ReviewRisk factors for anxiety and depression in the elderly: A review
Introduction
Anxiety and depressive disorders are highly prevalent in the elderly, often appear as comorbid disorders and both have adverse consequences such as reduced quality of life and excess mortality (de Beurs et al., 1999, Charney et al., 2003). In addition, subthreshold symptoms of anxiety and depression are common and serious, causing significant disruption in daily living. Although late-life anxiety and depression are treatable conditions (Wetherell, 1998, McCusker et al., 1998), they are often underrecognized and undertreated in primary care (Mulsant and Ganguli, 1999, Olafsdottir et al., 2001, Volkers et al., 2004). Compared to elderly with a mood disorder, only a small percentage of the older adults with an anxiety disorder are referred to specialized mental health care, while this could be appropriate and cost-effective (de Beurs et al., 1999). For instance, a study that reviewed Medicare reimbursements for geriatric mental health treatment in the USA found that 55% of older mood disorder patients, but only 17% of older anxiety disorder patients, saw a mental health specialist (Ettner and Hermann, 1997). The lower prevalence of older patients with anxiety who get care from mental health specialists may be due to several factors related to the older adult or to the mental health care system. These include a tendency to somatize anxiety symptoms by the older adult or underrecognition by the general practitioner.
A cost-effective way to improve detection of people who suffer from anxiety and depression is to pay special attention to elderly at risk (Smit et al., 2006, Schoevers et al., 2006, Smit et al., 2007). Proper knowledge of risk factors for anxiety and depression helps to increase the detective power. Different risk profiles may be expected among the elderly in comparison with younger adults, as both the exposure to and the impact of risk factors change with age (Beekman et al., 2000). Previous studies suggest that longstanding vulnerability factors, such as family and personal histories of anxiety and depression, become less important in risk profiles among the older old as the most vulnerable elderly selectively leave the population (Beekman et al., 1995, Beekman et al., 1998, van Ojen et al., 1995). On the other hand, the prevalence of risk factors such as deteriorating physical health, cognitive decline and a diminishing social network increases with age. Further, the notion of ‘on-time’ versus ‘off-time’ occurrence of events may explain a change in the impact of risk factors in later life. Older adults are at a specific developmental stage where they are encountering frequent losses and may be more prepared to cope effectively as compared with younger individuals (Schum et al., 2005). For example, loss of a spouse may, for an older person, be more expected and in line with the later phases of life, possibly resulting in a relatively easier adjustment and acceptation.
Early detection and treatment help to reduce symptoms, increase quality of life and prevent an unfavorable prognosis. However, the negative consequences of a disorder are not always averted by treatment. Data from a mental health survey show that even with perfect coverage and evidence based treatment, only half the burden of anxiety disorders and 35% of years lived with a mood disorder could be averted (Andrews et al., 2004). Therefore, in addition to proper screening of prevalent cases, early detection of people who are likely to develop an anxiety or depressive disorder in the near future is desirable. Hence, a distinction should be made between risk factors for the incidence (longitudinal studies) and prevalence (cross-sectional studies) of anxiety and depression. While cross-sectional studies may indicate factors that either precede or are concomitant with anxiety or depression, or may be a consequence, risk factors for incidence derived from longitudinal studies may actually predict which older adults are at higher risk of becoming anxious or depressed in the future. However, prior research did not always find major differences between risk factors for the prevalence and incidence (Beekman et al., 2001).
Despite considerable research on risk factors for depression among elderly community subjects (Cole and Dendukuri, 2003, Djernes, 2006), limited attention has been paid to risk factors for anxiety in later life. Given the prevailing theories on the interrelationship between anxiety and depression, a dimensional approach may be more appropriate than categorical models (Goldberg, 1996, Goldberg, 2000). According to a dimensional model, with comorbid anxiety and depression on the most severe end of both the depression and the anxiety spectrum, it is likely that anxiety and depression share common risk factors (Goldberg and Huxley, 1992). Kendler (1996) however argues that these disorders may well have a common genetic basis, but environmental variables may help to determine which set of symptoms becomes predominant. For instance, Finlay-Jones and Brown (1981) have shown that there is a tendency for danger events to be followed by anxious symptoms, and loss by depressive symptoms. Further, there is some evidence for a tripartite model indicating that anxiety and depression share a common distress factor referred to as negative affect (Cook et al., 2004). On the other hand, more differences than similarities were found in a study comparing risk factors associated with anxiety and depressive disorders in older adults, suggesting they represent useful categories with shared but distinct underpinnings (Beekman et al., 2000).
Additionally for clinical reasons, correlates that are unique to depression or anxiety may identify factors that will help improve their differential diagnosis and in turn aid in the recognition of these disorders. As these disorders are often comorbid, it can be difficult to differentiate between anxiety and depression, while the optimal treatment is not necessarily the same.
The aim of this study is to give a comprehensive overview and compare risk factors for symptoms as well as clinically relevant levels of anxiety and depression in later life, based on cross-sectional and longitudinal studies. This knowledge may provide direction for recognition and preventive mental health strategies.
The research questions are:
- 1.
Which risk factors are associated with anxiety and/or depression in the elderly?
- 2.
Are there differences between risk factors for anxiety and depression in the elderly?
Section snippets
Selection of articles
To answer the research questions, we reviewed studies on factors associated with the prevalence and incidence of symptom or clinically relevant levels of depressive disorders (i.e. minor and major depression) and anxiety disorders (i.e. generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), panic disorder, phobic disorders and obsessive–compulsive disorder (OCD)) in the elderly. In order to improve comparability between studies and study populations, and to provide
Included studies
Based on the inclusion criteria 80 articles were considered to be relevant for this review study, including 8 studies on risk factors for anxiety, 63 on risk factors for depression and 9 on risk factors for both anxiety and depression. In these studies, almost 60 different risk factors were studied. To improve the accessibility of the findings on risk factors, they were divided into three main categories; biological, psychological and social. This clustering was arbitrary for some factors. For
Discussion
The purpose of this study was to give a comprehensive overview and compare risk factors for anxiety and depression in the elderly. The reviewed studies show that personality traits, inadequate coping strategies, previous psychopathology, qualitative aspects of social network, stressful life events and female gender are risk factors associated with both prevalence and incidence of anxiety in the elderly. Chronic diseases and functional limitations showed only cross-sectional associations with
Role of funding source
The funding source had no involvement on this manuscript.
Conflict of interest
None.
Acknowledgements
The Knowledge Centre of Psychiatry in the Elderly is subsidized by the Netherlands Ministry of Health, Welfare and Sport.
Rob Kok is acknowledged with many thanks for helpful comments on earlier drafts.
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