In pediatrics, clinicians and researchers are oft reminded that children are not simply smaller adults. Instead, they are taught that child health forms a distinct clinical specialty area with different disease presentations and treatment algorithms. This metaphor holds true for older age – psychiatric presentations in older adult populations are significantly different to presentations in younger adult populations, and thus should be treated as such. One example of the differences between adults and older adults is seen in the differences in estimations of prevalence that arise from the use of a tool developed for adults compared with the same tool adapted to older adults. The US National Comorbidity Survey Replication study used the Composite International Diagnostic Interview (CIDI) and found 12-month prevalence of DSM-IV anxiety disorders of 7% (Gum et al., Reference Gum, King-Kallimanis and Kohn2009) in the age group 65 years and older, which is quite different to the Europe/Israel MentDis_ICF65+ study that used the CIDI 65+, which was an adaptation to the age-group 65–84 years, finding a 12-month DSM-IV prevalence of anxiety disorders of 17.2% (Canuto et al., Reference Canuto2018). The difference in these prevalence figures is greater than would be expected on the basis of demographic and cultural variation alone. Furthermore, the importance of aging-related diagnostic variations has been highlighted in the context of multiple psychiatric diagnoses (Jeste et al., Reference Jeste, Blazer and First2005).
Looking more broadly, the under-representation and exclusion of older people from research have been widely recognized (Watts, Reference Watts2012), and there is a consensus that this must change going forward. Similarly, a number of reviews have found that there is low representation of older adults and/or those with multiple comorbid conditions in Clinical Practice Guidelines (Cox et al., Reference Cox, Kloseck, Crilly, Mcwilliam and Diachun2011, Vitry and Zhang, Reference Vitry and Zhang2008). Clinical Practice Guidelines are so important for clinicians as they distil a vast evidence base into practical recommendations which can be applied to the needs and circumstances of the individual in front of them.
In our experience, Clinical Practice Guidelines in psychiatry often have relatively small amounts of guidance specific to the needs of older adults. For example, this is reflected in the current clinical practice guidelines for treating anxiety disorders in Australia and New Zealand, which are derived from the current literature in the field (Andrews et al., Reference Andrews2018). Whilst the guidelines themselves are 64 pages in length, only three paragraphs are dedicated to the discussion of treatment of late-life anxiety (Andrews et al., Reference Andrews2018).
When we look specifically at anxiety in later life, we see that this area has been relatively neglected by researchers when compared with other mental illnesses in older age such as late-life depression. Using the number of Medline indexed publications from 1946 to August 2019 as a proxy for research attention, there were 5,738 publications for late-life anxiety, compared with 18,119 for late-life depression (Chong et al., Reference Chong, Lautenschlager, Anstey and Bryant2020b). Reinforcing our suspicion of an age bias, when the same Medline search was performed without the “aged” MeSH term, the results were 32,993 publications for anxiety and 72,024 publications for depression (Chong et al., Reference Chong, Lautenschlager, Anstey and Bryant2020b).
The relative neglect of late-life anxiety may also be occurring in clinical practice, and this is particularly concerning given the significant distress and disability that it causes, as well as the economic costs. The COVID-19 pandemic has added further challenges. In clinical practice, increasing levels of anxiety have been observed anecdotally (Chong et al., Reference Chong, Curran, Ames, Lautenschlager and Castle2020a). Furthermore, a recent study found that COVID-19 health worries and ageism were positively associated with anxiety symptoms (Bergman et al., Reference Bergman, Cohen-Fridel, Shrira, Bodner and Palgi2020). In 2008, Beekman’s editorial entitled “Anxiety in Aging: A Newly Chartered Territory” was published, implying that research in this area was in its relative infancy (Beekman, Reference Beekman2008). Thus, it is critically important that research which examines the validity and usefulness of scales in older adults is performed, including that of Johnco et al. (Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021).
Over the last decade or so, our understanding of late-life anxiety, including late-life generalized anxiety disorder, has expanded thanks to an increasing amount of interest in the field. There has been increased awareness of the prevalence of generalized anxiety disorder in older populations, along with its consequent distress, disability and adverse impact on quality of life. Furthermore, the development of rating scales for late-life anxiety, such as the Geriatric Anxiety Inventory (Pachana et al., Reference Pachana, Byrne, Siddle, Koloski, Harley and Arnold2007) and Geriatric Anxiety Scale (Segal et al., Reference Segal, June, Payne, Coolidge and Yochim2010), has improved the recognition of late-life generalized anxiety disorder.
However, despite the increased awareness of the differences between adult and late-life generalized anxiety disorder, there have been no studies of the validity of using the PSWQ and PSWQ-A to measure treatment response in older adults (Johnco et al., Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021). This means that we are guided by adult standards and treatment practices, rather than treatment paradigms tailored towards older individuals.
Perhaps this is why the research of Johnco et al. (Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021) is critical to the development of late-life generalized anxiety disorder as separate to generalized anxiety disorder in other life stages, with distinct treatment recommendations. The study takes the Penn State Worry Questionnaire (PSWQ) and its abbreviated version, the PSWQ-A, and compares these measures to diagnostic interviews to assess treatment response and remission in older adults with generalized anxiety disorder receiving cognitive-behavioral therapy as the primary intervention. The main aim of the study was to establish optimal guidelines for assessing treatment response and remission in late-life generalized anxiety disorder using the PSWQ and PSWQ-A (Johnco et al., Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021). The study pooled participant data from seven studies in four different sites resulting in a sizeable sample of 259 participants (Johnco et al., Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021).
Of note, both the PSWQ and PSWQ-A were developed for use with adult populations. Despite this, and despite the development of multiple geriatric-specific anxiety measures over the last decade, it remains a frequently used measure in assessing treatment response and remission in an older population. Johnco et al. (Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021) establish that the parameters used to establish treatment response and remission in previous studies are likely to have underestimated the treatment response in late-life generalized anxiety disorder. For an already under-served population, the clinical implications of this are far-reaching.
Having these validated PSWQ and PSWQ-A definitions of remission will help facilitate more valid research into this under-researched area, while it is also important to note the finding that although the PSWQ could be used to define treatment response, the PSWQ-A was not suitable for this purpose (Johnco et al., Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021). Johnco et al. (Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021) raise the need to consider whether late-life specific scales such as the Geriatric Anxiety Inventory and Geriatric Anxiety Scale may be more useful for assessing treatment response. These findings provide guidance to clinicians and health services in their interpretation of trial results in order to provide and target evidence-based interventions to those who would most benefit from them.
Our next steps are to continue refining our tools for late-life anxiety and validate them across geographical boundaries, language and culture. We must also continue to challenge the “double discrimination” that our patients sometimes face given that mental health care is sometimes seen as a lower priority to other areas of health care, in addition to ageism which unfortunately still exists. Furthermore, we must strive to overcome the stigma that older individuals face in recognizing that they have an anxiety disorder and then feeling empowered to seek help for what is a very treatable condition. Despite these challenges, it is tremendously heartening to witness the recent growth and development of research into late-life anxiety, and we hope to see that this momentum can be harnessed going forward into the future. This is made all the more important by emerging evidence from Karim et al. (Reference Karim2021) that showed the association between worry and rumination with accelerated aging in late life, and discussed the theory that trans-diagnostic repetitive negative thoughts may lead to “cognitive debt” that depletes cognitive reserve and increases risk of developing Alzheimer’s disease. Of note, Karim et al. (Reference Karim2021) used the PSWQ scale, with their results showing that for every point higher on this scale, brain age was 1.3 months older.
Aside from the “cognitive debt” caused by anxiety, there is also “economic debt” in the form of financial cost to individuals, health services, and the community due to late-life anxiety. Older adults experiencing symptoms of anxiety, regardless of the level of severity, were more likely to utilize health care services than their peers without symptoms of anxiety (Hohls et al., Reference Hohls, Konig, Raynik and Hajek2018). This increase in service utilization was not only seen in mental health service utilization, but also in the use of health care services for physical health concerns (Hohls et al., Reference Hohls, Konig, Raynik and Hajek2018). Interestingly, one of the key findings of this systematic review was the relative paucity of studies investigating the impact of late-life anxiety on health care utilization (Hohls et al., Reference Hohls, Konig, Raynik and Hajek2018), reinforcing the urgent need to change the current under-investment in research and clinical services for late-life anxiety.
In 2015, Beekman et al. wrote that late-life anxiety was coming of age, but despite this, treatment approaches have lagged behind (Beekman et al., Reference Beekman, Voshaar and Pachana2015). However, the increasing research attention focusing on important issues such as assessment of treatment response and remission in late-life anxiety suggests that late-life anxiety is starting to resolve its Eriksonian stage of “role confusion” to form its own “identity.”
You have
Access
In pediatrics, clinicians and researchers are oft reminded that children are not simply smaller adults. Instead, they are taught that child health forms a distinct clinical specialty area with different disease presentations and treatment algorithms. This metaphor holds true for older age – psychiatric presentations in older adult populations are significantly different to presentations in younger adult populations, and thus should be treated as such. One example of the differences between adults and older adults is seen in the differences in estimations of prevalence that arise from the use of a tool developed for adults compared with the same tool adapted to older adults. The US National Comorbidity Survey Replication study used the Composite International Diagnostic Interview (CIDI) and found 12-month prevalence of DSM-IV anxiety disorders of 7% (Gum et al., Reference Gum, King-Kallimanis and Kohn2009) in the age group 65 years and older, which is quite different to the Europe/Israel MentDis_ICF65+ study that used the CIDI 65+, which was an adaptation to the age-group 65–84 years, finding a 12-month DSM-IV prevalence of anxiety disorders of 17.2% (Canuto et al., Reference Canuto2018). The difference in these prevalence figures is greater than would be expected on the basis of demographic and cultural variation alone. Furthermore, the importance of aging-related diagnostic variations has been highlighted in the context of multiple psychiatric diagnoses (Jeste et al., Reference Jeste, Blazer and First2005).
Looking more broadly, the under-representation and exclusion of older people from research have been widely recognized (Watts, Reference Watts2012), and there is a consensus that this must change going forward. Similarly, a number of reviews have found that there is low representation of older adults and/or those with multiple comorbid conditions in Clinical Practice Guidelines (Cox et al., Reference Cox, Kloseck, Crilly, Mcwilliam and Diachun2011, Vitry and Zhang, Reference Vitry and Zhang2008). Clinical Practice Guidelines are so important for clinicians as they distil a vast evidence base into practical recommendations which can be applied to the needs and circumstances of the individual in front of them.
In our experience, Clinical Practice Guidelines in psychiatry often have relatively small amounts of guidance specific to the needs of older adults. For example, this is reflected in the current clinical practice guidelines for treating anxiety disorders in Australia and New Zealand, which are derived from the current literature in the field (Andrews et al., Reference Andrews2018). Whilst the guidelines themselves are 64 pages in length, only three paragraphs are dedicated to the discussion of treatment of late-life anxiety (Andrews et al., Reference Andrews2018).
When we look specifically at anxiety in later life, we see that this area has been relatively neglected by researchers when compared with other mental illnesses in older age such as late-life depression. Using the number of Medline indexed publications from 1946 to August 2019 as a proxy for research attention, there were 5,738 publications for late-life anxiety, compared with 18,119 for late-life depression (Chong et al., Reference Chong, Lautenschlager, Anstey and Bryant2020b). Reinforcing our suspicion of an age bias, when the same Medline search was performed without the “aged” MeSH term, the results were 32,993 publications for anxiety and 72,024 publications for depression (Chong et al., Reference Chong, Lautenschlager, Anstey and Bryant2020b).
The relative neglect of late-life anxiety may also be occurring in clinical practice, and this is particularly concerning given the significant distress and disability that it causes, as well as the economic costs. The COVID-19 pandemic has added further challenges. In clinical practice, increasing levels of anxiety have been observed anecdotally (Chong et al., Reference Chong, Curran, Ames, Lautenschlager and Castle2020a). Furthermore, a recent study found that COVID-19 health worries and ageism were positively associated with anxiety symptoms (Bergman et al., Reference Bergman, Cohen-Fridel, Shrira, Bodner and Palgi2020). In 2008, Beekman’s editorial entitled “Anxiety in Aging: A Newly Chartered Territory” was published, implying that research in this area was in its relative infancy (Beekman, Reference Beekman2008). Thus, it is critically important that research which examines the validity and usefulness of scales in older adults is performed, including that of Johnco et al. (Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021).
Over the last decade or so, our understanding of late-life anxiety, including late-life generalized anxiety disorder, has expanded thanks to an increasing amount of interest in the field. There has been increased awareness of the prevalence of generalized anxiety disorder in older populations, along with its consequent distress, disability and adverse impact on quality of life. Furthermore, the development of rating scales for late-life anxiety, such as the Geriatric Anxiety Inventory (Pachana et al., Reference Pachana, Byrne, Siddle, Koloski, Harley and Arnold2007) and Geriatric Anxiety Scale (Segal et al., Reference Segal, June, Payne, Coolidge and Yochim2010), has improved the recognition of late-life generalized anxiety disorder.
However, despite the increased awareness of the differences between adult and late-life generalized anxiety disorder, there have been no studies of the validity of using the PSWQ and PSWQ-A to measure treatment response in older adults (Johnco et al., Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021). This means that we are guided by adult standards and treatment practices, rather than treatment paradigms tailored towards older individuals.
Perhaps this is why the research of Johnco et al. (Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021) is critical to the development of late-life generalized anxiety disorder as separate to generalized anxiety disorder in other life stages, with distinct treatment recommendations. The study takes the Penn State Worry Questionnaire (PSWQ) and its abbreviated version, the PSWQ-A, and compares these measures to diagnostic interviews to assess treatment response and remission in older adults with generalized anxiety disorder receiving cognitive-behavioral therapy as the primary intervention. The main aim of the study was to establish optimal guidelines for assessing treatment response and remission in late-life generalized anxiety disorder using the PSWQ and PSWQ-A (Johnco et al., Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021). The study pooled participant data from seven studies in four different sites resulting in a sizeable sample of 259 participants (Johnco et al., Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021).
Of note, both the PSWQ and PSWQ-A were developed for use with adult populations. Despite this, and despite the development of multiple geriatric-specific anxiety measures over the last decade, it remains a frequently used measure in assessing treatment response and remission in an older population. Johnco et al. (Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021) establish that the parameters used to establish treatment response and remission in previous studies are likely to have underestimated the treatment response in late-life generalized anxiety disorder. For an already under-served population, the clinical implications of this are far-reaching.
Having these validated PSWQ and PSWQ-A definitions of remission will help facilitate more valid research into this under-researched area, while it is also important to note the finding that although the PSWQ could be used to define treatment response, the PSWQ-A was not suitable for this purpose (Johnco et al., Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021). Johnco et al. (Reference Johnco, Wuthrich, Brenes, Wetherell and Mohlman2021) raise the need to consider whether late-life specific scales such as the Geriatric Anxiety Inventory and Geriatric Anxiety Scale may be more useful for assessing treatment response. These findings provide guidance to clinicians and health services in their interpretation of trial results in order to provide and target evidence-based interventions to those who would most benefit from them.
Our next steps are to continue refining our tools for late-life anxiety and validate them across geographical boundaries, language and culture. We must also continue to challenge the “double discrimination” that our patients sometimes face given that mental health care is sometimes seen as a lower priority to other areas of health care, in addition to ageism which unfortunately still exists. Furthermore, we must strive to overcome the stigma that older individuals face in recognizing that they have an anxiety disorder and then feeling empowered to seek help for what is a very treatable condition. Despite these challenges, it is tremendously heartening to witness the recent growth and development of research into late-life anxiety, and we hope to see that this momentum can be harnessed going forward into the future. This is made all the more important by emerging evidence from Karim et al. (Reference Karim2021) that showed the association between worry and rumination with accelerated aging in late life, and discussed the theory that trans-diagnostic repetitive negative thoughts may lead to “cognitive debt” that depletes cognitive reserve and increases risk of developing Alzheimer’s disease. Of note, Karim et al. (Reference Karim2021) used the PSWQ scale, with their results showing that for every point higher on this scale, brain age was 1.3 months older.
Aside from the “cognitive debt” caused by anxiety, there is also “economic debt” in the form of financial cost to individuals, health services, and the community due to late-life anxiety. Older adults experiencing symptoms of anxiety, regardless of the level of severity, were more likely to utilize health care services than their peers without symptoms of anxiety (Hohls et al., Reference Hohls, Konig, Raynik and Hajek2018). This increase in service utilization was not only seen in mental health service utilization, but also in the use of health care services for physical health concerns (Hohls et al., Reference Hohls, Konig, Raynik and Hajek2018). Interestingly, one of the key findings of this systematic review was the relative paucity of studies investigating the impact of late-life anxiety on health care utilization (Hohls et al., Reference Hohls, Konig, Raynik and Hajek2018), reinforcing the urgent need to change the current under-investment in research and clinical services for late-life anxiety.
In 2015, Beekman et al. wrote that late-life anxiety was coming of age, but despite this, treatment approaches have lagged behind (Beekman et al., Reference Beekman, Voshaar and Pachana2015). However, the increasing research attention focusing on important issues such as assessment of treatment response and remission in late-life anxiety suggests that late-life anxiety is starting to resolve its Eriksonian stage of “role confusion” to form its own “identity.”