ReviewInterventions for generalized anxiety disorder in older adults: Systematic review and meta-analysis
Highlights
► We compared pharmacological and psychotherapeutic trials for late-life GAD. ► Overall quality was similar between pharmacological and psychotherapeutic trials. ► Pooled results favored the intervention over the control condition.
Introduction
Recent research on late-life anxiety disorders has failed to confirm some previously held beliefs, including the notions that anxiety disorders rarely have their onset in later life or usually occur in comorbid relation to other disorders (Wetherell, Maser, & van Balkom, 2005). A recent review indicated that the prevalence of anxiety disorders ranged from 1.2 to 15% in community dwelling adults aged 55 years and older, and was almost twice as high in clinical settings (Bryant, Jackson, & Ames, 2008). In a national representative sample of community dwelling adults the prevalence of anxiety disorders was twice as high as the prevalence of mood disorders (Byers, Yaffe, Covinsky, Friedman, & Bruce, 2010). Generalized anxiety disorder (GAD) is one of the most common anxiety disorders in older adults, with surveys conducted with representative older cohorts obtaining 12-month rates between 1.0 (Grant et al., 2005) and 7.3% (Beekman et al., 1998).
Anxiety symptoms and disorders have widespread consequences for the person and the society. At an individual level, anxiety symptoms and disorders have been found to be associated with increased sleep disturbance (Brenes et al., 2009), intake of anxiety related medication (Gonçalves, Pachana, & Byrne, 2011), disability (Brenes et al., 2005), mortality (Ostir & Goodwin, 2006), and decreased cognitive functioning (Beaudreau and O’Hara, 2009, Mantella et al., 2007). At a societal level, late-life anxiety was related to increased use of health services, namely longer appointments with physicians (Stanley, Roberts, Bourland, & Novy, 2001), and inability to perform daily functions (Trollor, Anderson, Sachdev, Brodaty, & Andrews, 2007).
GAD has a low likelihood of spontaneous remission (Lenze, Mulsant, Mohlman, et al., 2005). An observational longitudinal study of community dwelling older adults found that at a 3-year follow-up more than half of those diagnosed with GAD at baseline fulfilled criteria for a mental health disorder (Schoevers, Deeg, van Tilburg, & Beekman, 2005). Despite the high prevalence, widespread impact and chronic course of the disorder, individuals with this disorder seldom seek the help of mental health professionals (Hunt, Issakidis, & Andrews, 2002), and there is a two-year mean delay between the onset of the disorder and the initiation of treatment (Grant et al., 2005).
Older adults are even less likely than young and middle aged people to seek help from a mental health professional, with the primary care physician being the first choice of the majority of older people with anxiety disorders (De Beurs et al., 1999). However, contrary to what has been previously believed, older adults seem to display positive attitudes towards mental health professionals and would be willing to accept help if offered (Arean et al., 2002, Mackenzie et al., 2008). A recent survey conducted with a sample of healthy older adults showed that when confronted with a hypothetical scenario of an anxiety disorder, three quarters of the participants chose psychotherapy as the preferred treatment, with the remaining participants selecting either pharmacotherapy or combined treatment (Mohlman, in press).
In comparison with other anxiety disorders, GAD has been neglected by researchers, with a relative paucity of published research devoted to this disorder (Byrne and Pachana, 2010, Dugas et al., 2010). There is an even more limited literature on the treatment of late-life GAD, in comparison with reports of treatment trials in other age groups and for other disorders. As older adults have an increased likelihood of comorbid physical disorders and polypharmacy, pharmacological trials have often used older age as an exclusion criterion (e.g., Enkelmann, 1991, Lecrubier et al., 1993). Even in those trials in which no age ceiling was defined, the proportion of older adults has been relatively small, with studies reporting an average sample age of approximately 40 years (e.g., Gelenberg et al., 2000, Rickels et al., 1997).
The limited recognition given to anxiety disorders in later life, along with the reluctance of older people to seek consultations with mental health professionals, might partially explain the sparseness of psychotherapeutic trials (Wetherell, Lenze, & Stanley, 2005). However, over the past decade there has been a gradual change in this trend, with an increasing number of treatment trials on anxiety disorders in older people being reported. Recent studies have reported on the efficacy of both pharmacological and psychotherapeutic interventions, with published reports generally favoring treatment over a control condition (Nordhus & Pallesen, 2003). Effect sizes for both clinician-rated and self-rated anxiety were found to be moderate to large for behavioral interventions and large for pharmacological interventions (Pinquart & Duberstein, 2007). In older people with a variety of different anxiety disorders, cognitive behavioral therapy (CBT) has been found to be significantly more effective in worry reduction than a waiting list control condition, although not more so than an active comparator (Hendriks, Voshaar, Keijsers, Hoogduin, & van Balkom, 2008). Conversely, another meta-analysis that included both controlled and uncontrolled trials found no additional gains to older adults with a variety of anxiety disorders when other CBT components were added to relaxation training alone (Thorp et al., 2009).
Notwithstanding the previously published results, it should be noted that the comparison of treatment trials has been constrained by the range of different anxiety disorders studied and the diversity of control conditions employed. Against this background, we undertook a systematic review and meta-analysis of controlled interventions for GAD in older adults, namely pharmacological, psychological, behavioral and alternative or life-style therapies. The main goal was to identify studies that had been conducted with the purpose of treating GAD in older adults. Only studies that reported a control condition, either active or passive, were included. Studies were assessed using qualitative and quantitative parameters. The quality of studies was assessed through the quality rating system developed by the Cochrane Collaboration Depression, Anxiety and Neurosis Review Group (CCDAN, Moncrieff, Chruchill, Drummond, & Mcguire, 2001). Quantitative analyses were conducted through random-effects analysis (DerSimonian & Laird, 1986), whereas publication bias was assessed using the funnel plot technique (Begg & Mazumdar, 1994). Because participant attrition can inflate results and reduce generalizability, we adopted an intent-to-treat approach to the analysis. This means that all baseline participants were included in the analysis, with drop-outs being rated as non-responders (Hollis & Campbell, 1999).
Section snippets
Search protocol
During January 2011 four electronic databases (ISI Web of Knowledge; PsycINFO; PubMed; Cochrane) were searched for the terms older (adult* or person or people) or elder* or late-life or geriat*, combined with intervention or treatment or therapy or trial or randomized, and generalized anxiety disorder. No language or date restrictions were used. The Database of Abstracts of Reviews of Effects (DARE) and Dissertation Abstracts International (DAI) were also searched for the terms “generalized
Search results
The search strategy identified 670 original titles (Fig. 1). Abstract screening resulted in the exclusion of 572 papers, with the main reasons for exclusion being a focus on a disorder other than GAD (178 papers) and reporting factors related with GAD, such as prevalence and risk factors, but not an intervention trial (120 papers). Of the 98 papers retrieved for detailed inspection, 67 were excluded as they failed to fulfill one or more inclusion criteria, such as having a control group (15
Discussion
Pooled results for pharmacological trials and psychotherapeutic trials that used a waiting list or minimal contact condition demonstrate efficacy for both approaches for the treatment of GAD in older adults. However, no significant pooled treatment effects could be demonstrated for psychotherapeutic trials that used an active control condition (e.g. a discussion group) or compared one form of psychotherapy with another. Our findings were obtained using a secondary intent-to-treat analysis,
Role of funding source
Daniela Gonçalves was supported by a scholarship from the Fundação para a Ciência e Tecnologia, Portugal (SFRH/BD/30226/2006) and an anonymous benefactor. Gerard Byrne was supported by grants from the National Health and Medical Research Council (456182), the Alzheimer's Association (Chicago) (IIRG-07-59015) and the Royal Brisbane and Women's Hospital Research Foundation.
Conflict of interests
None to declare.
References (81)
- et al.
Late-life anxiety and cognitive impairment: a review
American Journal of Geriatric Psychiatry
(2008) - et al.
Age and racial differences in the presentation and treatment of generalized anxiety disorder in primary care
Journal of Anxiety Disorders
(2008) - et al.
Insomnia in older adults with generalized anxiety disorder
American Journal of Geriatric Psychiatry
(2009) - et al.
The prevalence of anxiety in older adults: methodological issues and a review of the literature
Journal of Affective Disorders
(2008) - et al.
Meta-analysis in clinical trials
Controlled Clinical Trials
(1986) - et al.
Generalized anxiety disorder publications: where do we stand a decade later?
Journal of Anxiety Disorders
(2010) - et al.
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) - et al.
Treatment of poststroke generalized anxiety disorder comorbid with poststroke depression: merged analysis of nortriptyline trials
American Journal of Geriatric Psychiatry
(2003) - et al.
Multi-center controlled study of oxazepam in anxious elderly outpatients
Psychosomatics
(1982) - et al.
Generalized anxiety disorder in late life: lifetime course and comorbidity with major depressive disorder
American Journal of Geriatric Psychiatry
(2005)
Older adults’ help-seeking attitudes and treatment beliefs concerning mental health problems
American Journal of Geriatric Psychiatry
Interactions between anxiety, social support, health status and buspirone efficacy in elderly patients
Progress in Neuro-Psychopharmacology & Biological Psychiatry
Cognitive impairment in late-life generalized anxiety disorder
American Journal of Geriatric Psychiatry
Improving the quality of reports of meta-analyses of randomised controlled trials: the QUORUM statement
Lancet
More power to the executive? A preliminary test of CBT plus executive skills training for treatment of late-life GAD
Cognitive and Behavioral Practice
The role of executive functioning in CBT: a pilot study with anxious older adults
Behaviour Research and Therapy
Standard and enhanced cognitive-behavior therapy for late-life generalized anxiety disorder – two pilot investigations
American Journal of Geriatric Psychiatry
High anxiety is associated with an increased risk of death in an older tri-ethnic population
Journal of Clinical Epidemiology
Treatment of anxiety disorders in older adults: a meta-analytic comparison behavioral and pharmacological interventions
American Journal of Geriatric Psychiatry
Depression and generalized anxiety disorder: co-occurrence and longitudinal patterns in elderly patients
American Journal of Geriatric Psychiatry
A randomized, controlled trial of the effectiveness of cognitive-behavioral therapy and sertraline versus a waitlist control group for anxiety disorders in older adults
American Journal of Geriatric Psychiatry
Development and initial validation of a self-report assessment tool for anxiety among older adults: The Geriatric Anxiety Scale
Journal of Anxiety Disorders
Treatment of generalized anxiety in older adults: a preliminary comparison of cognitive-behavioral and supportive approaches
Behavior Therapy
Cognitive-behavior therapy for late-life generalized anxiety disorder in primary care – preliminary findings
American Journal of Geriatric Psychiatry
Meta-analysis comparing different behavioral treatments for late-life anxiety
American Journal of Geriatric Psychiatry
Prevalence of mental disorders in the elderly: The Australian National Mental Health and Well-being Survey
American Journal of Geriatric Psychiatry
Evidence-based treatment of geriatric anxiety disorders
Psychiatric Clinics of North America
Modular psychotherapy for anxiety in older primary care patients
American Journal of Geriatric Psychiatry
Acceptance and commitment therapy for generalized anxiety disorder in older adults: a preliminary report
Behavior Therapy
Would older medical patients use psychological services?
Gerontologist
The association of anxiety and depressive symptoms with cognitive performance in community-dwelling older adults
Psychology and Aging
Anxiety disorders in later life: a report from the Longitudinal Aging Study Amsterdam
International Journal of Geriatric Psychiatry
Operating characteristics of a rank correlation test for publication bias
Biometrics
The influence of anxiety on the progression of disability
Journal of the American Geriatrics Society
Treatment of anxiety with ketazolam in elderly patients
Clinical Therapeutics
High occurrence of mood and anxiety disorders among older adults: The National Comorbidity Survey Replication
Archives of General Psychiatry
Anxiety and depression in the elderly: do we know any more?
Current Opinion in Psychiatry
Double-blind safety and efficacy comparison of alprazolam and placebo in the treatment of anxiety in geriatric-patients
Current Therapeutic Research: Clinical and Experimental
Efficacy and tolerability of duloxetine in elderly patients with generalized anxiety disorder: a pooled analysis of four randomized, double-blind, placebo-controlled studies
Human Psychopharmacology: Clinical and Experimental
Consequences of anxiety in older persons: its effect on disability, well-being and use of health services
Psychological Medicine
Cited by (116)
Efficacy of low intensity interventions for geriatric depression and anxiety – A systematic review and meta-analysis
2024, Journal of Affective DisordersAnxiety Disorders in Later Life
2022, Comprehensive Clinical Psychology, Second EditionNavigating ruptures, repairs, and termination within the therapeutic process
2024, Navigating Ruptures, Repairs, and Termination Within the Therapeutic ProcessA multi- and mixed-method adaptation study of a patient-centered perioperative mental health intervention bundle
2023, BMC Health Services Research