain and physical distress for which there is no identifiable cause, may represent psychological problems among older adults (Beekman, et al., 1998; Carmin, Wiegartz, & Scher, 2000; de Waal, et al., 2004; Dugue & Neugroschl, 2002; Flint & Rifat, "Relationship," 2002; Sable & Jeste, 2001. Evidence Grade = C1).

Factors That Increase the Likelihood That Anxiety Will Occur

Factors that are consistently associated with increased risk of clinically significant anxiety in late life, including anxiety disorders, include the following:

• Physical Illness, including those listed in Table 2 in the original guideline document (Astrom, 1996; Beekman, et al., 1998; Beyer, 2004; Carroll, et al., 1993; Cohen, et al., 2006; Hocking & Koenig, 1995; Kvaal, et al., 2001; Levy et al., 2007; Smith, et al., 2002. Evidence Grade = C1).
• Psychosocial Stress, including death or illness of family members, traumatic events such as falling or being victimized (Beekman et al., 1998; De Beurs, et al., 2000; Gagnon, et al., 2005; Palmer, Jeste, & Sheikh, 1997. Evidence Grade = C1).
• Depression, including undiagnosed depression (Alexopoulos, 1990; Andreescu, et al., 2007; Cohen, et al., 2006; Flint & Rifat, 1997, 2002a; Kirby, et al., 1999; Kroenke, et al., 2007; Lenze, et al., 2000; Lenze, et al., 2001; Steffens & McQuoid, 2005; Stordal, et al., 2003. Evidence Grade = C1).
• Cognitive Impairment, including both dementia and mild cognitive impairment (Ballard, et al., 1996; Eustace, et al., 2002; Fossa & Dahl, 2002; Geda, et al., 2004; Haupt, Kurz, & Janner, 2000; Hwang, et al., 2004; Lyketsos, et al., 2002; Mega, et al., 1996; Ownby, et al., 2000; Sinoff & Werner, 2003; Teri, et al., 1999. Evidence Grade = C1).
• Personal Characteristics that are associated with anxiety should be considered together with other risk factors, including:
  • Female gender (Beekman, et al., 1998; Blazer, et al., 1991; De Beurs, et al., 2000; Heun, Papassotiropoulos, & Ptok, 2000; Regier, et al., 1998. Evidence Grade = C1).
  • Advanced age (Christensen, et al., 1999; Cohen, et al., 2006; Evidence Grade = C1).
  • Lower educational or professional levels (Beekman, et al., 1998; Cohen, et al., 2006; Heun, Papassotiropoulos, & Ptok, 2000; Evidence Grade = C1).
  • External locus of control (Beekman, et al., 1998; Powers, Wisocki, & Whitbourne, 1992. Evidence Grade = C1).
  • Family history of anxiety disorder (Beekman, et al., 1998; Hettema, Neale, & Kendler, 2001. Evidence Grade = C1).
  • Evidence of alcohol or drug use (Beekman, et al., 1998; Cohen, et al., 2006; Grant, et al., 2004; Mohlman, et al., 2004. Evidence Grade = C1).
  • Latino ethnicity (Diefenbach, et al., 2004; Lewis-Fernandez et al., 2002; Tolin, et al., 2005. Evidence Grade = C1).

Assessment Criteria

Any person aged 60 years and older who expresses worry or fear, and who is identified as being at risk according to the factors listed in the section above (e.g., physically ill, recent psychosocial stress, depressed, cognitively impaired, somatic complaints for which there are no identifiable causes), should be evaluated for anxiety. Common sources of worry and fear among older adults are noted in Table 3 below.

Table 3: Worries and Fears in Older Adults*

* These worries and fears were commonly expressed by older adults, but not by younger ones, in research comparing the content of worries in younger and older people.

Sources: Diefenbach, Stanley, & Beck, 2001; Kogan & Edelstein, 2004; Ladouceur et al., 2002; Wisocki, 1988. Evidence Grade = C1.

Differentiating anxiety that is unrealistic, excessive, and life-altering from usual worry is often difficult in older adults. The type of worries and fears expressed by older adults are different than the worries and fears of younger people. For example, older adults are more likely to express worry about health and illness compared to younger people (Diefenbach, Stanley, & Beck, 2001; Kogan, Edelstein, & McKee, 2000; Ladouceur, et al., 2002; Wisocki, 1988. Evidence Grade = C1).

Given that older people worry about realistic problems—such as falling, losing hearing or eyesight, and becoming dependent on others—considerable effort is often needed to determine if the extent of worry interferes with daily function (Beck & Stanley, 2001; Flint, 2001. Evidence Grade = C1). Additional evidence suggests that meta-worry, which is worry about one's own thoughts or worrying about worrying, significantly predicts the degree of interference of worry in daily life for older adults (Nuevo, Montorio, & Borkovec, 2004. Evidence Grade = C1).

The overlap between physical health problems in late life and anxiety is another important area to consider. Anxiety is observed to interact with physical illness in several important ways (Beyer, 2004; Flint, 2001; Sable & Jeste, 2001; Sheikh, 1991. Evidence Grade = D):

• Physical illness can directly cause anxiety related symptoms.
• Physical illness can trigger a reaction of anxiety, worry and/or fear.
• Somatic (physical) symptoms of anxiety are often the focus of older adults' complaints.
• Medications used to treat physical illness may cause anxiety-related symptoms.
• Circular problems, in which increased anxiety results in behaviors that contribute to worsening of physical health conditions, are common.

Thorough review of physical health conditions and their treatment are often essential to differentiating the source of anxiety-related symptoms, particularly when physical symptoms are the focus of complaints (e.g., sleep disturbance, headache, fatigue, palpitations).

Assessment Tools and Forms

There are many different types of anxiety assessment scales. Because this guideline focuses on general anxiety detection (not diagnosis or detection of change related to treatment), four scales that are designed for screening anxiety are included in Appendix A in the original guideline document, including:

• The Geriatric Anxiety Inventory (GAI), a 20-item self-report measure that is scored yes and no (Pachana, et al., 2007). See Appendix A.1 in the original guideline document.
• The Short Anxiety Screening Test (SAST), a 10-item scale that is rated on a 4-point scale and that may be clinician scored based on interview, or may be used as a self-report measure (Sinoff, et al., 1999; Sinoff & Werner, 2003). See Appendix A.2 in the original guideline document.
• The Hospital Anxiety and Depression Scale (HADS) includes 7 items each for anxiety and depression that are self-rated using a 4-point scale, and excludes physical symptoms to help distinguish anxiety and depression from medical problems (Spinhoven, et al., 1997; Wetherell et al., 2007; Zigmond & Snaith, 1983). See Appendix A.3 in the original guideline document.
• Rating Anxiety in Dementia (RAID) that includes 20 items that are rated on a 3-point scale using a combination of direct observation and interview, and the report of a person who knows the older person well, and is appropriate for use with persons who are cognitively impaired (Shankar, et al., 1999). See Appendix A.4 in the original guideline document.
• Mini-Mental State Exam (MMSE) may be used to assess the person's cognitive function if questions arise about the reliability of his/her self report of feelings, sensations, and experiences (Folstein, Folstein, & McHugh, 1975). See Appendix A.5 in the original guideline document.

Each scale was designed to be used as a screening instrument to help clinicians identify the presence of anxiety. The SAST and HADS also assess the older person's perception of the severity of the symptoms. The RAID may be used if the person appears to have cognitive impairments that might interfere with his/her accurate report of symptoms. In this case, the MMSE (Folstein, Folstein, & McHugh, 1975) may be used to assess level of cognitive impairment. Based on this information, additional physical and mental health-related assessment may be undertaken to differentiate anxiety from other problems, and institute appropriate therapies.

Description of the Practice

The scales recommended in this guideline are designed to screen for anxiety, not 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 included are guided by specific instructions that are individualized to the scale. Important points to remember when using any of these scales are:

• Explain why you are asking these questions, emphasizing the important relationship between physical and emotional health.
• Explain that there are no right or wrong answers.
• Encourage the older adult to choose the answer that is closest to how they have been feeling recently (in the past week).
• Provide sufficient time to complete the scale without the client feeling hurried.
• Provide a private area where others may not easily see responses.

The following steps are recommended:

1. If cognitive impairment is suspected (which may interfere with accurate self report), use the Mini-Mental State Exam (MMSE) to assess level of function (Folstein, Folstein, & McHugh, 1975). See Appendix A.5 in the original guideline document.
   1. If the person scores below 24 of 30 points (≤23) on the MMSE, the Rating Anxiety in Dementia (RAID) scale may be more suitable for assessing anxiety symptoms. See Appendix A.4 in the original guideline document.
   2. If the person scores 24 or above on the MMSE (≥24), administer the Short Anxiety Screening Test (SAST). See Appendix A.2 in the original guideline document.
2. The SAST may be self-administered or clinician-scored based on interview. Persons scoring 22 or above (≥ 22) on the 40 point scale should be referred for further evaluation of the person's increased risk for anxiety. See Appendix A.2 in the original guideline document.
3. If the person has difficulty using the SAST (which is scored on a 4-point scale), substitute the Geriatric Anxiety Inventory (GAI). The GAI includes 20 statements that are scored "yes" or "no". Individuals with a score of 8 or greater (≥8) should be referred for further evaluation. See Appendix A.1 in the original guideline document.
4. If the person presents with both anxious and depressed symptoms, administer the Hospital Anxiety and Depression Scale (HADS). The HADS is self-administered and results in subscale scores for anxiety and depression. A score of 8 or greater (≥8) on either subscale should trigger further evaluation. See Appendix A.3 in the original guideline document.
5. If the person scores below 22 (< 22) on the SAST, 8 on the GAI (< 8) , or 8 on either subscale of the HADS, continue to monitor anxiety-related symptoms, including those related to:
   • Mood disturbance, including visible signs (e.g., grimacing, worried facial expression or vocal inflection, sighing, jitteriness) and symptoms expressed as worries, fears, apprehensions, ruminations.
   • Behaviors, including restlessness, fidgeting, repetitive behaviors (e.g., rubbing, twisting hair, questions/comments), irritability, pacing, vigilance.
   • Physical symptoms, including diaphoresis, dizziness, dry mouth, dyspnea, flushing, insomnia (getting to sleep, staying asleep, early awakening), headaches, palpitations, or trembling.
   • Refer again to Table 1 in the original guideline document to review common late life anxiety signs and symptoms.
6. Remember that subthreshold anxiety (anxiety that does not meet criteria for being an anxiety disorder) is often clinically significant, causing distress, discomfort, and disability that interferes with quality of life.
7. Monitor the severity and persistence of anxiety signs and symptoms—at least weekly, if not more often—to assure that steps are taken to rule in/out other causes of distress.

Definitions:

The grading scheme used to make recommendations is as follows:

A1: Evidence from well-designed meta-analysis or well-done systematic review with results that consistently support a specific action (e.g., assessment, intervention, or treatment)

A2: Evidence from one or more randomized controlled trials with consistent results

B1: Evidence from high quality evidence-based practice guidelines

B2: Evidence from one or more quasi experimental studies with consistent results

C1: Evidence from observational studies with consistent results (e.g., correlational, descriptive studies)

C2: Inconsistent evidence from observational studies or controlled trials

D: Evidence from expert opinion, multiple case reports, or national consensus reports

A clinical algorithm is provided in the original guideline document for the detection and assessment of late life anxiety.

The type of supporting evidence is identified and graded for selected recommendations (see "Major Recommendations").

• Smith M, Ingram T, Brighton V. Evidence-based practice guideline. Detection and assessment of late life anxiety. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core; 2008 Nov. 51 p. [112 references]

Not applicable: The guideline was not adapted from another source.

2008 Nov

University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core - Academic Institution

Developed with the support provided by Grant #P30 NR03979, [PI: Toni Tripp-Reimer, The University of Iowa College of Nursing], National Institute of Nursing Research, NIH.

Not stated

Authors: Marianne Smith, PhD, ARNP, BC; Todd Ingram, MA, RN; Veronica Brighton, MA, ARNP, CS

Series Editor: Marita G. Titler, PhD, RN, FAAN

Not stated

This is the current release of the guideline.

None available

This summary was completed by ECRI Institute on August 10, 2009. The information was verified by the guideline developer on September 9, 2009.

This summary is based on content contained in the original guideline, which is subject to terms as specified by the guideline developer. These summaries may be downloaded from the NGC Web site and/or transferred to an electronic storage and retrieval system solely for the personal use of the individual downloading and transferring the material. Permission for all other uses must be obtained from the guideline developer by contacting the John A. Hartford Foundation's Center of Geriatric Nursing Excellence at the University of Iowa Gerontological Nursing Intervention Research Center, Research Translation and Dissemination Core.