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1.  Bad Dream Frequency in Older Adults with Generalized Anxiety Disorder: Prevalence, Correlates, and Effect of Cognitive Behavioral Treatment for Anxiety 
Behavioral sleep medicine  2013;12(1):10.1080/15402002.2012.755125.
This study investigated the relation between generalized anxiety disorder (GAD) and frequency of bad dreams in older adults. A secondary analysis from a randomized clinical trial comparing cognitive behavioral therapy for anxiety (CBT) to enhanced usual care (EUC), it assessed bad dream frequency at baseline, post-treatment (3 months), and 6, 9, 12 and 15 months. Of 227 participants (mean age = 67.4), 134 met GAD diagnostic criteria (CBT = 70, EUC = 64), with the remaining 93 serving as a comparison group. Patients with GAD had significantly more bad dreams than those without, and bad dream frequency was significantly associated with depression, anxiety, worry, and poor quality of life. CBT for anxiety significantly reduced bad dream frequency at post-treatment and throughout follow-up compared to EUC.
doi:10.1080/15402002.2012.755125
PMCID: PMC3690155  PMID: 23470116
Bad dreams; older adults; anxiety; GAD; CBT
2.  Treating late-life GAD in primary care: An effectiveness pilot study 
Objective
To increase sustainability of Cognitive Behavior Therapy (CBT) in primary care for late-life anxiety, we incorporated non-expert counselors, options for telephone meetings, and integration with primary care clinicians.
Method
This open trial examines the feasibility, satisfaction and clinical outcomes of CBT delivered by experienced and non-experienced 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).
Results
Following 3 months of treatment, Cohen’s d effect sizes for worry and anxiety ranged from .48 to .78. Patients treated by experienced and non-experienced counselors had similar reductions in worry and anxiety, although treatment outcomes were more improved on the Beck Anxiety Inventory for experienced therapists.
Conclusion
Preliminary results suggest adapted CBT can effectively reduce worry. The piloted modifications can provide acceptable and feasible evidence-based care.
doi:10.1097/NMD.0b013e31828e0fd6
PMCID: PMC3644354  PMID: 23588228
cognitive behavioral therapy; generalized anxiety disorder; primary care; older adults; mental health
3.  The Pittsburgh Sleep Quality Index in Older Primary Care Patients with Generalized Anxiety Disorder: Pyschometrics and Outcomes Following Cognitive Behavioral Therapy 
Psychiatry research  2012;199(1):24-30.
The Pittsburgh Sleep Quality Index (PSQI) is a widely used, comprehensive self-report measure of sleep quality and impairment, which has demonstrated good psychometric properties within various populations, including older adults. However, the psychometric properties of the PSQI and its component scores have not been evaluated for older adults with generalized anxiety disorder (GAD). Additionally, changes in PSQI global or component scores have not been reported following cognitive-behavioral treatment (CBT) of late-life GAD. This study examined (1) the psychometric properties of the PSQI within a sample of 216 elderly primary care patients age 60 or older with GAD who were referred for treatment of worry and/or anxiety; as well as (2) response to CBT, relative to usual care, for 134 patients with principal or coprincipal GAD. The PSQI demonstrated good internal consistency reliability and adequate evidence of construct validity. Those receiving CBT experienced greater reductions in PSQI global scores at post-treatment, relative to those receiving usual care. Further, PSQI global and domain scores pertaining to sleep quality and difficulties falling asleep (i.e., sleep latency and sleep disturbances) demonstrated response to treatment over a 12-month follow-up period. Overall, results highlight the usefulness of the PSQI global and component scores for use in older adults with GAD.
doi:10.1016/j.psychres.2012.03.045
PMCID: PMC3401329  PMID: 22503380
Pittsburgh Sleep Quality Index; psychometrics; generalized anxiety disorder; elderly; cognitive behavioral therapy
4.  Treatment Response for Late-Life Generalized Anxiety Disorder: Moving Beyond Symptom-Based Measures 
Response to treatment for late-life generalized anxiety disorder has been defined by a variety of methods, all based on statistically significant reductions in symptom severity. However, it is unknown whether these improvements in symptom severity are associated with meaningful differences in everyday functioning. The current study used four methods to define response to treatment for 115 primary care patients, age 60 and older, with a principal or co-principal diagnosis of generalized anxiety disorder. The methods examined included percent improvement, reliable change index and minimal clinically significant differences. Agreement among classification methods and their associations with general and mental health related quality of life were assessed. Results indicated moderate agreement among symptom-based classification methods and significant associations with measures of quality of life.
doi:10.1097/NMD.0b013e31822feda6
PMCID: PMC3187557  PMID: 21964278
GAD; older adults; treatment response; quality of life
5.  Cognitive Behavior Therapy for Generalized Anxiety Disorder Among Older Adults in Primary Care: A Randomized Clinical Trial 
Jama  2009;301(14):1460-1467.
Context
Cognitive behavior therapy (CBT) is effective for late-life generalized anxiety disorder (GAD), but, only pilot studies have been conducted in primary care, where older adults most often seek treatment. .
Objective
To examine effects of CBT relative to enhanced usual care (EUC) in older adults with GAD in primary care.
Design, Setting, and Participants
A randomized clinical trial with 134 older adults (mean age, 66.9 years) recruited from March 2004 to August 2006 in two primary care settings. Treatment was provided for 3 months; assessments were conducted at baseline, post-treatment (3 months), and over a 12-month follow-up (6, 9, 12, and 15 months).
Intervention
CBT (n = 70) was conducted in the primary care clinics. Treatment included education and awareness, relaxation training, cognitive therapy, exposure, problem-solving skills training, and behavioral sleep management. Patients assigned to EUC (n = 64) received biweekly calls to ensure patient safety and provide minimal support.
Main Outcome Measures
Primary outcomes included worry severity (Penn State Worry Questionnaire) and GAD severity (GAD Severity Scale).. Secondary outcomes included anxiety (Hamilton Anxiety Rating Scale, Beck Anxiety Inventory), coexistent depressive symptoms (Beck Depression Inventory II), and physical/mental health quality of life (SF-12).
Results
CBT significantly improved worry severity [45.6; 95% CI 44.4 to 47.8; vs. 54.4; 95% CI 51.4 to 57.3; p < .0001), depressive symptoms (10.2; 95% CI 8.5 to 11.9; vs. 12.8; 95% CI 10.5 to 15.1; p = .02), and general mental health (49.6; 95% CI 47.4 to 51.8; vs. 45.3; 95% CI 42.6 to 47.9; p=.008) compared with EUC. . According to intent-to-treat analyses, response rates defined according to worry severity were higher following CBT than EUC at 3 months (40.0% [28/70] vs. 21.9% [14/64], p = .02).
Conclusion
Compared to EUC, CBT resulted in greater improvement in worry severity, depressive symptoms, and general mental health for older patients with GAD in primary care.
doi:10.1001/jama.2009.458
PMCID: PMC3328789  PMID: 19351943
6.  The Roles of Social Support and Self-efficacy in Physical Health's Impact on Depressive and Anxiety Symptoms in Older Adults 
Physical illness may precipitate psychological distress among older adults. This study examines whether social support and self-efficacy moderate the associations between physical health and depression and anxiety. Predictions were tested in 222 individuals age 60 or older presenting for help with worry. Physical health was assessed through self-report (subjective) and physical diagnoses (objective). Objective physical health did not have a significant association with depression or anxiety. Worse subjective physical health was associated with increased somatic anxiety, but not with depression or worry. The relationship between subjective physical health and depressive symptoms was moderated by self-efficacy and social support. As predicted, when self-efficacy was low, physical health had its strongest negative association with depressive symptoms such that as physical health improved, depressive symptoms also improved. However, the moderation effect was not as expected for social support; at high levels of social support, worse physical health was associated with increased depressive affect.
doi:10.1007/s10880-010-9211-6
PMCID: PMC3053526  PMID: 21110074
elderly; depression; anxiety; social support; self-efficacy; physical health
7.  Comparison of Self-report Measures for Identifying Late-life Generalized Anxiety in Primary Care 
This study evaluated the Penn State Worry Questionnaire, Penn State Worry Questionnaire—Abbreviated, and the Generalized Anxiety Disorder Questionnaire-IV for identifying generalized anxiety disorder in older medical patients. Participants were 191 of 281 patients screened for a clinical trial evaluating cognitive-behavior treatment, n = 110 with generalized anxiety disorder, 81 without. Participants completed the Penn State Worry Questionnaire and Generalized Anxiety Disorder Questionnaire-IV at pretreatment. Kappa coefficients estimated agreement with the Structured Clinical Interview for Diagnosis. Receiver operating characteristic curves compared sensitivity and specificity of self-report measures. The Penn State Worry Questionnaire (cutoff = 50) provided the strongest prediction of generalized anxiety disorder (sensitivity, 76%; specificity, 73%; 75% correctly classified; kappa = .49. Item 2 of the Generalized Anxiety Disorder Questionnaire-IV demonstrated comparable accuracy. The Penn State Worry Questionnaire, Generalized Anxiety Disorder Questionnaire-IV, and briefer versions of these measures may be useful in identifying late-life generalized anxiety disorder in medical settings.
doi:10.1177/0891988708324936
PMCID: PMC2597543  PMID: 19017779
late-life anxiety; PSWQ; GAD-Q-IV; PRIME-MD; primary care psychology; sensitivity; specificity
8.  Psychometric Properties of the Depression Anxiety and Stress Scale-21 in Older Primary Care Patients 
Journal of affective disorders  2008;110(3):248-259.
The Depression Anxiety Stress Scale (DASS) was designed to efficiently measure the core symptoms of anxiety and depression and has demonstrated positive psychometric properties in adult samples of anxiety and depression patients and student samples. Despite these findings, the psychometric properties of the DASS remain untested in older adults, for whom the identification of efficient measures of these constructs is especially important.
To determine the psychometric properties of the DASS 21-item version in older adults, we analyzed data from 222 medical patients seeking treatment to manage worry. Consistent with younger samples, a three-factor structure best fit the data. Results also indicated good internal consistency, excellent convergent validity, and good discriminative validity, especially for the depression scale. Receiver operating curve analyses indicated that the DASS-21 predicted the diagnostic presence of generalized anxiety disorder and depression as well as other commonly used measures.
These data suggest that the DASS may be used with older adults in lieu of multiple scales designed to measure similar constructs, thereby reducing participant burden and facilitating assessment in settings with limited assessment resources.
doi:10.1016/j.jad.2008.01.023
PMCID: PMC2709995  PMID: 18304648
Depression Anxiety Stress Scale; Older Adults; GAD; Anxiety; Assessment
9.  THE UTILITY OF THE GENERALIZED ANXIETY DISORDER SEVERITY SCALE (GADSS) WITH OLDER ADULTS IN PRIMARY CARE 
Depression and anxiety  2009;26(1):E10-E15.
Background
The Generalized Anxiety Disorder Severity Scale (GADSS) is an interview rating scale designed specifically for assessing symptom severity of generalized anxiety disorder (GAD), which has demonstrated positive psychometric data in a sample of adult primary care patients with GAD and panic disorder. However, the psychometric properties of the GADSS have not been evaluated for older adults.
Methods
This study evaluated the psychometric properties of the GADSS, administered via telephone, with a sample of older primary care patients (n = 223) referred for treatment of worry and/or anxiety.
Results
The GADSS demonstrated adequate internal consistency, strong inter-rater reliability, adequate convergent validity, poor diagnostic accuracy, and mixed discriminant validity.
Conclusions
Results provide mixed preliminary support for use of the GADSS with older adults. Depression and Anxiety 26:E10–E15, 2009.
doi:10.1002/da.20520
PMCID: PMC2709998  PMID: 18839400
Generalized Anxiety Disorder Severity Scale; generalized anxiety disorder; elderly; primary care; measurement; psychometrics

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