Structural differentiation of self-reported depression and anxiety in late life

Research has shown impressive support for tripartite models of anxiety and depression that include a common factor of negative affect, and the unique factors positive affect and arousal. It is not clear whether this structure extends into later life. The current study used confirmatory factor analysis to model the structural relationship of anxiety and depression in two samples of older adults: a large probability sample (N = 1429) and a smaller convenience sample (N = 210). Across all analyses, a correlated, two-factor, psychometric model was most parsimonious. The tripartite model could be fit to the data, but added no explanatory power; in some cases a one-factor model also fit. The results suggest that there is a unitary factor of "distress" that incorporates anxiety and depression, but that the structure is not consistent with factor structures found in younger samples. Instead, the broad constructs may be represented in a more complex manner among older adults, and are less easily differentiated.     

Cognitive-behavior therapy for generalized anxiety in late life: an evaluative overview

Of the pervasive anxiety disorders diagnosed in late life, generalized anxiety disorder (GAD) is the most prevalent. In this paper, the clinical features of GAD among older adults are described, with particular attention to differences in the nature of relevant symptoms among older and younger cohorts. Outcome studies addressing the efficacy of cognitive-behavior therapy (CBT) for younger and middle-aged adults with GAD then are reviewed briefly. Next, early literature investigating the potential usefulness of cognitive-behavioral treatments among older anxious community volunteers is then reviewed and critiqued in some detail. More recent work, some of which is currently in progress, has focused on the efficacy of CBT for older adults with well-diagnosed GAD. This research also is reviewed, and directions for future research in this area are provided.     

Neurocognitive predictors of long-term outcome in CBT for late life generalized anxiety disorder

Generalized anxiety disorder (GAD) is currently recognized as one of the most common and impairing psychiatric conditions in adults age 65 and over. Although clinical trials have indicated that cognitive behavior therapy (CBT) is efficacious, it has not shown consistent superiority over other types of psychosocial interventions. This study sought to identify baseline neurocognitive predictors of posttreatment and distal follow-up outcome of CBT for late life GAD, which could be used to estimate response and optimize the intervention. First, results indicated that CBT was effective in reducing worry and other symptoms immediately following and 18 months after the last full session of treatment. Regression models of baseline predictors included pretreatment worry scores, the number of comorbid conditions, hypertension, and scores on a working memory task or hippocampal volumes as predictors of endpoint PSWQ scores. Results replicated known baseline predictors of outcome at both assessment points, and identified one new predictor of distal outcome. Clinicians may benefit from including working memory tasks as assessment and augmentation tools in treating older GAD patients.     

A preliminary investigation of developmentally sensitive items for the assessment of social anxiety in late life

The current study aimed to examine the salience of anxiety-provoking social situations for older adults. A list of potentially anxiety-provoking situations was developed from a review of existing measures of social anxiety. In addition to items derived from existing measures, the investigators generated items thought to be particularly relevant for older adults. One hundred and four older adults were asked, “Please check all situations where you might feel uncomfortable, nervous, scared, worried, embarrassed, or anxious.” Participants were also prompted to record any additional situations in which they experienced anxiety. Older adults endorsed items not included on typical measures of social anxiety at high rates. Exploratory analyses of the effects of gender on item endorsement were examined and significant differences were found for several items. The authors discuss these findings and their implications for the assessment of late-life social anxiety.     

Comorbid anxiety disorder in late life depression: association with memory decline over four years

OBJECTIVE: In elderly persons with Major Depressive Disorder (MDD), coexisting Generalized Anxiety Disorder (GAD) or Panic Disorder (PD) is associated with more severe symptoms and poorer short-term treatment outcomes. The purpose of this study was to determine whether comorbid GAD or PD was associated with poorer long-term outcomes of late-life MDD, in terms of symptoms, functional disability, and cognitive status. METHODS: Seventy-nine older subjects with major depressive disorder who had responded to initial treatment in clinical trials were followed at yearly intervals for up to four years with assessment of their symptoms, cognitive status, and functional disability. For this analysis, subjects were divided into two groups, anxious and non-anxious, based on presence (n = 37) or absence (n = 42) of a lifetime diagnosis of GAD and/or PD. RESULTS: The anxious group showed a greater decline in memory, but not in other cognitive measures or measures of functional status. Depression recurrence was similar in the anxious and non-anxious groups. Among those in the anxious group, a later age of onset (> 55) of the anxiety disorder was associated with worse overall cognition at baseline, but a similar rate of decline in cognition over time, compared with early-onset anxiety disorder. CONCLUSION: We found evidence that comorbid GAD or PD is associated with a greater decline in memory in late-life MDD. The data also suggest that anxiety disorders with an onset later in life may be associated with cognitive impairment, although further study is needed to confirm this finding.     

Depression in late life

Despite its prevalence and seriousness, depression in late life remains underappreciated as a source of disability and suffering for older people and their families. Despite a solid and substantial body of research, recognition of depression remains problematic and is often attributed to normal developmental changes in aging. Treatment efficacy data notwithstanding, the adequacy and appropriateness of treatment is highly variable. This paper contains a broad overview of new research developments in depression in late life and the disabilities associated with it Serving as an introduction to the specific papers that follow in this issue of Dialogues in Clinical Neuroscience, this article scans the knowledge base in basic, clinical, and health services research, identifying the highlights of current work in the area and proposing areas of needed expansion of research efforts.     

Generalized anxiety disorder in late life: lifetime course and comorbidity with major depressive disorder.

OBJECTIVE: Generalized anxiety disorder (GAD) in elderly persons is highly prevalent, but little is known about its course, age at onset, and relationship to comorbid major depressive disorder (MDD). The authors assessed the course and comorbidity of late-life GAD and MDD. METHODS: Authors assessed elderly subjects in anxiety or depression intervention studies who had a lifetime history of GAD, with current MDD (N=57) or without (N=46). Subjects' lifetime course of illness was charted retrospectively. RESULTS: The 103 subjects had a mean age of 74.1 years, and a mean age at onset of GAD of 48.8 years; 46% were late-onset. GAD episodes were chronic, and 36% were longer than 10 years. Of the comorbid GAD-MDD patients, most had different times of onset and/or offset of the disorders; typically, GAD preceded MDD. CONCLUSIONS: Elderly subjects with GAD tended to have chronic symptoms lasting years-to-decades, without interruption, and many have late onset. Elderly persons with lifetime GAD and MDD tend to have different onset and offset of the two disorders. Findings characterize late-life GAD as a chronic disorder distinct from MDD.     

Emotion dysregulation and anxiety in late adulthood

Recent research has highlighted the important role of emotion dysregulation in the occurrence and maintenance of anxiety symptoms. The purpose of the present study was to investigate the relationship between anxiety symptoms and older adults’ ability to regulate emotional experiences. A total of 167 community dwelling older adults completed self-report measures of affect and were asked to report how often they use specific emotion regulation strategies. Consistent with previous theories older adults experiencing increasing levels of anxiety reported greater difficulties in regulating emotional responses. Present results provide support for previous findings demonstrating that experiencing anxiety symptoms affects the ability to regulate emotional experiences. Current findings are likely to be informative in terms of understanding emotion dysregulation in older adults at risk of experiencing clinical symptoms of anxiety.     

Antidepressant-associated mania in late life

BACKGROUND: Elderly patients can present with mania for the first time late in life, and some elders treated with antidepressants can present with mania. Clinical characteristics of antidepressant-associated mania (AAM) in late life have not been examined. OBJECTIVES: The aims of the study were to identify elders with AAM and to compare selected clinical characteristics to those of manic elders who had not been treated with an antidepressant. We hypothesized that AAM patients would have later age at presentation of bipolar disorder. METHODS: We retrospectively reviewed inpatients with manic disorder who were aged >or=60 years. The sample was selected from admissions prior to 1990. RESULTS: AAM patients (n = 11) were more often experiencing first manic episode, and they had later age at onset of first manic episode, compared to non-AAM patients (n = 46). Most of the AAM patients had been treated with tricyclic agents. CONCLUSIONS: These preliminary findings invite further investigation. Related studies may contribute to risk-benefit analyses for the use of particular antidepressants in the elderly. Also, first episode mania in late life may prove to be a useful model of vulnerability to AAM.     

Complicated grief in late life

Complicated grief (CG) is a syndrome that affects 10% to 20% of grievers regardless of age, although proportionally more will face the death of loved ones in late life, CG is characterized by preoccupying and disabling symptoms that can persist for decades such as an inability to accept the death, intense yearning or avoidance, frequent reveries, deep sadness, crying, somatic distress, social withdrawal, and suicidal ideation. This syndrome is distinct from major depression and post-traumatic stress disorder, but CG maybe comorbid with each. This communication will focus on the impact of CG in late life (over age 60) and will include a case vignette for illustrating complicated grief therapy.     

Personality disorders in late life

There is growing empiric evidence to suggest that a large number of elderly patients who have chronic depression frequently have comorbid personality disorders as well. In addition, contrary to commonly held clinical beliefs, a recent meta-analysis suggests that rates of personality disorders among older adults are essentially equivalent to that of younger groups. Although understudied, personality-disordered elderly patients have been shown to be less responsive to mental health interventions, and personality dysfunction may be one of the most relevant factors to account for when examining late-life depression remission and relapse. The paper considers briefly the notion of personality and personality disorders in late-life, examines prevalence rates including a recent meta-analysis, explores relevant issues associated with treatment, and discusses new developments in treatment.     

Treatment-resistant depression in late life

Depression is the most prevalent functional psychiatric disorder in late life. It is associated with a high risk of mortality from comorbid medical illness and from suicide. Successful antidepressant treatment is one of the most effective ways to reduce disability, prevent morbidity, and improve quality of life in an older depressed patient. Treatment-resistant depression is a common clinical problem, reported to affect up to one-third of older depressed patients. However, published data on this clinically important topic are sparse. Available data and clinical experience indicate that many depressed patients labeled as "treatment resistant" or even "treatment refractory" are so labeled because of variables involving the diagnostic or treatment process, rather than because they suffer from a depression that is truly unresponsive to treatment. Unidentified comorbid medical or psychiatric conditions and misdiagnosis often contribute to treatment resistance. Atypical depressive symptoms, such as somatic and cognitive symptoms, and comorbid medical conditions that can themselves produce depressive symptoms often make it difficult to accurately assess antidepressant response in this age group. This often leads to inadequate pharmacotherapy, another major factor contributing to apparent treatment resistance. In older patients, as in younger patients, the selection of the right antidepressant, the right dose, and the right treatment duration constitute the treatment variables essential in ensuring optimal therapeutic response. Approach to treatment-resistant depression in the elderly involves reconsideration of the diagnosis and use of alternate therapeutic measures in a systematic way, including switching to another agent, combination therapy, and electroconvulsive therapy.