C International Psychogeriatric Association 2011 International Psychogeriatrics: page 1 of 8 doi:10.1017/S1041610211001505
Psychometric properties of the Spanish version of the Geriatric Anxiety Inventory .........................................................................................................................................................................................................................................................................................................................................................................
Mar´ıa M´arquez-Gonz´alez,1 Andr´es Losada,2 Virginia Fern´andez-Fern´andez2 and Nancy A. Pachana3 1
Departamento de Psicolog´ıa Biol´ogica y de la Salud, Universidad Aut´onoma de Madrid, Madrid, Spain Departamento de Psicolog´ıa, Universidad Rey Juan Carlos, Madrid, Spain 3 School of Psychology, University of Queensland, Brisbane, Australia 2
ABSTRACT
Background: The Geriatric Anxiety Inventory (GAI) was developed for assessing anxiety in older adults. The objectives of this work were: (a) to analyze the psychometric properties of the Spanish version of the GAI, and (b) to explore the associations between anxiety and other variables related to emotional distress (depression) and emotion regulation (rumination, experiential avoidance, and emotion suppression). Methods: Three-hundred-and-two people (75.5% female) aged 60 years and over living in the community participated in this study. Anxiety, depression, rumination, suppression and experiential avoidance were measured. Results: Three factors explaining 50.11% of the variance were obtained. The obtained internal consistency for the total scale was 0.91, with alphas ranging between 0.71 and 0.89 for the factors. Significant associations between all the GAI factors, the GAI total score, and depression, rumination, and experiential avoidance were found (all p < 0.01). Women reported higher scores than men for both the GAI total score and for all of the subscales. However, no significant gender differences were found between people with scores higher than the cut-off score for the GAI. Conclusions: The results of this study suggest that the Spanish version of the GAI displays good psychometric properties. Further, our data suggest that the scale can be recommended for measuring anxiety in non-clinical older Spanish persons, and may be a useful instrument to be used in research studies aimed at analyzing anxiety and its correlates among older adults. Key words: anxiety, assessment, elderly, factor analysis, emotion regulation
Introduction The number of studies aimed at analyzing anxiety in older adults has grown exponentially in the past two decades. Even though the prevalence rates for anxiety disorders are lower for this population group than for other age groups, the number of older persons suffering anxiety is far from negligible, and the available data demonstrate that these disorders are among the most prevalent psychiatric disorders in later life (Bryant et al., 2008). Even when there is significant overlap between anxiety symptoms of younger and older adults, some important differences exist, such as older adults being more likely to focus on the somatic aspects Correspondence should be addressed to: Mar´ıa M´arquez-Gonz´alez, Facultad de Psicolog´ıa. Departamento de Psicolog´ıa Biol´ogica y de la Salud. Universidad Auto´ noma de Madrid, Madrid, Spain, 28049. Email:
[email protected]. Received 15 Mar 2011; revision requested 6 Apr 2011; revised version received 14 Jun 2011; accepted 17 Jun 2011.
of their experience of anxiety, presenting higher comorbidity between anxiety and other mental (e.g. depression) or physical problems, and higher rates of subthreshold anxiety (Bryant et al., 2008; Wolitzky-Taylor et al., 2010). It has been suggested that prevalence estimates of anxiety in late-life based on available assessment measures and diagnostic criteria (which have been developed with younger adult samples) are likely to be underestimated (Carmin et al., 2000). Hence, limitations to the assessment of anxiety symptoms later in life may be related to the non-diagnosis or under-diagnosis of anxiety disorders among older adults (WolitzkyTaylor et al., 2010) The need for diagnostic instruments specifically developed for older adults has been highlighted by both clinicians and researchers, and the need to develop and validate screening measures in the Spanish language has been pointed out as a necessary first step towards the improvement of the
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care provided to older Spanish speaking persons (Diefenbach et al., 2004). One of the measures developed specifically for assessing anxiety in later life is the Geriatric Anxiety Inventory (GAI; Pachana et al., 2007). Good to excellent psychometric properties were obtained for the GAI, such as internal consistency indexes (Cronbach’s α) ranging from 0.91 to 0.93. A cut-off point of 10/11 was reported that allowed the correct classification of 83% of patients attending a psychogeriatric service who were diagnosed with Generalized Anxiety Disorder (GAD), with a specificity of 84% and a sensitivity of 75%. In support of its convergent validity, significant correlations with other measures assessing anxiety were also obtained. The GAI has been translated and validated in languages other than English. For example, Rozzini et al. (2008) validated an Italian version of the scale with an older sample diagnosed with mild cognitive impairment (MCI). This group reported good to excellent psychometric properties of the scale. In a study aimed at testing the psychometric properties of anxiety measures applied to older adults receiving home care services, the GAI showed the strongest psychometric properties (Diefenbach et al., 2009), including being the measure with the least frequently reported problems related to confusion and difficulty, and it was recommended as a screening measure. However, in the Diefenbach et al. study (2009), the GAI showed a weak divergent validity score when correlated with a measure of depressive symptomatology. With regard to GAI factorial structure, although Byrne and Pachana (2011) describe their scale as being unidimensional, they do not present any data on a factor analysis of the scale. The purported unidimensionality of this measure of anxiety contrasts with findings from previous studies using other measures of anxiety among older adults, which report on different dimensions of anxiety in this population (e.g. cognitive and somatic, in Kabacoff et al., 1997; cognitive, autonomic, neuromotor, and panic symptoms in Wetherell and Arean, 1997). Given the contrast between these findings and the unidimensionality assumed for the GAI, it seems evident that the analysis of the factorial structure of the GAI would contribute to a great extent to establish its psychometric quality. The already mentioned paucity in the available assessment measures for the study of anxiety in later life may partially explain the limited research conducted so far on psychological correlates of anxiety in older adults. With respect to this, there are some variables whose relationship with anxiety seem especially interesting, especially in light of their ability to improve our clinical understanding
and treatment of anxiety disorders in older adults. As mentioned above, empirical data clearly show that anxiety among older adults seems to be particularly related to depression. Also, there are data suggesting that anxiety may be associated, in the general population, with the use of specific emotion regulation strategies which seem to be particularly maladaptive, namely: rumination, experiential avoidance and emotion suppression. Although rumination has been analyzed for the most part in relation to depression, it also has been suggested to be characteristic of people with mixed anxiety and depressive symptoms (NolenHoeksema, 2000). With regard to experiential avoidance or the tendency to avoid contact with unpleasant or upsetting internal experiences (Hayes et al., 1996), it has been found to be a core mechanism in the development and maintenance of psychological distress in general, and anxiety disorders in particular, in the general population (Roemer et al., 2005). Older people reporting higher scores on experiential avoidance report lower scores on quality of life (Butler and Ciarrochi, 2007) and higher levels of anxiety (Andrew and Dulin, 2007; Robertson and Hopko, 2009). Emotion suppression, or the tendency to hide or inhibit the expression of positive and negative emotions, is highly related to experiential avoidance and is considered by some authors to be a component of this variable (e.g. Kashdan et al., 2006). This response-focused emotion regulation strategy has also been found to be significantly associated with higher levels of negative affect in the general population (John and Gross, 2004). Available empirical evidence on age-differences in the use of emotion suppression is mixed, with some studies finding that older adults use this strategy less frequently than younger persons (John and Gross, 2004) and other research revealing the opposite pattern (M´arquez-Gonz´alez et al., 2008). Considering all these variables together, very little is known regarding their role in the explanation of psychological distress in general, and of anxiety in particular, among older adults. Returning to the GAI, to our knowledge, no translation into the Spanish language, nor any validation of the scale in Spain, has been completed so far. Nor has a factor analysis of the scale been attempted, which could provide useful information for researchers and clinicians using this measure. The main objective of this work is to analyze the psychometric properties of the Spanish version of the GAI, including its reliability (internal consistency) and factorial validity, through an exploratory factor analysis of the scale. A second objective of the study is to explore the associations
Spanish version of the Geriatric Anxiety Inventory
between anxiety, as measured by the GAI, and other variables related to emotional distress (depression) and emotion regulation (rumination, experiential avoidance, and emotion suppression). These analyses will allow us to obtain relevant information on GAI criterion validity.
Methods Sample Three-hundred-and-two people (75.5% female) living in the community participated in this study. All the participants were 60 years of age or older, with a mean age of 71.68 years (SD = 6.85). The average number of years of formal education was 11.3 (SD = 7.14), and most of them were married (42.3%) or widowed (31.3%). All of them were recruited through cultural and social centers in Madrid, and freely agreed to participate in the study. Measures All the participants completed a questionnaire that covered the following set of variables, assessed by the scales described. ANXIETY – the Geriatric Anxiety Inventory (GAI; Pachana et al., 2007). The GAI consists of 20 dichotomous items measuring anxiety symptoms in older people (e.g. “I worry a lot of the time.”). Possible answers to these items are “agree” or “disagree”. This scale has displayed good to excellent psychometric properties in community and clinical populations, as well as with people with MCI (Pachana et al., 2007; Rozzini et al., 2008). The Spanish version of the scale was developed in collaboration with the authors of the original version. Only one significant adaptation was considered necessary due to cultural differences in expressing anxiety symptoms. Specifically, regarding the item “I often feel like I have butterflies in my stomach”, the reference to butterflies not being common in Spain, a similar expression is used referring to ants (“A ´ menudo siento hormigueo en mi estomago”). DEPRESSION – the Center for Epidemiological Studies - Depression scale (CES-D; Radloff, 1977; Spanish validation by Losada et al., 2008), a 20item scale whose items assess depressive symptoms that participants might have felt during the past week (e.g. “I felt sad”). Responses can range from 0 “rarely or none of the time (less than 1 day)” to 3 “most or all of the time (5–7 days)”. The CES-D was found to be a good indicator of anxiety in the Longitudinal Aging Study – Amsterdam (Beekman
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et al., 2000). The internal consistency (Cronbach’s α) found for this scale in this study was 0.87. RUMINATION – the short version of the Ruminative Responses Scale (RRS-reduced version; Jackson and Nolen-Hoeksema, 1998; Spanish validation by Losada et al., 2008). It is a ten-item scale that assesses self- and symptom-focused responses to sadness and distress (e.g. “I think about how sad I feel”). Scores range from 0 “never” to 3 “always”. The internal consistency found in this study was 0.91 (Cronbach’s α). EXPERIENTIAL AVOIDANCE – the Acceptance and Action Questionnaire (AAQ; Hayes et al., 2000; Spanish validation by Barraca, 2004). It has nine items (e.g. “When I feel depressed or anxious, I am unable to take care of my responsibilities”) that measure people’s unwillingness to remain in contact with particular private experiences (e.g. emotions), taking steps to alter the form or frequency of these experiences or the contexts that occasion them (Hayes et al., 1996). Response options range from 1 “never true” to 7 “always true”. The internal consistency (Cronbach’s α) found for this scale in this study was 0.62. SUPPRESSION – the suppression factor of the Emotion Regulation Questionnaire (ERQ; Gross and John, 2003; Spanish validation by M´arquezGonz´alez et al., 2008). It is composed of four items (e.g. “When I am feeling negative emotions, I make sure not to express them”) that measure a response that involves inhibiting ongoing emotion-expressive behavior (Gross and John, 2003). Responses were rated on a scale from 1 “strongly disagree” to 7 “strongly agree”. The internal consistency (Cronbach’s α) of this scale in this study was 0.77.
Procedure The Department of Psychology of the Universidad Rey Juan Carlos (Madrid) has established collaboration agreements with cultural and social centers for older persons within the Red Cross organization. In these centers, the users participate in several courses focused on literature, painting, the internet, etc. One of the aims of these agreements is to develop screenings of the mental health of the users in order to develop psychoeducational programs directed to their observed needs. During the courses, users were requested to participate by completing the assessment protocol. Two trained psychologists were present during the assessments and answered all the possible questions by the participants. The average time for the assessments was 30 to 40 minutes.
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Table 1. Factor loadings of the GAI items FAC TO R S COGNITIVE
AROUSAL
S O M AT I C
..........................................................................................................................................................................................................................................................................................................................
I worry a lot of the time (Me paso mucho tiempo preocupado) ´ I find it difficult to make a decision (Me resulta dif´ıcil tomar una decision) I often feel jumpy (A menudo me siento asustadizo) I find it hard to relax (Me resulta dif´ıcil relajarme) I often cannot enjoy things because of my worries (A menudo no puedo disfrutar de las cosas debido a mis preocupaciones) ˜ cosas me molestan mucho) Little things bother me a lot (Las pequenas I often feel like I have butterflies in my stomach (A menudo siento hormigueo en ´ mi estomago) I think of myself as a worrier (Me considero una persona preocupadiza) I can’t help worrying about even trivial things (No puedo evitar preocuparme por cosas triviales) I often feel nervous (A menudo me siento nervioso) My own thoughts often make me anxious (Mis propios pensamientos me hacen sentir ansioso) ´ I get an upset stomach due to my worrying (Tengo molestias de estomago debido a mis preocupaciones) I think of myself as a nervous person (Me considero una persona nerviosa) I always anticipate the worst will happen (Siempre anticipo que ocurrir´a lo peor) I often feel shaky inside (A menudo me siento tembloroso) I think that my worries interfere with my life (Creo que mis preocupaciones interfieren en mi vida) My worries often overwhelm me (Mis preocupaciones me sobrepasan con frecuencia) I sometimes feel a great knot in my stomach (Algunas veces siento un gran nudo ´ en mi estomago) I miss out on things because I worry too much (Me pierdo cosas porque me preocupo mucho) I often feel upset (A menudo me siento alterado)
0.741 0.477 0.372 0.606 0.677 0.477 0.752 0.677 0.517
0.374
0.415
0.748 0.359 0.744 0.697
0.622 0.373
0.401
0.708 0.431
0.582
0.733 0.694 0.489
0.360
Note: Items in Spanish are shown between brackets. Numbers in bold in each column represent items clustered to the corresponding factor. Items
