Gerard J. Byrne

Development and validation of the Geriatric Anxiety Inventory

BACKGROUND Anxiety symptoms and anxiety disorders are highly prevalent among elderly people, although infrequently the subject of systematic research in this age group. One important limitation is the lack of a widely accepted instrument to measure dimensional anxiety in both normal old people and old people with mental health problems seen in various settings. Accordingly, we developed and tested of a short scale to measure anxiety in older people. METHODS We generated a large number of potential items de novo and by reference to existing anxiety scales, and then reduced the number of items to 60 through consultation with a reference group consisting of psychologists, psychiatrists and normal elderly people. We then tested the psychometric properties of these 60 items in 452 normal old people and 46 patients attending a psychogeriatric service. We were able to reduce the number of items to 20. We chose a 1-week perspective and a dichotomous response scale. RESULTS Cronbachs alpha for the 20-item Geriatric Anxiety Inventory (GAI) was 0.91 among normal elderly people and 0.93 in the psychogeriatric sample. Concurrent validity with a variety of other measures was demonstrated in both the normal sample and the psychogeriatric sample. Inter-rater and test-retest reliability were found to be excellent. Receiver operating characteristic analysis indicated a cut-point of 10/11 for the detection of DSM-IV Generalized Anxiety Disorder (GAD) in the psychogeriatric sample, with 83% of patients correctly classified with a specificity of 84% and a sensitivity of 75%. CONCLUSIONS The GAI is a new 20-item self-report or nurse-administered scale that measures dimensional anxiety in elderly people. It has sound psychometric properties. Initial clinical testing indicates that it is able to discriminate between those with and without any anxiety disorder and between those with and without DSM-IV GAD.

A systematic review of insomnia and complementary medicine

In concert with growing public interest in complementary and alternative medicine (CAM), these therapies and products have been increasingly studied over the past two decades for the treatment of sleep disorders. While systematic reviews have been conducted on acupuncture and valerian in the treatment of insomnia, to date no comprehensive review has been conducted on all major CAM treatments. We sought to address this via a rigorous systematic review of hypnotic CAM interventions, including herbal and nutritional medicine, acupuncture, acupressure, yoga, tai chi, massage, aromatherapy and homoeopathy. The electronic databases MEDLINE (PubMed), CINAHL, PsycINFO, and The Cochrane Library were accessed during late 2009 for CAM randomized controlled trials (RCTs) in the treatment of chronic insomnia. Sixty-four RCTs were identified, of which 20 studies involving eight CAM interventions met final inclusion criteria. Effect size calculations (where possible) and a quality control analysis using a modified Jadad scale were undertaken. Many RCTs lacked methodological rigor, and were commonly excluded due to small sample size or an inadequate control condition. Among the studies that met inclusion criteria, there was evidentiary support in the treatment of chronic insomnia for acupressure (d=1.42-2.12), tai chi (d=0.22-2.15), yoga (d=0.66-1.20), mixed evidence for acupuncture and L-tryptophan, and weak and unsupportive evidence for herbal medicines such as valerian. Surprisingly, studies involving several mainstream CAM therapies (e.g., homoeopathy, massage, or aromatherapy) were not located or did not meet basic inclusion criteria. If CAM interventions are to be considered as viable stand-alone or adjuvant treatments for sleep disorders, future researchers are urged to use acceptable methodology, including appropriate sample sizes and adequate controls. RCTs evaluating other untested CAM therapies such as massage, homoeopathy, or osteopathy are encouraged, as is the exploration of using CAM therapies adjuvantly with conventional therapies.

WHOQOL-BREF as a measure of quality of life in older patients with depression

OBJECTIVE To assess the reliability and validity of a brief measure of quality of life recently developed by the World Health Organization, the WHOQOL-BREF, and to examine its association with a variety of clinical and sociodemographic factors in older depressed patients. DESIGN Cross-sectional study. METHODS Older depressed patients (N=41) underwent diagnostic assessment using the Composite International Diagnostic Interview (CIDI) and were independently assessed on a variety of measures including the WHOQOL-BREF (a 26-item self-report questionnaire generating four domain scores), Hamilton Depression Rating Scale (HAM-D); Geriatric Depression Scale (GDS); Mini-mental State Examination (MMSE); Modified Barthel Index (MBI); Instrumental activities of daily living (IADL), and measures of physical health status and social relationships. Estimates of inter-rater and test-retest reliability, and concurrent validity were made. RESULTS 39 subjects completed the study. The majority of subjects (94.9%) received a diagnosis of DSM-IV Major Depressive Disorder. Levels of comorbidity were high. Three of the four domains of the WHOQOL-BREF (Physical, Psychological and Environment domains) demonstrated satisfactory reliability and validity. However, the Social Relationships domain exhibited poor validity. Quality of life scores were strongly correlated with severity of depression, number of self-reported physical symptoms and self-assessed general health status. There was no relationship between diagnostic comorbidity and quality of life scores. CONCLUSIONS The WHOQOL-BREF was successfully administered to older depressed patients although the concurrent validity of one of its four domains was poor. Quality of life scores were strongly correlated with severity of depression, raising the issue of measurement redundancy.

Factors associated with suicidal thoughts in a large community study of older adults.

BACKGROUND Thoughts about death and self-harm in old age have been commonly associated with the presence of depression, but other risk factors may also be important. AIMS To determine the independent association between suicidal ideation in later life and demographic, lifestyle, socioeconomic, psychiatric and medical factors. METHOD A cross-sectional study was conducted of a community-derived sample of 21 290 adults aged 60-101 years enrolled from Australian primary care practices. We considered that participants endorsing any of the four items of the Depressive Symptom Inventory -Suicidality Subscale were experiencing suicidal thoughts. We used standard procedures to collect demographic, lifestyle, psychosocial and clinical data. Anxiety and depressive symptoms were assessed with the Hospital Anxiety and Depression Scale. RESULTS The 2-week prevalence of suicidal ideation was 4.8%. Male gender, higher education, current smoking, living alone, poor social support, no religious practice, financial strain, childhood physical abuse, history of suicide in the family, past depression, current anxiety, depression or comorbid anxiety and depression, past suicide attempt, pain, poor self-perceived health and current use of antidepressants were independently associated with suicidal ideation. Poor social support was associated with a population attributable fraction of 38.0%, followed by history of depression (23.6%), concurrent anxiety and depression (19.7%), prevalent anxiety (15.1%), pain (13.7%) and no religious practice (11.4%). CONCLUSIONS Prevalent and past mood disorders seem to be valid targets for indicated interventions designed to reduce suicidal thoughts and behaviour. However, our data indicate that social disconnectedness and stress account for a larger proportion of cases than mood disorders. Should these associations prove to be causal, then interventions that succeeded in addressing these issues would contribute the most to reducing suicidal ideation and, possibly, suicidal behaviour in later life.

THE PSYCHOLOGICAL SYMPTOMS OF CONJUGAL BEREAVEMENT IN ELDERLY MEN OVER THE FIRST 13 MONTHS

Objective. The purpose of this study was to investigate the psychological symptoms experienced by recently widowed older men. It was hypothesized that conjugal bereavement in this group would be characterized by a mixture of depression, anxiety and loneliness.

A longitudinal study of bereavement phenomena in recently widowed elderly men

A three-phase longitudinal design was used to study bereavement phenomena in a cohort (N = 78) of recently widowed elderly Australian men. One group of 57 widowers was compared with a second group of 21 widowers on a waiting list. A brief, interviewer-administered, structured questionnaire was used to rate the frequency of 22 self-reported bereavement phenomena. The prevalence and temporal evolution of these phenomena are described. Half of a subgroup of elderly widowers reporting high levels of bereavement phenomena at 6 weeks post-bereavement went on to exhibit persistent or chronic grief at 13 months post-bereavement. The prevalence of persistent or chronic grief throughout the first 13 months post-bereavement was 8.8%. Income, education and expectedness of the death were all negatively correlated with frequency of self-reported bereavement phenomena at 6 weeks post-bereavement. In a multiple regression analysis only expectedness of the death contributed significantly to prediction of the frequency of bereavement phenomena at 6 weeks post-bereavement. Widowers who were unable to anticipate their wifes death, even when their wife had suffered a long final illness, had a more severe bereavement reaction.

Personality changes in Alzheimer's disease: a systematic review†

People with Alzheimers disease (AD) commonly exhibit changes in personality that sometimes precede the other early clinical manifestations of the condition, such as cognitive impairment and mood changes. Although these personality changes reflect the impact of progressive brain damage, there are several possible patterns of personality change with dementia. Early identification of personality change might assist with the timely diagnosis of AD. The objective of this study was to review studies of personality change in AD.

The clinical utility of the Hopkins Verbal Learning Test as a screening test for mild dementia

The purpose of this study was to determine whether the Hopkins Verbal Learning Test (HVLT) could be used as a valid and reliable screening test for mild dementia in older people, and to compare its performance to that of the Mini‐Mental State Examination (MMSE).

Development and validation of a short form of the Geriatric Anxiety Inventory – the GAI-SF

BACKGROUND Anxiety symptoms and anxiety disorders are highly prevalent among older people and are associated with considerable disability burden. While several instruments now exist to measure anxiety in older people, there is a need for a very brief self-report scale to measure anxiety symptoms in epidemiological surveys, in primary care and in acute geriatric medical settings. Accordingly, we undertook the development of such a scale, based on the Geriatric Anxiety Inventory. METHODS This is a cross-sectional study of randomly selected, community-residing, older women (N = 284; mean age 72.2 years) using receiver operating characteristic (ROC) analyses. DSM-IV diagnostic interviews were undertaken using the Mini International Diagnostic Interview, fifth edition (MINI-V). RESULTS We developed a 5-item version of the Geriatric Anxiety Inventory, which we have termed the Geriatric Anxiety Inventory - Short Form (GAI-SF). We found that a score of three or greater was optimal for the detection of DSM-IV Generalized Anxiety Disorder (GAD) in this community sample. At this cut-point, sensitivity was 75%, specificity was 87%, and 86% of participants were correctly classified. GAI-SF score was not related to age, MMSE score, level of education or perceived income adequacy. Internal consistency was high (Cronbachs α = 0.81) and concurrent validity against the State-Trait Anxiety Inventory was good (rs = 0.48, p < 0.001). CONCLUSIONS The GAI-SF is a short form of the Geriatric Anxiety Inventory, which we recommend for use in epidemiological studies. It may also be useful in primary care and acute geriatric medical settings.

The clinical spectrum of anxiety in Parkinson's disease

Anxiety is common in Parkinsons disease (PD), and contributes to increased disability and poorer quality of life. In spite of its significant impact, the symptomatology, chronology, and neurobiology of anxiety in PD are all poorly understood, and this hinders accurate diagnosis and development of effective treatment strategies. This review investigates and updates literature related to the clinical spectrum of anxiety in PD. The reported prevalence of anxiety in PD varies considerably, with emerging interest in the frequency of the DSM‐IV residual category of “Anxiety disorder, not otherwise specified” (Anxiety disorder NOS), which is observed in up to 25% of PD patients. By design, there are no standardized diagnostic criteria for Anxiety disorder NOS, because this is the category applied to individuals who do not meet diagnostic criteria for any other current anxiety disorder. Anxiety rating scales incompletely capture anxiety symptoms that relate specifically to PD symptoms and the complications arising from PD therapy. Consequently, these scales have been deemed inappropriate for use in PD, and there remains a need for the development of a new PD‐specific anxiety scale. Research establishing accurate symptom profiles of anxiety in PD is sparse, although characterizing such symptomatology would likely improve clinical diagnosis and facilitate targeted treatment strategies. Research into the neurobiological and psychological underpinnings of anxiety in PD remains inconclusive. Anxiety can precede the onset of PD motor symptoms or can develop after a diagnosis of PD. Further investigations focused on the chronology of anxiety and its relationship to PD diagnosis are required.