The association of anxiety and/or depression with quality of life among community- dwelling older adults.

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The association of anxiety and/or depression with quality of life among             community- dwelling older adults. A comparison between Ireland and Latvia.


1. Literature Review          

1.1 Defining Old Age

1.2 Health and Quality of Life

1.3 The Aging Population and Its Economic Implications  

1.4  Depression and Anxiety in Older Adults

1.5  Factors Contributing to Anxiety and/ or Depression in Older Adults

1.5.1        Biological Factors

1.5.2        Psychological Factors

1.5.3        Social Factors

1.6  Clinical Symptoms of Anxiety and Depression

1.7  Diagnostic Evaluation

1.7.1        Screening for Anxiety

1.7.2   Screening for Depression

     1.8 Evaluating Quality of Life

     1.9 Treatment of Anxiety and Depression in Older Adults

  1.9.1    Multidisciplinary Approach

  Role of Primary Care (?)

1.9.2  Non-pharmacological Treatment

1.9.3    Pharmacological Treatment

2. Methodology          

2.1  Data collection          

2.2  Data analysis  




Literature Review


1.1 Defining Old Age


   Aging is an inevitable part of the life cycle and old age is commonly understood as the later stage within the life cycle. There are currently no universal definitions for the onset of old age. In many societies, the point at which an individual enters this stage is determined by cultural assumptions, legislation or policy. 

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   The United Nations suggests that the stage of older adulthood is entered when an individual reaches the chronological age of 60, however, in the European Union, an older adult is defined as an individual who is 65 years of age or older. Irrespective of these differences in the definition of old age, it is widely accepted that as people become older, their health needs tend to become more complex, with an increased probability of having one or more chronic diseases and a general trend towards declining capability. Nevertheless, there is a general belief that the “baby boomer” generation (those born after World War II, between 1949 and 1961) have greater aspirations for themselves as they approach old age.                                    Compared with their predecessors, they are better educated, have higher disposable incomes and enter old age in better health and as they advance in age, they continue to have aspirations for optimal health, positive well-being and a good quality of life.  [Biggs, S., Carstensen, L. and Hogan, P. (2012) Social capital, lifelong learning and social innova- tion. In: Beard, J., Biggs, S., Bloom, D., Fried, L., Hogan, P., Kalache, A. and Olshanky, J. (eds) (on behalf of the World Economic Forum) Global Population Ageing: Peril or promise? Geneva: World Economic Forum Global Agenda Council on Ageing Society, pp. 39–41.

1.2 Health and Quality of Life

What is health?

Health, as defined by the World Health Organisation (WHO), is a “state of physical, mental and social well-being’’, and not simply the absence of a disease”. It is therefore necessary that the measurement of health must include an estimation of well-being which can be assessed by measuring the quality of life.

Quality of life, as defined by WHO, is “an individual’s perception of their position in life, in the context of culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns” [ WHO | WHOQOL: Measuring Quality of Life. [online]. 2018. [Accessed 23  October  2018]. Available from:].   It takes into consideration an individual’s physical health, psychological state, level of independence and social relationships. [WHO | WHOQOL: Measuring Quality of Life. [online]. 2018. [Accessed 23  October  2018]. Available from:

There is an ongoing paradigm shift towards adopting a holistic, biopsychosocial approach to health in the fields medicine and psychiatry. [The biopsychosocial approach and global mental health: Synergies and opportunities Emmanuel Babalola1, Pia Noel2, Ross White3 ]

The implementation of this model is particularly useful in geriatric care because aging people are faced with an increasing number of comorbid chronic conditions.  According to an expert panel on care of older adults, more than 50% of older adults suffer from three or more chronic conditions.

 [Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians]

Mental health problems often occur simultaneously with these physical health problems, thus affecting their manifestation and detection and complicating treatment plans. [Depression and health status in elderly patients with heart failure: A 6-month prospective study in primary care Sullivan, M.D., Newton ] The complexities of geriatric care, therefore calls for an integrated approach in order to reduce  the risk of adverse outcomes such as  death, disability and unnecessary healthcare utilization. Importantly, this approach allows for the opportunity to maximize quality of life in older adults.

1.3 The Aging Population and Economic Implications


According to Eurostat 2016 projections, the proportion of older persons (65 years and over) in the EU will increase from 97.7 million to 151 million by 2080. As such, the proportion of elderly in Ireland is predicted to rise from 13.2% to 21.9% and 19.6% to 23.8% in Latvia [1- People in the EU – population projections – Statistics Explained. [online]. 2018. [Accessed 23  October  2018]. Available from:].

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A report published by the Ageing Working Group of the Economic Policy Committee (EPC) and the European Commission’s Directorate-General for Economic and Financial Affairs (DG ECFIN) in May 2018 showed that economic costs related to ageing (in particular, government spending on health care and long term care arrangements) will rise significantly in the coming decades as the proportion of Europe’s ageing population continues to grow.  [2- The 2018 Ageing Report – (2018). [online] Available at: [Accessed 3 Dec. 2018]. Coupled with Europe’s declining birth rates and thus, shrinking work force, this means that the old-age dependency ratio will increase from 29.6% (2016) to 51.2% in 2070. [2- The 2018 Ageing Report – (2018). [online] Available at: [Accessed 3 Dec.

These projections highlight the major economic and societal challenges which lie ahead and indicate the need to identify the factors that affect health in the older population in order to reduce the associated public health burden.

1.4 Depression and Anxiety in Older Adults


Depression and anxiety are two of the most common psychiatric conditions in the elderly population.   [3 LENZE, ERIC J., MULSANT, BENOIT H., SHEAR, M. KATHERINE, ALEXOPOULOS, GEORGE S., FRANK, ELLEN and REYNOLDS, CHARLES F. Comorbidity of depression and anxiety disorders in later life. 

To date, depression in later life has been extensively researched as it is widely recognised as the one of the most important causes of increased mortality from suicide in this age group. According to WHO statistics, older adults suffering from depression have an increased risk of suicide and are proportionally more likely to complete suicide in comparison to younger age groups. [ Depression in older adults Joanne Rodda, Zuzana Walker, Janet Carter ]

Additionally, depression plays a significant role in contributing to the morbidity of chronic conditions, disability and impaired life quality in later life.

In contrast with depression, the study of anxiety disorders in older adults is a relatively new field and studies focusing on this area are very scarce. Interestingly, a recent study by Andreas et al., found that anxiety was the most prevalent mental health disorder amongst community-dwelling older adults in Europe. [Prevalence of mental disorders in elderly people: the European MentDis_ICF65+ study- Sylke Andreas 2017]

There are a range of anxiety disorders which occur in later life. These include generalised anxiety disorder, specific phobias (for example, fear of falling), panic disorder and social anxiety disorder. Generalised anxiety disorder is the most common anxiety disorder encountered in the older population, with prevalence estimates ranging from 1.2% to 7.3%.
[ Prevalence of mood, anxiety, and substance—abuse disorders for older Americans in the National Comorbidity Survey Replication – Gum AM, King-Kallimanis B, Kohn R]

[Anxiety disorders in later life: a report from the Longitudinal Aging Study Amsterdam

Beekman AT, Bremmer MA, Deeg DJ]

1.5 Factors Contributing to Anxiety and/ or Depression in Older Adults


Detection of anxiety and/ or depression in older adults may be improved by paying special attention to the risk factors that predispose this population to these conditions. In comparison with younger adults, different risk factors may be expected among the elderly because the exposure to and impact of these risk factor change with age [Beekman et al., 2000. Anxiety and depression in later life: coccurrence and communality of risk factors.] [Risk factors for anxiety and depression in the elderly: A review-  Dagmar Vink]

The comorbid occurrence of anxiety and depression symptoms suggests that they may share common risk factors. The risk factors discussed in this chapter will be categorised into three parts 1) Biological risk factors 2) Psychological risk factors 3) Social risk factors

1.5.1 Biological Risk Factors

Studies have indicated that certain biological factors are linked to symptoms of anxiety and/or depression or disorders in later life. [Vink, D., Aartsen, M. J., & Schoevers, R. A. (2008). Risk factors for anxiety and depression in the elderly: A review. Journal of Affective Disorders] These include (a) chronic health conditions such as diabetes, cardiovascular diseases, cerebrovascular diseases (b) cognitive impairments, (c) chronic pain (d) functional limitations or disability which hinder daily activity (e) impaired self-perceived health (f) polypharmacy (g) drug habits i.e. alcohol or medication abuse.

1.5.2. Psychological Risk Factors

Personality traits such as neuroticism, lower level of self-mastery and control have been shown to increase the risks of anxiety and depression symptoms or disorders in the elderly. Similarly, dysfunctional coping strategies, poor self-esteem, previous psychiatric history, stressful life events and adverse childhood events play a role in predisposing individuals to anxiety and depression in later life. [Vink, D., Aartsen, M. J., & Schoevers, R. A. (2008). Risk factors for anxiety and depression in the elderly: A review. Journal of Affective Disorders]

1.5.1 Social Risk Factors 

Reviews of pertinent literature revealed some similarities as well as differences in social risk factors that may contribute to depression and anxiety symptoms or disorders in older adults.

Similar associations were found regarding marital status, bereavement, decreased social support, level of education, gender and urbanization. [Acierno, R., Brady, K., Gray, M., Kilpatrick, D.G., Resnick, H., Best, C.L., 2002. Psychopathology following interpersonal violence: a comparison of risk factors in

older and younger older and younger adults. J. Clin. Geropsychol. 8, 13–23] [Schoevers, R.A., Beekman, A.T.F., Deeg, D.J.H., Jonker, C., van Tilburg, W., 2003b. Comorbidity and risk-patterns of depression, generalised anxiety disorder and mixed anxiety–depression in later life: results from the AMSTEL study. Int. J. Geriatr. Psychiatry 18, 994–1001.]

Some studies, however, reported that low frequency of social contact, being childless, lower income and having prior negative/ traumatic life events were associated with anxiety, but not depression. On the other hand, other studies reported that having a smaller social network and being unmarried were linked with depression, but not anxiety. [Vink, D., Aartsen, M. J., & Schoevers, R. A. (2008). Risk factors for anxiety and depression in the elderly: A review. Journal of Affective Disorders] Despite the differing opinions, it is clear that there is a wide overlap in the risk factors  that contribute to development of anxiety and/ depression in older adults

1.6 Clinical Symptoms of Anxiety and Depression


Anxiety and depression in older adults often manifest as somatic symptoms such as headaches, sleep disturbances, muscle tension or pain, heart palpitations and gastrointestinal complaints [3]. In addition, they can present as an exacerbation of physical symptoms of a co-existing medical condition, or as a somatization disorder.

Primary care plays a critical role in the recognition and treatment of anxiety and depression in older adults. It is the first port of call and point of continual care for patients within a healthcare system. For this reason and more, several studies have suggested that primary care is the de facto mental health system [4].

However, various primary care studies have shown a decreased detection of anxiety and depression in older patient or those whose symptoms were predominantly somatic [3]. This results in an increase in costly and unnecessary investigations, increased healthcare utilisation and an impairment of health status [4].

Various studies have described the negative impact of anxiety and depression on quality of life in the general population [7;8;9], however, there still remains a shortage of research focusing on geriatric populations in primary care settings.

Considering the progressive aging of the population in both Ireland and Latvia, benefits of improved detection and treatment include a reduction in the public health cost burden associated with unnecessary testing, a reduction in the risk of unfavourable outcomes, and importantly, an opportunity to maximise the quality of life of older adults.

  1. People in the EU – population projections – Statistics Explained. [online]. 2018. [Accessed 23  October  2018]. Available from:
  2. Hickie IB, Davenport TA, Scott EM, Hadzi-Pavlovic D, Naismith SL, Koschera A. Unmet need for recognition of common mental disorders in Australian general

practice. Med J Aust. 2001 Jul 16;175 Suppl:S18-24

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