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! 2014 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2014.971148

ORIGINAL ARTICLE

Factors associated with anxiety among elderly hypertensive in primary

care setting
Zaliha Ismail, Mariam Mohamad, Mohamad Rodi Isa, Mohd Ariff Fadzil, Siti Munira Yassin, Khin Thuzar Ma, and
Mohamad Hariszamani bin Abu Bakar

Department of Population Health and Preventive Medicine, Faculty of Medicine, Universiti Teknologi MARA Sungai Buloh Campus, Jalan Hospital,
Sungai Buloh Selangor, Malaysia
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Abstract Keywords
Background: There is increasing evidence showing that anxiety is associated with morbidity in Elderly, Hospital Anxiety and Depression
the older age group. Factors contributing to anxiety may vary among different diseases and Scale, hypertensive, primary care
settings.
Aims: The aim of this study was to determine the factors associated with anxiety symptoms History
among elderly hypertensive at the primary care level.
Methods: A cross-sectional study and face-to-face interviews using Hospital Anxiety and Received 15 April 2014
Depression Scale (HADS) were conducted among elderly hypertensive. Revised 4 August 2014
Results: The mean (SD) age of subjects was 68.8 (6.76) years and comprised of 49.5% and 50.5% Accepted 27 August 2014
of males and females, respectively. The majority of respondents were Malays (76.1%), followed Published online 29 October 2014
by Chinese (14.3%), and Indians (9.5%). The mean (SD) duration of hypertension was 8.44 (7.29)
For personal use only.

years and the prevalence of anxiety symptoms was 13.3% (95% CI: 9.9, 16.7). Multiple logistic
regression analysis showed that elderly hypertensive with a past history of stroke (adjusted OR:
4.472; 95% CI: 1.754, 11.405; p ¼ 0.002) and depression (adjusted OR: 3.715; 95% CI: 2.009, 6.872;
p50.001) was significantly associated with the factors for anxiety.
Conclusion: Elderly hypertensive with a history of stroke and having depressive symptoms are
susceptible to get the anxiety. Therefore, screenings of risk factors and early intervention may
improve the quality of life among elderly.

Introduction Frequently, anxiety is associated with age-related medical and

chronic conditions such as dementia, chronic obstructive
Anxiety symptoms in older adult are quite common. It has
airway disease (Yohannes et al., 2006) and cancers (Zhang &
been reported that in many clinical settings the prevalence
Cooper, 2010). It has also been shown to increase fatal
ranges from 15% to 56% (Bryant et al., 2008). In primary care
coronary heart disease (Kawachi et al., 1994) and cardiovas-
practice, 5% of the elderly aged between 60 and 85 years has
cular event (Player & Peterson, 2011). Some studies have also
anxiety (Ringoir et al., 2014). While in the East coast of
shown that high scores of Hospital Anxiety and Depression
Malaysia, a study has shown that the prevalence of anxiety in
Score (HADS) were associated with age, lower quality of life
the community was 12.9% (Wong & Lua, 2011). The various
and persistent depressive symptoms (Al-Haddad et al., 1999;
reported prevalence levels were possibly contributed by the
van der Windt et al., 2002; Watts et al., 2002).
differences in the settings, medical/physical conditions as
Furthermore, the presence of anxiety among elderly may
well as the assessment tools used for anxiety symptoms. Thus,
affect the quality of life as well as limit their activities which
it is reasonable to determine the prevalence of anxiety in
will further worsen the process of ageing (Saboya et al., 2010;
different settings as well as many other medical/physical
Serafini et al., 2010). By having the symptoms of anxiety, the
conditions.
elderly predicted to have limitations in their activities of daily
Compared with younger adults, older people tend to
living (Brenes et al., 2005). Therefore, identifying the factors
underreport their symptoms due to confounding of symptoms
associated with anxiety is important in early recognition and
such as co-morbidity illness (Lauderdale & Sheikh, 2003).
intervention of the disease. By doing early intervention, it will
be able to maintain their activities and their independence.
In Malaysia, the overall prevalence of hypertension among
Correspondence: Zaliha Ismail, Population Health and Preventive the elderly was 74.0% (Kiau et al., 2013). More than 50% of
Medicine, Faculty of Medicine Universiti Teknologi MARA Sungai
elderly Malays living in the rural areas are hypertensive
Buloh Campus, Jalan Hospital, 47000, Sungai Buloh Selangor, Malaysia.
Tel: +603 6126 5000/7178. Fax: +603 6126 7073. E-mail: drzie65@ (Rashid & Azizah, 2011) and the majority of them sought
gmail.com; zaliha78@salam.uitm.edu.my treatment at the primary care settings. This provides an
 2 Z. Ismail et al. J Ment Health, Early Online: 1–4

opportunity for healthcare professionals to screen out elderly Statistical analysis

for anxiety symptoms and to offer them some sort of
Data were entered and analyzed using SPSS Statistics Version
intervention to reduce the medical consequences of anxiety.
20 (SPSS Inc, Chicago, IL). According to Yusoff et al. (2011),
Our aim of this study was to estimate the prevalence of
the scores of HADS 411 were used as indicators of clinically
anxiety symptoms in elderly hypertensive and identifying the
relevant anxiety or depression, those between 8 and 10 were
factors associated with the anxiety. An elderly with hyper-
considered borderline anxiety and depression, and those 58
tension was chosen because they are the majority group that
were seen as normal. However, in our study, we categorized
can be easily recruited during their follow-up clinics at
those with the scores of equal or more than 8 as having
primary care levels. As limited studies were found on anxiety
anxiety symptoms and less than 8 as normal. The same
among elderly hypertensive people, by doing this study, it will
category also applied for depression symptoms. Univariable
offer some basic epidemiological data on the problem.
analysis was done using the Chi-square and independent t-
test. All the significant univariables analyses were further
Methods analyzed by bivariate analysis. Bivariate analysis was done
using the simple logistic regression. To develop the best
This cross-sectional study was conducted in two primary care-
fitting model for the associated factors of anxiety, multiple
based hypertensive clinics at District in West Coast, Malaysia.
logistic regressions were performed. The findings were
Data were collected from June to September 2013 involving
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presented with adjusted odds ratios (OR), 95% confidence

known hypertensive patients on a follow-up. Since the exact
interval (CI) and p value. A p value of less than 0.05 was
prevalence of anxiety among elderly hypertensive is not
judged to be statistically significant.
known, the sample size was calculated using the higher range
of prevalence found in clinical setting (15–56%) (Bryant
Results
et al., 2008). Considering 80% power with 95% confidence,
the required sample size is 379. We have decided to take 500 A total of 500 subjects were interviewed. Out of 500, 398
respondents to cater for unresponses and incomplete infor- (79.6%) completed all the questionnaires. The remaining 102
mation. The respondents were selected using systematic (20.4%) either refused to participate or had language prob-
random sampling based on the list of their attendance in each lems. However, the total numbers of completed questionnaires
clinic session during the follow-up day. The odd numbers of were more than our required sample size. The mean (SD) age
For personal use only.

attendance list were chosen. Overlapping of respondents was of subjects was 68.8 (6.76) years and comprised of 49.5% and
checked by clinic registration number (Clinic Identification 50.5% of females and males, respectively (Table 1). The
Number). Elderly people aged 60 and above who were known majority of respondents were Malays (76.1%), followed by
to be hypertensive and able to converse in Malay language Chinese (14.3%) and Indians (9.5%). The prevalence of
were included in the study. Respondents were interviewed by anxiety symptoms in our study was 13.3% (95% CI: 9.9,
trained interviewers using questionnaires which contained the 16.7). The mean (SD) duration of hypertension was 8.44
Malay version of the Hospital Anxiety and Depression Scale (7.29) years.
(HADS). There were 14 items with four-point Likert-scale for Using univariate analysis, other than a history of stroke
each item in HADS. Seven of the items relate to anxiety and and depression symptoms, living arrangement status was
another seven items relate to depression. Each item on the found to be significantly associated with anxiety as shown in
questionnaire is scored from 0 to 3. The maximum 3 score Table 2. It was found that those living with others were
was given to ‘‘Yes, definitely’’, and minimum zero score was significantly associated with anxiety (p ¼ 0.027).
given to for ‘‘No, not at all’’. According to Bjelland et al. Simple logistic regressions showed that the only history of
(2002), HADS had shown to have a good case-finding stroke and having depression symptoms were associated with
property as defined by Diagnostic and Statistical Manual of anxiety (Table 3). Multiple logistic regressions (Table 4)
Mental Disorders (DSM)-IV in primary care and hospital reveal that those who had a history of stroke are more than
settings. The validated Malay version of the HADS was also four times odds to have anxiety compared with those without
shown to have good internal reliability and construct validity
(Yusoff et al., 2011). The questionnaire had been tested for
Table 1. Sociodemographic characteristics of the respondents (n ¼ 398).
constructing validity and reliability among similar popula-
tions from different districts. The HADS was used in this Variables Frequency (%) Mean (SD)
study because it has been shown that it is valid, sensitive and
Age (years) 68.82 (6.76)
economic for screening of anxiety and depression in clinical
Gender
samples (Barth & Martin 2005; Bjelland, Dahl et al., 2002; Female 197 (49.5)
Herrmann, 1997; Lowe et al., 2003). Male 201 (50.5)
Patient sociodemographic information sheet including age, Ethnicity
Malay 303 (76.1)
gender, ethnicity and medical history was attached to the Chinese 57 (14.3)
HADS questionnaire. The medical histories required were Indian 38 (9.5)
obtained from medical records such as history of hyperten- Duration of hypertension (years) 8.44 (7.29)
sion, diabetes, stroke and any other co-morbid illness. Anxiety
No 345 (86.7)
Informed consents were obtained from all subjects. The Yes 53 (13.3)
study gained approval by the Research Ethics Committee
(Human), Universiti Teknologi MARA, Malaysia. SD, standard deviation.
 DOI: 10.3109/09638237.2014.971148 Anxiety among elderly hypertensive 3
Table 2. Association of living arrangement and anxiety status of elderly hypertensive nature had anxiety (Wei & Wang, 2006).
with hypertension.
Similarly, Wong & Lua (2011) revealed almost equal
Chi-square
prevalence of anxiety (12.9%) among the general community
Factors Anxiety No anxiety (df) p valuea in the East coast of Malaysia. By using more specific tools
such as Generalized Anxiety Disorder Assessment (GAD 7), a
Living arrangement:
Living alone 1 (2.4) 41 (97.6) 4.865 (1) 0.027 study in South Netherlands reported a lower percentage of
Living with others 52 (14.6) 304 (85.4) anxiety (5%) among elderly hypertensive between 60 and 85
a
years (Ringoir et al., 2014). Our prevalence of anxiety among
Fisher’s exact test.
elderly hypertensive was also slightly lower than those with
other medical conditions such as chronic obstructive airway
disease (18%) (Yohannes et al., 2008) and stroke (25.5–40%)
Table 3. Factors associated with anxiety among elderly hypertensive in a (Masskulpan et al., 2008; Vuletic et al., 2012).
primary care set-up in Hilir Perak, Malaysia (n ¼ 398).
Our study found two factors that were associated with
Anxiety, No anxiety
higher odds of having anxiety symptoms in elderly hyperten-
Risk factors n (%) n (%) Crude ORa 95% CI sive, i.e. history of stroke and elderly who have depressive
symptoms. The odds of having anxiety are four times among
History of stroke
those with a history of stroke compared with those without a
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Yes 9 (39.1) 14 (60.9) 4.836

No 44 (11.7) 330 (88.3) 1 1.977, 11.829 history of stroke. Nevertheless, since our study was a cross-
Depression sectional study, the anxiety as the consequence of stroke
Yes 25 (27.8) 65 (72.2) 3.846
cannot be established. However, it does contribute to the
No 28 (9.1) 280 (90.9) 1 2.104, 7.030
knowledge that the elderly hypertensive with a history of
OR, odds ratio based on the exponential beta; CI, confidence interval.
a
stroke has almost five times higher odds of having anxiety
Simple logistic regression. symptoms compared with those without a history of stroke.
This new finding should be further investigated in prospective
studies.
Other studies have also shown a positive correlation
Table 4. Adjusted association between the risk factors and anxiety between depression and anxiety (Masskulpan et al., 2008;
among elderly hypertensive in primary care set-up in Hilir Perak,
For personal use only.

Malaysia (n ¼ 398).
Vuletic et al., 2012). Anxiety often coexists with depression in
older adult and the clinical presentation of anxiety in later life
Adjusted Adjusted may be more likely to be mixed with depressive symptoms
Risk factors beta (SE) Wald df ORa 95% CI p value (Braam et al., 2014). A study conducted among community-
History of stroke resident men and women without disability aged 70–79
Yes 1.498 (0.478) 9.834 1 4.472 1.754, 11.405 0.002 showed that anxiety symptoms occurred in 43% of older
No 1 people with depression (Mehta et al., 2003). Our finding
Depression
further supports this relationship. One longitudinal study by
Yes 1.312 (0.314) 17.496 1 3.715 2.009, 6.872 50.001
No 1 De Beurs et al. (2001) found that the vulnerability for
depression and anxiety was similar, but different stressful life
CI, confidence interval; Wald, value of Wald statistics; df, degree of events may lead to anxiety or depression differently. Thus,
freedom; p value, p value of the Wald test. Hosmer and Lemeshow
test ¼ 0.678. Receiver operating characteristic (ROC) curve ¼ 0.663. one can further interpret this to have distinct symptoms
Overall percentage of classification: 87.7%. The model was reasonably between depression and anxiety. Moreover, it was suggested
fit. Model assumptions are met. There is no interaction and that risk factors for anxiety and depression in old age showed
multicollinearity problem. many similarities, although a number of differences were
detected. This may help to differentiate between elderly
at risk of anxiety or those who may have depression (Vink
a history of stroke (adjusted OR: 4.472; 95% CI: 1.754, et al., 2008).
11.405; p ¼ 0.002). Subjects who had abnormal and border- Living alone has been used as a proxy for low social
line depression score were also at increased risk of having support, feeling isolated or even loneliness. Many factors
anxiety, where they were almost four times odds to have were associated with feeling loneliness among elderly
anxiety when compared with those who do not have (Hacihasanoglu et al., 2012). A study done by Iliffe et al.
depression (adjusted OR: 3.715; 95% CI: 2.009, 6.872; (1992) in developed countries showed that living alone at old
p50.001). age is a common phenomenon and may not be associated with
isolation or loneliness. They may have extensive social
support networks that they utilized to maintain their inde-
Discussion
pendence. In contrast, our study has shown that those who live
The prevalence of anxiety symptoms in our study was 13.3%. together with others were significantly associated with
This showed that anxiety symptoms were quite frequent from anxiety symptoms (p ¼ 0. 027). Among the Malay population,
elderly hypertensive who received treatment at our primary mostly of elderly people still live together with their kids or
care clinics. Our prevalence of anxiety showed almost similar close families. More studies in the area of social or family
with the study done in China. By using Zung self-rating support and anxiety may be needed to support this
anxiety scale, they reported that about 12% of their relationship.
 4 Z. Ismail et al.
Limitations of the study
The consequences of significant factors associated with
anxiety in elderly hypertensive cannot be established since
our study is a cross-sectional study. We are unable to make a
generalization to all elderly hypertensive, since our study only
involved two primary care clinics.
Conclusion
This study shows relatively high prevalence of anxiety
symptoms among elderly hypertensive seeking treatment
at a primary care set-up. Elderly with hypertension with a
history of stroke and having depressive symptoms are
susceptible to anxiety. Therefore, there is a need for anxiety
screening and further assessment of significant factors among
elderly in a primary care set-up. Early intervention may
improve the quality of life among elderly and will help our
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nation in achieving the goals of healthy aging.
Acknowledgements
The study was approved by the Research Ethics Committee
(Human), Universiti Teknologi MARA. The authors grate-
fully acknowledge the help and cooperation from the Primary
Care Physician and staff of the participating clinics. We also
thank all subjects who made this study possible.
Declaration of interest
For personal use only.
The authors have declared that they have no conflicts of
interests. The study was self-funded.
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