GERIATRIC ANXIETY SCALE: DEVELOPMENT AND PRELIMINARY

VALIDATION OF A LONG-TERM CARE ANXIETY ASSESSMENT MEASURE

by

MARISSA A. PIFER

B.A., West Virginia University, 2015

A thesis submitted to the Graduate Faculty of the

University of Colorado Colorado Springs

in partial fulfillment of the

requirements for the degree of

Master of Arts

Department of Psychology

2019




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 ii

This thesis for the Master of Arts degree by

Marissa A. Pifer

has been approved for the

Department of Psychology

by

Daniel Segal, Chair

Leilani Feliciano

Fred Coolidge

Date 9/20/2019
Pifer, Marissa A. (M.A., Psychology)

Geriatric Anxiety Scale: Development and Preliminary Validation of a Long-Term Care

Anxiety Assessment Measure

Thesis directed by Professor Daniel Segal

ABSTRACT

Introduction: Anxiety symptoms and disorders are common in later-life but they

often go undetected and untreated in long-term care settings. This may be linked to the

lack of a go-to reliable anxiety screener validated for use in this population. This study

examined the psychometric properties of an anxiety measure specifically designed for use

in long-term care settings, the Geriatric Anxiety Scale – Long Term Care Version (GAS-

LTC). Method: Data were collected from residents (N = 66; M age = 84.4 years, range =

59 to 100 years; 74.2% women) of three nursing homes and assisted living facilities.

Participants completed four self-report measures. The measures included the GAS-LTC,

the Geriatric Anxiety Inventory (GAI), the Geriatric Depression Scale -15 (GDS-15), and

the Prospective-Retrospective Memory Questionnaire (PRMQ). Results: The GAS-LTC

demonstrated good internal consistency (α = .80), good convergent validity with a

measure of anxiety, the GAI (r = .70, p < .01), and a measure of depression, the GDS-15

(r = .67, p < .01). It was also found that internal consistency on the GAS-LTC did not

significantly vary between groups with high (α = .75) and low (α = .77) self-reported

memory impairment. Discussion: The results from this study preliminarily indicate that

the GAS-LTC is a promising assessment measure of anxiety for older adults in long-term

care settings. The measure demonstrated good internal consistency, as well as good
 iv

convergent validity with measures of anxiety and depression, and subjective memory

complaints.
 TABLE OF CONTENTS

CHAPTER

I. INTRODUCTION .........................................................................................1

Anxiety Disorders in Older Adults ....................................................2

Anxiety in Nursing Home Residents .................................................5

Assessment of Anxiety in Older Adults.............................................10

Hypotheses .........................................................................................15

II. METHOD ......................................................................................................17

Partcipants ..........................................................................................17

Measures ............................................................................................18

Geriatric Anxiety Scale-Long Term Care Version ................18

Geriatric Anxiety Inventory ...................................................20

Geriatric Depression Scale – 15 Items ...................................20

Prospective and Retrospective memory Questionnaire .........21

Procedures ..........................................................................................23

III. RESULTS ......................................................................................................24

Hypothesis 1: Reliability....................................................................24

Hypothesis 2: Convergent Validity....................................................25

Hypothesis 3: Divergent Validity ......................................................28

Exploratory Hypothesis 2: Memory Impairment ...............................28

Additional Analyses ...........................................................................29

IV. DISCUSSION ................................................................................................31

 vi

Limitations .........................................................................................35

Future Directions ...............................................................................38

Conclusions ........................................................................................40

REFERENCES ..........................................................................................................41

APPENDIX A: GERIATRIC ANXIETY SCALE ....................................................48

APPENDIX B: IRB APPROVAL .............................................................................49

 vii

LIST OF TABLES

TABLE

1. Demographic Characteristics of Sample........................................................19

2. Reliability of GAS-LTC ................................................................................26

3. Reliability of GAI ..........................................................................................26

4. Reliability of GDS-15 ....................................................................................27

5. Reliability of PRMQ and Subscales ..............................................................27

6. Correlations Between GAS-LTC and Other Measures ..................................28

7. Correlations Between Psychological Variable with Continuous

Demographic Variables .................................................................................30

8. Score Distribution for Geriatric Anxiety Scale – Long Term Care Version .30
 CHAPTER I

INTRODUCTION

Anxiety disorders are diagnosed when one’s experience of fear and worry is out

of proportion to the actual threats present in one’s environment, or when one’s symptoms

of anxiety cause personal distress or impairments in one’s ability to function effectively.

Although anxiety disorders can be diagnosed at any age, anxiety disorders are, in fact,

among the most common mental disorders seen in older adults (Bryant, Jackson, & Ames

2008; Edelstein & Segal, 2011; Segal, Qualls, & Smyer, 2018). Anxiety problems are

also common among older nursing home and long-term care (LTC) residents, but they

often go undetected and untreated in this growing population (Creighton, Davison, &

Kissane, 2018). A primary reason for this lack of detection and lack of subsequent

intervention is that there are insufficient assessment instruments for anxiety as it uniquely

presents for older adults in LTC and nursing homes (Gerolimatos & Edelstein, 2012).

Nursing homes and assisted living facilities often house residents with significant

cognitive, social, and physical impairments which may impact their scores on traditional

anxiety questionnaires, especially those that were not developed with older respondents

in mind. As such, the use of properly validated measures for detecting anxiety in long-

term care settings is vital.

The Geriatric Anxiety Scale (GAS) is a reliable and well-validated screening

instrument for anxiety in older adults (Segal, June, Payne, Coolidge, & Yochim, 2010).

This instrument assesses the unique presentation of anxiety symptoms for older adults
 2

and is increasingly popular in diverse research and clinical settings in the US and

internationally. Although providers and researchers often rely on this instrument for their

older adult clients and participants in diverse settings, including nursing homes, the

psychometric properties of the GAS have not yet been fully evaluated for its use in LTC

settings. In the current study, we slightly modified the GAS-10 (i.e., the short form of the

GAS) for greater ease of completion for nursing home residents, and we explored the

psychometric properties of this new instrument, the GAS-Long Term Care Version

(GAS-LTC), for the evaluation of anxiety symptoms among LTC residents. The

following sections will discuss the general nature of anxiety in later life, followed by a

review of anxiety assessment in nursing homes to set the stage for the proposed study to

develop and preliminarily validate the GAS-LTC version.

Anxiety Disorders in Older Adults

The older adult population is the most rapidly growing segment of the US

population, with currently 15.2% of the population in the US aged 65 or older (US

Census, 2017), and this number is expected to increase to 25% by 2060 (US Census

2015). Anxiety disorders are the most common mental disorders among older adults, with

about 15% of older adults having some form of diagnosable anxiety symptoms (Bryant et

al., 2008; Edelstein & Segal, 2011), and up to 52% having sub-syndromal anxiety

symptoms (Wolitzky-Taylor, Castriotta, Lenze, Stanley, & Craske, 2010). Yet despite a

significant prevalence of anxiety symptoms in older adults, research on the assessment

and treatment of anxiety in this population has lagged behind that of other mental

disorders, especially depression and cognitive disorders. This lag is likely due to the

limited availability of anxiety assessment instruments for older adults, forcing clinicians
 3

and researchers to use measures designed and tested for younger populations. Most

anxiety screening instruments are based on DSM criteria for anxiety disorders, which in

general were developed for symptom presentation of anxiety disorders in young to

middle adulthood (Wolitzky-Taylor et al., 2010). This is problematic, as these

instruments do not account for age-related differences in the presentation of anxiety.

Older adults tend to endorse more somatic symptoms of anxiety, rather than cognitive or

behavioral, and often use less pathology-laden terms when describing their anxiety

(Gerolimatos & Edelstein, 2012).

Wolitzky-Taylor and colleagues (2010), in their comprehensive review, described

several specific risk-factors which increase the likelihood of having an anxiety disorder in

late life. These include: being female; having multiple chronic medical conditions; being

single, divorced, or separated; and having a lower education level, impaired subjective

health, stressful life events, physical limitations on daily activities, adverse events in

childhood, and neuroticism. These researchers also reported that advancing age has

important effects on anxiety symptom experience and expression. For older adults,

anxiety symptoms, specifically worry, tend to revolve around their health and disabilities

compared to younger adults who are more likely to have anxiety related to work,

finances, and family stressors (Wolitzky-Taylor et al., 2010). Another prominent theme

of worry for older adults is the fear of becoming a burden on others.

Overall, anxiety disorders in older adults are not as common as they are for

younger adults, and also seem to have less severe symptomology (Wolitzky-Taylor et al.,

2010). For example, panic disorder for older adults presents with fewer panic symptoms,

less anxiety and arousal, and higher levels of functioning than younger adults. Yet older
 4

adults were just as likely to have cardiac or psychological concerns during panic attacks,

and there was no difference in the frequency of panic attacks between the two age groups

(Wolitzky-Taylor et al., 2010). According to Flint, Cook, and Rabins (1996) less severe

presentation is possibly due to changes in the aging brain, such as a decrease in both

noradrenergic activity and neurotransmitter systems thought to be involved in anxiety,

which results in a natural “calming” effect. Nevertheless, anxiety disorders still present a

common and serious problem for older adults. Indeed, anxiety disorders in older adults

are associated with lower quality of life, and overall more anxiety, worry, social fears,

and depression compared to older adults without anxiety disorders (Wolitzky-Taylor et

al., 2010).

Anxiety disorders often co-occur with depression, a comorbidity which is

associated with greater clinical severity, poorer treatment response, and greater risk of

suicide (Sherbourne & Wells, 1997; Cairney, Corna, Veldhuizen, Hermann, & Streiner,

2008). Cairney and colleagues (2008) investigated patterns of comorbidity, subjective

well-being, and impairment of anxiety disorders and depression in a sample of 12,792

older adults aged 55 and older and found that 23% of participants who met criteria for

major depressive disorder, also met criteria for a current anxiety disorder. Similarly,

another population study by Hek et al. (2011) found the co-occurrence of anxiety and

depression for older adults to be 18%. Furthermore, half of all persons with a current

anxiety disorder have had a past depression diagnosis as well (Hek et al., 2011). These

results, as well as countless other studies demonstrating a link between anxiety and

depression, suggest that anxiety and depression are related disorders and they often co-
 5

occur in older adults. This notable pattern often complicates diagnostic and assessment

practices.

Anxiety in Nursing Home Residents

Although most older adults are able to continue living on their own well into older

adulthood, specific challenges that accompany aging makes this impossible for some

notably frail and ill older adults. Older adults may choose to leave independent living

situations for many reasons, but usually make the decision as sensory, cognitive, or

physical challenges begin to significantly interfere with their activities of daily living

(ADLs; Segal, Qualls, & Smyer, 2018). In cases such as these, many older adults

subsequently enter supportive living situations, also referred to as long-term care (LTC).

LTC includes assisted living, nursing homes, home health care, and adult day programs

which all differ in the degree of assistance provided for residents (Segal et al., 2018).

Most commonly, moves into LTC are due to cognitive impairment – even if a person’s

physical health is in good condition, cognitive impairment undermines their ability to

complete basic ADLs (Segal et al., 2018). Nursing homes are a common option which

provide long-term care for older adults, or may simply be used as a rehabilitation step

after surgery or illness (Segal et al., 2018). Among people over the age of 65, two-thirds

will need LTC services at some point, and about 46% will spend at least some time in a

nursing home (Segal et al., 2018). This is expected to increase significantly over the next

few decades due to the projected increase in number of people aged 65 and older (US

Census, 2015).

Nursing homes are live-in resident locations which provide care for people who

are functionally dependent and chronically ill, both with physical and cognitive
 6

difficulties (Snowdon, 2001; Segal et al., 2018). Nursing homes often resemble hospitals,

in their models of care and design, and often function as long-term psychiatric hospitals

for older adults, though this is not their intention and best practices of care for psychiatric

conditions is rarely implemented in these settings (Snowdon, 2001; Segal et al., 2018).

Snowdon (2001) reported that 80-91% of nursing home residents have some form of a

mental disorder, with dementia estimates reaching over 80% of residents. Although

recently there has been a push to deter the use of nursing homes as psychiatric facilities

for older adults, rates of mental disorders remain high in nursing homes to this day (Segal

et al., 2018). Policies put in place have helped this problem, but due to a lack of

alternative housing for older persons living with severe mental disorders, and the high

rate of comorbid mental disorders accompanying physical disabilities which require

skilled nursing care, mental disorders will likely remain common in nursing homes.

Estimates of anxiety disorders in nursing home residents range from 3-20% having at

least sub-syndromal anxiety, and many with symptoms severe enough to warrant an

anxiety disorder diagnosis (Creighton et al., 2015) compared to about 15% of community

dwelling older adults (Bryant et al., 2008; Edelstein & Segal, 2011), suggesting that

nursing home residents may experience more anxiety symptoms than older adults in the

community. Additionally, it has been found that anxiety symptoms can complicate care

and increase caregiver burden, leading to a 15% increase in likelihood of nursing home

placement for people with Alzheimer’s disease and anxiety symptoms (Gibbons et al.,

2002). This suggests that the decision to place someone in a nursing home or assisted

living might be impacted by increased anxiety levels, making it more likely for people in

nursing homes to have higher anxiety than community-dwelling samples.

 7

These estimates are likely on the conservative side, due to a lack of research

studies on prevalence data in this area (Creighton et al., 2018). Anxiety disorder

diagnoses are rare for older adults in LTC (Drageset, Eide, & Ranhoff, 2013), despite

them being at an increased risk for the development of anxiety disorders (Selbaek,

Kirkevold, & Engedal, 2007; Smalbrugge, Pot, Jongenelis, Beekman, & Eefsting, 2005),

and endorsing high levels of anxiety on self-report measures (Drageset et al., 2013).

Reasons for this may be systematic, as nursing homes operate on a medical model and

tend to prioritize medical care, focusing less on quality of life and mental health (Segal et

al., 2018; Snowdon, 2001). Nursing homes also tend be understaffed and underfunded,

especially those which service lower income individuals (Shipman & Hooten, 2007),

making it harder for nursing home staff to have the time or money for effective anxiety

screening and interventions. In general, mental disorders such as depression and anxiety

in nursing home residents are treated as less important to assess for and treat than medical

disorders or diseases. The residents of nursing home facilities are more likely to be frail,

disabled, cognitively impaired, and are more dependent on other people than community

dwelling older adults, putting them at a higher risk for the development of anxiety

disorders (Smalbrugge et al., 2005; Selbaek et al., 2007). Anxiety symptoms are often

quite debilitating for older adults in LTC, studies have found that older adults with

anxiety symptoms have significantly impaired quality of life and present a much more

substantial caregiving burden than their non-anxious counterparts (Drageset, Eide, &

Ranhoff, 2011; Koenig & Blazer, 2004). Older adults in LTC with anxiety are at a higher

risk for hospitalization, dementia, and death (Drageset et al., 2011). Thus, anxiety

presents a significant risk concerning the health and well-being of older adults in LTC.
 8

However, there are considerable inconsistencies across studies regarding the prevalence

of anxiety symptoms and disorders for nursing home residents, making it difficult to draw

firm conclusions as to how many nursing home residents are experiencing anxiety

symptoms. This is likely due to the lack of anxiety measures designed or validated for use

with this population.

Smalbrugge and colleagues (2006) examined the impact of depression and anxiety

on wellbeing and the use of health care services in 14 nursing homes in the Netherlands.

Participants were 333 nursing home residents aged 55 or older who did not have severe

hearing or cognitive impairments. Patients with depression and/or anxiety (this variable

included those with comorbid anxiety and depression, pure depression, and pure anxiety)

rated their wellbeing to be 25% lower compared to patients without depression or

anxiety, as measured by the Philadelphia Geriatric Centre Morale Scale. Additionally,

patients with depression and/or anxiety needed more assistance with ADLs, had higher

use of medical specialist consultation, and were taking more medication. Furthermore,

these researchers found that patients with pure anxiety symptoms had significantly more

consultations with medical specialists than those without anxiety or depression. This

study shows anxiety in nursing homes not only affects patient well-being, but also

impacts costs for nursing home facilities due to increased use of specialized services.

A recent study by Creighton and colleagues (2018) was the first in 10 years to

examine the prevalence of anxiety disorders and comorbid depression in nursing home

settings. Creighton et al. (2018) examined a sample of 180 nursing home residents and

found prevalence rates to be at 19.4% for diagnosable anxiety disorders using DSM-5

criteria and 11.7% for subthreshold anxiety disorders. The most common threshold
 9

anxiety disorder among this population was generalized anxiety disorder (GAD), with

11.1% of participants meeting criteria, and 3.3% having subthreshold GAD symptoms.

Specific phobia was the second most common threshold anxiety disorder, with 6.1% of

participants meeting criteria for specific phobia, and 2.8% having subthreshold

symptoms. Agoraphobia was the most common subthreshold anxiety disorder, with 3.9%

of participants having subthreshold symptoms of agoraphobia, and 2.8% of participants

actually meeting criteria for an agoraphobia diagnosis. Social anxiety disorder (SAD) and

panic disorder both had threshold prevalence rates of 1.7%, though SAD had a higher

subthreshold prevalence rate, with 3.3% of participants having subthreshold SAD

symptoms, and no participants having subthreshold panic disorder symptoms.

The prevalence of participants with any threshold anxiety disorder was within the

upper estimates reported by previous studies (Smalbrugge et al, 2005). A possible reason

for more people meeting the threshold for anxiety disorders rather than subthreshold may

be the use of the newer DSM-5 criteria, which removed the requirement for the

individual to consider the anxiety to be excessive or disproportionate (Creighton et al.,

2018). Nursing home residents often have less insight, and therefore may not recognize

the significant impact of their anxiety, or may not interpret their anxiety as excessive or

disproportionate (Creighton et al., 2018), thus removing this criteria may have allowed

more people to meet criteria for diagnosis. Nursing home settings may also exacerbate

existing anxiety, so that people who may have been at subthreshold in the community

experience an increase of symptoms, allowing them to meet threshold for an anxiety

disorder.
 10

Whereas Creighton and colleagues (2018) found a significant number of people

living with either threshold or subthreshold anxiety symptoms, less than half of them had

any kind of anxiety symptom indicated in their medical records, demonstrating the

significant under-reporting of anxiety disorders in nursing home settings. Despite this

under reporting of anxiety in the medical records, 56% of patients with threshold or

subthreshold anxiety disorders were receiving medication which could potentially be

prescribed for anxiety such as anti-depressants, benzodiazepines, and/or antipsychotics,

though the specific reasons for the prescribing of these medications is unknown.

Furthermore, only 8.6% of those with threshold anxiety symptoms were receiving any

kind of psychological treatment, such as psychotherapy, for their anxiety. No participants

with subthreshold anxiety symptoms were receiving psychological treatment. Despite the

increased negative side effects of psychotropic medication when used with older adults,

the outcome of this study by Creighton et al (2018) is consistent with previous studies

(Davison et al., 2007; Davison et al., 2012) indicating that psychotropic medication and

polypharmacy is typically the first line of treatment for mental disorders in nursing home

settings.

Assessment of Anxiety in Older Adults

With the increase in number of older adults in nursing homes, comes the need for

better assessment and treatment of mental disorders in this population. Psychological

assessment for mental disorders among older adults is particularly challenging, as

symptoms often present differently among these folks than the young adults for which

assessment measures and diagnostic criteria is based on (Edelstein et al., 2008). Measure

sensitivity is compromised when used on a population for which the measures were not
 11

designed nor validated with, decreasing the ability of these measures to accurately detect

anxiety. Ideally, researchers and clinicians would have a measure specifically designed

for the assessment of anxiety in LTC. The paucity of instruments developed specifically

for use with older adults means clinicians are forced to either forego formal assessment

and make judgments for diagnosis and treatment based on clinical presentation alone, or

use measures that were not designed for older adults, only some of which have empirical

support for their use within this population (Edelstein et al., 2008). This creates barriers

for older adults, independently living and those in LTC, to get the treatment they need if

they are living with an anxiety disorder.

An important development in the field has been the creation of a few assessment

tools that were designed specifically for the measurement of anxiety in older adults.

These elder-specific measures include the Geriatric Anxiety Inventory (GAI; Pachana et

al., 2007), the Geriatric Anxiety Scale (GAS; Segal et al., 2010), and the Adult Manifest

Anxiety Scale-Elderly Version (AMAS-E; Reynolds, Richmond, & Lowe, 2003).

Although these measures were designed for use with older adults, they were not designed

for use in LTC. That being said, both the GAI and the GAS have been evaluated

psychometrically in LTC settings (described further below).

Gerolimatos, Gregg, and Edelstein (2013) evaluated the use of the GAI and the

GAI short form (GAI-SF) among 75 older adult (range 52-94 years of age) residents of a

state-operated nursing home. This study involved the review of residents’ medical

records for completed GAI measures, as the nursing home had been using this measure

for anxiety screening since 2008. If GAI measures were found, the residents then

completed a few other measures such as the Geriatric Depression Scale (GDS), the Adult
 12

Functional Adaptive Behavior Scale (AFABS), and the Executive Interview (EXIT).

Diagnosis of anxiety disorders were made based on GAI scores and a clinical interview.

Using the cut-off score for the GAI suggested by Byrne and Pachana (2011), 36 of 75

residents (48%) were determined to have clinically significant anxiety symptoms.

Internal consistency for the GAI was excellent, with a Cronbach’s alpha coefficient of

0.92. The GAI-SF had a slightly lower Cronbach’s alpha coefficient of .73, but still

within acceptable range. Researchers assessed convergent validity with Pearson

correlations between the GAI and the GAI-SF and found a significant positive correlation

between the two measures, r=.89. Divergent validity of the GAI and GAI-SF were

evaluated by Pearson correlations with measures not assessing anxiety such as the GDS,

AFABS and the EXIT. Moderate correlations were found with both GAI measures and

the GDS (GAI: r = .42; GAI-SF: r = .40), and weak correlations were found among both

GAI measures with AFABS (GAI: r = -.29; GAI-SF: r = -.24) and with EXIT (GAI: r =

.21; GAI-SF: r = .19).

While this study provides evidence for the clinical utility of the GAI and GAI-SF

in nursing homes, some study limitations need to be addressed. First, the sample was not

randomly selected, but rather it only included patients in the nursing home facility who

had been given the GAI previously. This may have biased the sample to being more

likely to have an anxiety disorder or significant anxiety symptoms. Additionally, since

the GAI data was not collected by the researchers, administration of the measure was not

ensured to be uniform and consistent with research standards. Another issue could be the

convergent validity being evaluated with two versions of the GAI, the GAI and the GAI-

SF. While the convergent validity was excellent, this is to be expected, as the measures
 13

were created by the same researchers, based on the same theory, and use many of the

same items. Evidence of convergent validity for this population may be more compelling

if it had been evaluated by another common measure of anxiety, rather than the short

form of the same measure. While this measure was shown to be acceptable for use for the

assessment of anxiety in LTC, the GAI tends to have a heavy focus on symptoms of

worry, which could be problematic in LTC because older adults may be more likely to

endorse somatic anxiety symptoms rather than worry symptoms (Gerolimatos &

Edelstein, 2012). The GAI is also a proprietary measure that is not freely available.

The Geriatric Anxiety Scale (GAS) is another commonly used assessment

measure for anxiety in older adults. This measure was designed to assess anxiety levels

specifically among older adults (Segal et al., 2010). There are two versions of this

measure, the standard GAS (with 30 items) and the GAS-10 Short Form. Both have been

shown to have high validity and reliability for older adults with anxiety (Segal et al.,

2010; Mueller et al., 2015). The GAS is advantageous compared to other measures of

anxiety in older adults because it gets at multiple different symptom types, rather than

having a heavy focus on worry such as the GAI (Segal et al., 2010). This measure was

developed for the purposes of creating a brief self-report measure of anxiety for use with

older adults, focusing on three common domains of anxiety: somatic symptoms,

cognitive symptoms, and affective symptoms (Segal et al., 2010). The GAS was

developed using the diagnostic criteria of anxiety disorders from the DSM-IV-TR (Segal

et al., 2010), which is unique as most anxiety measures for older adults do not cover

specific diagnostic criteria. A wide range of criteria, for a wide range of anxiety
 14

disorders, were used during development of the GAS, reflecting its breadth of symptom

coverage.

The initial validation of the GAS was conducted with a community dwelling older

adult sample of 101 older adults, aged 60-90 (Segal et al., 2010). Among this sample,

internal consistency reliability for the GAS total score was excellent (α=.93), and internal

consistency estimates for the subscales were good to excellent (Cognitive α=.90; Somatic

α=.86; Affective α=.92; Segal et al., 2010). Convergent validity was established for the

GAS through medium to large positive correlations between the GAS and other anxiety

measures. These anxiety measures included the State-Trait Anxiety Inventory, both the

state (r = .74) and trait (r = .79) subscales, the Beck Anxiety Inventory (r = .82), and the

AMAS-E (r = .76; Segal et al., 2010). The GAS also had a strong correlation with the

GDS (r = .78), as is expected due to the overlap of anxiety and depression symptoms.

Overall, the GAS appears to have excellent internal consistency reliability, and strong

evidence of convergent validity as measured by the strong and positive correlations with

other measures of anxiety.

A 10 item short form of the GAS (called the GAS-10) was created to aid in ease

of use, as short forms are often preferred in busy clinical settings and they reduce the

burden of administration and scoring time, as well as pose less burden on patients

particularly for older respondents (Mueller et al., 2015). The GAS-10 was created using

item response theory (IRT) by taking the items with the highest discrimination

parameters and information curve peaks from each of the subscales (Mueller et al., 2015).

Three items were retained from the somatic and affective subscales, and 4 items were

retained from the cognitive subscale (Mueller et al., 2015). All items were examined to
 15

be sure that they would not collect redundant information. Discrimination parameters

were also investigated, to ensure that each question could be endorsed by those with high

and low anxiety severity. The GAS-10 is most useful for people with average anxiety up

to 2.5 SD above the mean (Mueller et al., 2015). A reasonable amount of information is

provided by the GAS-10 in comparison to the full GAS version, and the GAS-10 did not

lose much precision because of reduced items (Mueller et al., 2015). The GAS-10

performed similarly to the full GAS in terms of internal consistency (GAS-10: α= .89;

GAS: α = .93; Segal et al., 2010) and was positively correlated with the GAS total score

(r = .96, p < 0.001) and subscales (cognitive: r = .92, p < .001, affective: r = .89, p <

.001, somatic: r = .82, p < .001; Mueller et al., 2015). This suggests the GAS-10 is an

acceptable alternative to the full GAS measure, with precision not being compromised

due to a reduction in items.

The purpose of the current study was to develop and investigate the reliability and

validity of a GAS measure specifically designed for older adults within LTC settings: the

Geriatric Anxiety Scale-Long Term Care Version (GAS-LTC). The development of an

anxiety measure specifically designed for older adults in LTC settings will cut down on

reliability error and provide a go-to measure for clinicians and researchers to use for

anxiety assessment in LTC settings. This will aid in diagnosis and treatment of older

adults in LTC, hopefully helping to mediate the disabling effects of anxiety on this

population.

Hypotheses

1. It was hypothesized the GAS-LTC would demonstrate acceptable or better

internal consistency as evidenced by a Cronbach’s alpha greater than .80. This is

 16

expected due to the high Cronbach’s alpha coefficient seen with the GAS (α =

0.90; Segal et al., 2010) and the GAS-10 (α = 0.89; Mueller et al., 2015). The

GAS-LTC has similar items to both the GAS and the GAS-10, and is therefore

expected to perform similarly in terms of internal consistency.

2. It was hypothesized that the GAS-LTC would have strong convergent validity as

demonstrated by a positive correlation with another anxiety measure (the GAI)

and with a depression measure (the GDS-15), with expected validity coefficients

for both measures exceeding .50, reflecting a large effect size.

3. It was hypothesized that the GAS-LTC would have good divergent validity with

the Prospective Memory Questionnaire (PRMQ), with an expected correlation

coefficient being under .30.

The following hypotheses are offered but are purely exploratory in nature:

1. It was hypothesized that as cognition varies from high to low, the validity or

reliability of the GAS-LTC would remain stable, as the validity and reliability of

the GAS have not been shown to be affected by reading ability or processing

speed (Yochim, Mueller, June, & Segal, 2010), nor with memory ability (Gould et

al., 2014).

2. Using the same groups of high and low cognition, it was hypothesized that those

in the lower cognition group would have higher scores on the GAS-LTC than the

higher cognition group, as subjective perception of poor memory is a cause of

significant distress for older adults (Wolitzky-Taylor et al., 2010).

 CHAPTER II

METHOD

Participants

The study sample consisted of 66 older adult participants (74.2 % women; 25.8 %

men) recruited from assisted living and skilled nursing settings within the Colorado

Springs area. The mean age of participants was 84.4 years (SD = 8.7 years). The majority

of the sample identified as Caucasian (93.9%) whereas a small percentage identified as

African American (3%), East Asian (1.5%), or Other (1.5%). Mean education level was

13.97 years (SD = 3.12 years), ranging from 4 years to 22 years. Self-reported

socioeconomic status (SES) placed 50% of participants in the middle-class range, 19.7%

identified as upper middle class, 3% were affluent or wealthy, 4.5% were working class,

6.1% were working poor, and 1.5% were poverty level, with 15.2% choosing not to

answer. Participants had been residents in these facilities ranging from one week to up to

11 years (M = 18.10 months, SD = 20.73 months), with the vast majority of participants

residing in assisted living (89.4 %), rather than skilled nursing settings (10.6%). The

majority of participants were widowed (65.2%), 9% were divorced, 7% were married, 5%

were single, 1% were married, and 1% reported other for their partnership status.

Overall, the sample displayed minimal anxiety levels on both the GAS-LTC (M =

2.16, SD = 2.38) and the GAI (M = 3.53, SD = 4.54), as well as low levels of depression

on the GDS-15 (M = 3.38, SD = 3.40). GAS-LTC scores were non-normally distributed

with skewness of 1.14 (SE = 0.30) and kurtosis of 0.57 (SE = 0.58). GAI scores were also
 18

non-normally distributed with a skewness of 1.81 (SE = 0.30) and kurtosis of 2.97 (SE =

0.58). Results from the PRMQ (M = 33.35, SD = 9.12) also showed low levels of

subjective memory impairment. Participants were excluded from the study if they had

significant cognitive impairment which prevented them from being able to complete the

self-report measures included in the study. See Table 1 for complete demographic data.

Measures

Geriatric Anxiety Scale-Long Term Care Version (GAS-LTC): The GAS-LTC

is a 10 item self-report assessment tool designed specifically for use with older adults in

LTC settings. The measure contains items endorsing 3 symptom types of anxiety;

somatic, cognitive, and affective. Higher scores indicate higher levels of anxiety. The

GAS-LTC was developed using the GAS-10, modifying certain items to accommodate

the lower level of functioning characteristic of nursing home residents. Specifically, item

1 was changed from “I was irritable” to “I was irritable or grumpy,” and item 3 was

changed from “I felt like I was in a daze” to “I felt like I was in a daze, or foggy-headed.”

Both of these changes added a more layman’s term for the concept we wanted to

measure, while keeping the original item intact. Aside from these items, the response

format of the GAS-LTC has been modified to a simpler ‘Yes-No’ response format, rather

than the 4-point Likert-type scale, 0 (Not at all) to 3 (All of the time), used on the GAS-

10. This was done to make responding as simple as possible for those who may have

some degree of cognitive or physical impairments. This study provides initial

psychometrics for the GAS-LTC with a sample of nursing home residents. See Appendix

A for measure.
 19

Table 1

Demographic Characteristics of Sample

N (frequency) Percent M SD Min Max

Age 66 — 84.35 8.68 59 100
Education 65 — 13.97 3.12 4 22
Time in Facility 49 — 18.10 20.73 0.06 132

Ethnicity
Not Hispanic or 62 93.6 — — — —
Latino
Hispanic or Latino 3 3 — — — —
Race
White/Caucasian 62 93.6 — — — —
Black/African 2 3 — — — —
American
East Asian 1 1.5 — — — —
Other 1 1.5 — — — —
Partnership Status
Widowed 43 65.2 — — — —
Divorced 9 13.6 — — — —
Married 7 10.6 — — — —
Single 5 7.6 — — — —
Partnered 1 1.5 — — — —
Other 1 1.5 — — — —
Facility Type
Assisted Living 59 89.4 — — — —
Skilled Nursing 7 10.6 — — — —
SES
Affluent/Wealthy 2 3 — — — —
Upper Middle Class 13 19.7 — — — —
Middle Class 33 50 — — — —
Working Class 3 4.5 — — — —
Working Poor 4 6.1 — — — —
Poverty Level 1 1.5 — — — —
Prefer Not to Answer 10 15.2 — — — —
GAS-LTC Total 66 — 2.16 2.38 0 9
GAI Total 66 — 3.53 4.54 0 20
GDS-15 Total 66 — 3.38 3.40 0 13
PRMQ Total 62 — 33.35 9.12 16 53
PRMQ-P Total 62 — 17.45 5.17 8 28
PRMQ-R Total 63 — 16.05 4.55 8 27
Note. Age reported in years. Education reported in years. Time in facility reported in
months. SES = Socioeconomic Status; GAS-LTC = Geriatric Anxiety Scale – Long Term
Care Version; GAI = Geriatric Anxiety Inventory; GDS-15 = Geriatric Depression Scale-
15; PRMQ = Prospective and Retrospective Memory Questionnaire; PRMQ-P =
Prospective memory subscale of PRMQ; PRMQ-R = Retrospective memory subscale of
PRMQ.
 20

Geriatric Anxiety Inventory (GAI; Pachana et al., 2007): The GAI is a 20-item

self-report measure of anxiety symptoms over the past week for older adults. The items

are rated “agree” or “disagree” with higher scores indicating higher levels of anxiety. The

properties of the GAI have been examined with community-dwelling older adults

(Pachana et al., 2007; Byrne et al., 2010), older adults seeking outpatient clinical services

(Pachana et al., 2007), and older adults in long-term care settings (Gerolimatos et al.,

2013). A cut-off score of 10 shows specificity of 84% and sensitivity of 75% for

detecting Generalized Anxiety Disorder (GAD), and a cut-off score of 8 was used for the

detection of any anxiety disorder with a specificity of 80% and sensitivity of 78%. One-

week test-retest reliability was excellent (r = .91) in a sample of non-clinical community

dwelling older adults. Cronbach’s Alpha was .91 in a sample of community dwelling

older adults, and 0.93 for older adults seeking outpatient services, showing high internal

consistency (Pachana et al., 2007). The GAI has strong correlations with the State-Trait

Anxiety Inventory (r =.80; Spielberger, Gorsuch, & Luchene, 1970) and the Goldberg

Anxiety Scale (r =.70; Goldberg, Bridges, Duncan-Jones, & Grayson, 1988) providing

evidence of convergent validity. Discriminant validity has been established through weak

to moderate correlations with the Mini-Mental State Examination (r = -.04; Byrne &

Pachana, 2011) and subjective memory function (r = -.20; Byrne et al., 2010).

Geriatric Depression Scale – 15 Item (GDS-15; Sheikh & Yesavage, 1986): The

GDS-15 contains 15 items asking about depressive symptoms over the past week. The

original GDS is a 30-item assessment of depression specifically designed for older adults.

The GDS has a simple yes-no format, and higher scores indicate higher rates of

depression with a cut off score of 5 for detecting major depression. This cut off has
 21

specificity of 89% and 92% sensitivity for a sample of community-dwelling older adults

and older adults seeking treatment for depression (Sheikh & Yesavage, 1986), and

specificity of 78% and sensitivity of 72% for older adult home healthcare patients

(D’Ath, Katona, Mullan, Evans, & Katona, 1994). Test-retest reliability over 7-14 days

was 0.85 in community-dwelling older adults (Steiner et al., 1996). GDS also shows

strong correlations with other measures of depression such as the Montgomery Asberg

Depression Rating Scale (r = .78; Montgomery & Asberg, 1979) and the 30-item GDS (r

= .89; Lesher & Berryhill, 1994). Boey (2000) found weak to moderate correlations with

positive affect (r = -.16), self-reported health (r = -.26), and somatic complaints (r = .33)

among older adults showing adequate discriminant validity. Internal consistency has been

examined in several populations including functionally impaired primary care patients

(α=.75; Friedman, Heisel, & Delavan, 2005), older adults receiving home care (α = .80;

Marc, Raue, & Bruce, 2008), and adults receiving rehabilitation services (α = .74;

Pomeroy, Clark, & Philp, 2001).

Prospective and Retrospective Memory Questionnaire (PRMQ; Smith, Sala,

Logie, & Maylor, 2000): The PMRQ is a 16 item, self-report measure examining daily

prospective and retrospective memory failures. This measure was designed for use with

older adults with Alzheimer’s disease, but can be used to measure memory lapses in older

adults without a specific memory pathology as well. Initial validation by Smith et al.

(2000) included data from 304 Alzheimer’s disease patients and their care givers (152

pairs), and 396 control participants, with 242 older adults and 154 young adult

participants. For each item, memory lapses are rated by assigning numerical values as

follows: Very Often = 5, Quite Often = 4, Sometimes= 3, Rarely= 2, Never = 1.

 22

Prospective memory is the ability to remember to carry out intended actions in the future,

while retrospective memory is the ability to remember or recognize information, events,

people, or places from the past. Eight of the items examine prospective memory (e.g. Do

you decide to do something in a few minutes’ time and then forget to do it?) and eight

items examine retrospective memory (e.g. Do you fail to recognize a place you have

visited before?). The measure produces a total score, as well as individual scores for the

prospective and retrospective subscales. The measure is designed to inquire equally about

self-cued and environmentally cued memory, and short-term vs. long-term memory. The

split half reliability for each type of memory was calculated using the Spearman-Brown

formula and was reported to be high, rSB= .84. Data from an ongoing longitudinal

memory study was examined by Ronnlund, Mantyla, and Nilsson (2008), who found

Cronbach’s alpha for the total scale, as well as the two subscales, to have appropriate

levels of internal consistency, with coefficient alphas of .89, .86, and .78, respectively, in

a sample of 540 participants aged 35-90. In the initial validation of the PRMQ, there was

no significant difference found between self-report and collateral report of memory

difficulties among Alzheimer’s disease patients. Furthermore, a study by Hsu, Huang, Tu,

and Hau (2014) found that higher scores on the PRMQ reliably predicted greater

dementia severity, identifying an optimal cut-score of 31.5. This offers support to the

notion that data concerning memory lapses can be reliably obtained through self-report

measures and suggests that even those with severe memory impairment are able to

reliably complete this measure (Smith et al., 2000).

 23

Procedures

This study was granted approval from the University of Colorado Institutional

Review Board (IRB) as well as approval from the directors of three local nursing homes

and assisted living facilities. The research team, which consisted of three trained graduate

students in clinical psychology, personally visited the LTC facilities and approached

residents about participating in the study. Participants were explained the consent form

and participated only if this was signed and understood. Due to the self-report format of

the measures, residents were given instructions for each measure and were handed the

packet to complete themselves. Some residents had physical difficulties which prevented

them from completing the packets on their own, such as visual difficulties or tremors, in

which case the questions were read aloud to the residents who verbally indicated their

answers. The research team was available while the residents were completing the

packets in order to answer any questions they had and to ensure the participants were able

to complete the questionnaires. The research team collected each packet before leaving

the facility. Each participant was assigned a number which was not associated with their

name in order to ensure confidentiality of responses. All participants received $10 for

their participation in the study and a debriefing form that explained the purpose of the

study and included contact information for the primary researchers in this study.
 CHAPTER III

RESULTS

Hypothesis 1: Reliability

Internal consistency of GAS-LTC scores was evaluated using a Cronbach’s alpha

coefficient. As expected, the GAS-LTC demonstrated good internal consistency of scale

scores (α = .80) indicating that the items of this measure are highly related and measuring

aspects of the same construct. Item-total correlations revealed a range of moderate to

strong positive correlations (range r: .35-.65) between each individual item and the total

GAS-LTC score, with a median correlation of .44 (see Table 2). To evaluate the impact

of cognition on the reliability of the GAS-LTC, Cronbach’s alpha coefficients were

calculated for the high and low subjective memory impairment groups. Participants were

split into high and low subjective memory impairment groups based on the suggested

optimal cut point of 31.5 from Hsu et al. (2014). The resulting alpha values were

compared using a Fisher’s z test. Cronbach’s alpha coefficients were acceptable to good

in both the high memory impairment group (α = .79.; N = 35) and the low memory

impairment group (α = .57; N = 27). These alphas were not significantly different, Z = -

1.57, p > .05.

In addition to Cronbach’s alpha, reliability of the GAS-LTC was examined using

McDonald’s omega, due to the relatively small number of items on the GAS-LTC and the

positively skewed sample. Results showed similar good internal consistency using

McDonald’s omega (ω = .80) as with Cronbach’s alpha.

 25

Reliability analyses were conducted for the GAI, GDS-15, and PRMQ scores as

well, in the present sample. The GAI demonstrated excellent internal consistency (α =

.90). Item-total correlations revealed a range of moderate to strong positive correlations

(range r: .40-.70) between each individual item and the total GAI score, with a median

correlation of .56 (see Table 2). Comparison between the internal consistency of the

GAS-LTC and the GAI for this population revealed that the GAI had significantly better

internal inconsistency than the GAS-LTC, Z = 2.1, p < .05. The GDS-15 demonstrated

good internal consistency as well, with a Cronbach’s alpha coefficient of α=.85. Item-

total correlations for GDS-15 items revealed a range of weak to strong positive

correlations (range r: .17-.66) between each individual item and the total GDS-15 score,

with a median correlation of .52 (see Table 4). The PRMQ demonstrated good internal

consistency for the full scale (α=.87). Item-total correlations for the PRMQ items

revealed a range of moderate to strong positive correlations (range r: .32-.67) between

each individual item and the PRMQ total score, with a median correlation of .52 (see

Table 5). Both the PRMQ prospective subscale (α=.78) and retrospective subscale

(α=.76) demonstrated acceptable internal consistency as well.

Hypothesis 2: Convergent Validity

Regarding convergent validity, the GAS-LTC demonstrated a strong positive

correlation with another measure of anxiety, the GAI (r = .70, p < .01), with 49% of

variance shared between the two measures. Similarly, the GAS-LTC demonstrated a

strong positive correlation with a measure of depression, the GDS-15 (r = .67, p < .01),

with 45% of variance shared. These results demonstrate good convergent validity for the
 26

Table 2

Reliability of GAS-LTC

M SD Corrected Item-Total α
Correlation
GAS-LTC Total 2.16 2.38 .80
GAS-LTC Item 1 .23 0.42 .57
GAS-LTC Item 2 .14 0.35 .37
GAS-LTC Item 3 .12 0.33 .49
GAS-LTC Item 4 .18 0.39 .44
GAS-LTC Item 5 .18 0.39 .45
GAS-LTC Item 6 .23 0.42 .61
GAS-LTC Item 7 .49 0.50 .43
GAS-LTC Item 8 .26 0.44 .65
GAS-LTC Item 9 .27 0.44 .42
GAS-LTC Item 10 .06 0.24 .35
Note: N = 66 overall. α = Cronbach’s coefficient alpha. GAS-LTC = Geriatric Anxiety
Scale – Long Term Care Version.

Table 3

Reliability of GAI

M SD Corrected Item-Total α
Correlation
GAI Total 3.53 4.54 .90
GAI Item 1 .24 0.43 .56
GAI Item 2 .15 0.36 .40
GAI Item 3 .17 0.38 .45
GAI Item 4 .24 0.43 .40
GAI Item 5 .17 0.38 .64
GAI Item 6 .29 0.46 .53
GAI Item 7 .06 0.24 .54
GAI Item 8 .29 0.46 .57
GAI Item 9 .27 0.45 .51
GAI Item 10 .21 0.41 .63
GAI Item 11 .36 0.48 .66
GAI Item 12 .11 0.31 .56
GAI Item 13 .12 0.33 .67
GAI Item 14 .14 0.35 .38
GAI Item 15 .17 0.38 .64
GAI Item 16 .18 0.39 .69
GAI Item 17 .11 0.31 .63
GAI Item 18 .06 0.24 .55
GAI Item 19 .08 0.27 .54
GAI Item 20 .12 0.33 .70
Note: N = 66 overall. α = Cronbach’s coefficient alpha. GAI = Geriatric Anxiety
Inventory.
 27

Table 4

Reliability of GDS-15

M SD Corrected Item-Total α
Correlation
GDS Total 3.34 3.38 .85
GDS Item 1 .14 0.35 .58
GDS Item 2 .38 0.49 .52
GDS Item 3 .18 0.39 .62
GDS Item 4 .36 0.48 .62
GDS Item 5 .06 0.24 .17
GDS Item 6 .11 0.31 .50
GDS Item 7 .17 0.38 .36
GDS Item 8 .24 0.43 .59
GDS Item 9 .41 0.49 .31
GDS Item 10 .17 0.38 .42
GDS Item 11 .15 0.36 .54
GDS Item 12 .21 0.41 .61
GDS Item 13 .54 0.50 .39
GDS Item 14 .11 0.31 .66
GDS Item 15 .12 0.33 .47
Note: N = 66 overall. α = Cronbach’s coefficient alpha. GDS-15 = Geriatric Depression
Scale-15.

Table 5

Reliability of PRMQ and Subscales

M SD Corrected Item-Total α
Correlation
PRMQ Total 33.35 9.12 .87
PRMQ-P Total 17.45 5.17 .78
PRMQ-R Total 16.05 4.55 .76
PRMQ Item 1 2.42 0.95 .32
PRMQ Item 2 1.66 0.85 .50
PRMQ Item 3 2.02 0.95 .54
PRMQ Item 4 2.42 0.93 .42
PRMQ Item 5 2.45 1.21 .63
PRMQ Item 6 1.66 0.89 .59
PRMQ Item 7 2.18 1.08 .53
PRMQ Item 8 1.98 1.02 .43
PRMQ Item 9 2.06 0.92 .53
PRMQ Item 10 2.32 1.16 .67
PRMQ Item 11 2.47 0.94 .44
PRMQ Item 12 1.94 0.96 .46
PRMQ Item 13 1.71 0.89 .63
PRMQ Item 14 1.95 1.00 .54
PRMQ Item 15 1.94 0.90 .45
PRMQ Item 16 2.18 0.93 .45
Note: N = 62 overall. α = Cronbach’s coefficient alpha. Prospective and Retrospective
Memory Questionnaire; PRMQ-P = Prospective memory subscale of PRMQ; PRMQ-R =
Retrospective memory subscale of PRMQ.
 28

GAS-LTC. Additionally, the GAI and the GDS-15 were also strongly positively

correlated (r = .65, p < .01.), with 42% of variance shared (see Table 6).

Table 6

Correlations Between GAS-LTC and Other Measures

Scales GAS-LTC Total Score GAI Total Score

GAI Total Score .70
GDS-15 Total Score .67 .65
PRMQ Total Score .54 .56
Note: GAS-LTC = Geriatric Anxiety Scale-Long Term Care Version; GAI = Geriatric
Anxiety Inventory; GDS-15 = Geriatric Depression Scale-15; PRMQ = Prospective and
Retrospective Memory Questionnaire. All correlations are significant at the 0.01 level (2-
tailed).

Hypothesis 3: Divergent Validity

The GAS-LTC displayed a strong positive correlation with a measure of

subjective memory impairment, the PRMQ (r = .54, p < 0.01), in contrast to the

hypothesis that the GAS-LTC would have correlation coefficient < .30 (see Table 6).

Exploratory Hypothesis 2: Memory Impairment

An independent samples t-test revealed that those with higher levels of subjective

memory impairment on the PRMQ also displayed higher levels of anxiety on the GAS-

LTC (M = 4.18, SD = 2.64) than those with lower subjective memory impairment (M =

1.40, SD = 1.90), t(60) = -4.53, p < .001, as expected, with a large effect size, Cohen’s d

= 1.21. This pattern was also similar to the GAI, as participants with higher scores on the

PRMQ also reported higher levels of anxiety (M = 8.13, SD = 6.08) than those with lower

scores (M = 1.85, SD = 2.61), t (16.96), with a large effect size, Cohen’s d = 1.34.
 29

Additional Analyses

Demographics

A series of analyses were conducted to examine the influence of demographic

factors on self-reported anxiety, depression, or memory impairment. Variables considered

included race, ethnicity, gender, age, partnership status, education level, socioeconomic

status, and the amount of time living in a long-term care setting. There was a significant

weak negative correlation between anxiety and SES, seen with the GAS-LTC (r = -.33, p

< 0.05) in that those who self-reported themselves as being part of a lower SES category,

also reported higher levels of anxiety. However, this relationship did not emerge for the

GAI (r = -.01, p > .05). There was also a significant weak positive correlation between

time in facility and anxiety scores on the GAI (r = .32, p < .05). No other demographic

variables were found to be significantly correlated with self-reported levels of depression,

anxiety, or subjective memory impairment (see table 7), and there were no significant

mean differences for any categorical demographic variables, such as race, ethnicity,

gender, and partnership status.

Score Distribution and Interpretive Guidelines

T-scores and percentiles were calculated for GAS-LTC items to establish scoring

and interpretive guidelines for this new measure (see table 8). As can be seen in table 8,

scores on the GAS-LTC ranged from 0 (t = 40.9; 25th percentile) to 9 (t = 78.7; 98th

percentile). See table 8.

 30

Table 7

Correlations Between Psychological Variable with Continuous Demographic Variables

Scale Age Education SES Time in Facility

GAS-LTC -.08 -.18 -.33* .25
GAI -.04 -.19 -.01 .32*
GDS-15 .10 -.22 -.15 .27
PRMQ .06 -.18 -.16 .25
PRMQ-P -.01 -.19 -.25 .19
PRMQ-R .09 -.16 -.09 .23
Note. Age reported in years. Education reported in years. Time in facility reported in
months. SES = Socioeconomic Status; GAS-LTC = Geriatric Anxiety Scale – Long Term
Care Version; GAI = Geriatric Anxiety Inventory; GDS-15 = Geriatric Depression Scale-
15; PRMQ = Prospective and Retrospective Memory Questionnaire; PRMQ-P =
Prospective memory subscale of PRMQ; PRMQ-R = Retrospective memory subscale of
PRMQ. * Correlation is significant at the 0.05 level (2-tailed).

Table 8

Score Distribution for Geriatric Anxiety Scale – Long Term Care Version

Raw T-Score Percentile Descriptive Category

0 40.9 25 Minimal
1 45.1 40 Minimal
2 49.3 60 Minimal/Mild
3 53.5 70 Mild
4 57.7 77 Mild/Moderate
5 61.9 81 Moderate
6 66.1 90 Severe
7 70.3 95 Severe
8 74.5 96.5 Severe
9 78.7 98 Severe
10 99+ Severe
Note: N = 66 overall.
 CHAPTER IV

DISCUSSION

The primary purposes of this study were to develop the GAS-LTC and to examine

the preliminary psychometric properties of the GAS-LTC, as a new measure of anxiety

specifically designed for the use in LTC settings. The reliability and the validity of this

measure for use in LTC settings was evaluated, in addition to other analyses in order to

increase knowledge about anxiety in LTC settings. This study adds to the literature on

anxiety assessment and expression in LTC, as it was the first study to examine the use of

the GAS-LTC in LTC settings and it adds to the literature on validity of the use of the

GAI, GDS-15, and PRMQ in these settings as well. As the population continues to live

longer, the number of people moving into and spending a significant number of years in

LTC is increasing as well (Ortman, Velkoff, & Hogan, 2014). It is estimated that 25% of

people will spend at least some time in a nursing home, and that 5% of people over the

age of 65 are currently living in LTC, increasing to 24.5% of people over the age of 80,

and 50% of those over the age of 95 (Ortman et al., 2014). Anxiety in these settings is

quite common, therefore the demand for accurate and easy screening tools for clinicians

in these settings is paramount.

Results from the present study indicate good internal consistency for the GAS-

LTC, as demonstrated with high Cronbach’s alpha and McDonald’s omega coefficients.

This means that the items of the GAS-LTC are closely related and are likely all

measuring the same construct of anxiety. Item analysis of the GAS-LTC demonstrated
 32

that all items were moderately to strongly positively correlated to the total GAS-LTC

score, and that removal of one item from the scale did not significantly alter the reliability

coefficient of the scale. This indicates that all items are contributing meaningfully to the

total score, and that no one item is artificially inflating or deflating the total. Furthermore,

although all items are measuring the construct of anxiety, none of the item-total

correlations are exactly the same indicating that they are all measuring a different aspect

of the same construct. In short, the GAS-LTC appears to be an accurate measure of

different aspects or symptoms of anxiety for older adults in LTC settings. Furthermore,

reliability of the GAS-LTC was essentially the same for groups of high and low

subjective memory impairment. This adds further support for use of the GAS-LTC in

LTC settings, where cognitive impairment impacts a large majority of residents.

Reliability analyses also revealed that the GAI, GDS-15, and the PRMQ all

demonstrated good to excellent internal consistency in the present LTC settings.

Specifically, the GAI demonstrated excellent internal consistency. This is consistent with

previous research on the GAI (Gerolimatos et al., 2013) which found that the GAI was a

reliable and valid measurement of anxiety in nursing homes. The GAI had significantly

better internal consistency when compared to the GAS-LTC. This could be due to the

greater number of items on the GAI (20) compared to the GAS-LTC (10 items), as scales

with more items tend to have higher internal consistency. It may also indicate that the

GAI is a more reliable measure of anxiety for this population than the GAS-LTC.

However, the GAS-LTC has the advantage of being shorter and has a simpler language.

Therefore, when working with patients who have lessened ability for sustained attention

or substantial cognitive impairment, the GAS-LTC appears to be a good, quick

 33

alternative. Previous studies have found that the GDS-15 performance is variable across

nursing home samples (Li et al., 2015; Mitchell, Bird, Rizzo, & Meader, 2010). The

present findings add support for use of the GDS-15 in LTC settings when a shorter

assessment for depression is needed. The PRMQ also demonstrated good internal

consistency for the full scale as well as the subscales. The PRMQ had not yet been

validated for use in LTC settings prior to the current study, and these results provide

initial psychometric support for its use in these settings.

Convergent validity refers to the degree to which two measures that should be

related theoretically, are actually related. Convergent validity of the GAS-LTC was

confirmed using the GAI, as both of these instruments are designed to assess anxiety

among older adults. A strong positive correlation was observed, indicating that they are

strongly related as expected. Note however, that the measures do appear to tap some

different aspects of anxiety, as the shared variance was only 49%. The GAS-LTC

measure was derived from the full GAS measure, which was designed to capture several

different aspects of anxiety (i.e., somatic, cognitive, and affective; Segal et al., 2010),

whereas the GAI tends to focus primarily on worry symptoms. This may explain the large

amount of variance that is not shared between the two measures, despite their large

positive relationship. Convergent validity was also confirmed with a strong positive

correlation between the GAS-LTC and the GDS-15. Although the GDS-15 is a measure

of depression, anxiety and depression are overlapping constructs. As mentioned

previously, a number of studies have found positive correlations between anxiety and

depression (Sherbourne & Wells, 1997; Cairney et al., 2008; Hek et al., 2011; Clark &

Watson, 1991; Cummings, Caporino, & Kendall, 2014; Kessler et al., 2008), and anxiety
 34

and depression in later life often share the same etiological features. Therefore, it is

expected that a measure of anxiety would be strongly associated with a measure of

depression. The results of this study indicate that the GAS-LTC has good convergent

validity with anxiety and depression. This provides strong support for the validity of the

GAS-LTC for use as a screening measure of anxiety in LTC settings.

Divergent validity is the degree to which two measures that should not

theoretically be related are not, in fact, related. For this study, divergent validity was

evaluated using the PRMQ, as it was hypothesized that subjective memory impairment

would not be related to anxiety. However, this hypothesis was not supported, therefore

divergent validity for the GAS-LTC was not confirmed with the PRMQ. George (2001)

has found that concerns about memory are among the top contributors of anxiety for

older adults. Dementia related anxiety (DRA) is a fairly new concept, and recent studies

have found it to be pervasive, especially among older adults (Anderson, Day, Beard,

Reed, & Wu, 2009; Cantegriel-Kallen & Pin, 2012; Cutler, 2015). DRA is the worry that

one will develop, or is already developing, dementia. Older adults tend to be more

vigilant with memory errors, and these memory errors cause them significantly more

anxiety than the same memory errors cause young and middle age adults (Alladi, Arnold,

Mitchell, Nestor, & Hodges, 2006; Williams, Wasserman, & Lotto, 2003). It is

hypothesized that because the number one risk factor for dementia is age, older adults

view themselves as being at higher risk for developing dementia and consequently have

more anxiety concerning memory lapses (Williams et al., 2003; Kinzer & Suhr, 2016). It

is possible that although memory ability and anxiety are not necessarily related

constructs, the belief that one has significant difficulty with their memory (i.e. subjective
 35

memory impairment) may be related to anxiety, especially for older adults. Therefore, the

PRMQ may not have been an appropriate measure for divergent validity in this study.

This idea that subjective memory impairment may be related to anxiety was

supported by the results of this study. This was offered as an exploratory hypothesis,

based on previous research that memory can be a significant source of worry for older

adults (George, 2001; Kinzer & Suhr, 2016). Results of the current study found that mean

scores on the GAS-LTC were significantly higher for those who reported a higher

frequency of memory lapses on the PRMQ. These results are consistent with previous

research demonstrating that older adults who perceive themselves as having more

difficulty with memory also tend to have higher levels of anxiety (Kinzer & Suhr, 2001;

Warwick & Salkovskis, 1990; Williams et al., 2003). It is unclear from the results of this

study whether this is an increase in general anxiety, or anxiety primarily due to worry

about memory impairment, as the GAS-LTC is a screener for anxiety and does not assess

for specific types of anxiety.

Limitations

There are several important limitations of the current study. These include a

largely heterogeneous sample regarding race, ethnicity, gender, SES, partnership status,

and location, a modest sample size, and a lack of objective data on cognitive ability. As

for diversity in the sample, the majority of participants were Caucasian (93.9%). This is

likely due to the lack of diversity within the older adult population in the Colorado

Springs area, as well as the lack of diversity within the LTC settings chosen for this

study. Additional LTC settings had been contacted for participation in this research

project, though many declined. In addition to lack of racial and ethnic diversity, the
 36

majority of the sample identified as female. However, this may not necessarily be a

limitation, as this is reflective of the gender distribution found in most LTC settings.

Further studies with more male residents of LTC settings are clearly needed, as well as

analyses of the impact of gender of GAS-LTC scores. Additionally, while attempts were

made to include equal numbers of participants in assisted living and skilled nursing

facilities, this was not possible due to limited ability to collect data in skilled nursing

facilities, and therefore almost 90% of the sample was recruited from assisted living

facilities. In addition to low diversity in the sample, most participants reported minimal

anxiety, minimal depression, and minimal subjective memory impairment. While there is

a significant body of research indicating that anxiety and depression does tend to

decrease with age (Wolitzky-Taylor et al., 2010), many studies have still found that

anxiety and depression are prevalent and common in older adults (Wolitzky-Taylor et al.,

2010) and higher in LTC settings (Creighton et al., 2015). Therefore, these low levels of

anxiety and depression seen in this sample do not seem to be reflective of the true

prevalence of these conditions in LTC settings. It is possible that the participants who

participated in the study were disproportionately likely to have low levels of anxiety and

depression, as residents with higher levels may have been less likely to engage with a

researcher and participate in a research study. It is also possible that residents who were

administered the packet verbally, rather than reading it themselves, were less likely to

endorse high levels of anxiety, depression, or memory lapses. Researchers did not record

the number of subjects who were given the packet to complete themselves versus those

who were read the questionnaires verbally, therefore we are unable to analyze the effect

this might have had on participant answers.

 37

Another limitation is the modest sample size of this study. An a-priori G-Power

analysis was conducted and established a required sample size of 115, however the

current study was only able to recruit 66 participants. The small sample size indicates that

the study may have been underpowered to detect smaller effects. However, results of the

study were still largely significant, indicating that the effect size of the variables were

large enough to detect even when underpowered. Future studies with larger samples are

needed, especially in traditional nursing home settings with more impaired residents.

Finally, the study did not include an objective measure of cognition for

participants, relying on a self-report measure of memory impairment for information

about participants’ cognitive ability. While this measure provided rich information about

the impact of subjective memory impairment on participants’ anxiety levels, it did not

allow the researchers to draw accurate conclusions about the true cognitive capability of

participants. This is important when evaluating psychiatric conditions in the context of

LTC, as upwards of 65% nursing home residents have some form of cognitive

impairment (Department of Health and Human Services, Centers for Medicare &

Medicaid Services, 2013). Due to the majority of participants being in assisted living as

opposed to skilled nursing, it is possible that the cognitive ability of participants in this

study is higher than that within the true population of LTC settings. Including an

objective measure of cognitive impairment or mental status would have helped answer

this question and provide further information about the clinical utility of the GAS-LTC

for residents of all cognitive abilities.

 38

Future Directions

This was the first study to evaluate the psychometric properties the GAS-LTC,

therefore additional studies are needed to further evaluate the reliability and validity of

this new measure. Specifically, it is important for future studies to focus on evaluating the

reliability and validity of the GAS-LTC for use with more diverse samples. This sample

consisted of primarily Caucasian, non-Hispanic or Latino participants. Therefore, studies

focusing on the reliability and validity of the GAS-LTC among specific ethnic groups

would be beneficial for understanding the psychometric properties of this measure in

samples that are not predominantly Caucasian. Additionally, it is important for future

studies to evaluate the use of the GAS-LTC in a wider variety of LTC settings, as this

study had a majority of participants from assisted living and a small number from skilled

nursing. Other LTC settings such as skilled nursing facilities, acute rehab settings,

independent living, and memory care should be included in future studies on the

psychometric properties of the GAS-LTC.

Another possible direction for future research on the psychometric properties of

the GAS-LTC is to include samples with more variable levels of anxiety, depression, and

cognition. Specifically, the relatively low levels of anxiety in this sample made it difficult

to determine the clinical utility of the GAS-LTC. It is important to evaluate how the

GAS-LTC performs with patients who do have meaningful levels of anxiety. The low

levels of anxiety in this sample do not appear to be due to lack of measurement sensitivity

of the GAS-LTC, as GAI and GDS-15 scores were also disproportionately low. Future

studies may want to recruit participants who report higher levels of anxiety, or who have

been pre-identified as having higher levels of anxiety. This would help to create a more
 39

accurate scoring interpretation system for the GAS-LTC, as well as improve

understanding of how the GAS-LTC performs with patients who have more significant

anxiety. A larger proportion of participants with higher levels of anxiety and depression

would also add to understanding of the convergent and divergent validity of the GAS-

LTC and other related constructs, such as depression. Future studies may also want to

include a sample with more subjective memory concerns, as has been found to be a

significant source of anxiety for this population. It is possible that the participants in this

sample had very little concern about their memory and cognitive functioning, and

therefore had less anxiety and depression overall.

An especially challenging aspect of evaluating anxiety in older adults is the

overlap between somatic anxiety symptoms and physical problems due to aging. Future

studies should evaluate how this might impact scores on the GAS-LTC. This might be

done by gathering more information from participants about their possible complicating

medical diagnoses and ensuring that the answers they provide about symptoms of anxiety

are due to anxiety rather than a medical diagnosis, such as tremors or arthritis.

Furthermore, future studies should include an objective measure of participants’

cognitive ability. This study used the PRMQ in order to gain knowledge of participants’

own subjective evaluation of their memory ability and the possible impact this might

have on their anxiety, however it might be more clinically useful to evaluate cognition

more objectively, such as through the use of a mental state evaluation. This may shed

more light on the usefulness of this measure in settings with more impaired residents,

such as in memory care units or skilled nursing care.

 40

Conclusions

Results of the current study were mostly as expected, providing strong support for

the psychometric reliability and validity of the GAS-LTC. Reliability was not affected by

cognitive ability, though cognition was measured subjectively rather than objectively.

Despite a few limitations, such as limited diversity and modest sample size, this study

provides support for the use of the GAS-LTC in LTC settings, specifically in assisted

living and skilled-nursing facilities. This will be especially important, as people are

living longer and many are spending more time in LTC settings than ever before. Anxiety

is the most common mental disorder in older adulthood, and is common in LTC facilities.

However, it often goes undetected and untreated in these settings. The GAS-LTC may

help to remedy this problem, as it is a quick and easy to administer screen for anxiety. It

could be administered by anyone in contact with the residents in these settings and help

alert clinicians and staff to a potential anxiety disorder that warrants attention. The GAS-

LTC appears to be an accurate and reliable measure of anxiety in LTC facilities and can

be used as a go-to anxiety screen for clinicians working in these settings in order to help

better detect anxiety in their patients, leading to better detection, treatment and outcomes.

Further research and scrutiny certainly appear warranted.

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 48

APPENDIX A

GERIATRIC ANXIETY SCALE

Geriatric Anxiety Scale

Long Term Care Version (GAS-LTC)
© Daniel L. Segal, Ph.D., 2015

Below is a list of common symptoms of anxiety or stress. Please read

each item in the list carefully. Indicate whether or not you have
experienced each symptom during the PAST WEEK, INCLUDING TODAY
by checking under the corresponding answer, either YES or NO.

Yes No (0)
(1)

1. I was irritable or grumpy.

2. I felt detached or isolated from others.

3. I felt like I was in a daze or foggy-headed.

4. I had a hard time sitting still.

5. I could not control my worry.

6. I felt restless, keyed up, or on edge.

7. I felt overly tired.

8. My muscles were tense or tight.

9. I felt like I had no control over my life.

10. I felt like something terrible was going to happen to

me.
 49

APPENDIX B

IRB APPROVAL