Psychometric properties of worry and anxiety measures in a sample of african american and caucasian older adults.

Objective: The aim of our study was to examine the psychometric properties of commonly used anxiety and worry assessment measures in a community-based, low-income sample of African American and Caucasian older adults.Method: African American and Caucasian participants from three community-based clinical trials testing treatments for late-life worry/anxiety were pooled to examine the factor structure, internal consistency reliability, and convergent, discriminant, and predictive validity of the Penn State Worry Questionnaire-Abbreviated (PSWQ-A), Generalized Anxiety Disorder-7 (GAD-7) and Geriatric Anxiety Inventory-short form (GAI-SF).Results: All three measures demonstrated an adequate fit to a one-factor structure. Internal consistency reliability was adequate for the PSWQ-A and GAD-7 in the total sample and racial subgroups but was acceptable for the GAI-SF only in the African American subgroup. The PSWQ-A and GAD-7 demonstrated good convergent, discriminant, and predictive validity. The GAI-SF has adequate convergent and divergent validity in the African American subgroup.Conclusion: Our study offers preliminary evidence for use of the PSWQ-A and GAD-7 for assessment of anxiety in a sample of low-income, predominantly African American participants. These measures may facilitate identification of anxiety symptoms, which are often overlooked in this population. More research is needed to examine the accuracy of these measures in other racial/ethnic groups.

Community-Based Outreach and Treatment for Underserved Older Adults With Clinically Significant Worry: A Randomized Controlled Trial.

OBJECTIVE: To determine whether Calmer Life (CL) improved worry, generalized anxiety disorder-related (GAD-related) symptoms, anxiety, depression, sleep, trauma-related symptoms, functional status, and quality of life better than Enhanced Community Care with Resource Counseling (ECC-RC) at 6 months and 9 months. METHODS: A randomized, controlled, comparative-effectiveness study involving underserved, low-income, mostly minority neighborhoods in Houston, Texas, looked at individuals ≥50 with significant worry and interest in psychosocial treatment. Interventions were CL, cognitive behavioral therapy with resource counseling, facilitation of communication with primary care providers about worry/anxiety, integration of religion/spirituality, person-centered skill content and delivery and nontraditional community providers, ECC-RC, and enhanced standard community-based information/ resource counseling addressing basic unmet and mental health needs. Primary outcomes were worry and GAD-related symptom severity. Secondary outcomes were anxiety, depression, sleep difficulties, trauma-related symptoms, functional status, quality of life, service use and satisfaction. RESULTS: Similar, moderate improvements followed CL and ECC-RC on worry, GAD-related symptoms, anxiety, depression, sleep, trauma-related symptoms, and mental health quality of life at 6 and 9 months, but with symptoms at both times and higher satisfaction with CL at both. Fewer ECC-RC participants reported a hospital admission in the prior 3 months than those in CL at 6 and 9 months; at 9 months, fewer reported a visit with a provider in the previous 3 months. CONCLUSION: Both interventions showed similar improvements at 6 and 9 months, but symptoms remained that might require care. Either intervention or a combination may be useful for low-income older adults with identified worry/anxiety.

Expanding the geriatric mental health workforce through utilization of non-licensed providers.

OBJECTIVES: We evaluate policy and practice strategies for bolstering the geriatric mental healthcare workforce and describe costs and considerations of implementing one approach. METHOD: Narrative overview of the literature and policy retrieved from searches of databases, hand searches, and authoritative texts. We identified three proposed strategies to increase the geriatric mental healthcare workforce: (1) production of more geriatric mental health providers; (2) team-based care; and (3) non-licensed providers. We evaluate each in terms of challenges and potential and provide estimates of costs, policy, and practice considerations for training, employing, and supervising non-licensed mental health providers. RESULTS: Use of non-licensed providers is key to reforms needed to allow a more older adults to access necessary mental healthcare. Licensed and non-licensed providers have achieved similar improvements for generalized anxiety disorder among patients, although non-licensed providers did so at a lower cost. CONCLUSION: Supervised non-licensed providers can extend the reach of licensed providers for specific mental health conditions, resulting in lower costs and increased number of patients treated. Although several barriers to implementation exist, policy and infrastructure changes that may support this type of care delivery model are emerging from reforms in financing and associated delivery initiatives created by the Affordable Care Act.

Cognitive behavior therapy for late-life generalized anxiety disorder delivered by lay and expert providers has lasting benefits.

OBJECTIVE: Peaceful Living, a cognitive-behavioral treatment (CBT) for late-life generalized anxiety disorder (GAD), produced positive outcomes in GAD severity, anxiety, depression, insomnia, and mental health quality of life relative to usual care with treatment delivered by either bachelor-level lay providers (BLPs) or PhD-level expert providers (PLPs). We examined long-term maintenance of gains during 12 months following CBT for patients in this trial who received the intervention delivered by BLPs and PLPs and completed post-treatment assessments. METHODS: Participants were 112 older adults (mean age, 66.83 years) with GAD recruited from primary care who received CBT from BLPs (n = 52) or PLPs (n = 60) and completed post-treatment assessments. Assessments were given at post-treatment and at 6- and 12-month follow-up. Primary outcomes assessed long-term maintenance of gains in worry (Generalized Anxiety Disorder Severity Scale) and anxiety (State-Trait Anxiety Inventory, Structured Interview Guide for the Hamilton Anxiety Scale). Secondary outcomes assessed depression (Patient Health Questionnaire), mental health quality of life (Medical Outcomes Study Short Form - mental wellness scale), and sleep (Insomnia Severity Index). RESULTS: At 6- and 12-month follow-ups, post-treatment reductions in GAD severity, anxiety, depression, and improvements in mental health quality of life and sleep were maintained for patients in both groups. No differences were found, based on provider group. CONCLUSION: Treatment of late-life anxiety delivered by nonexpert lay providers working under supervision of licensed providers has lasting benefits. These findings support the potential of new models of care for older adults that may expand reach of mental health services. Copyright © 2016 John Wiley & Sons, Ltd.

Alcohol use, anxiety, and insomnia in older adults with generalized anxiety disorder.

OBJECTIVES: To examine alcohol consumption among older primary care patients with generalized anxiety disorder (GAD); its relationship to demographic variables, insomnia, worry, and anxiety; and its moderating role on the anxiety-insomnia relationship. We expected alcohol use to be similar to previous reports, correlate with higher anxiety and insomnia, and worsen the anxiety-insomnia relationship. DESIGN: Baseline data from a randomized controlled trial. SETTING: Michael E. DeBakey VA Medical Center and Baylor College of Medicine. PARTICIPANTS: 223 patients, 60 years and older, with GAD. MEASUREMENTS: Frequency of alcohol use, insomnia (Insomnia Severity Index), worry (Penn State Worry Questionnaire - Abbreviated, Generalized Anxiety Disorder Severity Scale), and anxiety (State-Trait Anxiety Inventory - Trait subscale, Structured Interview Guide for the Hamilton Anxiety Rating Scale [SIGH-A]). RESULTS: Most patients endorsed alcohol use, but frequency was low. Presence and frequency were greater than in previous reports of primary care samples. Alcohol use was associated with higher education, female gender, less severe insomnia, and lower worry (Generalized Anxiety Disorder Severity Scale) and anxiety (State-Trait Anxiety Inventory-Trait subscale; SIGH-A). Whites reported more drinks/week than African-Americans. More drinks/week were associated with higher education and lower anxiety (SIGH-A). Weaker relationships between worry/anxiety and insomnia occurred for those drinking. Drink frequency moderated the positive association between the Penn State Worry Questionnaire-Abbreviated and insomnia, which was lower with higher frequency of drinking. CONCLUSIONS: Older adults with GAD use alcohol at an increased rate, but mild to moderate drinkers do not experience sleep difficulties. A modest amount of alcohol may minimize the association between anxiety/worry and insomnia among this group.

Lay providers can deliver effective cognitive behavior therapy for older adults with generalized anxiety disorder: a randomized trial.

BACKGROUND: The Institute of Medicine recommends developing a broader workforce of mental health providers, including nontraditional providers, to expand services for older adults. Cognitive behavior therapy (CBT) is effective for late-life generalized anxiety disorder (GAD), but no study has examined outcomes with delivery by lay providers working under the supervision of licensed providers. The current study examined the effects of CBT delivered by lay, bachelor-level providers (BLP) relative to Ph.D.-level expert providers (PLP), and usual care (UC) in older adults with GAD. METHODS: Participants were 223 older adults (mean age, 66.9 years) with GAD recruited from primary care clinics at two sites and assigned randomly to BLP (n = 76), PLP (n = 74), or UC (n = 73). Assessments occurred at baseline and 6 months. CBT in BLP and PLP included core and elective modules (3 months: skills training; 3 months: skills review) delivered in person and by telephone, according to patient choice. RESULTS: CBT in both BLP and PLP groups significantly improved GAD severity (GAD Severity Scale), anxiety (Spielberger State-Trait Anxiety Inventory; Structured Interview Guide for the Hamilton Anxiety Scale), depression (Patient Health Questionnaire), insomnia (Insomnia Severity Index), and mental health quality of life (Short-Form-12), relative to UC. Response rates defined by 20% reduction from pre- to posttreatment in at least three of four primary outcomes were higher for study completers in BLP and PLP relative to UC (BLP: 38.5%; PLP: 40.0%; UC: 19.1%). CONCLUSION: Lay providers, working under the supervision of licensed providers, can deliver effective CBT.

The peaceful mind program: a pilot test of a cognitive-behavioral therapy-based intervention for anxious patients with dementia.

OBJECTIVES: To assess feasibility and to conduct a preliminary evaluation of outcomes following Peaceful Mind, a cognitive-behavioral therapy-based intervention for anxiety in dementia, relative to usual care. DESIGN: Pilot randomized controlled trial including assessments at baseline and 3 and 6 months. SETTING: Houston, TX. PARTICIPANTS: Thirty-two outpatients diagnosed with mild (47%) or moderate (53%) dementia receiving care through outpatient clinics at the Veterans Affairs medical center, Baylor College of Medicine, Harris County Hospital District, and community day centers for dementia, and their collaterals, who spent at least 8 hours a week with them. INTERVENTION: Peaceful Mind included up to 12 weekly in-home sessions (mean: 8.7, SD: 2.27) during the initial 3 months and up to eight brief telephone sessions (mean: 5.4, SD: 3.17) during months 3-6, involving self-monitoring for anxiety, deep breathing, and optional skills (coping self-statements, behavioral activation, and sleep management). Patients learned skills, and collaterals served as coaches. In usual care, patients received diagnostic feedback, and providers were informed of inclusion status. MEASUREMENTS: Neuropsychiatric Inventory-Anxiety subscale, Rating Anxiety in Dementia scale, Penn State Worry Questionnaire-Abbreviated, Geriatric Anxiety Inventory, Geriatric Depression Scale, Quality of Life in Alzheimer disease, Patient Health Questionnaire, and Client Satisfaction Questionnaire. RESULTS: Feasibility was demonstrated with regard to recruitment, attrition, and treatment characteristics. At 3 months, clinicians rated patients receiving Peaceful Mind as less anxious, and patients rated themselves as having higher quality of life; collaterals reported less distress related to loved ones' anxiety. Although significant positive effects were not noted in other outcomes or at 6-month follow-up, the pilot nature of the trial prohibits conclusions about efficacy. CONCLUSIONS: Results support that Peaceful Mind is ready for future comparative clinical trials.

Treating late-life generalized anxiety disorder in primary care: an effectiveness pilot study.

To increase the sustainability of cognitive behavior therapy (CBT) in primary care for late-life anxiety, we incorporated nonexpert counselors, options for telephone meetings, and integration with primary care clinicians. This open trial examines the feasibility, satisfaction, and clinical outcomes of CBT delivered by experienced and nonexperienced counselors for older adults with generalized anxiety disorder (GAD). Clinical outcomes assessed worry (Penn State Worry Questionnaire), GAD (Generalized Anxiety Disorder Severity Scale), and anxiety (Beck Anxiety Inventory and Structured Interview Guide for Hamilton Anxiety Scale). After 3 months of treatment, Cohen's d effect sizes for worry and anxiety ranged from 0.48 to 0.78. Patients treated by experienced and nonexperienced counselors had similar reductions in worry and anxiety, although treatment outcomes were more improved on the Beck Anxiety Inventory for experienced therapists. Preliminary results suggest that adapted CBT can effectively reduce worry. The piloted modifications can provide acceptable and feasible evidence-based care.

Psychometric properties of a structured interview guide for the rating for anxiety in dementia.

OBJECTIVES: The Rating Anxiety in Dementia (RAID; Shankar, K.K., Walker, M., Frost, D., & Orrell, M.W. (1999). The development of a valid and reliable scale for rating anxiety in dementia (RAID). Aging and Mental Health, 3, 39-49.) is a clinical rating scale developed to evaluate anxiety in persons with dementia. This report explores the psychometric properties and clinical utility of a new structured interview format of the RAID (RAID-SI), developed to standardize administration and scoring based on information obtained from the patient, an identified collateral, and rater observation. METHOD: The RAID-SI was administered by trained master's level raters. Participants were 32 persons with dementia who qualified for an anxiety treatment outcome study. Self-report anxiety, depression, and quality of life measures were administered to both the person with dementia and a collateral. RESULTS: The RAID-SI exhibited adequate internal consistency reliability and inter-rater reliability. There was also some evidence of construct validity as indicated by significant correlations with other measures of patient-reported and collateral-reported anxiety, and non-significant correlations with collateral reports of patient depression and quality of life. Further, RAID-SI scores were significantly higher in persons with an anxiety diagnosis compared to those without an anxiety diagnosis. CONCLUSION: There is evidence that the RAID-SI exhibits good reliability and validity in older adults with dementia. The advantage of the structured interview format is increased standardization in administration and scoring, which may be particularly important when RAID raters are not experienced clinicians.

Early response to psychotherapy and long-term change in worry symptoms in older adults with generalized anxiety disorder.

OBJECTIVES: To determine the association of early and long-term reductions in worry symptoms after cognitive behavior therapy (CBT) for generalized anxiety disorder (GAD) in older adults. DESIGN: Substudy of larger randomized controlled trial. SETTING: Family medicine clinic and large multispecialty health organization in Houston, TX, between March 2004 and August 2006. PARTICIPANTS: Patients (N = 76) aged 60 years or older with a principal or coprincipal diagnosis of GAD, excluding those with significant cognitive impairment, bipolar disorder, psychosis, or active substance abuse. INTERVENTION: CBT, up to 10 sessions for 12 weeks, or enhanced usual care (regular, brief telephone calls, and referrals to primary care provider as needed). MEASUREMENTS: Penn State Worry Questionnaire (PSWQ) administered by telephone at baseline, 1 month (mid treatment), 3 months (posttreatment), and at 3-month intervals through 15 months (1-year follow-up). The authors used binary logistic regression analysis to determine the association between early (1 month) response and treatment responder status (reduction of more than 8.5 points on the PSWQ) at 3 and 15 months. The authors also used hierarchical linear modeling to determine the relationship of early response to the trajectory of score change after posttreatment. RESULTS: Reduction in PSWQ scores after the first month predicted treatment response at posttreatment and follow-up, controlling for treatment arm and baseline PSWQ score. The magnitude of early reduction also predicted the slope of score change from posttreatment through the 15-month assessment. CONCLUSION: Early symptom reduction is associated with long-term outcomes after psychotherapy in older adults with GAD.

The involvement of multiple caregivers in cognitive-behavior therapy for anxiety in persons with dementia.

OBJECTIVES: Peaceful Mind, a cognitive-behavioral therapy for treating anxiety in persons with dementia, is a promising new treatment currently under investigation. This article reports results of our examination of a modification of the treatment protocol in two cases that included multiple caregivers in treating two persons with dementia. METHOD: Two case presentations of the benefits and challenges of including multiple caregivers in treatment are discussed. Treatment outcome data for these cases were collected as part of a larger investigation of Peaceful Mind. RESULTS: The involvement of multiple collaterals resulted in several benefits, including increased family communication, as well as increased opportunities for the practice of new skills. These cases have also presented unique challenges requiring alterations in therapy structure and attention to issues of family conflict. CONCLUSIONS: Including multiple collaterals in cognitive-behavioral therapy for treating anxiety in persons with dementia is feasible and may be beneficial in maximizing treatment gains and increasing the family's investment in therapy.

Peaceful Mind: an open trial of cognitive-behavioral therapy for anxiety in persons with dementia.

BACKGROUND: Anxiety has a high prevalence among individuals with dementia, and it has a significant negative impact on their functioning; yet intervention studies are lacking. We developed Peaceful Mind, a cognitive-behavioral intervention for persons with dementia. In this paper, we describe the intervention and results of an open trial evaluating the feasibility and utility of the intervention and assessment procedures. METHODS: Peaceful Mind is implemented over a period of three months in the participant's home with involvement of a caregiver or "collateral." Dyads are followed for an additional three months via telephone. An assortment of simplified skills is offered, including self-awareness, breathing, behavioral activation, calming thoughts, and sleep skills. RESULTS: Nine participants were enrolled, eight completed the three-month assessment, and seven completed the six-month assessment. Overall, participants and collaterals were satisfied with the intervention and reported that they benefited in terms of anxiety, depression, and collateral distress. CONCLUSIONS: A randomized controlled trial would help determine whether this promising new treatment has a statistically significant impact on anxiety in this population.

Calmer Life: A Hybrid Effectiveness-implementation Trial for Late-life Anxiety Conducted in Low-income, Mental Health-Underserved Communities.

OBJECTIVE: Anxiety is common among older adults and is associated with multiple negative outcomes. Late-life anxiety is usually unrecognized by providers and undertreated, although evidence supports the effectiveness of psychosocial treatment. Access to mental health care is especially poor among African American seniors. New treatment models are needed to expand the reach of mental health care to minority elders. METHODS: Our article outlines a study designed to test the effectiveness and implementation potential of Calmer Life (CL), a community-based, person-centered, flexible and culturally tailored intervention for late-life anxiety and worry, offered in low-income, mental health-underserved and predominantly African American communities. CL is skills-based, but also includes resource counseling and an option to integrate religion/spirituality. The study population includes individuals 50 years of age and older who are experiencing high levels of worry. The program was developed in the context of a community-academic partnership with organizations that provide services for seniors in underserved communities, and it trains nontraditional community providers to deliver the intervention. RESULTS: Study progress to date, challenges, and lessons learned are discussed. Data collection is ongoing, and study findings will be available in late 2017. CONCLUSIONS: CL will offer valuable information to help expand the reach of anxiety treatment among minority seniors living in underserved neighborhoods.

Enabling lay providers to conduct CBT for older adults: key steps for expanding treatment capacity.

The Institute of Medicine advocates the examination of innovative models of care to expand mental health services available for older adults. This article describes training and supervision procedures in a recent clinical trial of cognitive behavioral therapy (CBT) for older adults with generalized anxiety disorder (GAD) delivered by bachelor-level lay providers (BLPs) and to Ph.D.-level expert providers (PLPs). Supervision and training differences, ratings by treatment integrity raters (TIRs), treatment characteristics, and patient perceptions between BLPs and PLPs are examined. The training and supervision procedures for BLPs led to comparable integrity ratings, patient perceptions, and treatment characteristics compared with PLPs. These results support this training protocol as a model for future implementation and effectiveness trials of CBT for late-life GAD, with treatment delivered by lay providers supervised by a licensed provider in other practice settings.

Cognitive-behavioral therapy for late-life anxiety: Similarities and differences between Veteran and community participants.

Cognitive-behavioral therapy (CBT) is an evidence-based treatment for anxiety; however, a growing body of research suggests that CBT effect sizes are smaller in Veteran samples. The aim of this study was to perform secondary data analyses of a randomized controlled trial of CBT for late-life generalized anxiety disorder compared with treatment as usual (TAU) in a Veteran (n = 101) and community-based (n = 122) sample. Veterans had lower income and less education than community participants, greater severity on baseline measures of anxiety and depression, poorer physical health, and higher rates of psychiatric comorbidity. Treatment effects were statistically significant in the community sample (all ps < 0.01), but not in Veterans (all ps > 0.05). Further analyses in Veterans revealed that poorer perceived social support significantly predicted poorer outcomes (all ps < 0.05). Our results underscore the complexity of treating Veterans with anxiety, and suggest that additional work is needed to improve the efficacy of CBT for Veterans, with particular attention to social support.

Predictors of CBT outcome in older adults with GAD.

The current study is a secondary analysis of data from a randomized controlled trial of CBT for late-life GAD (Stanley et al., 2014) which provided an opportunity to examine predictors of outcome among those who received CBT. Participants were 150 older adults who were randomized to receive 10 sessions of CBT. Completer analyses found that homework completion, number of sessions attended, lower worry severity, lower depression severity, and recruitment site predicted 6-month worry outcome on the PSWQ-A, whereas homework completion, credibility of the therapy, lower anxiety severity, and site predicted 6-month anxiety outcome on the STAI-T. In intent-to-treat multivariate analyses, however, only initial worry and anxiety severity, site, and number of sessions completed predicted treatment outcome. These results are largely consistent with predictors of outcome in younger adults and suggest that lower initial symptom severity and variables consistent with greater engagement in treatment predict outcome.

The Peaceful Mind manual: a protocol for treating anxiety in persons with dementia.

Anxiety disorders are highly prevalent among individuals with dementia and have a significant negative impact on their lives. Peaceful Mind is a form of cognitive-behavioral therapy for anxiety in persons with dementia. The Peaceful Mind manual was developed, piloted, and modified over 2 years. In an open trial and a small randomized, controlled trial, it decreased anxiety and caregiver distress. The treatment meets the unique needs of individuals with dementia by emphasizing behavioral rather than cognitive interventions, slowing the pace, limiting the material to be learned, increasing repetition and practice, using cues to stimulate memory, including a friend or family member in treatment as a coach, and providing sessions in the home. The manual presented here includes modules that teach specific skills, including awareness, breathing, calming self-statements, increasing activity, and sleep management, as well as general suggestions for treatment delivery.

Characteristics of generalized anxiety disorder in patients with dementia.

BACKGROUND: Overlap of cognitive and anxiety symptoms (i.e., difficulty concentrating, fatigue, restlessness) contributes to inconsistent, complicated assessment of generalized anxiety disorder (GAD) in persons with dementia. METHODS: Anxious dementia patients completed a psychiatric interview, the Penn State Worry Questionnaire-Abbreviated, and the Rating for Anxiety in Dementia scale. Analyses to describe the 43 patients with and without GAD included the Wilcoxon Mann-Whitney two-sample test, Fisher's exact test. Predictors of GAD diagnosis were identified using logistic regression. RESULTS: Those with GAD were more likely to be male, have less severe dementia and endorsed more worry, and anxiety compared to patients without GAD. Gender, muscle tension and fatigue differentiated those with GAD from those without GAD. CONCLUSIONS: Although this study is limited by a small sample, it describes clinical characteristics of GAD in dementia, highlighting the importance of muscle tension and fatigue in recognizing GAD in persons with dementia.