Self-help guided by trained lay providers for generalized anxiety disorder in older adults: study protocol for a randomized controlled trial.

BACKGROUND: Only a small proportion of older patients with generalized anxiety disorder (GAD) seek professional help. Difficulties in accessing treatment may contribute to this problem. Guided self-help based on the principles of cognitive-behavioral therapy (GSH-CBT) is one way of promoting access to psychological treatment. Moreover, because the therapist's role in GSH-CBT is limited to supporting the patient, this role could be assumed by trained and supervised lay providers (LPs) instead of licensed providers. The main goal of this study is to evaluate the efficacy of GSH-CBT guided by LPs for primary threshold or subthreshold GAD in older adults. METHODS: We will conduct a multisite randomized controlled trial comparing an experimental group receiving GSH-CBT guided by LPs (n = 45) to a wait-list control group (n = 45). Treatment will last 15 weeks and will be based on a participant's manual. Weekly telephone sessions with LPs (30 min maximum) will be limited to providing support. Data will be obtained through clinician evaluations and self-assessment questionnaires. Primary outcomes will be the tendency to worry and severity of GAD symptoms. Secondary outcomes will be anxiety symptoms, sleep difficulties, functional deficit, diagnosis of GAD, and cognitive difficulties. For the experimental group, measurements will take place at pre- and post-treatment and at 6 and 12 months post-treatment. For the control group, three evaluations are planned: two pre-treatment evaluations (before and after the waiting period) and after receiving treatment (post-treatment). The efficacy of GSH-CBT will be established by comparing the change in the two groups on the primary outcomes. DISCUSSION: This project will provide evidence on the efficacy of a novel approach to treat GAD in older adults. If effective, it could be implemented on a larger scale and provide many older adults with much needed mental health treatment through an expanded workforce. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov, number NCT03768544 , on December 7, 2018.

Six-month prevalence and correlates of generalized anxiety disorder among primary care patients aged 70 years and above: Results from the ESA-services study.

OBJECTIVES: To estimate the 6-month prevalence of generalized anxiety disorder (GAD) in primary care patients aged 70 years and above and to describe their clinical profile, including types of worries. METHODS/DESIGN: Participants (N = 1193) came from the Étude sur la Santé des Aînés (ESA) services study conducted in Quebec, Canada. An in-person structured interview was used to identify GAD and other anxiety/depressive disorders as well as to identify types of worries. Three groups were created (ie, patients with GAD, patients with another anxiety disorder, and patients without anxiety disorders) and compared on several sociodemographic and clinical characteristics using multinomial logistic regression analyses. RESULTS: The 6-month prevalence of GAD was 2.7%. Findings also indicated that the most common types of worries were about health, being a burden for loved ones, and losing autonomy. Compared with respondents without anxiety disorders, older patients with GAD were more likely to be women, be more educated, suffer from depression, use antidepressants, be unsatisfied with their lives, and use health services. In comparison with respondents with another anxiety disorder, those with GAD were 4.5 times more likely to suffer from minor depression. CONCLUSIONS: GAD has a high prevalence in primary care patients aged 70 years and above. Clinicians working in primary care settings should screen for GAD, since it remains underdiagnosed. In addition, it may be associated with depression and life dissatisfaction. Screening tools for late-life GAD should include worry themes that are specific to aging.

Psychometric properties of the French Canadian version of the Geriatric Anxiety Inventory.

BACKGROUND: The Geriatric Anxiety Inventory (GAI) and a short form of this instrument (GAI-SF) were developed to assess the severity of anxiety symptoms in older adults in order to compensate for the lack of validated screening tools adapted to the elderly population. This study examined the psychometric properties of the French Canadian version of the GAI, in its complete (GAI-FC) and short form (GAI-FC-SF). METHOD: A total of 331 community-dwelling seniors between 65 and 92 years old participated in this study. RESULTS: Both the GAI-FC and the GAI-FC-SF have sound psychometric properties with, respectively, a high internal consistency (α = .94 and .83), an adequate convergent validity (r = .50 to .86 with instruments known to evaluate constructs similar to the GAI or related to anxiety), a good test-retest reliability (r = .89 and .85), in addition to a single-factor structure. CONCLUSIONS: The results support the use of both the GAI-FC and the GAI-FC-SF. The GAI-FC-SF seems to be an interesting alternative to the GAI-FC as a screening tool when time available for assessment is limited.

Assessment of inattention in the context of delirium screening: one size does not fit all!

BACKGROUND: Despite its high prevalence and deleterious consequences, delirium often goes undetected in older hospitalized patients and long-term care (LTC) residents. Inattention is a core symptom of this syndrome. The aim of this study was to explore the usefulness of ten simple and objective attention tests that would enable efficient delirium screening among this population. METHODS: This was a secondary analysis (n = 191) of a validation study conducted in one acute care hospital (ACH) and one LTC facility among older adults with, or without, cognitive impairment. The attention test tasks (n = 10) were drawn from the Concentration subscale the Hierarchic Dementia Scale (HDS). Delirium was defined as meeting the criteria for DSM-5 delirium. The Confusion Assessment Method (CAM) was used to determine the presence of delirium symptoms. RESULTS: The Months of the Year Backward (MOTYB) test, which 57% of participants completed successfully, showed the best balance between sensitivity and specificity (82.6%; 95% CI [61.2-95.0], and 62.5%; 95% CI [54.7-69.8] respectively) for the entire group. Subgroup analyses revealed that no test had both sensitivity and specificity over 50% in participants with cognitive impairment indicated in their medical chart. CONCLUSIONS: Our results revealed that these tests varied greatly in performance and none can be earmarked to become a single-item screening tool for delirium among older patients and residents with, or without, cognitive impairment. The presence of premorbid cognitive impairment may necessitate more extensive assessments of delirium, especially when a change in general status or mental state is observed.

Guided self-help for generalized anxiety disorder in older adults.

OBJECTIVE: The main objective of this study was to examine the efficacy of a guided self-help treatment based on cognitive behavioral principles (CBT-GSH) for generalized anxiety disorder (GAD) in older adults. METHODS: Three older adults aged from 66 to 70 and diagnosed with GAD were included in a single-case experimental multiple-baseline protocol. Data were collected using daily self-monitoring, standardized clinician ratings, and self-report questionnaires at pretest, posttest, and 6-month and 12-month follow-ups. Treatment consisted of awareness training, worry interventions, relaxation training, pleasant activities scheduling, and relapse prevention. Participants used a manual presenting weekly readings and at-home practice exercises. They also received weekly supportive phone calls from a therapist. RESULTS: At posttest, participants showed improvement on worries and GAD severity, on psychological process variables targeted by treatment (intolerance of uncertainty, negative problem orientation, cognitive avoidance, and perceived usefulness of worry), and on secondary variables associated with GAD (anxiety, depression, sleep difficulties, cognitive functioning, and disability). These results were generally maintained at 12 months after the end of treatment. Participants had favorable opinions toward the treatment. CONCLUSION: The results of this study suggest that CBT-GSH is both feasible and effective for the treatment of GAD in older adults.

Recognizing acute delirium as part of your routine [RADAR]: a validation study.

BACKGROUND: Although detection of delirium using the current tools is excellent in research settings, in routine clinical practice, this is not the case. Together with nursing staff, we developed a screening tool (RADAR) to address certain limitations of existing tools, notably administration time, ease-of-use and generalizability. The purpose of this study was not only to evaluate the validity and reliability of RADAR but also to gauge its acceptability among the nursing staff in two different clinical settings. METHODS: This was a validation study conducted on three units of an acute care hospital (medical, cardiology and coronary care) and five units of a long-term care facility. A total of 142 patients and 51 residents aged 65 and over, with or without dementia, participated in the study and 139 nurses were recruited and trained to use the RADAR tool. Data on each patient/resident was collected over a 12-hour period. The nursing staff and researchers administered RADAR during the scheduled distribution of medication. Researchers used the Confusion Assessment Method to determine the presence of delirium symptoms. Delirium itself was defined as meeting the criteria for DMS-IV-TR delirium. Inter-rater reliability, convergent, and concurrent validity of RADAR were assessed. At study end, 103 (74%) members of the nursing staff completed the RADAR feasibility and acceptability questionnaire. RESULTS: Percentages of agreement between RADAR items that bedside nurses administered and those research assistants administered varied from 82% to 98%. When compared with DSM-IV-TR criterion-defined delirium, RADAR had a sensitivity of 73% and a specificity of 67%. Participating nursing staff took about seven seconds on average, to complete the tool and it was very well received (≥98%) overall. CONCLUSIONS: The RADAR tool proved to be efficient, reliable, sensitive and very well accepted by nursing staff. Consequently, it becomes an appropriate new option for delirium screening among older adults, with or without cognitive impairment, in both hospitals and nursing homes. Further projects are currently underway to validate the RADAR among middle-aged adults, as well as in newer clinical settings; home care, emergency department, medical intensive care unit, and palliative care.

Relationship between delirium and behavioral symptoms of dementia.

BACKGROUND: Persons with dementia frequently present behavioral and psychological symptoms as well as delirium. However, the association between these has received little attention from researchers and current knowledge in this area is limited. The purpose of this study was to examine the relation between delirium and behavioral symptoms of dementia (BSD). METHODS: Participants were 155 persons with a diagnosis of dementia, 109 (70.3%) of whom were found delirious according to the Confusion Assessment Method. BSD were assessed using the Nursing Home Behavior Problem Scale. RESULTS: Participants with delirium presented significantly more BSD than participants without delirium. More specifically, they presented more wandering/trying to leave, sleep problems, and irrational behavior after controlling for cognitive problems and use of antipsychotics and benzodiazepines. Most relationships between participant characteristics and BSD did not differ according to the presence or absence of delirium, but some variables, notably sleep problems, were more strongly associated to BSD in persons with delirium. CONCLUSIONS: Although correlates of BSD in persons with delirium superimposed on dementia are generally similar to those in persons with dementia alone, delirium is associated with a higher level of BSD. Results of this study have practical implications for the detection of delirium superimposed on dementia, the management of behavioral disturbances in patients with delirium, and caregiver burden.

Anxiety among older adults during the COVID-19 pandemic.

A growing body of research examines the COVID-19 pandemic's effects on well-being. Only few studies focus on older adults or explore the predictors of COVID-19-related anxiety. Intolerance of uncertainty (IU) and some behaviors (e.g., avoidance, procrastination) are linked to anxiety among older adults and could both be relevant to consider in a pandemic context. This study measured the occurrence and anxiety levels among older adults and verified the possible role of IU and behaviors in predicting anxiety symptoms, impairment and distress related to COVID-19 health standards. It also examined the indirect effect of IU on symptoms, impairment and distress through behaviors. Participants aged 60 and over (N = 356) were recruited and administered questionnaires. Anxiety levels and symptom impairment were high and appeared to have increased since the beginning of the pandemic. IU and behavioral manifestations of anxiety were associated with higher anxiety symptoms, impairment and distress related to COVID-19 health standards. The indirect effects of IU on the tendency to worry and COVID-19-related anxiety through behavioral manifestations of anxiety were confirmed. This study provides knowledge on the relationship between COVID-19 and anxiety in older adults and identifies predictors relevant to this population.

Reducing verbal agitation in people with dementia: evaluation of an intervention based on the satisfaction of basic needs.

OBJECTIVES: Positive results have been reported with psychosocial interventions used to reduce verbal agitation (VA) in people with dementia, but there is no clear information regarding the proportion of persons who demonstrate significant behavioural improvement with such treatments. The main objectives of this pilot study are (a) to identify the proportion of persons with dementia who demonstrate significant behavioural improvement with a need-based intervention to reduce VA and (b) to further evaluate the effectiveness of this type of intervention. METHOD: A single-group repeated measures design was used (N = 26). An individualized multicomponent intervention addressing needs for comfort, social interaction and sensory stimulation was applied by a therapist during 30 min sessions during the time of day when VA was most severe. The frequency and duration of VA were measured through computer-assisted direct observation several times before, during and after the intervention. RESULTS: A statistically significant reduction of the duration of VA during the intervention phase relative to other phases of the protocol was found. This effect was limited to the period during which the treatment is being applied. Half of the participants (54%) demonstrated considerable behavioural improvement during the intervention (50% reduction of symptoms) and those whose functioning is best preserved showed the best response to the intervention. CONCLUSION: This need-based intervention appears promising for improving the behaviour of a considerable proportion of patients.

A Systematic Review of the Psychometric Properties of the Geriatric Anxiety Inventory.

The Geriatric Anxiety Inventory (GAI) and its short form (GAI-SF) are self-reported scales used internationally to assess anxiety symptoms in older adults. In this study, we conducted the first critical comprehensive review of these scales' psychometric properties. We rated the quality of 31 relevant studies with the COSMIN checklist. Both the GAI and GAI-SF showed adequate internal consistency and test-retest reliability. Convergent validity indices were highest with generalized anxiety measures; lowest with instruments relating to somatic symptoms. We detected substantial overlap with depression measures. While there was no consensus on the GAI's factorial structure, we found the short version to be unidimensional. Although we found good sensitivity and specificity for detecting anxiety, cut-off scores varied. The GAI and GAI-SF are relevant instruments showing satisfactory psychometric properties; to broaden their use, however, some psychometric properties warrant closer examination. This review calls attention to weaknesses in the methodological quality of the studies.

An Action Research to Optimize the Well-Being of Older People in Nursing Homes: Challenges and Strategies for Implementing a Complex Intervention.

Few studies have been conducted on strategies to promote the implementation of complex interventions in nursing homes (NHs). This article presents a pilot study intended to assess the strategies that would enable the optimal implementation of a complex intervention approach in NHs based on the meanings of screams of older people living with Alzheimer's disease. An action research approach was used with 19 formal and family caregivers from five NHs. Focus groups and individual interviews were held to assess different implementation strategies. A number of challenges were identified, as were strategies to overcome them. These latter included interactive training, intervention design, and external support. This study shows the feasibility of implementing a complex intervention to optimize older people's well-being. The article shares strategies that may promote the implementation of these types of interventions in NHs.

A Cross-National Analysis of the Psychometric Properties of the Geriatric Anxiety Inventory.

OBJECTIVES: Assessing late-life anxiety using an instrument with sound psychometric properties including cross-cultural invariance is essential for cross-national aging research and clinical assessment. To date, no cross-national research studies have examined the psychometric properties of the frequently used Geriatric Anxiety Inventory (GAI) in depth. METHOD: Using data from 3,731 older adults from 10 national samples (Australia, Brazil, Canada, The Netherlands, Norway, Portugal, Spain, Singapore, Thailand, and United States), this study used bifactor modeling to analyze the dimensionality of the GAI. We evaluated the "fitness" of individual items based on the explained common variance for each item across all nations. In addition, a multigroup confirmatory factor analysis was applied, testing for measurement invariance across the samples. RESULTS: Across samples, the presence of a strong G factor provides support that a general factor is of primary importance, rather than subfactors. That is, the data support a primarily unidimensional representation of the GAI, still acknowledging the presence of multidimensional factors. A GAI score in one of the countries would be directly comparable to a GAI score in any of the other countries tested, perhaps with the exception of Singapore. DISCUSSION: Although several items demonstrated relatively weak common variance with the general factor, the unidimensional structure remained strong even with these items retained. Thus, it is recommended that the GAI be administered using all items.

Burden of caregivers of people with stroke: evolution and predictors.

BACKGROUND: Caregiver burden differs according to the amount of care, but no study has really focused on that point. This study compares the evolution of burden of two groups of caregivers of people with a recent stroke who returned home after discharge from two different types of health care facilities. METHODS: Burden was assessed at 3 weeks and 3 and 6 months after discharge. The two groups of people with stroke and their caregivers were recruited from acute care (n = 69) and rehabilitation facilities (n = 89). Caregivers completed a questionnaire with three dimensions. In addition to sociodemographic characteristics, we assessed variables pertaining to the clinical, physical and cognitive functioning of the people with stroke. RESULTS: Differences in burden were noted. The best predictors of burden were the caregivers' characteristics, i.e. gender (female), occupation (retired), schooling (low), age (older) and hours of care given, and the stroke survivors' characteristics, i.e. depressive symptoms, poor motor function (leg), verbal comprehension deficits, difficulty walking and neurological deficits. CONCLUSION: These results reinforce the view that services (information, training and support) should be tailored to the needs of caregivers, depending on whether or not the recipient of care has received rehabilitation services.

The role of activity restriction in poststroke depressive symptoms.

OBJECTIVE: Little is known about the determinants of poststroke depression. The Activity Restriction Model of Depressed Affect (ARMDA) may be helpful in understanding poststroke depression but has never been tested in that context. The goal of this study was to examine the relation between activity restriction and depressive symptoms in stroke survivors during the period following discharge from the hospital. METHOD: Participants (N = 197) were assessed on three occasions: (1) time 1 (T1), 3 weeks following discharge; (2) time 2 (T2), 3 months after discharge; and (3) time 3 (T3), 6 months after discharge. RESULTS: Although both stroke severity and activity restriction were significantly related to depressive symptoms, the relation between stroke severity and depression was no longer significant after controlling for activity restriction. Moreover, restrictions in daily activities and social roles were both related to depressive symptoms, but these relations were found to vary during the course of the period following discharge. CONCLUSIONS: These findings support the ARMDA and have practical implications for the prevention of poststroke depression.

Older Adults' Knowledge of Anxiety Disorders.

OBJECTIVES: The underuse of mental health services for anxiety disorders is particularly pronounced among older adults and could, in part, be explained by a lack of knowledge on this subject in this population. The purpose of this study was to document senior's knowledge of anxiety. METHOD: Young adults (n = 64) and older adults (n = 78) completed a sociodemographic questionnaire (including clinical variables), the Beck Anxiety Inventory and a questionnaire measuring their knowledge of the various dimensions of anxiety disorders, including symptoms, risk factors, and treatments. RESULTS: Results show that older adults have less knowledge about anxiety disorders than young adults and that this difference is observable for all dimensions assessed. Low level of education is associated with less knowledge of anxiety disorders. Students and those who were employed scored better that those who were retired and those with incomes below $10,000 scored better than those with higher incomes. DISCUSSION: Results show the importance and the diversity of knowledge needs with regards to anxiety disorders among older adults. A strategy to enhance knowledge about anxiety disorders among older adults should be adapted to this specific population (with regards to its delivery approach) and includes diverse domains of knowledge.

Physically aggressive behaviors in older people living with cognitive disorders: a systematic scoping review protocol.

BACKGROUND: Physically aggressive behaviors are very common among older people living with cognitive impairment. These behaviors may have significant consequences for family and formal caregivers, as well as for the other people in the older people's environment, and are also a frequent cause of institutionalization. Two relevant systematic reviews have been published on the subject but do not specifically target physically aggressive behaviors or only focus on care in nursing homes. Moreover, they do not address the causes, associated factors, and consequences of these behaviors, even though these should indeed be considered when developing interventions. Thus, the purpose of this scoping review is to map the state of knowledge on these physically aggressive behaviors with a view to developing personalized interventions. Offering a humanist and relational perspective by which these behaviors may be examined, the Senses Framework will guide this review. METHODS: The scoping review method of Levac, Colquhoun, and O'Brien will be used. Several databases (e.g., CINAHL, PubMed, PsycINFO, SCOPUS, Grey Literature Report, clinical trials registries) will be searched for literature published in the past 15 years, using a combination of keywords and descriptors. Other data sources will be used to identify non-indexed literature or unpublished results (e.g., articles references, journal tables of content, contact with key authors). The literature will be selected regardless of setting, if it concerns older people, aged 65, or older with cognitive impairment who present physically aggressive behaviors. Data will be extracted systematically by the research team. A quality assessment of the literature will be done to consider this aspect in the data synthesis. A content analysis will be used to synthesize the results. DISCUSSION: No scoping review has been found on the physically aggressive behaviors of older people living with cognitive impairment in various settings. The results of this review will identify needs for further research and for clinical and training development on this problem from a humanist standpoint. SYSTEMATIC REVIEW REGISTRATION: Currently, it is not possible to register a systematic scoping review protocol (e.g., PROSPERO).

Discomfort and agitation in older adults with dementia.

BACKGROUND: A majority of patients with dementia present behavioral and psychological symptoms, such as agitation, which may increase their suffering, be difficult to manage by caregivers, and precipitate institutionalization. Although internal factors, such as discomfort, may be associated with agitation in patients with dementia, little research has examined this question. The goal of this study is to document the relationship between discomfort and agitation (including agitation subtypes) in older adults suffering from dementia. METHODS: This correlational study used a cross-sectional design. Registered nurses (RNs) provided data on forty-nine residents from three long-term facilities. Discomfort, agitation, level of disability in performing activities of daily living (ADL), and severity of dementia were measured by RNs who were well acquainted with the residents, using the Discomfort Scale for patients with Dementia of the Alzheimer Type, the Cohen-Mansfield Agitation Inventory, the ADL subscale of the Functional Autonomy Measurement System, and the Functional Assessment Staging, respectively. RNs were given two weeks to complete and return all scales (i.e., the Cohen-Mansfield Agitation Inventory was completed at the end of the two weeks and all other scales were answered during this period). Other descriptive variables were obtained from the residents' medical file or care plan. RESULTS: Hierarchical multiple regression analyses controlling for residents' characteristics (sex, severity of dementia, and disability) show that discomfort explains a significant share of the variance in overall agitation (28%, p < 0.001), non aggressive physical behavior (18%, p < 0.01) and verbally agitated behavior (30%, p < 0.001). No significant relationship is observed between discomfort and aggressive behavior but the power to detect this specific relationship was low. CONCLUSION: Our findings provide further evidence of the association between discomfort and agitation in persons with dementia and reveal that this association is particularly strong for verbally agitated behavior and non aggressive physical behavior.

RADAR: A Measure of the Sixth Vital Sign?

The objective of this study was to investigate the potential of RADAR (Recognizing Active Delirium As part of your Routine) as a measure of the sixth vital sign. This study was a secondary analysis of a study (N = 193) that took place in one acute care hospital and one long-term care facility. The primary outcome was a positive sixth vital sign, defined as the presence of both an altered level of consciousness and inattention. These indicators were assessed using the Confusion Assessment Method. RADAR identified 30 of the 43 participants as having a positive sixth vital sign and 58 of the 70 cases as not, yielding a sensitivity and specificity of 70% and 83%, respectively. Positive predictive value was 71%. RADAR's characteristics, including its brevity and acceptability by nursing staff, make this tool a good candidate as a measure of the sixth vital sign. Future studies should address the generalizability of RADAR among various populations and clinical settings.

A training program for managing agitation of residents in long-term care facilities: description and preliminary findings.

The purpose of this article is to describe a training program for managing agitation of long-term care residents and to report results of a pilot study. The program emphasizes the development of behavioral skills for the assessment, prevention, and reduction of both aggressive and non-aggressive agitated behavior. It includes 8 hours of class instruction followed by 8 hours of weekly supervision by the trainers. The nursing staff of all working shifts of a unit located in a large nursing home and the residents of this unit participated in the pilot study. Residents and staff were assessed prior to and after the 2-month training program. Staff members reported using behavioral techniques to a greater extent and feeling more effective in managing agitation after training. More than 90% of staff members were satisfied with the training program. During the supervision period, the staff developed and implemented individualized interventions for two residents. The interventions involved providing more attention to these residents and, in one case, modifying some aspects of the direct environment which seemed to trigger agitation. Both residents were less agitated after the interventions were implemented. Moreover, there was a reduction in the number and frequency of agitated behaviors for the other residents of the trainees' unit following staff training.