Application of a cognitive neuroscience perspective of cognitive control to late-life anxiety

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Highlights

  • We critically review empirical evidence supporting an association between anxiety and control processes that is particularly salient in older adults.

  • We describe constructs of anxiety and cognitive control from cognitive neuroscience and cognitive aging theoretical perspectives.

  • Methodological approaches and measures used to assess cognitive control are evaluated.

  • Hypotheses are provided regarding an interactive relationship between late-life anxiety and cognitive control.

  • Clinical implications for treatment, including behavioral and cognitive strategies, are discussed.

Abstract

Recent evidence supports a negative association between anxiety and cognitive control. Given age-related reductions in some cognitive abilities and the relation of late life anxiety to cognitive impairment, this negative association may be particularly relevant to older adults. This critical review conceptualizes anxiety and cognitive control from cognitive neuroscience and cognitive aging theoretical perspectives and evaluates the methodological approaches and measures used to assess cognitive control. Consistent with behavioral investigations of young adults, the studies reviewed implicate specific and potentially negative effects of anxiety on cognitive control processes in older adults. Hypotheses regarding the role of both aging and anxiety on cognitive control, the bi-directionality between anxiety and cognitive control, and the potential for specific symptoms of anxiety (particularly worry) to mediate this association, are specified and discussed.

Introduction

Although cognitive deficits in older individuals with depression have been the focus of numerous investigations, studies have only begun to investigate the relationship between anxiety and cognition. A small but growing literature has suggested there is a negative relationship between late-life anxiety and cognition. A recent critical review revealed weaker cognitive performance on effortful tasks among older adults with clinically significant anxiety symptoms compared with those with minimal or no symptoms (Beaudreau & O’Hara, 2008).

Recent theories (e.g., attention control theory; Eysenck, Derakshan, Santos, & Calvo, 2007) suggest that anxiety shifts cognitive resources away from goal-relevant information toward threat-focused information, and that this reallocation of resources leads to performance differences between anxious and non-anxious adults on cognitively demanding tasks. Converging evidence from multiple studies supports these theories by associating impaired cognitive control ability with self-reported anxiety (Beaudreau & O’Hara, 2009) and anxiety status in older individuals (Broomfield et al., 2007, Mantella et al., 2007; see Price & Mohlman, 2007 for an alternative view). The term ‘cognitive control’ refers to processes associated with goal-directed behavior in a mechanistic definition of ‘executive functions’ (Miller & Cohen, 2001). The current review examines the relationship between late-life anxiety and cognitive control from cognitive neuroscience and cognitive aging perspectives. Independent roles for aging, anxiety and their interaction are proposed.

Notably, comorbidity of anxiety and depression is widespread in the older population (Hek et al., 2011). Depressive symptoms and episodes frequently coexist with clinically significant anxiety symptoms and generalized anxiety disorder (GAD) in older age (Mackenzie et al., 2011, Richardson et al., 2011, Wolitzky-Taylor et al., 2010). The pervasiveness of co-existing late-life anxiety and depression has led to interest in combinations of these symptoms, particularly major depressive disorder (MDD) with anxiety symptoms referred to as ‘anxious depression.’ This review therefore encompasses late-life investigations of cognitive control in adults with GAD and anxious depression.

Studies of late-life anxiety or anxious depression and cognition that focus on cognitive control typically examine how anxious older individuals deal with the interference associated with negative emotion. Interference is generally measured in studies of anxiety by incorporating emotional content into the standard Stroop paradigm (Stroop, 1935). Resultant effects reflect the impact of negatively valenced stimuli (MacLeod & Rutherford, 1992) and emotional conflict (i.e., incongruence of emotion words and faces vs. congruence; Etkin, Egner, Peraza, Kandel, & Hirsch, 2006) on cognitive control. Although the literature has focused predominantly on Stroop interference associated with anxiety, the issue can be conceptualized as a more general problem of how an individual minimizes the interference caused by task-irrelevant information. A cognitive neuroscience framework may prove useful for elucidating the relationship of interference effects and cognitive control.

‘Top-down processing’ is a term often used interchangeably with ‘cognitive control processing’ to describe voluntary control of attention (Hirsch & Mathews, 2012). Deficient top-down processing has been shown to increase processing of threat information, and thus represents one possible contributor to states such as pathological worry (Hirsch & Mathews, 2012), including generalized anxiety disorder (GAD; MacLeod and Rutherford, 1992, MacLeod and Rutherford, 2004). Others have argued against such claims by suggesting that threat evaluation occurs before top-down processes could influence processing (Mogg & Bradley, 1998). Recent behavioral and imaging data suggest a role for both top-down and bottom-up processing of information during effortful tasks performed while in an anxious state (Reeck, LaBar, & Egner, 2012). Thus, complex interactions between both top-down and bottom-up processing appear to influence processing of threat-related information. Narrowing the focus of investigation to such factors allows for more precision in elucidating the relationship between late-life anxiety and cognition. For example, normal aging affects late-life cognitive processing even in the absence of anxiety, and therefore, any interactions with anxiety must be considered above and beyond the independent effects of aging.

Section snippets

Cognition in normal aging

Older adulthood gives rise to notable complexity and change in emotional processing (Scheibe & Carstensen, 2010) and cognitive functioning (Bosworth & Schaie, 1999). Older adults are believed to show greater emotional wellbeing and emotional stability, increased orientation to positive stimuli (Scheibe & Carstensen, 2010), and greater complexity and differentiation of emotional response to negative stimuli than their younger counterparts (Beaudreau, MacKay, & Storandt, 2009). The extent to

Late-life anxiety and cognitive control

Behavioral studies of clinically significant anxiety and cognitive control generally implicate increased interference on the Stroop task. Although increased interference is expected for both emotional and non-emotional versions of the Stroop task (Banich et al., 2009), Stroop performance in anxious older adults varies both by the version (emotional vs. neutral) and anxiety severity and type. Table 1 provides an overview of the results from late-life anxiety studies of cognitive control. As

Neurobiological evidence

Neuroimaging studies of cognitive control in older adults with anxiety disorders or anxious depression have provided a plausible biological explanation of observed behavioral findings between older anxious and nonanxious individuals, and between older and younger anxious adults. Regardless of the emotional content of the stimuli, regions of the dorsolateral prefrontal cortex (DLPFC) activate when attentional demands increase in the context of conflict arising from color incongruence or the

Discussion

Several observations and testable hypotheses emerge from the reviewed cognitive and emotional aging theories and behavioral and neuroimaging findings. First, age and anxiety independently affect cognitive control. A simple cognitive model of general slowing explains age-related cognitive control deficits on tasks with interfering irrelevant information (Verhaeghen, 2011, Verhaeghen and De Meersman, 1998); however, some age-related deficits on cognitive control tasks persist after accounting for

Implications and conclusions

Mohlman (2005) proposed that executive dysfunction due to deficits in PFC functioning potentially moderates treatment outcome among older adults with GAD. In a recent study of neuropsychological predictors of treatment response in late-life GAD, Butters et al. (2011) found that healthy controls had better baseline cognitive control in addition to better neuropsychological performance on a number of measures. Notably, in the GAD group treated with 12-weeks of an SSRI (escitalopram), improvement

Acknowledgements

We wish to thank Ms. Kaycee Rashid and Brittany Cerbone for their assistance with references and Ms. Katherine Lou and for reviewing and providing feedback on revisions.

References (73)

  • C.R. Hirsch et al.

    A cognitive model of pathological worry

    Behaviour Research and Therapy

    (2012)
  • C.S. Mackenzie et al.

    Prevalence and correlates of generalized anxiety disorder in a national sample of older adults

    American Journal of Geriatric Psychiatry

    (2011)
  • C. MacLeod et al.

    Anxiety and the selective processing of emotional information: mediating roles of awareness, trait and state variables, and personal relevance of stimulus materials

    Behaviour Research and Therapy

    (1992)
  • R.C. Mantella et al.

    Cognitive impairment in late-life generalized anxiety disorder

    American Journal of Geriatric Psychiatry

    (2007)
  • K. Mogg et al.

    A cognitive-motivational analysis of anxiety

    Behaviour Research and Therapy

    (1998)
  • J. Mohlman

    More power to the executive? CBT plus executive training for late life generalized anxiety disorder

    Cognitive & Behavioral Practice

    (2008)
  • J. Mohlman et al.

    The role of executive functioning in CBT: a pilot study with anxious older adults

    Behaviour Research and Therapy

    (2005)
  • Y.* Munakata et al.

    A unified framework for inhibitory control

    Trends in Cognitive Sciences

    (2011)
  • M.G. Newman et al.

    A novel theory of experiential avoidance in generalized anxiety disorder: a review and synthesis of research supporting a contrast avoidance model of worry

    Clinical Psychology Review

    (2011)
  • K.N. Ochsner et al.

    The cognitive control of emotion

    Trends in Cognitive Sciences

    (2005)
  • R.B. Price et al.

    Inhibitory control and symptom severity in late life generalized anxiety disorder

    Behaviour Research and Therapy

    (2007)
  • R.B. Price et al.

    Emotional Stroop performance in older adults: effects of habitual worry

    American Journal of Geriatric Psychiatry

    (2012)
  • G.S. Alexopoulos et al.

    ‘Vascular Depression’ hypothesis

    Archives of General Psychiatry

    (1997)
  • G.S. Alexopoulos et al.

    Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction: effect on disability

    Archives of General Psychiatry

    (2011)
  • O.P. Almeida et al.

    Anxiety, depression, and comorbid anxiety and depression: risk factors and outcomes over two years

    International Psychogeriatrics

    (2012)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (2000)
  • M.C. Anderson et al.

    Suppressing unwanted memories by executive control

    Nature

    (2001)
  • C. Andreescu et al.

    MRI studies in late-life mood disorders

    Current Topics in Behavioral Neuroscience

    (2012)
  • C. Andreescu et al.

    fMRI activation in late-life anxious depression: a potential biomarker

    International Journal of Geriatric Psychiatry

    (2009)
  • C. Andreescu et al.

    Altered cerebral blood flow patterns associated with pathologic worry in the elderly

    Depression and Anxiety

    (2011)
  • M.T. Banich et al.

    fMRI studies of Stroop tasks reveal unique roles of anterior and posterior brain systems in attentional selection

    Journal of Cognitive Neuroscience

    (2000)
  • S.A. Beaudreau et al.

    Older adults’ responses to emotional stimuli: a cautionary note

    Experimental Aging Research

    (2009)
  • S.A. Beaudreau et al.

    The association of anxiety and depressive symptoms with cognitive performance in community-dwelling older adults

    Psychology and Aging

    (2009)
  • A.T. Beck et al.

    Beck Anxiety Inventory manual

    (1993)
  • H.B. Bosworth et al.

    Survival effects in cognitive function, cognitive style, and sociodemographic variables in the Seattle Longitudinal Study

    Experimental Aging Research

    (1999)
  • T.S. Braver et al.

    Working memory, executive control and aging

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