Anxiety disorders are among the most common mental health issues in older adults.
If left untreated, they can lead to cognitive impairment, disability, poor physical health and a reduced quality of life.
But dementia also afflicts this age group, which means mood disorders such as anxiety and depression can be overlooked, as the symptoms are similar.
In 2005, Professor Nancy Pachana, a clinical geropsychologist within the UQ School of Psychology, recognised the need for a simple and reliable measure of anxiety in older adults.
“Many of the previously available measures of adult anxiety were not validated with older populations, and those that had been validated were inadequate in certain contexts,” she explains.
“In addition, many of the self-report tests that have been used in the past with older adults were originally designed for younger populations and so were less than ideal in reflecting the age-specific symptoms of anxiety.”
To remedy this gap, Professor Pachana and Professor Gerard Byrne from the UQ Faculty of Medicine designed the Geriatric Anxiety Inventory (GAI) – a simple tool that's now being used by practitioners around the world.
What is the Geriatric Anxiety Inventory?
The GAI is a 20-item questionnaire for quickly screening older people for anxiety disorders. Topics covered include feelings of fearfulness, worry, physical symptoms of anxiety, and concerns about the impacts of worry and anxiety.
The straightforward self-report ‘agree-disagree’ scale lets practitioners know whether they need to pursue a diagnosis of an anxiety disorder.
Being the first of its type available anywhere in the world, the inventory received immediate interest because it was developed to be easy to use in clinical settings.
“Our validation study was published online in 2007, and even before it was physically printed, we already had people wanting to take it up and use it,” Professor Pachana says.
“Very soon after publication, we were approached by a pharmaceutical company that wanted to use the inventory in a clinical trial.
"This was a fairly big deal as a lot of pharma research doesn’t include older people, so it was a very important step.”
Realising the potential demand, Professor Pachana and Professor Byrne turned to UQ’s commercialisation company, UniQuest, to bring the product to market.
“It was a very fruitful partnership because our two faculties – Medicine and Health and Behavioural Sciences – were on the same page,” she explains.
“We wanted to make this as widely available as possible, but also protect the intellectual property of UQ and the researchers who developed it.
“We quickly came to an agreement about how we were going to price it: a small charge for people in clinical settings, and for pure research it is free.”
Image: Westend61/Getty Images
Who can use the inventory?
Use of the GAI is widespread, from private practitioners and GPs to Queensland Health and other healthcare systems around the world.
The United States Department of Veterans Affairs uses it in their veterans’ hospitals across all 50 states.
Australian independent non-profit organisation Beyond Blue used the GAI in a large project screening for late-life depression and anxiety in community-dwelling Chinese migrants in Melbourne.
The inventory has been translated into 23 languages and used in 33 countries. It’s been used in an array of research, including pharma studies, longitudinal studies and randomised clinical trials.
Professor Pachana provides technical expertise to international researchers who use the inventory, ensuring all translations meet a certain quality assurance standard.
“It’s important that we’re using the most appropriate language and accommodating nuances in local expressions,” she says.
“For example, when we describe anxiety, we might refer to physical feelings such as ‘I have butterflies in my stomach’, but in Mediterranean countries ‘butterflies in my stomach’ means ‘I’m in love’.
“So in Spain it was translated to ‘it feels like I have ants in my chest’, and in Italy it was ‘I feel tight like the strings of a violin’. That captures the spirit of it without being a direct word-for-word translation.”
How effective is the inventory?
A recent study examining pooled data of GAI use in 10 countries showed that the items of the inventory had the same properties across cultures.
“Sometimes it’s hard to translate ideas about worry, but we now know that the inventory is asking the questions in a general enough way about how you feel that it’s relatively valid,” Professor Pachana explains.
“We can confidently say that if someone got a score of 7 in Thailand, then that was functionally equivalent to a 7 in Portugal.
“It’s important to look at things cross-culturally, particularly when anxiety is such a huge issue for older people.
"It’s actually a bigger issue than depression, and it places people at higher risk for things like suicide than depression does. So we really need to identify it and get people help."
Professor Pachana emphasises the importance of the collaborative approach being used to detect mental health issues such as anxiety in the modern age.
“While developing this tool, I’ve been really impressed with how it takes a village to build something like this,” she says.
“Both the University and UniQuest have been very supportive, and our colleagues overseas have been very generous with their data and their time.”
Professor Pachana believes the tool has also helped increase awareness and understanding of anxiety as a very real and potentially debilitating condition.
“I think it’s really shifted a conversation – it used to be that you didn’t hear much about anxiety 10 to 15 years ago, and now you see it discussed much more at conferences,” she says.
“For me, that’s been the most satisfying, because anxiety can be really paralysing. We are seeing more anxiety in the world, particularly recently with bushfires, floods and now COVID-19.
“Anxiety is not part of normal ageing, and I think finally that message is getting through.”
Image: KatarzynaBialasiewicz/Getty Images
The story so far
2007: The original GAI research is published, and UniQuest licensing is put into place.
2008: The validity of GAI in nursing homes is published.
2010: The American Psychological Association notes GAI as key assessment tool for late-life anxiety.
2011: A shorter version of the GAI (comprising five questions) is published.
2012: The GAI is validated in persons living with Parkinson’s disease.
2014: The GAI scores and their association with levels of cognitive impairment is published.
2015: A Chinese-Australian version of the GAI is developed for a Beyond Blue project.
2018: An independent study on the reliability and validity of the GAI published in Aging & Mental Health.
2019: The first study showing cross-cultural validity and comparative item sensitivity in 10 countries across five continents (Asia, Australia, North and South America and Europe) is published.
2020: The GAI international collaborative research network expands to 12 countries, with further cross-cultural studies planned for 2021.
Image: Oliver Rossi/Getty Images
Header image: KatarzynaBialasiewicz/Getty Images
Words by Dani Nash