Journals of Gerontology: MEDICAL SCIENCES
Cite journal as: J Gerontol A Biol Sci Med Sci. 2014 November;69A(S2):S61–S67
doi:10.1093/gerona/glu178
© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America.
All rights reserved. For permissions, please e-mail: [email protected].
Anxiety Among Community-Dwelling U.S. Chinese
Older Adults
XinQi Dong,1 Ruijia Chen,1 and Melissa A. Simon2
2
1
Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, Illinois.
Department of Obstetrics/Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
Address correspondence to XinQi Dong, MD, MPH, Professor of Medicine, Nursing and Behavioral Sciences. Director, Chinese Health,
Aging and Policy Program, Associate Director, Rush Institute for Healthy Aging, Rush University Medical Center,
1645 West Jackson, Suite 675, Chicago, IL 60612. Email: [email protected]
Background. This study aimed to explore the prevalence and correlates of anxiety disorders and any anxiety symptoms among community-dwelling U.S. Chinese older adults.
Methods. Guided by a community-based participatory research approach, 3,159 community-dwelling Chinese older
adults in the Greater Chicago area were interviewed in person between 2011 and 2013.
Results. Of 3,159 older adults surveyed, 8.5% had anxiety disorders and 65.0% reported having any anxiety symptoms. Being female, unmarried, poorer health status, lower quality of life, and worsening health over the past year were
positively correlated with anxiety disorders and any anxiety symptoms. Living with fewer people and having fewer
children were only correlated with any anxiety symptoms and lower income was only correlated with anxiety disorders.
Conclusions. This study emphasizes that interventions for anxiety among Chinese older adults should give special
attention to older women, those who are unmarried, with impaired health status, and poorer quality of life. Further longitudinal studies should be conducted to better understand risk factors and outcomes associated with anxiety among U.S.
Chinese older adults.
Key Words: Anxiety disorders—Anxiety symptoms—Older adults—Chinese—Psychological health.
Received May 4, 2014; Accepted August 27, 2014
Decision Editor: Stephen Kritchevsky, PhD
A
nxiety is the most common mental illness among
U.S. adults, with an estimated 12-month prevalence
of 18.1%, of which 22.8% are severe anxiety disorders (1).
Anxiety may cause significant adverse personal and societal
outcomes. At the individual level, anxiety has been linked to
physical disability (2), declines in cognitive function (3), and
even suicidal ideation and mortality (4,5). At the societal level,
anxiety may increase medical utilization and health care costs
(6). According to a report on the economic burden of anxiety
disorders, the cost of anxiety disorders is about $42 million
per year—one third of the U.S. total mental illness bill (7).
Anxiety is a major health problem in late life, yet anxiety
symptoms in older adults are often undiagnosed and untreated.
A study with 713 men and 1,338 women in Kentucky found
that although 20% of participants aged 55 and older experienced a high level of anxiety symptoms, only 10% of them
acknowledged the need to seek mental health treatment (8).
Despite the magnitude of the issue among older adults, compared with other mental health issues such as depression and
dementia, anxiety has received significantly less attention
from researchers and the public (9,10).
Additionally, the majority of studies on anxiety among
older adults focused on the occurrence of disorders. Anxiety
disorders may be manifested by a combination of symptoms such as having constantly worrying thoughts or not
being able to sit at ease. Given that a diagnosis of anxiety
disorders may require several symptoms, participants who
endorsed one or more symptoms but did not meet the criteria for anxiety disorders may be excluded from the estimate
of prior studies. Such exclusion of subsyndromal presentations may lead to the underestimation of the issue of anxiety among older adults (11). It is imperative for community
epidemiology surveys to depict more accurate and comprehensive pictures of the extent of anxiety among older adults.
The prevalence, presentation, and expression of anxiety
differ significantly by social and cultural factors. Anxiety,
especially social anxiety, is common and more likely to
interfere with social relationships in collectivistic cultures,
where harmony is highly emphasized within family and
society (12). In addition, responses to anxiety may vary by
cultural and ethnic groups. The Chinese culture is distinctive in the great emphasis given to individual and family
“face value,” in which respect and reputation are critical
(13). Although anxiety may be regarded as personality disorders, Chinese older adults are often inclined to deny anxiety so as to protect family honor and save individual “face.”
S61
S62
Dong et al.
The tendency to deny symptoms or express anxiety symptoms as somatic symptoms such as pain or fatigue may add
to the complexity of detecting anxiety among Chinese older
adults. Despite possibly unique cultural patterns of anxiety,
the research on anxiety disorders and anxiety symptoms
among Chinese older adults, regardless of their place of
residence, is still in its infancy.
The prevalence of anxiety cannot be fully understood
without taking the immigration context into account.
Language and cultural barriers experienced in a new country
may increase intergenerational conflicts and breakdowns of
traditional support systems (14–16). Furthermore, living in
a conflict environment, financial strain, and separation from
family members and relatives in the home country may predispose U.S. Chinese older adults to greater risk for anxiety.
Over the past several years, the number of U.S. Chinese older
adults has grown rapidly, to an estimated 540,000 people age
60 years or older in 2010 (17). The vulnerability and the
growth in the population of U.S. Chinese older adults warrant
a deeper understanding of their psychological well-being.
The objectives of the study were to (i) understand the prevalence of anxiety disorders and anxiety symptoms among
U.S. Chinese older adults and (ii) explore demographic,
socioeconomic, family structure, and health-related correlates of anxiety disorders and anxiety symptoms among
U.S. Chinese older adults.
Methods
Population and Settings
Data of this study were collected from 2011 to 2013, as
part of the Population Study of Chinese Elderly in Chicago
(PINE). The PINE study is a community-engaged, population-based epidemiological study of U.S. Chinese older adults
aged 60 and older conducted in the Greater Chicago area. The
project was initiated by a synergistic community-academic
collaboration among the Rush Institute for Healthy Aging,
Northwestern University, and many Greater Chicago area
community-based social service agencies and organizations.
To ensure the study’s relevance to the well-being of the
Chinese community and increase community participation,
the PINE study was guided by a community-based participatory research approach. A community advisory board played
a pivotal role in providing insights for our research activities.
Board members were community stakeholders and residents
enlisted from more than 20 civic, health, and social advocacy groups and community centers and clinics in the city
and suburbs of Chicago. The board worked extensively with
the investigative team to develop and test study instruments
to ensure cultural sensitivity and appropriateness.
Study Design and Procedure
The research team implemented a targeted communitybased recruitment strategy by first engaging community
centers in the Greater Chicago area. More than 20 social
service agencies, community centers, health advocacy
agencies, faith-based organizations, senior apartments, and
social clubs served as the basis of study recruitment sites.
Community-dwelling older adults aged 60 and older who
self-identified as Chinese were eligible to participate in the
study. Out of 3,542 eligible older adults approached, 3,159
agreed to participate in the study, yielding a response rate
of 91.9%. Details of the PINE study design are published
elsewhere (18).
Trained multicultural and multilingual interviewers conducted face-to-face home interviews with participants in
their preferred language (English or Chinese) and dialect (eg,
Cantonese, Taishanese, Mandarin, and Teochew). Based on
the available data drawn from the U.S. Census 2010 and a
random block census project conducted among the Chinese
community in Chicago, the PINE study is representative of
the Chinese aging population in the greater Chicago area
(19). The study was approved by the Institutional Review
Board of the Rush University Medical Center.
Measurements
Sociodemographics.—Basic demographic information
including age (in years), years of education completed,
annual personal income (0–$4,999 per year; $5,000–$9,999
per year; $10,000–14,999 per year; $15,000–$19,999 per
year; or more than $20,000 per year), marital status (married, separated, divorced, or widowed), number of children,
number of grandchildren, years in the community, and
years in the United States were assessed in all participants.
Living arrangement was categorized into four groups: (i)
living alone, (ii) living with one person, (iii) living with two
to three persons, or (iv) living with four or more persons.
Overall health status, quality of life, and health changes
over the last year.—Overall health status was measured by
“In general, how would you rate your health?” on a 4-point
scale (1 = poor, 2 = fair, 3 = good, 4 = very good). Quality of
life was assessed by asking “In general, how would you rate
your quality of life?” also on a 4-point scale ranging from
1 = poor to 4 = very good. Health changes over the last year
was measured by “Compared to one year ago, how would
you rate your health now?” on a 3-point scale (1 = worsened, 2 = same, 3 = improved).
Anxiety.—We used the Hospital Anxiety and Depression
Scale-Anxiety (HADS-A) to assess anxiety among Chinese
older adults (20). Participants were asked if they currently experienced the following symptoms: (i) felt tense
or wound up, (ii) had a frightened feeling as if something
awful is about to happen, (iii) had worrying thoughts, (iv)
sit at ease and feel relaxed, (v) had a frightened feeling like
butterflies in the stomach, (vi) had feelings of restless, or
(vii) had feelings of panic. Respondents indicated answers
Anxiety Among U.S. Chinese Older Adults
to each item on a 4-point scale ranging from 0 (not at
all) to 3 (most of the time). The item “sit at ease and feel
relaxed” was positively worded and reversed code as most
of the time = 0, a lot of time =1, occasionally = 2, and not at
all = 3. Participants scored eight or higher were considered
as having anxiety disorders. In addition, the severity of anxiety disorders was categorized into three levels according
to their score: mild (8–10), moderate (11–14), and severe
(15–21). The HADS-A has been tested in Chinese populations and has shown good interrater reliability (21,22).
The standardized Cronbach’s alpha for the Chinese anxiety
measure in the PINE study was .80.
Data Analysis
We used univariate descriptive statistics to summarize
demographic, socioeconomic, family structure, and healthrelated characteristics of the PINE participants. Chi-square
statistics and/or t test were used to compare these characteristics between groups with and without anxiety disorders and
any anxiety symptoms. Pearson correlation coefficients and
Spearman’s rank correlation were calculated to determine
the relationships of the demographic, socioeconomic, family
structure, and health-related variables with anxiety disorders
and anxiety symptoms. All statistical analyses were undertaken using SAS, Version 9.2 (SAS Institute Inc., Cary, NC).
Results
Characteristics of PINE Study Participants by Any Anxiety
Symptoms
Of the 3,159 Chinese older adults surveyed, 58.9% were
women. Approximately 8.5% of the participants had anxiety
disorders. More specifically, 4.6% of the participants reported
mild anxiety disorders, 2.7% had moderate anxiety disorders,
and 1.1% had severe anxiety disorders. In addition, 65.0% of
participants reported having any anxiety symptoms.
Participant characteristics are presented in Table 1.
Compared with older adults without anxiety, those with
anxiety disorders were more likely to be female (74.0% vs
56.5%), widowed (32.7% vs 23.7%), with poorer health status (49.4% vs 15.9%), with poor quality of life (9.1% vs
2.6%), and with worsening health status (65.5% vs 40.3%).
Similarly, compared with those without anxiety symptoms,
a larger percentage of those with anxiety symptoms were
female (63.2% vs 50.9%), were widowed (26.0% vs 21.2%),
had 0–1 children (17.1% vs 11.7%), lived alone (22.8% vs
18.5%), had poorer health status (22.7% vs 10.8%), had fair
or poor quality of life (55.5% vs 37.2%), and had worsened
health status over the past year (46.6% vs 34.3%).
Presence of Symptoms of Anxiety
Table 2 presents the prevalence of each anxiety symptom.
Feeling tense or wound up was the most common anxiety
S63
symptom (29.7%), followed by having worrying thoughts
(26.7%), feeling restless (24.0%), having frightened feeling
like butterflies in the stomach (21.4%), having frightened
feeling like something awful is about to happen (19.1%),
sudden feelings of panic (16.5%), and inability to sit at ease
and relax (12.6%).
Prevalence of Symptoms of Anxiety by Self-reported
Health Status
Table 3 presents anxiety disorders and anxiety symptoms
by health status. The prevalence of anxiety disorders and
anxiety symptoms increased with poorer health status—
older adults with poor health status had the highest prevalence of anxiety disorders (22.4%) and anxiety symptoms
(80.5%). Similarly, the presence of anxiety disorders and
symptoms was high among those whose health status
worsened over the past year (disorders: 13.0%; symptoms:
72.6%). Anxiety disorders and symptoms were reported
by a higher percentage of older adults with fair (disorders:
11.6%; symptoms: 74.6%) or poor quality of life (disorders:
24.7%; symptoms: 73.2%) compared with older adults with
good or very good quality of life.
Correlations Between Anxiety and Demographic,
Socioeconomic, Family Structure, and Health-Related
Variables
Being female (r = .10, p < .001), lower income (r = .05,
p < .01), unmarried (r = .06, p < .001), poorer health status
(r = .21, p < .001), lower quality of life (r = .15, p < .001),
and worsening health status (r = .14, p < .001) were positively correlated with anxiety disorders.
Being female (r = .14, p < .001), unmarried (r = .07,
p < .001), living with fewer people (r = .05, p < .01), having fewer children (r = .04, p < .05), poorer health status
(r = .27, p < .001), lower quality of life (r = .22, p < .001),
and worsening health status (r = .15, p < .001) were positively correlated with having one or more symptoms of any
anxiety.
Discussion
The PINE study represents the first large-scale population-based epidemiological study of anxiety among community-dwelling U.S. Chinese older adults. We found that
anxiety was a significant mental health issue among U.S.
Chinese older adults, with 8.5% of participants reported
anxiety disorders and 65.0% of participants reporting one
or more symptoms. Being female, unmarried, poorer health
status, lower quality of life, and worsening health over the
past year were positively correlated with anxiety disorders
and any anxiety symptom. Living with fewer people and
having fewer children were correlated with anxiety symptoms only, whereas lower income was only correlated with
anxiety disorders.
S64
Dong et al.
Table 1. Characteristics of PINE Study Participants by Any Anxiety Disorders
Anxiety Disorders
Any Disorders
(N = 265)
Age, N (%)
60–64
57 (21.5)
65–69
61 (23.0)
70–74
48 (18.1)
75–79
47 (17.7)
80–84
27 (10.2)
85 and older
25 (9.4)
Sex
Male
69 (26.0)
Female
196 (74.0)
Education (y), N (%)
0
25 (9.5)
1–6
94 (35.6)
7–12
95 (36.0)
13–16
43 (16.3)
17+
7 (2.7)
Income (USD), N (%)
$0–$4,999
105 (39.8)
$5,000–$9,999
131 (49.6)
$10,000–$14,999
19 (7.2)
$15,000–$19,999
6 (2.3)
$20,000 and over
3 (1.1)
Marital status, N (%)
Married
164 (62.4)
Separated
7 (2.7)
Divorced
6 (2.3)
Widowed
86 (32.7)
Number of children, N (%)
0
18 (6.8)
1
34 (12.9)
2–3
136 (51.5)
4 and more
76 (28.8)
Living arrangement, N (%)
Living alone
62 (23.4)
1
106 (40.0)
2–3
39 (14.7)
4 or more
58 (21.9)
Years in the United States, N (%)
0–10
69 (26.2)
11–20
76 (28.9)
21–30
72 (27.4)
31 and more
46 (17.5)
Years in the community, N (%)
0–10
153 (58.2)
11–20
63 (24.0)
21–30
31 (11.8)
31 and more
16 (6.1)
Country of origin, N (%)
Mainland China
244 (92.1)
Others
21 (7.9)
Overall health status, N (%)
Very good
4 (1.5)
Good
41 (15.5)
Fair
89 (33.6)
Poor
131 (49.4)
Quality of life, N (%)
Very good
8 (3.0)
Good
66 (24.9)
Fair
167 (63.0)
Poor
24 (9.1)
No Disorders
(N = 2,866)
χ2
Anxiety Symptom
df
No Symptoms
(N = 1,050)
χ2
df
p Value
231 (22.0)
226 (21.5)
201 (19.1)
178 (17.0)
124 (11.8)
90 (8.6)
447 (21.8)
403 (19.6)
399 (19.4)
371 (18.1)
259 (12.6)
175 (8.5)
2
5
.83
755 (36.8)
1,299 (63.2)
516 (49.1)
534 (50.9)
44
1
<.001
.14
132 (6.4)
760 (37.1)
727 (35.5)
372 (18.2)
58 (2.8)
55 (5.2)
405 (38.6)
364 (34.7)
197 (18.8)
29 (2.8)
2.4
4
.67
.06
669 (32.8)
1,073 (52.6)
196 (9.6)
42 (2.1)
59 (2.9)
364 (34.9)
516 (49.5)
109 (10.5)
26 (2.5)
28 (2.7)
3.4
4
.49
.006
1,414 (69.4)
45 (2.2)
48 (2.4)
530 (26.0)
788 (75.4)
10 (1.0)
25 (2.4)
222 (21.2)
16.0
3
.001
.07
96 (4.7)
250 (12.2)
1,096 (53.4)
609 (29.7)
32 (3.1)
90 (8.6)
616 (58.7)
311 (29.7)
16.2
3
.001
.85
468 (22.8)
861 (41.9)
306 (14.9)
418 (20.4)
194 (18.5)
431 (41.1)
171 (16.3)
254 (24.2)
11.8
3
.01
.71
559 (27.3)
647 (31.6)
476 (23.2)
366 (17.9)
272 (26.1)
307 (29.4)
273 (26.2)
192 (18.4)
4.0
3
.26
579 (55.2)
270 (25.7)
128 (12.2)
72 (6.9)
5.4
3
.15
p Value
622 (21.7)
577 (20.1)
556 (17.6)
504 (17.6)
361 (12.6)
246 (8.6)
2.5
5
.77
1,247 (43.5)
1,619 (56.5)
30.4
1
<.001
162 (5.7)
1,079 (37.7)
1,007 (35.2)
531 (18.6)
80 (2.8)
930 (32.7)
1,480 (52.0)
290 (10.2)
62 (2.2)
84 (3.0)
2,056 (72.2)
49 (1.7)
67 (2.4)
674 (23.7)
110 (3.8)
306 (10.7)
1,596 (55.8)
851 (29.7)
608 (21.2)
1,197 (41.8)
440 (15.4)
620 (21.6)
771 (27.0)
877 (30.7)
690 (24.2)
518 (18.1)
6.9
9.0
12.5
7.1
0.79
1.39
4
4
3
3
3
3
Any Symptoms
(N = 2,054)
1,643 (57.5)
670 (23.4)
354 (12.4)
192 (6.7)
0.26
3
.97
1,205 (58.9)
455 (22.2)
252 (12.3)
135 (6.6)
2,661 (92.9)
205 (7.2)
0.22
1
.64
1,898 (92.4)
156 (7.6)
982 (93.5)
68 (6.5)
1.3
1
.25
<.001
68 (3.3)
589 (28.7)
930 (45.3)
467 (22.7)
71 (6.8)
490 (46.7)
376 (35.8)
113 (10.8)
151.3
3
<.001
<.001
110 (5.4)
804 (39.1)
1,069 (52.0)
71 (3.5)
105 (10.0)
554 (52.8)
34 (34.7)
26 (2.5)
98.7
3
<.001
135 (4.7)
1,050 (36.6)
1,226 (42.8)
455 (15.9)
208 (7.3)
1,311 (45.8)
1,273 (44.4)
73 (2.6)
187.6
71.7
3
3
S65
Anxiety Among U.S. Chinese Older Adults
Table 1. Continued
Anxiety Disorders
Any Disorders
(N = 265)
No Disorders
(N = 2,866)
Health changes over the last year, N (%)
Improved
28 (10.6)
Same
63 (23.9)
Worsened
173 (65.5)
246 (8.6)
1465 (51.1)
1,155 (40.3)
Anxiety Symptom
χ2
p Value
df
74.2
2
<.001
Any Symptoms
(N = 2,054)
190 (9.3)
907 (44.2)
956 (46.6)
No Symptoms
(N = 1,050)
χ2
df
p Value
82 (7.8)
608 (57.9)
360 (34.3)
53.2
2
<.001
Note: df = degrees of freedom.
Table 2. Presence of Symptoms of Anxiety
HADS-Anxiety Items
Tense or “wound up”
Frightened feeling, something awful is about to happen
Worrying thoughts go through my mind
Sit at ease and relaxed
Frightened feeling like “butterflies” in stomach
Feel restless as I have to be on the move
Sudden feelings of panic
Not at All (%)
Occasionally (%)
A Lot of Time (%)
Most of the Time (%)
2,201 (70.3)
2,531 (80.8)
2,259 (73.3)
395 (12.6)
2,458 (78.7)
2,370 (75.8)
2,610 (83.5)
760 (24.3)
377 (12.0)
58 (18.9)
153 (4.9)
524 (16.8)
431 (13.8)
290 (9.3)
132 (4.2)
173 (5.5)
162 (5.3)
758 (25.1)
85 (2.7)
242 (7.5)
174 (5.6)
40 (1.3)
51 (1.6)
81 (2.6)
1,793 (57.4)
58 (1.9)
85 (2.7)
53 (1.7)
Note: HADS = Hospital Anxiety and Depression Scale.
Table 3. Prevalence of Anxiety Disorders by Self-reported Health Status
Overall Health Status
Very Good
(N = 139)
Good
(N = 1,091)
Fair
(N = 1,315)
Poor
(N = 586)
N (%)
N (%)
N (%)
N (%)
Anxiety
Any Symptom
4 (29)
68 (48.9)
Quality of Life
Anxiety
41 (3.8)
Any Symptom
Anxiety
589 (54.6)
89 (6.8)
Any Symptom
930 (71.2)
Anxiety
Any Symptom
131 (22.4)
467 (80.5)
Very Good
(N = 216)
Good
(N = 1,377)
Fair
(N = 1,440)
Poor
(N = 97)
N (%)
N (%)
N (%)
N (%)
Anxiety
Any Symptom
8 (3.7)
110 (51.2)
Health Status Changes
Over the Last Year
Anxiety
66 (4.8)
Any Symptom
Anxiety
Any Symptom
804 (59.2)
167 (11.6)
1,069 (74.6)
Anxiety
Any Symptom
24 (24.7)
71 (73.2)
Improved
(N = 274)
Same
(N = 1,528)
Worsened
(N = 1,328)
N (%)
N (%)
N (%)
Anxiety
Any Symptom
Anxiety
Any Symptom
Anxiety
28 (10.2)
190 (69.9)
63 (4.1)
907 (60.0)
65.5 (13.0)
This study extends current knowledge of anxiety among
minority older adults. Our academic-community partnership and community engagement facilitated the design of
culturally and linguistically appropriate research methods
(23). Due to our community-based participatory research
approach, participants may have been more comfortable
conversing in their preferred dialects, more trusting of
research assistants, and more willing to express emotions
and acknowledge their feelings.
Different measurement and sampling methods employed
in other studies makes it difficult to make clear comparisons; nevertheless, the prevalence of anxiety disorders
among U.S. Chinese older adults found in this study
was comparable to that in other aging populations. In a
Any Symptom
956 (72.6)
population-based study of 61,349 older participants in
Norway using the HADS-A with the same cutoff point,
9.6% of the participants reported having anxiety disorders
(24). As for the scope of anxiety symptoms, our finding
showed that anxiety symptoms may be higher among U.S.
Chinese older adults than older adults in the general population. For example, in a study of 3,041 older adults aged
70–79 years old, 15%–43% reported anxiety symptoms as
assessed using the Hopkins Symptom Checklist (25). In
another study of 966 persons aged 78 and older, anxiety
symptoms were present in 24.4% of participants as assessed
with the Comprehensive Psychopathological Rating Scale
(26). This may be partly explained by daunting acculturation stress, intensive intergenerational conflicts, and poor
S66
Dong et al.
coping strategies as results of immigration. It should be
noted that we did not have specific age subgroup restriction cutoff points (aged 60 and older) for the assessment
of the anxiety symptoms, which could potentially explain
the higher prevalence of anxiety symptoms in our sample.
Comparisons of our findings with studies among other
Chinese populations could achieve a better understanding
of cultural influences on the prevalence of anxiety symptoms, but we are impeded by the scarcity of relevant data.
Hence, there is a great need for improving our understanding of anxiety symptoms among Chinese older adults.
In accordance with a wide range of prior studies (3,8),
this study demonstrates that both anxiety disorders and anxiety symptoms were more prevalent in older women than in
older men. Gender differences in anxiety may be explained
by various biological and psychosocial factors. Women
often assume the role of kin keepers and are more likely to
develop confiding relationships with people other than the
spouse (27). Given that older women are more embedded in
network relationships, they may be more prone to network
strains that increase the risk of anxiety symptoms. In addition, as influenced by patriarchal cultural values, Chinese
women are socially and economically subordinate to men
and may suffer from financial burdens and educational disadvantages that may increase the risk for experiencing anxiety. However, gender differences in prevalence of anxiety
should be interpreted with caution due to potential reporting
bias. Compared with men, women may be more emotionally expressive and, thereby, may be more likely to disclose
anxiety symptoms.
In our study, poor health status was correlated with
anxiety disorders and any anxiety symptoms. This lends
credence to prior studies that suggest close associations
between health status and anxiety (8,24). Lower levels of
self-reported health status may give rise to sleep disturbance, fatigue, and pain that may trigger worry and anxiety
among older adults. The inverse association between anxiety and health status also raises the possibility that anxiety
may cause poorer health status. We postulate that the presence of anxiety may be associated with lower compliance
to medical treatments, thus undermining health. In addition,
anxiety among our sample of community-dwelling older
adults may be related to fears of falling. Such fears of falling may be salient during icy weather in Chicago and prevent older adults from going outside. Their reduced social
interaction and physical activity may exacerbate anxiety
and affect health status.
This study should be interpreted with limitations. First,
our analyses did not consider the effects of comorbid
depression, but anxiety symptoms often occur with depressive symptoms among older adults. Future studies may need
to distinguish between correlates of pure anxiety symptoms
and anxiety comorbid conditions. Second, this study only
investigated the prevalence of the anxiety disorders and
anxiety-related symptoms among U.S. Chinese older adults
and future studies should examine more specific symptoms
corresponding with specific anxiety disorders, such as generalized anxiety disorders, social phobia, panic disorders,
and obsessive-compulsive disorders. Third, the study did
not explore important risk and protective factors such as
elder mistreatment and social support of anxiety among
U.S. older adults (28). Fourth, we do not have qualitative
data to further understand the social and cultural context of
anxiety. Last, this study utilized a cross-sectional design,
and we could not postulate temporal correlations. Future
longitudinal studies should be conducted to better examine
risk factors and outcomes associated with anxiety among
U.S. Chinese older adults.
Despite these limitations, this study has important research
and policy implications. The findings suggest a need for more
research to better understand the epidemiology of anxiety
among minority older adults. In addition to epidemiologic
investigations on prevalence and risk factors of anxiety, concerted efforts should be put into developing evidence-based
psychotherapy treatments such as cognitive behavioral therapy for minority older adults. Moreover, health care professionals should improve the detection of anxiety symptoms
among Chinese older adults and provide culturally sensitive
treatments. In this study, sociodemographic and health-related
characteristics were similar among those with disorders and
those with any symptoms, emphasizing that special attention
should be given to older women, those who are unmarried,
with impaired health status, and poorer quality of life.
Furthermore, community organizations should improve
awareness on anxiety in Chinese populations. Educational
workshops that focus on the knowledge and coping strategies of anxiety may be one way to improve awareness
among Chinese older adults. To reduce the access barriers
for mental health services, increased efforts should be given
to improving home-based mental health care, promoting
mental health navigation services and assuring language
assistance in clinic-based mental health services.
Conclusion
This study suggested that anxiety is a significant mental health issue among U.S. Chinese older adults. Being
female, unmarried, poorer health status, inferior quality of
life, and worsening health over the past year were correlated with having anxiety disorders and any symptoms of
any anxiety among U.S. Chinese older adults. Future longitudinal studies should explore risk factors and outcomes of
anxiety among U.S. Chinese older adults.
Funding
X.D. and M.S. were supported by National Institute on Aging grant
(R01 AG042318, R01 MD006173, R01 CA163830, R34MH100443,
R34MH100393, P20CA165588, R24MD001650, and RC4 AG039085),
Paul B. Beeson Award in Aging, The Starr Foundation, American
Federation for Aging Research, John A. Hartford Foundation, and The
Atlantic Philanthropies.
Anxiety Among U.S. Chinese Older Adults
Acknowledgment
We are grateful to Community Advisory Board members for their continued effort in this project. Particular thanks are extended to Bernie Wong,
Vivian Xu, and Yicklun Mo with the Chinese American Service League
(CASL); Dr. David Lee with the Illinois College of Optometry; David Wu
with the Pui Tak Center; Dr. Hong Liu with the Midwest Asian Health
Association; Dr. Margaret Dolan with John H. Stroger Jr. Hospital; Mary
Jane Welch with the Rush University Medical Center; Florence Lei with
the CASL Pine Tree Council; Julia Wong with CASL Senior Housing; Dr.
Jing Zhang with Asian Human Services; Marta Pereya with the Coalition
of Limited English Speaking Elderly; and Mona El-Shamaa with the Asian
Health Coalition.
References
1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters
EE. Lifetime prevalence and age-of-onset distributions of DSM-IV
disorders in the National Comorbidity Survey Replication. Arch Gen
Psychiatry. 2005;62:593–602.
2. Lenze EJ, Rogers JC, Martire LM, et al. The association of late-life
depression and anxiety with physical disability: a review of the literature and prospectus for future research. Am J Geriatr Psychiatry.
2001;9:113–135.
3. Bierman EJ, Comijs HC, Jonker C, Beekman AT. Symptoms of anxiety and depression in the course of cognitive decline. Dement Geriatr
Cogn Disord. 2007;24:213–219.
4. Coryell W, Noyes R Jr, House JD. Mortality among outpatients with
anxiety disorders. Am J Psychiatry. 1986;143:508–510.
5. Simon NM, Pollack MH, Ostacher MJ, et al. Understanding the link
between anxiety symptoms and suicidal ideation and behaviors in outpatients with bipolar disorder. J Affect Disord. 2007;97:91–99.
6. Wittchen HU. Generalized anxiety disorder: prevalence, burden, and
cost to society. Depress Anxiety. 2002;16:162–171.
7. Greenberg PE, Sisitsky T, Kessler RC, et al. The economic burden of
anxiety disorders in the 1990s. J Clin Psychiatry. 1999;64:1465–1475.
8. Himmelfarb S, Murrell SA. The prevalence and correlates of anxiety
symptoms in older adults. J Psychol. 1984;116(2d Half):159–167.
9. Beekman AT, Bremmer MA, Deeg DJ, et al. Anxiety disorders in later
life: a report from the Longitudinal Aging Study Amsterdam. Int J
Geriatr Psychiatry. 1998;13:717–726.
10. Flint AJ. Epidemiology and comorbidity of anxiety disorders in the
elderly. Am J Psychiatry. 1994;151:640–649.
11. Fuentes K, Cox BJ. Prevalence of anxiety disorders in elderly adults:
a critical analysis. J Behav Ther Exp Psychiatry. 1997;28:269–279.
12.Heinrichs N, Rapee RM, Alden LA, et al. Cultural differences
in perceived social norms and social anxiety. Behav Res Ther.
2006;44:1187–1197.
13. Hu HC. The Chinese concept of “face”. Am Anthropol. 1944;46:45–64.
S67
14.Dong X, Chang ES, Wong E, Simon M. The perceptions, social
determinants, and negative health outcomes associated with depressive symptoms among U.S. Chinese older adults. Gerontologist.
2012;52:650–663.
15.Dong X, Chang E, Wong E, Wong B, Skarupski KA, Simon MA.
Assessing the health needs of Chinese older adults: findings from
a community-based participatory research study in Chicago’s
Chinatown. J Aging Res. 2011;2010:124246.
16. Prina AM, Ferri CP, Guerra M, Brayne C, Prince M. Prevalence of
anxiety and its correlates among older adults in Latin America, India
and China: cross-cultural study. Br J Psychiatry. 2011;199:485–491.
17. U.S. Census Bureau. American FactFinder. 2010. http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml. Accessed November 20, 2013.
18.Dong X, Wong E, Simon MA. Study design and implementa
tion of the PINE study. J Aging Health. 2014 26:1085–1099.
doi:10.1177/0898264314526620
19. Simon M, Chang E-S, Rajan KB, Welch MJ, Dong X. Demographic
characteristics of U.S. Chinese older adults in the greater Chicago
area: assessing the representativeness of the PINE study. J Aging
Health. 2014;26:1100–1115.
20. Zigmond AS, Snaith RP. The hospital anxiety and depression scale.
Acta Psychiatr Scand. 1983;67:361–370.
21. Leung CM, Ho S, Kan CS, Hung CH, Chen CN. Evaluation of the
Chinese version of the Hospital Anxiety and Depression Scale.
A cross-cultural perspective. Int J Psychosom. 1993;40:29–34.
22. Lam CL, Pan PC, Chan AW, Chan SY, Munro C. Can the Hospital
Anxiety and Depression (HAD) Scale be used on Chinese elderly in
general practice? Fam Pract. 1995;12:149–154.
23. Dong X, Chang E-S, Wong E, Simon M. Working with culture: lessons learned from a community-engaged project in a Chinese aging
population. Aging Health. 2011;7s:529–537.
24. Mykletun A, Bjerkeset O, Dewey M, Prince M, Overland S, Stewart
R. Anxiety, depression, and cause-specific mortality: the HUNT study.
Psychosom Med. 2007;69:323–331.
25. Mehta KM, Simonsick EM, Penninx BW, et al. Prevalence and correlates of anxiety symptoms in well-functioning older adults: findings
from the health aging and body composition study. J Am Geriatr Soc.
2003;51:499–504.
26.Forsell Y, Winblad B. Feelings of anxiety and associated vari
ables in a very elderly population. Int J Geriatr Psychiatry.
1998;13:454–458.
27. Antonucci TC, Akiyama H. An examination of sex differences in social
support among older men and women. Sex Roles. 1987;17:737–749.
28. Dong X, Chen R, Chang ES, Simon M. Elder abuse and psychological well-being: a systematic review and implications for research and
policy—a mini review. Gerontology. 2013;59:132–142.