e, PhD, RN, FGSA; Nancy A. Pachana, PhD, MA; and Sara J. Franklin, BPsych Sci (Hons.) Dr.

Beattie is Professor and Director, Dementia Collaborative Research Centre: Carers and Consumers, and Ms. Franklin is Research Associate, School of Nursing and Midwifery, Queensland University of Technology, Kelvin Grove, and Dr. Pachana is Associate Professor, School of Psychology, University of Queensland, Brisbane, Queensland, Australia. The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Elizabeth Beattie, PhD, RN, FGSA, Professor and Director, Dementia Collaborative Research Centre: Carers and Consumers, Room 615, Level 6, N Block, School of Nursing and Midwifery, Queensland University of Technology, Kelvin Grove, Queensland, Australia 4059; e-mail: elizabeth.beattie@qut.edu.au. Received: October 20, 2009; Accepted: May 3, 2010; Posted: June 30, 2010 doi:10.3928/19404921-20100528-99 ABSTRACT Comorbid depression and anxiety in late life present challenges for geriatric mental health care providers. These challenges include identifying the often complex diagnostic presentations both clinically and in a research context. This potent comorbidity can be conceived as double jeopardy in older adults, further diminishing their quality of life. Geriatric health care providers need to understand psychiatric comorbidity of this type for accurate diagnosis and early referral to specialists, and to coordinate interdisciplinary care. Researchers in the field also need to recognize potential multiple impacts of comorbidities with respect to assessment and treatment domains. This article describes the prevalence of late-life depression and anxiety disorders and reviews studies on this comorbidity in older adults. Risk factors and protective factors for anxiety and depression in later life are reviewed, and information is provided about comparative symptoms, the selection of assessment tools, and challenges to the provision of interdisciplinary, evidence-based care. Complex psychiatric comorbidity in late life presents challenges for clinicians, not only in carefully making diagnoses but also in responding to the personal anguish of patients. Depression has been described as a frequent cause of decreased quality of life in later years, and much research has focused on mood disorders in this cohort. However, anxiety disorders in later life are less well studied. The extent and severity of comorbid anxiety disorders, particularly generalized anxiety disorder (GAD), with depression in this client group is of concern. Potent comorbidities such as these can be conceived as double jeopardy, subjecting already vulnerable older patients to additional suffering, compounding burden, and diminishing quality of life. Likewise, research that focuses on single disorders is less generalizable to older adults for whom comorbid disorders are a fact of life. Geriatric health care providers need to understand psychiatric comorbidity of this type to engage in the interdisciplinary provision of responsive, compassionate care. The purpose of this article is to describe the prevalence of depression and anxiety disorders in late life and to review Beattie, Pachana, & Franklin studies of and risk and protective factors for this comorbidity. In addition, information about comparative symptoms and the selection of robust assessment tools for depression and

anxiety is provided, and strategies for the development of interdisciplinary treatment and care planning are suggested. Prevalence of late-life DePression In the National Comorbidity Survey Replication (Kessler et al., 2005), the lifetime prevalence of major depressive disorder (MDD) as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000) was estimated to be 10.6% in U.S. adults older than 60 compared with 18.8% in those younger than 60. Point prevalence estimates of MDD vary with setting as expected. For example, the point prevalence estimate of MDD is lowest (1% to 4%) among communitydwelling older adults (Beekman, Copeland, & Prince, 1999; Blazer, Hughes, & George, 1987; Steffens et al., 2000); this is followed by older adults in primary care (6% to 9%) and hospitalized older adults (10% to 12%), with the highest estimate for residents of long-term care facilities (12% to 20%) (Bruce, 2002; Kessler et al., 2005). In those 85 and older, the 1-year incidence of depressive symptoms has been estimated at 13% (Meller, Fichter, & Schroppel, 1996). International estimates of prevalence of major depression among community-dwelling older adults are surprisingly consistent: Australia, 1.8% (Pirkis et al., 2009); England, 2.9% (Copeland et al., 1987); Netherlands, 2% (Beekman et al., 1999); Sweden, 5.6% (Palsson, stling, & Skoog, 2001); and Nigeria, 1.6% (Baiyewu et al., 2007; Bruce, 2002; Krishnan, 2002). It has been argued that rigorous application of the DSM-IV-TR (APA, 2000) criteria for MDD results in the exclusion of a large portion of older adults with depressive symptoms and associated functional impairment (Arean & Cook, 2002). According to Alexopoulos (2005), the prevalence of minor or subsyndromal depression is arguably higher than that of MDD, with functional impairment, medical burden, and quality of life lower than in MDD but higher than in older adults without any depression. One study (Lyness et al., 2006) comparing nondepressed older adults with those with minor or subsyndromal depression showed a 5.5-fold risk for major depression at 1 year after controlling for demographic characteristics. Prevalence of anxiety DisorDers in olDer aDults Prevalence estimates of overall anxiety disorder in older adults from rigorous large-scale surveys range between 0.9% (Copeland et al., 1987) and 15% (Manela, Katona, & Livingston, 1996). In a U.K. survey of community-dwelling older adults visiting general practitioners (N = 1,070), only 26 older adults (2.4%) met criteria for neurosis, including anxiety neurosis (n = 10, 0.9%) (Copeland et al., 1987). Older adults in the Copeland study were assessed using the Geriatric Mental State schedule and algorithm (GMS/ AGECAT). A later U.K. study (N = 169 home care recipients older than 65) using the same GMS/AGECAT measure found 2.4% of anxiety disorder cases, with 24 (14.2%) subcases (Banerjee, 1993). In a more recent U.K. survey (N = 694 community-dwelling low-income older adults) using

a different measure, the Anxiety Disorder Scale, Manela et al. (1996) found a considerably higher prevalence of 15%, which included GAD. An early five-site U.S. study, using the Diagnostic Interview Schedule to generate a DSM-III anxiety diagnosis other than GAD, found a 1-month prevalence of 6.8% for any anxiety disorder in adults older than 65 (Regier, Narrow, & Rae, 1990). Prevalence rates for specific anxiety disorders in late life range from less than 1% to approximately 7% for GAD (Banerjee, 1993; Copeland et al., 1997; Manela et al., 1996) and as high as 12% for phobias (Copeland et al., 1987; Flint, 1994). Panic disorder is uncommon in late life (0% to 0.3%) and occurs primarily in women (Flint, Cook, & Rabins, 1996). Obsessive-compulsive disorder is also uncommon (<1.5%), and figures for posttraumatic stress disorder in late life are unclear, except in specific groups such as veterans and Holocaust survivors (Flint, 1994). It has been suggested that prevalence rates for anxiety disorders in late life appear lower than might be expected and lower than in earlier life stages because older adults may be too ill to participate or may not want to participate in research. However, a more likely explanation of variation in prevalence rates may be the use of different diagnostic measures and algorithms (Jorm, 2000). Findings from a recent study by Flint et al. (2010) suggest that the age-related decline in the prevalence of anxiety disorders is less about failure to detect than about lower overall lifetime and current frequencies of anxiety disorders, especially current and lifetime panic disorder, social anxiety disorder, and posttraumatic stress disorder. In summary, symptoms of depression, and to a lesser extent, anxiety, decrease with age. When major depression does occur in late life, the disease course is chronic and remitting, with lower recovery rates related to the presence of comorbid medical illness, dementia, poor instrumental social support, and poor self-rated health (Blazer, 2003). Overall late-life anxiety symptoms are more prevalent among long-term care residents and women.Research in Gerontological Nursing Vol. 3, No. 3, 2010 211 Anxiety and Depression in Late Life comorbiDity of DePression anD anxiety in late life It has been well established that a significant comorbidity exists between anxiety disorders and depressive disorders throughout life (Cameron, Abelson, & Young, 2004). In late life, the picture is complex because it is unclear which disorder develops first. For example, in one study of comorbid anxiety disorder in inpatient and outpatient older adults (N = 336) with MDD, 15 of 177 inpatients (8.5%) met diagnostic criteria for a lifetime comorbid anxiety disorder. Among 159 outpatients, 9 (5.7%) met diagnostic criteria for a

current anxiety disorder, and 13 (8.2%) met diagnostic criteria for a lifetime anxiety disorder (Mulsant, Reynolds, Shear, Sweet, & Miller, 1996). Among 659 older participants in the Netherlands Longitudinal Aging Study using the Center for Epidemiologic Studies Depression Scale and the Diagnostic Interview Schedule, 111 participants (16.8%) met diagnostic criteria for an anxiety disorder, mainly GAD and social phobia (Beekman et al., 2000). Approximately one quarter (26.1%) of those with an anxiety disorder also met diagnostic criteria for MDD, and approximately half (47.5%) of those with depression also met diagnostic criteria for an anxiety disorder. A comparison of risk factors associated with pure MDD and anxiety disorders revealed more differences than similarities. In an early literature review of 66 studies meeting inclusion criteria of showing a significant and independent association between depression and disability, 5 studies also assessed symptoms of anxiety (using screening instruments) or anxiety disorders (using psychiatric interviews) (Lenze et al., 2001). All of the studies found high comorbidity between depression and anxiety. In another recent study of 79 older adults with MDD, approximately 50% (n = 37) had a lifetime diagnosis of GAD or panic disorder (DeLuca et al., 2005). In older adults with MDD, coexisting GAD or panic disorder is associated with more severe symptoms, greater burden, and poorer short-term treatment outcomes, including suicidal ideation and attempted suicide (Judd et al., 1998; Porensky et al., 2009). In summary, comorbid depression and anxiety and anxious depression in late life are associated with more severe overall psychopathology than nonanxious depression. Somatic symptoms are higher in older adults with comorbid depression and anxiety than in those with anxiety alone. Significantly, older adults with comorbid depression and GAD have greater suicidal ideation (Lenze et al., 2001). An excellent current review of anxiety in late life (WolitzkyTaylor, Castriotta, Lenze, Stanley, & Craske, 2010) affirms the highly comorbid status of anxiety with depression in older adults. Authors recommend extending the text on age-specific features of late-life anxiety disorders in the fifth edition of the DSM and providing additional diagnostic guidance. risk anD Protective factors for anxiety anD DePression in late life The risk factors for anxiety and depression overlap significantly across the life span; this holds true for older adults as well (e.g., Beekman et al., 2000). Women are at greater risk of developing symptoms of depression or anxiety than men at all stages of the life span, including later life (e.g., Schoevers, Beekman, Deeg, Jonker, & van Tilburg, 2003). The male-to-female ratios for both conditions in later life exceed 2:1 (e.g., Regier et al., 1990) and in some cases are significantly higher for women (e.g., simple phobias). Similarly, lower socioeconomic levels, particularly lower income levels, have been significantly associated with greater chance of experiencing either condition. Marital status

presents a more complex picture for each disorder, with risk of partnered individuals developing either disorder TABle 1 Comparison of Symptoms for Depression and Anxiety Disorders with Normal Aging Symptom Normal Aging GAD/Panic/Phobia Major Depression Memory difficulties Minor Moderate Severe Worry Severe Moderate Sleep disturbance Minor Moderate Moderate Appetite changes a Minor Breathing difficulties a,b Moderate Anhedonia Moderate Hopelessness Moderate Note. GAD = generalized anxiety disorder. a May change in individuals taking medications that affect appetite or breathing. b May change in individuals with a particular illness such as chronic obstructive pulmonary disease.212 Copyright SLACK Incorporated Beattie, Pachana, & Franklin TABle 2 Comparison of Tools Used to Measure Anxiety and Depression Tool Measures/ Specific to Older Adults? Completed By No. of Items/ Subscales Scoring Cut-Off Point for Clinical Significance Psychometric Properties Sensitivity & Specificity Availability GAI (Pachana et al., 2007) Anxiety/Yes Self-report 20/Single scale Yes/No Older patients with any anxiety disorder: 8/9; patients with GAD from those without GAD: 10/11 Good reliability in both normal community and psychiatric samples (Cronbachs alpha coefficient = 0.91 and 0.93, respectively); high concurrent validity with other measures such as the STAI (Spielberger, Gorsuch, & Lushene, 1970) and GAS (Goldberg, Bridges, DuncanJones, & Grayson, 1988) Sensitivity: 73% for any anxiety disorder, 75% for GAD Specificity: 80% for any anxiety disorder, 84% for GAD Available on the GAI website: http://www.gai. net.au/ RAID

(Shankar, Walker, Frost, & Orrell, 1999) Anxiety/Yes Self-report or direct observation and interview, and informant report 18/Four subscales: worry, apprehension and vigilance, motor tension, and autonomic hypersensitivity a 4-point scale: 0 (absent) to 3 (severe) Scores >8 on subscales trigger further evaluation and scores >11 suggest significant clinical anxiety Interrater agreement (82% to 100% for individual items) and test-retest reliability (kappa range = 0.53 to 1.00 for individual items, over a period of 7 to 10 days) for direct observation by 2 raters; internal consistency (Cronbachs alpha coefficient = 0.83); RAID correlates with some but not all measures of anxiety, with correlations ranging from 0.16 to 0.62 (Gibbons, Teri, Logsdon, & McCurry, 2006; Shankar et al., 1999) Sensitivity: 0.90 Specificity: 0.79 (Shankar et al., 1999) Available in the original article (Shankar et al., 1999) AMAS-E (Reynolds, Richmond, & Lowe, 2003) Anxiety/Yes Self-report 44/Five scales: total anxiety, lie, and three anxiety subscales consisting of fear of aging, physiological anxiety, and worry/ oversensitivity Yes/No (yes indicates how an older adult generally thinks, feels, or acts) Total anxiety: Cronbachs alpha coefficient = 0.9037, CI = 0.8840 to 0.9216, r = 0.91, intraclass correlation coefficient = 0.91; Cronbachs alpha coefficients on the total anxiety score for men and women were 0.91 and 0.92,

respectively (Lowe & Reynolds, 2006) Sensitivity: N/A Specificity: N/A Can be purchased on the Western Psychological Services website: http://portal. wpspublish.com CES-D (Radloff & Teri, 1986) Depression/ No Self-report or interviewer administered 20/Single scale 4-point scale: 0 = rarely or none of the time (<1 day ), 1 = some or a little of the time (1 to 2 days), 2 = occasionally or a moderate amount of time (3 to 4 days), and 3 = most or all of the time (5 to 7 days) Higher scores indicate more depressive symptoms; scores >16 are used as the cut-off point for high depressive symptoms (Radloff, 1977); scores of 16 to 26 are considered indicative of mild depression; scores >27 are indicative of major depression (Ensel, 1986; Zich, Attkisson, & Greenfield, 1990) Validated in older populations, Cronbachs alpha coefficient for each item >0.70, internal consistency = 0.93 (total score); CES-D has been shown to be reliable for assessing the number, types, and duration of depressive symptoms across racial, gender, and age categories; high internal consistency has been reported with Cronbachs alpha coefficients ranging from 0.85 to 0.90 across studies (Radloff, 1977) Sensitivity: 74.1 for scores >16; 68.2 for scores >18; and 61.2 for scores >20 Specificity: 57.2 for scores >16; 68.2 for scores >18; and 75.6 for scores >20 Available on Brown Universitys Center for

Gerontology & Health Care Research website: http://www.chcr. brown.edu/pcoc/ cesdscale.pdf GDS (Yesavage et al., 1982-1983) Depression/ Yes b Self-report and informant versions 30/Three subscales: fear of aging, physiological anxiety, and worry and oversensitivity Yes/No (some items reverse coded for scoring) Scores of 0 to 9 = normal, 10 to 19 = mild depression, and 20 to 30 = severe depression. For the 15-item short form, scores >5 are suggestive of depression and warrant follow-up interview; scores >10 are almost always depression Cronbachs alpha coefficient = 0.99; test-retest reliability = 0.94 (Montorio & Izal, 1996); for the total scale, Cronbachs alpha coefficient = 0.749, and with items deleted, Cronbachs alpha coefficient range = 0.720 to 0.755; internal consistency of the GDS-15 estimated by Cronbachs alpha coefficient = 0.81, CI = 0.73 to 0.87 (Almeida & Almeida, 1999) Sensitivity: 82% to 90% with cut-off >9 Specificity: 75% to 94% with cut-off >9 Available on the Stanford University website: http:// www.stanford. edu/~yesavage/ GDSResearch in Gerontological Nursing Vol. 3, No. 3, 2010 213 Anxiety and Depression in Late Life TABle 2 Comparison of Tools Used to Measure Anxiety and Depression Tool Measures/ Specific to Older Adults? Completed By No. of Items/ Subscales Scoring

Cut-Off Point for Clinical Significance Psychometric Properties Sensitivity & Specificity Availability CSDD (Alexopoulos, Abrams, Young, & Shamoian, 1988) Depression/ Yes Informant report 19/Five groupings: mood and related signs, behavioral disturbance, physical signs, cyclic functions, and ideational disturbance a = unable to evaluate, 0 = absent, 1 = mild to intermittent, and 2 = severe Scores >10 to 12 = probable depression, scores >18 indicate definite major depression, and scores <6 are associated with absence of significant depressive symptoms Criterion validity in the total population showed the CSDD as the better scale with sensitivity and specificity of 93% and 97%, respectively, with cut off >6 (Kurlowicz, Evans, Strumpf, & Maislin, 2002) Sensitivity: 93% with cut-off >6 Specificity: 97% with cut-off >6 Available on the Quality Net website: http://www. qualitynet.org HDRS (Hamilton, 1960) Depression c / No Self-report or observation and interview 17/Single scale Items scored on a scale of 0 to 4 or 0 to 2 In patients with AD, the optimal cut-off score was 7/8 for diagnostic purposes

Test-retest reliability = 0.95 and interrater reliability = 0.90 (Naarding, Leentjens, van Kooten, & Verhey, 2006) Sensitivity: 0.90 with cut-off of 7/8 d Specificity: 0.71 with cut-off of 7/8 d Available on the Servier website: http://www. servier.com/ App_Download/ Neurosciences/ Echelles/HDRS.pdf PHQ-9 e (Kroenke, Spitzer, & Williams, 2001; Spitzer, Kroenke, & Williams, 1999) Depression/ No Self-report 9/Single scale 4-point scale: 0 (not at all) to 3 (nearly every day) Scores of 5 to 9 = minimal symptoms, scores 10 to 14 = minor depression or mild major depression, scores of 15 to 19 = major depression (mild), and scores >20 = major depression (severe); as a severity measure, the PHQ-9 score can range from 0 to 27 (each of the 9 items can be scored from 0 to 3) Internal reliability was excellent, with Cronbachs alpha coefficient = 0.89 in the PHQ Primary Care Study and 0.86 in the PHQ Ob-Gyn Study; test-retest reliability was good; correlation between PHQ-9 completed by patients and PHQ-9 administered by telephone by MHPs within 48 hours was 0.84; mean scores were almost identical (5.08 versus 5.03) (Spitzer, Williams, Kroenke, Hornyak, & McMurry, 2000) Sensitivity: 88% for major depression Specificity: 88% for major depression Terms of use can be reviewed

at http://www. mapi-trust. org/services/ questionnaire licensing/ catalogue questionnaires/ 129-phq DASS (Lovibond & Lovibond, 1995) Anxiety and depression/ No Self-report 42 f /Three subscales: depression, anxiety, and tension/stress 4-point severity/frequency scale rates the extent to which each state is experienced during the past week, and scores for the three subscales are calculated by summing the scores for the relevant items Normal: depression = 0 to 9, anxiety = 0 to 7, and stress = 0 to 14; mild: depression = 10 to 13, anxiety = 8 to 9, and stress = 15 to 18; moderate: depression = 14 to 20, anxiety = 10 to 14, and stress = 19 to 25; severe: depression = 21 to 27, anxiety = 15 to 19, and stress = 26 to 33; extremely severe: depression = 28+, anxiety = 20+, and stress = 37+ Cronbachs alpha coefficient = 0.88 (95% CI = 0.87 to 0.89) for the depression scale, 0.82 (95% CI = 0.80 to 0.83) for the anxiety scale, 0.90 (95% CI = 0.89 to 0.91) for the stress scale, and 0.93 (95% CI = 0.93 to 0.94) for the total scale; reliability for the DASS-21 total score was p = 0.94 (Brown, Chorpita, Korotitsch, & Barlow, 1997) Sensitivity: 0.91 for depression scale with cut-off >12 and 0.92 for anxiety scale with cut-off >5 Specificity: 0.46 for depression scale

with cut-off >8 and 0.40 for anxiety scale with cut-off >5 g Available on the University of New South Wales School of Psychology website: http://www2. psy.unsw.edu. au/groups/dass/ (CoNT NU i eD)214 Copyright SLACK Incorporated Beattie, Pachana, & Franklin varying by gender in most studies (e.g., Himmelfarb & Murrell, 1984). Symptom expression, symptom interpretation, and social response to both anxiety and depression vary widely, and ignorance or misunderstandings of culturespecific symptoms may lead to underrecognition or misidentification of psychological distress. Recent research confirms that somatization occurs in all contexts, serving as a cultural idiom of distress in many ethnocultural groups (Kirmayer, 2001). A recent comprehensive review (LewisFernandez, Das, Alfonso, Weissman, & Olfson, 2005) of the mental health literature in the past 15 years regarding cultural or race- and ethnicityrelated factors that might limit the universal applicability of the diagnostic criteria for six anxiety disorders revealed possible mismatches between the DSM-IV-TR criteria, with local presentations of the disorder in specific cultural contexts found for three anxiety disorders (panic disorder, social anxiety disorder, and GAD). Although studies of the role of ethnicity are more prolific, methodological difficulties such as underrepresentation or no representation of specific ethnic groups (e.g., Native Americans) TABle 2 Comparison of Tools Used to Measure Anxiety and Depression Tool Measures/ Specific to Older Adults? Completed By No. of Items/ Subscales Scoring

Cut-Off Point for Clinical Significance Psychometric Properties Sensitivity & Specificity Availability HADS (Zigmond & Snaith, 1983) Anxiety and depression/ No Self-report 14/Two subscales: anxiety and depression 4-point scale ranging from yes, definitely to no, not at all; scores for each subscale are added individually Scores >8 on either subscale trigger further evaluation Cronbachs alpha coefficient = 0.89; inter-item correlations (mean) = 0.47 to 0.72 (0.58); Pearsons correlation coefficients between the anxiety and depression subscales indicated the subscales were highly significantly and positively correlated (r = 0.63, p <0.0005) (Olsson, Mykletun, & Dahl, 2005) Sensitivity: 0.89 for anxiety scale and 0.80 for depression scale with cut-off >8 Specificity: 0.75 for anxiety scale and 0.88 for depression scale with cut-off >8 Terms of use can be reviewed at http://www. mapi-trust.org/ test/55-hads. Zung Scale for Depression (Zung, 1965) Depression/ No Self-report 20/Single scale rates four common aspects of depression: pervasive effect, physiological equivalents, other disturbances, and psychomotor activities 4-point scale: 1 = a little of the time, 2 = some of the time, 3 = good part of the

time, and 4 = most of the time Scores of 20 to 49 = normal, 50 to 59 = mildly depressed, 60 to 69 = moderately depressed, and >70 = severely depressed Split-half reliability studies in a psychiatric population found a correlation (r) of 0.73; in a community survey of 1,173 participants, Cronbachs alpha coefficient was satisfactory (0.79) (Zung, 1972) Sensitivity: 88.9% Specificity: 83.3% Available on the University of Massachusetts Medical School website: http://healthnet. umassmed.edu/ mhealth/Zung SelfRated DepressionScale. pdf Note. AD = Alzheimers disease; AMAS-E = Adult Manifest Anxiety Scale-Elderly Version; CES-D = Center for Epidemiologic Studies Depression Scale; CI = confidence interval; CSDD = Cornell Scale for Depression in Dementia; DASS = Depression Anxiety Stress Scale; GAD = generalized anxiety disorder; GAI = Geriatric Anxiety Inventory; GAS = Goldberg Anxiety Scale; GDS = Geriatric Depression Scale; HADS = Hospital Anxiety and Depression Scale; HDRS = Hamilton Depression Rating Scale; MHP = mental health practitioner; N/A = not available; RAID = Rating Anxiety in Dementia; STAI = State-Trait Anxiety Inventory. a The RAID has two additional items on phobias and panic attacks that are not included in the total score. b The GDS is less effective with older adults in nursing homes than in the community. c Strong evidence suggests other scales are more robust in detecting depression (see Bagby, Ryder, Schuller, & Marshall, 2004). d In a group of patients with AD (N = 243) (Naarding et al., 2006). e The PHQ-9 is the depression scale from the Patient Health Questionnaire. f A short version, the DASS21, is available. g The DASS demonstrates high sensitivity but low specificity: The higher the sensitivity score, the lower the specificity score. (CoNT NU i eD)Research in Gerontological Nursing Vol. 3, No. 3, 2010 215 Anxiety and Depression in Late Life within samples make interpretation and comparison of findings difficult (Stanley & Beck, 2000). Strong evidence suggests Latino ethnicity (Diefenbach, Robison, Tolin, & Blank, 2004; Lewis-Fernandez et al., 2005; Tolin, Robison, Gaztambide, & Blank, 2005) as a risk factor for the development of anxiety disorders in late life and the potential vulnerability of older African American men to depression

(Watkins, Green, Rivers, & Rowell, 2006). A family history of depression predicts onset of the condition at younger ages but less so with later onset (Fiske, Kasl-Godley, & Gatz, 2001). Lack of a family history of depression is a positive prognostic indicator for late-onset depression (Fiske, Wetherell, & Gatz, 2009). Although family history in general is a positive risk factor for the development of anxiety, its influence in late-onset anxiety disorders is less well understood. Medical conditions serve to increase the likelihood of anxiety or depression in older adults; in turn, anxiety or depression exacerbate the symptoms and negatively influence the prognosis of most medical conditions in late life (Katon, Lin, & Kroenke, 2007; Stanley & Beck, 2000). In conditions such as dementia, anxiety or depression negatively affect functionality and may hasten institutionalization (Smith, Samus, et al., 2008; Teri et al., 1999). Older adults with chronic breathing disorders have surprisingly high rates of illness. In one study, 80% of participants assessed with the Primary Care Evaluation of Mental Disorders (PRIME-MD) screened positive for depression, anxiety, or both (Kunik et al., 2005). Persistent insomnia is a well-established risk factor for the development of new-onset and recurrent MDD in older adults (Cole & Dendukuri, 2003; Fiske et al., 2009; Pigeon et al., 2008; Roberts, Shema, Kaplan, & Strawbridge, 2000). Findings from a recent study (Pigeon et al., 2008) add to this growing body of evidence suggesting that insomnia may actually serve to potentiate depression. With current rates of insomnia in older adults of concernranging from 23% to 57% and becoming more common in women (McCrae, 2009)the importance of sleep hygiene practices is increasing not only for reducing risk of depression but also for improving overall health status. Individual coping styles and social support have significantly influenced both the risk of developing anxiety or depression as well as responses to treatment throughout the life span. Negative affect has been cited in several studies as a common factor in models of both depression and anxiety in later life (e.g., Mineka, Watson, & Clark, 1998). Personality styles such as neuroticism, generally understood as an enduring tendency to experience negative emotional states, such as anxiety, anger, guilt, and depression, have been associated with risk of developing both depression and anxiety in older adults (e.g., Roelofs, Huibers, Peeters, Arntz, & van Os, 2008). issues in the interDisciPlinary assessment of late-life DePression anD anxiety Depression and anxiety are difficult to assess later in life for a variety of reasons. Medical conditions common in older adults (e.g., pulmonary disorders) may have symptoms that mimic those found in these disorders (e.g., shortness of breath in panic disorder). Similarly, medications may have side effects (e.g., tachycardia) that are difficult to distinguish from common symptoms of depression or anxiety (e.g., rapid heart rate in panic disorder). As in all age groups, psychiatric symptoms may be indicative of underlying medical conditions (e.g., cancer). Accurate diagnosis of conditions is essential, but for older populations, symptoms of depression and anxiety may be incorrectly labeled as age-appropriate and as such go uninvestigated as

well as untreated, with unfortunate results. Older adults often reflect feelings of anxiety or depression in somatic terms, which may hamper diagnosis by inexperienced clinicians and researchers alike, especially if inappropriate assessment tools are used. Older adults may also be reluctant to describe feelings of anxiety or depression to health professionals or researchers, especially if they have had little contact with mental health professionals. Agitation and memory loss in older adults may be mistaken for dementia rather than recognized as symptoms of anxiety, depression, or both. Again, such misdiagnosis hampers timely treatment as well as resulting in excess burden for patients. Unfortunately, some diagnostic and screening tools used in both research and clinical practice were largely developed for younger cohorts and may lead to missed diagnoses, especially as subthreshold presentations of conditions such as anxiety and depression are more common in older populations (Pachana, 1999). As with all assessment interviews with older adults, careful consideration of sensory impairment is key in both conducting the assessment as well as interpreting results in light of the context of such deficits. Similarly, the presence of acute or chronic pain may influence scores on both cognitive and psychiatric assessment scales. Finally, educational level and cultural factors may influence reporting of symptoms. Administration and interpretation of tests through interpreters, even registered interpreters, requires caution. A primary consideration in assessing depression and anxiety is whether it is the symptoms or diagnosis being 216 Copyright SLACK Incorporated Beattie, Pachana, & Franklin ascertained. Readers of the literature in this area would do well to keep this distinction in mind, for a variety of reasons. First, the prevalence of symptoms of depression and anxiety in community samples of older adults in general outstrips cases meeting diagnostic criteria. Second, some studies rely on participant reports of symptoms, then report results in terms of clinical conditions without actually ascertaining a diagnosis through either a clinical or diagnostic interview. Finally, there is ample evidence that older adults experience and report the symptoms of both depression and anxiety differently than younger cohorts (Cameron, 2007). This needs to be considered when selecting assessment tools across clinical as well as research settings. interDisciPlinary imPlications of tool selection A variety of instruments are available to ascertain a diagnosis of anxiety or depressive disorders in later life, including the Structured Clinical Interview for DSM-IV (SCID) (First, Spitzer, Gibbon, & Williams, 1996), the Composite International Diagnostic Interview (CIDI) (Kessler et al., 2004), and the Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998). All of these instruments have been used in older populations with good results. In addition, several symptom severity checklists developed for younger populations have been normed on older adults. Commonly used examples include the Beck Depression Inventory and the Beck Anxiety Scale (Beck, Epstein, Brown, & Steer, 1988). Several instruments in this category purport to measure both anxiety and

depressive symptoms; these include the Hospital Anxiety and Depression Scale (HADS) and the Depression Anxiety Stress Scale (DASS) (Lovibond & Lovibond, 1995). Neither of these latter instruments has robust data for use in older populations. As there is much research to support the unique experience of depressive and anxious symptoms in older cohorts, instruments specifically developed for older populations have some distinct advantages (see Edelstein et al., 2007). For example, the Geriatric Depression Scale (GDS) (Yesavage et al., 1982-1983) and the Geriatric Anxiety Inventory (GAI) (Pachana et al., 2007) have been designed with older adults in mind in terms of language commonly used by older adults and their experience of the symptoms in question. Both tools use simple response schemes of agreeing or disagreeing that a particular symptom has been experienced, and both keep somatic items to a minimum. As individuals with dementia may experience anxiety, depression, or both, instruments that allow for informant reporting of symptoms are desirable. Whereas the Cornell Scale for Depression in Dementia (CSDD) is well regarded as an informant tool for gauging depression in dementia, no equivalent tool exists for informant reporting of anxiety in this group. The Rating Anxiety in Dementia (RAID) tool is specifically a self-report tool, and the Neuropsychiatric Inventory (NPI) (Cummings et al., 1994) measures symptoms of behavioral and psychological symptoms of dementia in individuals with dementia. It includes anxiety and depression among its target symptoms, as does the Cambridge Mental Disorders of the Elderly Examination (CAMDEX) (Roth et al., 1986). Existing evidence-based practice guidelines specific to depression and anxiety in late life (Kurlowicz & Harvath, 2008; Smith, Ingram, & Brighton, 2008) embed assessment and tool selection as a critical initial step in quality clinical management. Mental health care professionals working with older populations need to be able to recognize and compare symptoms and effectively describe their concerns in referrals to their interdisciplinary team colleagues. In addition, they need to be aware of the plethora of available assessment tools and identify those most robust in detecting comorbidity. Table 1 compares common late-life symptoms across normal aging, anxiety disorders, and major depression, and Table 2 compares 11 commonly used tools. For researchers, an awareness of the tools generally used by interdisciplinary colleagues and a team evaluation of the strongest available tool for the study purposes are needed. Measurement burden is of particular concern when studying vulnerable older adults whose anxiety and depression comorbidity affects functioning. Care needs to be taken by the interdisciplinary team to minimize the studys overall measures burden, ensuring protection of the research participant while meeting the particular needs of the disciplines involved. challenges to the interDisciPlinary management of comorbiD DePression anD anxiety in late life

The unique aspect of integrated or interdisciplinary health care is information sharing among team members related to patient care and the development and implementation of a comprehensive treatment plan to address the biological, psychological, and social needs of patients. The shortage of geriatric specialists across health disciplines in the United States has posed challenges for interdisciplinary health care practice in both community and long-term care settings. In 2007, there was only one geriatric psychiatrist for every 11,372 older Americans (Warshaw, Bragg, Research in Gerontological Nursing Vol. 3, No. 3, 2010 217 Anxiety and Depression in Late Life Brewer, Meganathan, & Ho, 2007). Less than 1% of RNs (Kovner, Jones, Zahn, Gergen, & Basu, 2002), physician assistants (Wing, Langelier, Salsberg, & Continelli, 2003), and pharmacists (Institute of Medicine, 2008), and just 4% of social workers, are certified in geriatrics. The National Institute on Aging estimates that 5,000 full-time, doctoral-level geropsychologists will be needed by 2020, yet to date, there is no geriatric certification in the specialty of psychology, although discourse about competencies is currently underway (Molinari et al., 2003; Qualls, Segal, Norman, Niederehe, & Gallagher-Thompson, 2002). Despite workforce issues, interdisciplinary practice in mental health services is growing, emphasizing the potential of the complementary contributions of different disciplines to improve patient outcomes. Research findings related to the effectiveness of interdisciplinary approaches to depression in nursing homes are promising; however, studies have significant methodological limitations (Bartels, Moak, & Dums, 2002). One of the most successful models of interdisciplinary health care with older adults in primary care is the collaborative care model. Effective collaborative care is a multimodal intervention that has at least the core components of psychiatric consultation, clinical advice, and case supervision coupled with the use of allied health professionals in monitoring, education, and support roles. Numerous studies have demonstrated that collaborative care (care management) for depression improves outcomes; however, the majority of these studies focused on patients in young or mid-life, or included only a small proportion of older adults in samples (Gilbody, Bower, Fletcher, Richards, & Sutton, 2006). A recent multisite, randomized controlled trial of a collaborative intervention program for late-life depression (Gilbody, 2007; Unutzer et al., 2002) showed that intervention group patients had significantly lower depression severity and significantly higher rates of both treatment response and remission of depressive symptoms, including suicidal ideation, which persisted at least 1 year after the completion of the intervention. Several studies with promising results have focused on anxiety disorders including GAD and panic disorders, but similar to the depression studies, samples contained no or only a few older adults (e.g., Rollman et al., 2005). However, no published studies could be found reporting the use of a collaborative care model in a sample of older adults with comorbid depression and anxiety. The penetration of evidence for the collaborative care approach may be assisted by a recent protocol describing the steps

needed to tailor models for specific groups, local needs, resources, and priorities while maintaining fidelity to the evidence base (Fortney et al., 2009). conclusion In light of the importance of accurately assessing both anxiety and depression in older adults independently and in concert, as well as the many negative outcomes that can occur through misdiagnosis and treatment challenges (e.g., prolonged and unnecessary personal suffering, development or exacerbation of physical illness, social isolation and loneliness, relocation from home), the need for training the next generation of mental health researchers in geriatric mental health literacy becomes clear. All health professionals, whether in research or clinical settings, require such training as a basic part of their professional education because encounters with older cohorts are becoming routine. Jeste et al. (1999) have called for such training in physician education; nurses and other health professionals (e.g., psychologists) have made similar comments and calls (Tanner, 2005; Morris & Mentes, 2006; Pachana et al., 2007; Smith, Specht, & Buckwalter, 2005) in addition to instituting training guidelines for geriatric mental health to be incorporated into curricula (Knight, Karel, Hinrichsen, Qualls, & Duffy, 2009). This is necessary, as clinical aging researchers are as important as clinical specialists trained to deliver care to older generations. Improved assessment skills underpin our capacity to engage in the interdisciplinary dialogues central to excellent management, underpin empirically valid research, and advance the extant literature. references Alexopoulos, G.S. (2005). Depression in the elderly. The Lancet, 365, 1961-1970. Alexopoulos, G.S., Abrams, R.C., Young, R.C., & Shamoian, C.A. (1988). Cornell Scale for Depression in Dementia. Biological Psychiatry, 23, 271-284. Almeida, O.P., & Almeida, S.A. (1999). Short versions of the Geriatric Depression Scale: A study of their validity for the diagnosis of a major depressive episode according to ICD-10 and DSM-IV. International Journal of Geriatric Psychiatry, 14, 858-865. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). doi:10.1176/appi. books.9780890423349 Arean, P.A., & Cook, B.L. (2002). Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biological Psychiatry, 52, 293-303. Bagby, R.M., Ryder, A.G., Schuller, D.R., & Marshall, M.B. (2004). The Hamilton Depression Rating Scale: Has the gold standard become a lead weight? American Journal of Psychiatry, 161, 21632177. Baiyewu, O., Smith-Gamble, V., Lane, K.A., Gureje, O., Gao, S., Ogunniyi, A., et al. (2007). Prevalence estimates of depression in elderly community-dwelling African Americans in Indianapolis and Yoruba in Ibadan, Nigeria. International Psychogeriatrics, 19, 679-689.218 Copyright SLACK Incorporated Beattie, Pachana, & Franklin Banerjee, S. (1993). Prevalence and recognition rates of psychiatric disorder in the elderly clients of a community care service. International Journal of Geriatric Psychiatry, 8, 125-131.

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