Literature Review on Anxiety, Cognitive Impairment in Older Adults

This literature review delves into the intricate relationship between anxiety and cognitive impairment, particularly within the context of ageing. It examines various aspects of anxiety, including its definition, types, and associated disorders, alongside the physiological and neurological changes that occur with ageing. The review explores the prevalence of anxiety in older adults and those with cognitive impairments, discussing risk factors, comorbidities, and the impact on daily functioning. It highlights the neurological underpinnings of anxiety and its functional anatomical and neurochemical correlates, focusing on the interplay between anxiety and cognitive decline. The review also addresses subjective and objective cognitive impairments, including dementia, and their connections to anxiety symptoms. Ultimately, the study aims to investigate the potential relationship between anxiety and inhibitory cognitive control, analyzing how it affects various cognitive factors such as attention, information processing speed, reaction time, sleep quality, and memory. The review encompasses a comprehensive analysis of the existing literature, offering insights into the challenges faced by older adults and those with cognitive impairments, and the importance of understanding the complex interactions between anxiety and cognitive health.

Anxiety In Ageing, Subjective And
Objective Cognitive Impairment
(Literature Review)

TABLE OF CONTENTS
INTRODUCTION...........................................................................................................................1
1.1 ANXIETY..................................................................................................................................2
1.1.1 Definition and Types.....................................................................................................2
1.1.2 Anxiety Disorders..........................................................................................................4
1.1.3 Risk Factors/Assessment for Anxiety in Old Age.........................................................7
1.1.4 Co-Morbidities..............................................................................................................8
1.2 AGEING AND LATE LIFE....................................................................................................16
1.2.1 Cognitive Changes in Normal ageing..........................................................................20
1.2.2 Structural/Functional Brain Changes in Normal Ageing............................................28
1.2.3 Subjective and Objective cognitive impairment and Dementia .................................34
1.3 NEUROLOGY OF ANXIETY ...............................................................................................36
1.4 FUNCTIONAL ANATOMIC AND NEUROCHEMICAL CORRELATES IN ANXIETY
DISORDERS.................................................................................................................................40
1.5 NEUROPSYCHOLOGICAL RELATIONSHIP BETWEEN ANXIETY AND COGNITIVE
DECLINE......................................................................................................................................42
CONCLUSION..............................................................................................................................45
REFERENCES..............................................................................................................................47

INTRODUCTION
In older people and the ones having objective and subjective cognitive impairment and
AD, there is a high probability of having various anxiety symptoms. According to empirical
literature, it has been observed that anxiety is considered as a very common issue in moreover of
the population which creates issues in the later life. It has been analysed from taking samples
from community and it was on an estimation of 1.2% to 15% and from 1 to 28% in case of older
adults. This can be related to the various reasons such as ageing, other medical conditions or
because of the comorbid mental disorders (Bryant and et al., 2009; Therrien and Hunsley, 2011).
It has been observed that the patients that have been geriatric from the hospital has a prevalence
of about 43% in case of the anxiety issues. After taking samples from older people in the
community samples, it ranged about 15 to 25% and checking for the anxiety symptoms, it was
observed as 15 to 56%. These factors have helped in investigating the factors of anxiety in both
the cases of anxiety and in inhibitory cognitive control (Castriotta and et al., 2010; Therrien &
Hunsley, 2011). There has been observed a change in the estimation of cognitive control and
anxiety by different age groups, for people more than the age group of 85 and above. Dementia
is classified as a class of serious mental illness under the National institutes of health (NIH). The
data and information on the prevalence of Alzheimer represents the increasing rate of prevalence
(Kvaal et al., 2001). From the age of 65, the rate of dementia starts increasing from every five
years.
The chapter determines the need of examining the potential relationship between anxiety
and inhibitory cognitive control with relation to the functioning of brain which includes various
factors such attention, information processing speed, reaction time, reaction time variability,
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quality of sleep and memory etc. As the person starts ageing, it starts affecting the individual as
well, both physically and mentally as well. The whole process of ageing may also result in
various disorders such as anxiety as well as cognitive control. So, it can affect the older ones and
the people with subjective or objective cognitive impairment and AD. For the people suffering
from dementia or Alzheimer, anxiety is considered as a sort of inability to remember even the
basic facts. The symptoms of anxiety throw an impact on the personal well being of an
individual as it includes sleeping issues, short term memory. Along with this, it also has an
impact on the visual attention as the person may face issues with the eyesight as well. For
conducting this study, anxiety levels of various people including the younger ones and the elders
will be considered. All these factors that have been used for the whole investigation and will be
helpful enough in analyzing the potential relationship between anxiety and inhibitory cognitive
control and also how it affects the various factors of an individual cognition.
1.1 ANXIETY
1.1.1 Definition and Types
Anxiety is considered as an abnormal sense of feeling which disturbs the whole way of
doing activities. It is an intense feeling or emotion of uneasiness and worry which causes some
sort of interruption in doing activities of daily life (Cassidy & Rector, 2008; Lindesay, Stewart,
and Bisla, 2012). It is a very common issue that is being faced almost half of the population. It
can be because of various factors such as excess load in the work place, any stress factors or in
case if the person is going through a tough time. It is because stress itself makes the person tired
enough. When some tough times come and the person has to make some important decisions, in
that case when the person seems unable to think and understand what should be done, in that
case as well, the person feels high anxiety levels.
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It is not necessary that it would remain permanent only, it can be temporary as well.
Pathological anxiety is frequent and chronic and interferes with daily activities (Lindesay and et
al., 2012; Mah and et al., 2016). It has been observed that Sub-syndromal anxiety symptoms or
sub-clinical anxiety occurs more widely than pathological anxiety or anxiety disorders, with a
prevalence that ranges between 15 and 52% (Bryant and et al., 2008; Sherbourne, Sullivan and
et.al., 2010; Yochim and et.al, 2012). State anxiety describes temporarily experienced anxiety
which is considered as a very unpleasant emotion for facing any situation that seems threatening
and complicated. This type of anxiety is not related to the health or social status of the
individual, and passes as soon as the disturbing stimulus passes (Bryant et al., 2008; Eysenck &
Derakshan, 2011; Paulus & Stein, 2006). Trait anxiety is considered as a tendency which has
disturbing emotional arousal rather than a short-term event. This type of anxiety also lasts longer
than state anxiety. Trait anxiety is higher on the average among all the lower class individuals
but is termed lower among the middle and upper class (Bryant and et.al, 2008; Eysenck and
Derakshan, 2011; Paulus and Stein, 2006). State anxiety depends on the interaction between
situational stress and trait anxiety (Derakshan & Eysenck, 2009).
In general, anxiety is associated with a range of cognitive, physical, and effective
responses including muscle tension, apprehension, palpitations, sleep problems, restlessness,
poor concentration, and reassurance seeking behavior (Mah et al., 2016; Lindesay et al., 2012;
Goldin et al., 2009). Anxiety often coexists or is associated with various health issues such as
stroke, obesity, cancer, cardiovascular disease, diabetes, chronic physical illness, medical illness,
Alzheimer’s disease, pain, sleep issues, depression, and increasing frailty (Cassidy & Rector,
2008; Hek, Tiemeier, Newson, et al. 2011; Lindesay et al. 2012), and cognitive impairment and
decline (Derakshan & Eysenck, 2009).
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1.1.2 Anxiety Disorders
Anxiety disorders are based on physical symptoms related to anxiety; most of such
disorders constitute psychiatric disorders (Yates, 2015). Anxiety disorders make people to avoid
and neglect situations that can turn complex or complicated further. Anxiety disorders can be
observed by a huge number of factors and these can be environmental, genetic, substance abuse
etc. The environmental factors can be considered as when the person plays outside or spends
some time outside like for various different purposes such as while shopping, playing etc.
Genetic factors may include the fact that anxiety can be observed because of genes as well. Like
in case if one of the parent or both has the issue of anxiety, then in that case, there are high
chances of the fact that the children may also suffer from the same issue (Copeland et al., 2014;
Yates, 2015). Doing substance abuse has also been considered as a factor because smoking and
drinking can be even tolerated to a level but doing substance abuse cannot. It is because these
drugs affect the brain in a way that the person loses its ability to think what is right and what is
not. So, it takes the person in a zone where the person does not feel any external behavior and
even if the person is observing it, it does not have any impact on the person (Katerndahl &
Talamantes, 2000; Yates, 2015). It is because these substances makes the person in such a way
that the person is not being affected by any other external factor, whether it is noise or anything.
Anxiety disorders are caused by an interaction between biopsychosocial and environmental
factors to produce clinical syndromes. An example of a biopsychosocial factor is classified as the
genetic vulnerability; stress and trauma constitute examples of environmental factors. An
individual may be resilient to stress while another is vulnerable, leading to a disorder.
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Unrecognized medical conditions or use of substances such as herbal preparations and over-the-
counter medications may also lead to a disorder.
There are several types of anxiety disorders such as general anxiety disorder, panic disorder,
social anxiety disorder, late-life anxiety, as well as specific phobias (Cassidy & Rector, 2008).
General anxiety disorder (GAD) is described as a condition marked by feelings of fear, dread,
excessive worry and uneasiness lasting six months or longer (National Institutes for Health
[NIH], 2017). The persistent and exaggerated fears in GAD not a response to any threats or
related to concrete situations, rather the feeling of anxiety may be associated with anything. The
temporary physical state of alertness in which the body release's
Adrenaline in response to some stress, lasts much longer in people with GAD, causing
nervousness, muscle tension, lightheaded ness, increasing rate of the heartbeat or stomach
problems. This in turn can lead to exhaustion, poor concentration, and potentially other sleeps
problems (NIH, 2017). There are various risk factors as well as all the causes of the anxiety
disorders are not observed completely till now. In case of the anxiety disorders because of
various environmental, genetic factors, the person can take help of a medical practitioner.
Usually, the people who suffer from these disabilities and anxiety, does not seek for any help
because in that situation, they are themselves unaware of their own situation. They do not realize
that they are doing something wrong and are unable to take any specific measures against it as
well.
There is a quite difference between the GAD and various other panic disorders. Panic
disorder is triggered only by specific conditions and is a genetically inherited condition. Panic
can be triggered by injury, use of drugs such as cannabis, use of stimulants like decongestants,
interpersonal conflict, loss, illness, caffeine and other addictive substances, hyperventilation,
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public settings (in cases of agoraphobia), and inhalation of carbon dioxide (Dowden and Allen,
1997; Johnson and et.al., 1995; Yates, 2015). Social anxiety disorder or social phobia, is a type
of phobia with risks that are moderately heritable (Yates, 2015). Social phobia is based on the
interaction between genetic make-up and environmental events (Katerndahl & Talamantes,
2000). This phobia is triggered by events such as recurring negative experiences based on a
deficit of social skills or else traumatic social experiences such as embarrassment (Liebman &
Allen, 1995). This phobia is conceptualized in the psychoanalytic model as a symptom of a
deeper conflict such as low self-esteem. Social phobia is construed as a conditioned response due
to past associations in which negative emotional valence had occurred (Katerndahl &
Talamantes, 2000, Yates. 2015). Treatment is based on attempting to weaken and separate such
responses from the causative stimulus (Yates, 2015). Specific phobia such as blood-injury
phobia may also be acquired through modeling, conditioning, or trauma (Copeland et al., 2014).
Late-life anxiety also occurs in older adults. This type of anxiety may be difficult to diagnose as
older adults may have multiple medical and psychiatric issues. They may also be on medication
that affects the physiological pathways in anxiety such as the medication used for treating
Asthma, Depression, and High Blood Pressure (Cassidy & Rector, 2008; Liebman & Allen,
1995). Late-life anxiety will be discussed in detail in the subsequent chapter of this study.
The disorder of anxiety and cognitive decline are defined in both research and clinical settings.
With respect to ageing, it also affects the facial expressions of an individual because when a
person starts to age, the flexibility of the muscles starts decreasing as well (Lindesay, Stewart, &
Bisla, 2012; Lezak, Howieson, Bigler, et al., 2012). It is because the muscles of the skin and its
cells are very delicate and after a few times, it starts losing its capability to hold all the cells
together. So, when these cells moves apart, wrinkles start to appear on the face. So, it also
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affects the emotional expressions as well (American Psychiatric Association, 2013). According
to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), various
factors of the anxiety disorders were classified as fear, anxiety and other external disturbing
factors.
1.1.3 Risk Factors/Assessment for Anxiety in Old Age
There are three classes of factors that affects the risk of developing anxiety symptoms -
premorbid vulnerability factors, destabilization factors (triggering the onset of particular
episodes), and restitution factors (Lindesay and et al., 2012). Exposure to specific risk factors
varies across the lifespan (Acierno and et.al, 2006). Another way of classifying risk factors
related to anxiety is as - biological, psychological, or social. The primary biological factors
associated with the risk for anxiety symptoms and disorders includes poor self-perceived health,
functional limitation, and number of chronic health problems (Lindesay and et al., 2012; Vink,
Aartsen and Schovers, 2008). The psychological risk factors for anxiety includes variety of
factors such as neuroticism, poor coping strategies, external locus of control, and
psychopathology (Vink and et al., 2008).
Some identified social risk factors for anxiety in late life involve social demographic associations
like lower educational level, female gender (Vink et al., 2008), size and quality of social
networks (Lindesay et al., 2012). Infrequent social contacts, low income, childlessness, and
adverse life events have also been associated with anxiety. There is little evidence on difference
in prevalence rates of anxiety disorders among different racial and ethnic ageing groups
(Lindesay et al., 2012).
There are enormous number of anxiety assessment scales that are being used for adults
who come under the age of 65 and over, out of all those, only a few of them have sufficient
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psychometric evidence that can provide a sort of support to make use of it for this age group: the
Penn State Worry Questionnaire (PSWQ14), the Beck Anxiety Inventory (BAI13), and the
Geriatric Mental Status Examination (GMSE15) (Lindesay et al., 2012). In recent years,
however, more instruments can be developed to identify and for the measure anxiety or validated
specifically for older adults. Such recent instruments include the RAID (rating anxiety in
dementia) tool, Short Anxiety Screening Test (SAST) for medical in-patients and out-patients,
FEAR tool for older adults in primary care, the Worry Scale (WS), and the Geriatric Anxiety
Inventory (GAI20) tools (Lindesay et al., 2012). This study make use of the State-Trait Anxiety
Inventory (STAI) and Beck Anxiety Inventory (BAI). STAI is a validated tool that has been
observed that it is commonly used in clinical settings to diagnose anxiety, and while the
distinguishment of the anxiety from other depressive syndromes. In research, it is often used to
identify caregiver distress. The Beck Anxiety Inventory (BAI) is a 21-item validated self-report
inventory that is used to assess levels of anxiety in both adults and adolescents.
1.1.4 Co-Morbidities
Co morbidity is considered as the condition in which the person is suffering from two or
more than two diseases. The diseases sometimes overlaps with a few complications as well. The
issue can be any primary disorder or diseases. In this, both the diseases or all ones occur at the
same time. There is very less chance of the one occurring before or after the other one. The
diseases in a person occur each other. Co morbidity of various syndromes such as the
psychiatric syndrome are very common. Several conditions co-exist with anxiety. These
conditions are important in differential diagnosis. They are discussed following. It has been
observed that more than 50% of the older adults on an overall population, face this issue. The
prevalence of co morbid anxiety disorder along with the major depressive disorder (MDD), the
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average rate is estimated as high as 60%. Co morbidity refers to the situation when the same
person is facing two or more than two disorders. The occurrence of the both disorders is not
necessary to happen at some specific time. Anyone can occur before, so does the second one
following the first one. Various interactions are also being seen which can even make the whole
condition worst. According to GAD, the co morbidity rates have been evaluated as equal or in
some case, more than that of the anxiety disorders.
Fear
Both fear and anxiety act as signals of threat, danger, or motivational conflict. The two
emotions trigger appropriate adaptive responses to the stimuli or stress. However, they are
distinct emotions. Fear is a motivational state that is caused by specific stimuli or known external
danger, and leads to defensive behavior or escape (Steimer, 2002). Avoidance behavior may be
shown to fear situations that have been learned through previous exposure to pain or stress.
Sense of fear in a person can be because of various factors such as the person might have
experienced some bad experience, because of which the fear has been involved in the mental
status of the person that they are unable to forget it. Being afraid because of any such situation,
whether of past or current situation is called as fear. There are various ways as well which can
help in excluding out all the fear. It is important to compete with the fear, avoiding it can make
the person weaker and a looser as well. So, it is important to compete with the fear and do that
thing only from which the person is afraid from. It is because when once the person will face that
situation, in that case, they get more familiar to that thing, so they will stop being afraid of the
same. Doing that things again and again can help in increasing the rate of confidence so that the
person can be able to compete with it and in any part of the life, it does not act as a barrier or
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challenge. Anxiety on the other hand, is a generalized response to internal conflict or an
unknown threat (Steimer, 2002). The same brain structures are involves in the neurology of fear
and anxiety and these are discussed below.
Depression
Depression is a mood disorder characterized by loss of interest and persistent feeling of
sadness. Depression can be caused by various number of reasons such as because of family
issues, relationship issues or because of any other personal issues. Often when people go through
depression, various negative thoughts come in mind such as suicidal factors etc. It is because at
this time, the person feels demotivated because of their own life (Corna, Cairney, Herrmann et
al., 2007; Lindesay et al., 2012). It largely affects the lifestyle of the person as well because
somewhere it affects the mental stability of the person, so the person is not able to think and act
properly. In such situations, the person wants to stay alone, out of all the external world. There
are various symptoms of depression by which it is easy to ensure that the person is facing
depression or not. Some of very common and well known examples of it are considered as
tearfulness, in which the person feels sensitive enough that they are being affected by very small
things and starts crying on every small factors. Another symptom can be considered as
hopelessness in which the person is depressed to an extent that they have lost all its hopes that
they can do something in the future. Also, the person observes less appetite and lack of sleep as
well because in their mind, they have been thinking the same things and considerations only
which are bothering the person in actual, which is their main issue. Comorbidity is considered as
the situation when the person is suffering from one or more diseases or dis orders. It is also
termed as an additional source.
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