Special review articleThe prevalence of anxiety in older adults: Methodological issues and a review of the literature
Introduction
It has become almost commonplace to express the view that the study of anxiety in older people has been neglected. In 1998, Beekman et al. stated that epidemiological studies of psychopathology in later life have concentrated on depression and dementia, while anxiety disorders have received far less attention (Beekman et al., 1998). Recent articles by Flint (2005) and Wetherell et al., 2005a, Wetherell et al., 2005b have made a similar point. However, there has, in fact, been considerable research on the prevalence, nature and consequences of anxiety in older people in the 13 years since the literature was last comprehensively reviewed by Flint (1994). Research output in the area has increased significantly from an average of 215 publications per year being cited in the PsycINFO database in the early 1990s, to an average of 434 per year from 2002–2007.
Despite this increasing research output, key controversies as to the prevalence and nature of anxiety remain unresolved (Ayers et al., 2007, Schuurmans et al., 2005, Wetherell et al., 2005a). The views expressed in two recent editorials (Flint, 2005; Wetherell et al., 2005a) highlight the lack of consensus that persists in relation to key issues in the literature. Firstly, debate surrounds the nature of anxiety in older adults, with some commentators, such as Flint (2005), suggesting that it is qualitatively different from anxiety in younger persons, while others downplay these differences (Wetherell et al., 2005a, Wetherell et al., 2005b). Secondly, there is controversy regarding the comorbidity of anxiety with depression. Flint (2005) advocated the view that most anxiety co-occurs with depression; Wetherell et al. (2005a) stated that the prevalence of mixed anxiety and depression is lower than that of either disorder alone. Resolving this issue, and the question of whether anxiety becomes less prevalent as people get older, is complicated by the likelihood that current diagnostic criteria do not adequately capture the nature of anxiety in older adults (Flint, 2002, Jeste et al., 2005, Krasucki et al., 1999). Finally, the study of anxiety remains particularly neglected in the context of dementia and neurodegenerative disease.
These debates are not merely academic: Recent community surveys suggest that symptoms of anxiety are nearly twice as common as symptoms of depression — in the UK 2000 Survey of Psychiatric Morbidity, 3% of adults aged 70–74 met criteria for Generalised Anxiety Disorder, while 1.7% were deemed depressed (Singleton et al., 2000). Other studies have found that around 10% of community-dwelling older adults have a diagnosable anxiety disorder (Beekman et al., 1998), a rate that rises to 23.5% in caregivers of people with dementia (Mahoney et al., 2005). Prevalence rates are even higher in clinical populations — up to 18% in older adults with chronic pulmonary disease (Yohannes et al., 2000) and 24% in Puerto Rican primary care patients (Tolin et al., 2005). Anxiety causes considerable subjective distress (Ayers et al., 2007), reduces life satisfaction (Brenes et al., 2005) and increases the risk for the onset of disability, even in high-functioning older adults (Seeman et al., 1995). It also increases the risk of mortality, both from suicide (Allgulander and Lavori, 1993) and physical, especially cardiovascular diseases, with males being at particularly high risk (van Hout et al., 2004). Yet anxiety continues to be under-recognised, and therefore, under-treated (Forsell & Winblad, 1998; (van Hout et al., 2004), and is likely to be chronic and unremitting (Livingston et al., 1997).
It is, therefore, timely to review the growing literature on anxiety in older people. While there have been a number of \recent reviews of the literature on the treatment of anxiety in older adults (Ayers et al., 2007, Nordhus and Pallesen, 2003, Wetherell et al., 2005b), there has been no recent systematic review of the epidemiology of anxiety. The objective of this review is to provide a comprehensive survey of the literature on the prevalence of anxiety, in both community and clinical settings, with a view to evaluate the current status of the literature, and its implications for clinical practice and future research. A further aim is to examine the key conceptual and methodological issues regarding the presentation and nature of anxiety in older adults.
Section snippets
Method
This systematic review is based on literature published between 1980 and 2007, using the Medline, Web of Science and PsycINFO databases, entering the key terms ‘anxiety’, ‘anxiety disorders’, the names of specific disorders and restricting the search to articles on participants aged 60 and older. Articles were also retrieved through publishers' email alerting services and by following up references listed in articles. Although around 2500 articles were published in this time, the majority are
The prevalence of anxiety disorder in community samples
Table 1 provides a summary of the epidemiological studies of anxiety in old age conducted since the late 1980s. A number of studies have reported on the overall prevalence of anxiety disorders, for example, Beekman et al. (1998),Copeland et al., 1987a, Copeland et al., 1987b, Lindesay et al. (1989), Manela et al. (1996), Riedel-Heller et al. (2006), and Regier et al. (1988). There is wide variation in the prevalence of anxiety disorder reported in these studies — from 1.2% in New York (Copeland
Discussion
The studies reviewed indicate that both symptoms of anxiety and anxiety disorders are relatively common in older adults. Although only rarely the primary presenting problem in psychiatric settings (Flint, 1994), anxiety is highly prevalent in medical settings, where up to 65% of older adults experience anxiety symptoms (Ames et al., 1994a, Ames et al., 1994b). In community-dwelling populations, there are striking differences in reported prevalences, which range from 2.4% (Copeland et al., 1987a
Conclusion
There appear to be relatively few unequivocal conclusions to be drawn from the literature on anxiety in older people, and these are rather broad: In community samples, feelings of anxiety are quite common — reported by up to 24% of participants, but anxiety disorders, however defined, are much rarer. Overall prevalence rates of anxiety disorder vary from 2.4% in the study of Copeland et al., 1987a, Copeland et al., 1987b in Liverpool to 15% in the work of Manela et al. (1996). These differences
Role of funding source
The funding source had no say in the carrying out of the review or the subsequent writing of the paper.
Conflict of interest
No conflict declared.
Acknowledgements
This work was supported in part by NHMRC Grant number 310655.
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