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        The prevalence and predictors of anxiety and depression in near-centenarians and centenarians: a systematic review
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Abstract

Background:

Current research on the psychological health of near-centenarians (95−99 years old) and centenarians remains limited. Existing studies have mainly characterized their physical, cognitive, and social health. Results on the anxiety and depression of near-centenarians and centenarians (more than 95 years old) have been mixed with some studies, finding higher rates of anxiety and depression among those older than 95 years and others reporting no difference in rates compared with younger age groups. This study aims to synthesize the existing literature on the prevalence and predictors of anxiety and depression in near-centenarians and centenarians.

Method:

A systematic review was conducted using Ovid Medline, Embase, PsycINFO, CINAHL, SCOPUS, and the Cochrane database. Common and conflicting findings among the literature were examined.

Results:

Thirty-eight studies met the inclusion criteria. Six studies examined the prevalence and predictors of anxiety, and 37 studies investigated the prevalence and predictors of depression. Five studies examined both anxiety and depression in the same sample. Prevalence data on anxiety and depression varied significantly, as did comparisons with rates in younger populations. Findings on predictors of anxiety and depression were contradictory.

Conclusion:

There is a large degree of heterogeneity among studies of centenarians’ psychological status. Findings conflict on the prevalence and predictors of anxiety and depression and rates compared with younger age groups. Variation in findings may result from the different inclusion criteria, sampling methods, and measurement tools. Better harmonization of centenarian study methodologies may improve consistency of findings to aid in developing clinical interventions.

Introduction

The number of near-centenarians (95−99 years old) and centenarians is rapidly expanding worldwide. For example, the number of centenarians has increased by 254% in Australia between 1995 to 2015 (Australian Bureau of Statistics, 2015), by 66% in the USA from 1980 to 2010 (Meyer, 2012), and by 56% in Europe in the past 5 years (Teixeira et al., 2017). However, research into the psychological health of the oldest-old is limited.

Near-centenarians and centenarians (older than 95 years) can provide a model of successful ageing. They are a heterogeneous population group and have demonstrated several characteristics to achieve exceptional longevity (Richmond et al., 2012). Centenarians have been categorized into three types, based on their route to reaching extreme old age: survivors, delayers, and escapers (Evert et al., 2003). Survivors are centenarians who have been diagnosed with a common age-associated disease before the age of 80 years; delayers are those diagnosed with a common age-associated disease between the age of 80 years and 100 years, and escapers are individuals who have reached the age of 100 years but have not been diagnosed with any age-associated disease. Exploring the physical, cognitive, social, and psychological resources associated with longer life and the variability in the health profile of population groups older than 95 years may provide critical insights into healthy brain ageing.

The psychological health of those older than 95 years is a major predictor of longevity (Jopp et al., 2016b). However, research on the mental health of this group has produced conflicting results, with some reporting lower rates of depression in centenarians than in the general population (Richmond et al., 2011), while others (Scheetz et al., 2012) reporting higher levels of depressive symptoms than octogenarians and sexagenarians. There have also been large variations in the estimates of the prevalence rates of anxiety: in Australia, 9.5% of centenarians reported anxiety symptoms (Richmond et al., 2011), whereas in Portugal, the prevalence rate was almost five times higher (Ribeiro et al., 2015).

This is the first systematic review to examine the prevalence and predictors of anxiety and depression in near-centenarians and centenarians across ethnoregional groups. A better understanding of the mental health of the oldest-old may help to guide interventional studies and ameliorate prevention of negative psychological health in this vulnerable population.

Method

The protocol for this review is registered in International prospective register of systematic reviews (CRD42018096606). This systematic review follows the guidelines by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher et al., 2015).

Search strategy

This review systematically searched the literature across Medline, Embase, PsycINFO, CINAHL, SCOPUS, and the Cochrane Database of Systematic Reviews. The search was limited from 1990 to July 1, 2018. This cutoff was selected based on demographic statistics, as there were an estimated 96,000 centenarians in the world in 1990, which enabled researchers to study this population with significant sample sizes (United Nations, 2015). Language was limited to English, and the search was limited to humans. Search terms (Medical Subject Headings [MeSH] and keywords) used were “centenarian*,” “oldest-old,” “95 years old and over,” “aged 95+,” “longevity,” “mental health,” “anxiety,” and “depress*” (see Appendix 1 for full search strategy). The search strategy was adapted for each database in consultation with a research librarian. The MeSH term “longevity” and keywords “aged 95+” were omitted from the SCOPUS search strategy, as it resulted in a large number of irrelevant results. Reference lists of eligible articles and relevant reviews were examined to increase the scope of the review.

Study selection

Articles were screened using a two-stage process. Initially, articles were screened using the title and abstract, based on eligibility criteria. Pertinent articles were screened by examining the full-text. Inclusion criteria were papers that implemented community-based or population-based sampling, investigated a study population of near-centenarians (older than 95 years) and/or centenarians, and measured anxiety and/or depression. Studies were excluded if they were qualitative studies, dissertations, single-case reports, conference abstracts, book chapters, editorials, and letters or did not specify how the psychological health of the participants was measured. Review papers, although excluded, were screened to ensure no relevant literature was missed. Studies that did not conduct analyses specifically on persons aged 95 years and older, had a small sample size (fewer than 15 participants), used a clinical sample, or only examined personality traits, were excluded.

Quality assessment

One reviewer (A.C.) assessed the quality and bias of studies by using a modified version of the Newcastle-Ottawa Quality Assessment Scale used by Herzog et al. (2013) (see Appendix 2). The scale is adapted from the Newcastle-Ottawa Quality Assessment Scale for cohort studies and is specifically modified for observational studies. This scale assesses studies based on three major categories: the selection of the study sample, the comparability between different outcome groups, and the objectivity of measuring the outcome. The modified version of the Newcastle-Ottawa Quality Assessment Scale for observational studies is a commonly accepted tool and has been utilized in systematic reviews on the association between polypharmacy and dementia (Leelakanok and D’Cunha, 2018), the impact of neuropsychological and neuropathological deficits on functional health in older adults (Overdorp et al., 2016), and the role of amyloid-β peptides as a mediator of the association between Alzheimer’s disease and affective disorders (Abbasowa and Heegaard, 2014).

Data extraction

Data collected from articles included study design, sampling method, geographical region, demographic information (mean age, age range, and number of participants), measurement tool utilized and reported cutoff points, and relevant outcomes measured (anxiety or depression). To ensure reliability, 20 papers were initially reviewed by two independent reviewers (A.C. and Y.L.) for full-text screening to verify the eligibility criteria. There was good agreement with a Cohen’s kappa coefficient of 0.773. Disagreements were solved by a third independent reviewer (F.H.). Remaining papers were examined by A.C. Figure 1 depicts the PRISMA flowchart of the study selection.

Figure 1. Flowchart of study selection using the inclusion and exclusion criteria.

Results

Thirty-eight studies were included in this review (see Figure 1). Six studies examined anxiety, 37 studies analyzed depression, and 5 studies examined both. The characteristics of included studies are summarized in Tables 1 and 2.

Table 1. Key characteristics of included studies that measured the prevalence and predictors of anxiety in near-centenarians and centenarians

Key: aAnxiety disorder = Generalized anxiety disorder or any phobic disorder; LEIPAD = Internationally Applicable Instrument; BSI = Basic Symptom Inventory; PEQOL = Profile of Elderly Quality of Life; DSM-III-R = Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised; GAI-SF = Geriatric Anxiety Inventory-Short Form, clinically significant anxiety symptoms ≥3; HADS = Hospital Anxiety and Depression Scale; K10 = Kessler Psychological Distress Scale, a score of ≥20 indicates clinically significant anxiety and depressive symptoms.

Table 2. Key characteristics of included studies that measured the prevalence and predictors of depression in near-centenarians and centenarians

Key: CESD = Center for Epidemiological Studies Depression Scale; GDS-15 = Geriatric Depression Scale Short Version, 15 items; MADRS = Montgomery Äsberg Depression Rating Scale; DSM-III-R = Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Forth Edition; LEIPAD = Internationally Applicable Instrument; BSI = Basic Symptom Inventory; PEQOL = Profile of Elderly Quality of Life; GDS-30 = Geriatric Depression Scale Long Version, 30 items; Zung DSI = Zung Depression Status Inventory; GDS-14 = Chinese Version of the Geriatric Depression Scale, 14 items; PGDS-14 = Portuguese version of the Geriatric Depression Scale, 14 items; HADS = Hospital Anxiety and Depression Scale; OBS = Organic Brain Syndrome Scale.

Prevalence and predictors of anxiety

Only four of the six studies examining anxiety provided prevalence rates, and these were discrepant. Ribeiro et al. (2015) found that 45.4% of centenarians presented clinically significant anxiety symptoms in Portugal. Richmond et al. (2011) reported a low rate of 9.5% among centenarians in Australia, and Fässberg et al. (2013) found even fewer anxiety disorders among Swedish near-centenarians, with a prevalence rate of 5.9%. Based on the Kessler Psychological Distress Scale (K10) measures, Sachdev et al. (2013) reported that Australian centenarians scored 15.03 on average and 18.7% of the sample had a K10 score of ≥20, which indicates clinical levels of anxiety and depressive symptoms.

The only study that compared anxiety symptoms in centenarians and other age groups and found no significant differences in anxiety symptoms between centenarians, the 75−85 years age group, and the 86−89 years age group was by Dello Buono et al. (1998).

Five studies examined the predictors of anxiety in centenarians. In Portugal, 48.8% of women reported clinically significant anxiety symptoms compared with 18.2% of men (Ribeiro et al., 2015). However, both Australian studies (Richmond et al., 2011; Sachdev et al., 2013) found no significant sex differences. Key predictive factors of anxiety were negative subjective health perception, poor objective health status, income inadequacy, and loneliness (Ribeiro et al., 2015). Only one study (Richmond et al., 2011) did not find any significant associations between anxiety and physical, social, or cognitive functioning.

Prevalence and predictors of depression

Twenty of the 37 studies on depression provided prevalence rates of depression. The prevalence rates varied considerably across the literature: some studies indicated that depression is not common among centenarians. Clinically significant depressive symptoms were reported only by 13.5% of centenarians in Australia, as measured by the Hospital Anxiety and Depression Scale (HADS) (Richmond et al., 2011), and by 12.8% in Italy, as measured by the 30-item Geriatric Depression Scale (GDS-30) (Tafaro et al., 2002). By contrast, around 20% of centenarians in the U.S.A. met the criteria for clinical depression (Jopp et al., 2016b) and 29% of participants indicated depression based on the 15-item GDS in Mexico (Pedro et al., 2017).

Of 14 studies that compared prevalence rates or depression scores between centenarians and other age groups, 7 reported higher depression scores or rates in centenarians than the younger age groups and 7 found no significant difference between age groups. For instance, the Umeå 85+ study suggested that the prevalence of depression in Swedish near-centenarians and centenarians was almost double than that in 85-year-olds (32.3% vs 16.8%) (Bergdahl et al., 2005). However, Cohen-Mansfield et al. (2013) found no significant difference in depression score between the old (75−84 years), the old-old (85−94 years), and the oldest-old (older than 95 years).

Thirty-one of the 37 studies investigated variables associated with depression in centenarians. Depressive symptoms have been positively associated with poorer rates of physical health (Tafaro et al., 2002), back and neck pain (Hartvigsen and Christensen, 2008), and frailty (Lau et al., 2016; Ribeiro et al., 2018). The effects of poor health on depressive symptoms may be mediated through subjective health, as a negative self-perception of one’s health may lead to lower mental well-being (Jang et al, 2004). Depressive symptoms are also positively correlated with high levels of care, such as assisted living or institutionalization (Kato et al., 2016; Margrett et al., 2010) and reported levels of neuroticism, vision impairment, and traumatic events (Margrett et al., 2010; Oseland et al., 2016; Toyoshima et al., 2018).

Fewer depressive symptoms in centenarians have been associated with a positive attitude towards life (Kato et al., 2016), better perception of economic resources (Garasky et al., 2012), higher quality of life (Richmond et al., 2011), and better functional health (Jopp et al., 2016b).

In most studies, sex was not a significant predictor of depression prevalence (Bergdahl et al., 2005; Pedro et al., 2017; Richmond et al., 2011). The correlation of depressive symptoms in centenarians with cognition is also controversial, with a negative correlation reported by Davey et al. (2013) but not by Margrett et al. (2010), even though the latter did find that poorer cognition was linked to depression in octogenarians.

Longitudinal studies have found that near-centenarians present more depressive symptoms over time (Ailshire et al., 2011). This increase may not be a result of age per se but rather due to the deteriorations in physical health and social and living situation. However, the study failed to account for selective attrition. Cohen-Mansfield et al. (2013) found that the decreases in psychological well-being over time occurred only when there were changes in physical health status or institutionalization.

Quality assessment

While 36 of the 38 centenarian studies on anxiety and depression obtained reasonable representations of the target populations and adequate sample sizes, 18 failed to report analyses comparing the characteristics of respondents and nonrespondents (Table 3). Most centenarian studies relied on self-report tools, which are susceptible to reporting bias, and few studies used clinicians to diagnose anxiety or depression, using a diagnostic manual such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD). Only some studies controlled for potential confounding factors such as sociodemographic characteristics when analyzing the predictors of anxiety and depression. When providing prevalence rates for anxiety and depression between different age groups, significance tests were not always performed.

Table 3. Critical appraisal of included studies using an adapted Newcastle-Ottawa scale for cross-sectional and longitudinal studies

Discussion

We found significant heterogeneity in the literature on the psychological health of near-centenarians and centenarians. Even among the three studies that investigated the prevalence of anxiety symptoms in centenarians, large discrepancies existed. The percentage of centenarians with anxiety symptoms was more than four times higher in Portuguese centenarians (45.4%) compared with Australian centenarians (9.5%) and Swedish centenarians (5.9%) (Fässberg et al., 2013; Ribeiro et al., 2015; Richmond et al., 2011). The largely varied results may have arisen from cross-cultural differences, as there appears to be generally high levels of anxiety and psychological suffering in Portuguese participants (Ribeiro et al., 2015). For instance, the prevalence of anxiety symptoms measured by the 12-item General Health Questionnaire was 39.4% in Portuguese participants aged 55 years and over (Ribeiro et al., 2011), which is higher than other estimates on this age group, which ranged from 1.2% to 14% internationally based on other assessment tools (Bryant et al., 2008). The variation in anxiety prevalence rates might also be due to methodological differences, as Ribeiro et al. (2015) utilized the Anxiety Inventory – Short Form (GAI-SF), whereas Richmond et al. (2011) used the HADS and Fässberg et al. (2013) employed the DSM, Third Edition, Revised (DSM-III-R), or due to the use of different sampling strategies.

Most studies on near-centenarians and centenarians reported that poorer physical health is associated with higher levels of depressive symptoms (Hartvigsen and Christensen, 2008; Jang et al., 2004; Tafaro et al., 2002; Toyoshima et al., 2018). Poorer physical health can circumscribe social interactions and physical activity, which may reduce mental well-being (Jang et al., 2004). In addition, better functional health appeared to be generally correlated with fewer depressive symptoms (Jopp et al., 2016b; Poon et al., 1992; Tafaro et al., 2002). Higher levels of function and mobility allow the oldest-old to have greater autonomy over their lives, which is important for good psychological health and a greater sense of control (Vallerand et al., 1989). A positive attitude toward life is associated with lower levels of depression in extreme old age (Kato et al., 2016), more positive coping strategies, greater psychological resilience, and an improved ability for the oldest-old to compensate for declines in physical health (Reichstadt et al., 2007).

Our findings are consistent with a previous review on depression in the elderly (Djernes, 2006), which reported that somatic illness and functional impairment were significant predictors of depression. However, Djernes (2006) studied populations aged 60 years and over, whereas our systematic review analyzed only near-centenarians and centenarians, and thus, comparisons should be treated with care.

It remains unclear how prevalent depression is in centenarians, with worldwide estimates ranging from 0.0% to 65.0% (Kato et al., 2016; Kiljunen et al., 1997). Possible reasons for the substantial variation in prevalence rates of depression are differences in methodologies and cutoff points, sampling strategies, age ranges, inclusion and exclusion criteria, and different health conditions of the populations examined. Fifteen measurement tools were used across the centenarian studies in this review to investigate depression: the GDS-30, GDS-15, GDS-14, Portuguese version of the Geriatric Depression Scale (PGDS-14), GDS-10, Center for Epidemiological Studies Depression Scale (CES-D), Hospital Anxiety and Depression Scale (HADS), Zung Depression Status Inventory (Zung DSI), K10 Psychological Distress tool, Montgomery Äsberg Depression Rating Scale (MADRS), Basic Symptom Inventory (BSI), Internationally Applicable Instrument (LEIPAD), Organic Brain Syndrome Scale (OBS), the Cambridge Mental Disorders examination, and the DSM-IV criteria, with each specifying different criteria to define depression. Furthermore, some of the measurement tools such as the K10 Psychological Distress tool may overestimate the prevalence of depression, as several items in the questionnaire focus on symptoms related to fatigue, which although prevalent in centenarians, do not necessarily indicate depression.

Few studies have been conducted on the best measures to assess depression in near-centenarians and centenarians. A review by Balsamo et al. (2018) suggested that the GDS-30 is the most effective self-report instrument in assessing depression in the oldest-old compared with other existing tools such as the CES-D, because it contains items specifically tailored to geriatric participants. However, most self-report tools fail to differentiate pseudodementia from depression and unipolar depressive symptoms from bipolar disorder symptoms (Balsamo et al., 2018). Although gold-standard clinical diagnoses using the DSM or ICD criteria are preferred and can be considered the most accurate measures of assessing depression, there is limited feasibility in large population studies, as significant labor and resources are required.

There are many limitations with the current literature on the psychological health of centenarians, in particular the methodological challenges of investigating the oldest-old population. Many studies are susceptible to the healthy volunteer effect, as centenarians who participate must be able to complete the rigorous assessment process. These participants are less likely to suffer from dementia or mild cognitive impairment, which reduces the generalizability of the findings. Owing to the cross-sectional design, it is difficult to distinguish whether comparisons made between centenarians and other age groups are due to cohort effects or age differences. Centenarian studies’ inclusion and exclusion criteria differ. For example, the Sydney Centenarian Study includes all individuals who are aged 95 years or above in seven local government areas in Sydney, whereas the Georgia Centenarian Study includes only those aged 98 years or older. Some studies also have the tendency to report mean scores on anxiety or depression scales without any interpretation of their significance. Finally, most measurement tools used to assess anxiety and depression are self-report, which are susceptible to reporting bias. More recent centenarian studies (Sachdev et al., 2013) synthesize self- and informant-reported data, which improve the reliability of the results.

This review is limited by the exclusion of studies that examined broader concepts of psychological health such as positive affect, life satisfaction, and personality traits and by the restriction to English-language publications. A strength of this review is our use of multiple databases and the rigorous search strategy to capture all apposite centenarian research on anxiety and depression.

Personality traits and clinical syndromes may overlap, but they differ in that clinical syndromes generally have symptoms of greater severity and are associated with more disability or distress, and personality traits are usually lifelong. While we concede that most studies reported scale scores with or without threshold cut points and that measures of disability, distress, and longitudinal course are absent, the use of high-threshold cut scores on scales (Cheung and Lau, 2016; Kiljunen et al., 1997) and clinical diagnoses using established criteria (Bergdahl et al., 2007; Fässberg et al., 2013) add weight to their being clinical syndromes.

We identified a substantial gap in the literature concerning the psychological health of centenarians. Fewer studies reported rates of anxiety compared with depression, and very few studies explored both anxiety and depression in the same centenarian sample. Only five specifically examined the prevalence or predictors of anxiety.

This review has significant implications for future research. Centenarian researchers should address the methodological points covered previously. Multiple facets of psychological health, such as apathy, as well as positive affect and life satisfaction, should be examined in addition to anxiety and depression (Cheng et al., 2019). Future studies should also investigate the relationship between depression and the number of medications, specifically psychotropic medications, levels of physical activity (Martin et al., 2012), levels of mental and cognitive activity, and perceptions of economic resources (Garasky et al., 2012). As this review found that many centenarian studies utilize different measurement tools, cutoff points, and inclusion and exclusion criteria, future research should be directed toward the establishment of an international consortium to harmonize variables across studies, for example, as performed by the International Centenarian Consortium – dementia (Brodaty et al., 2016). Use of similar criteria to measure anxiety and depression would facilitate cross-cultural comparisons. The role of biomarkers for depression (Strawbridge et al., 2017) is yet to be explored in this very old population. Identification of prevalence rates and contributing variables to psychological morbidity in the oldest-old can assist clinicians in planning services to ameliorate these distressing symptoms.

Conflict of interest declaration

H.B. is on the advisory board of Nutricia Australia.

Description of authors’ roles

A.C., Y.L., F.H. and H.B. contributed to the design of the review. A.C., Y.L. and F.H. reviewed the studies for inclusion and exclusion. A.C. completed data extraction and undertook the quality assessment of studies. All authors assisted in editing and writing the paper.

Supplementary material

To view supplementary material for this article, please visit https://doi.org/10.1017/S1041610219000802.

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