International Psychogeriatrics (2016), 28:3, 423–433 

C International Psychogeriatric Association 2015

doi:10.1017/S1041610215001301

Anxiety symptoms in Korean elderly individuals: a two-year

longitudinal community study
...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Hee-Ju Kang, Kyung-Yeol Bae, Sung-Wan Kim, Il-Seon Shin, Jin-Sang Yoon
and Jae-Min Kim
Department of Psychiatry, Chonnam National University Medical School, Gwangju, South Korea

ABSTRACT

Background: Although late-life anxiety occurs frequently and is associated with higher morbidity, few
longitudinal studies have been concerned with the evaluation thereof. We investigated the prevalence,
incidence, and persistence of anxiety and related factors over a two-year period in community-dwelling
Korean elderly individuals.
Methods: A total of 1,204 Korean elderly individuals were evaluated at baseline, and 909 were followed up
two years later. The community version of the Geriatric Mental State Schedule was used to estimate anxiety
at both baseline and follow-up interviews. We defined “prevalence” as the rate of anxiety symptoms (for both
anxiety cases and sub-threshold anxiety) at baseline; “incidence” as the rate of anxiety symptoms at follow-up
in those without baseline anxiety symptoms; and “persistence” as the rate of anxiety symptoms at follow-up
in those with baseline anxiety symptoms. Associations between various covariates and anxiety status were
examined using multivariate logistic regression models.
Results: The prevalence, incidence, and persistence of anxiety symptoms were 38.1%, 29.3%, and 41.1%,
respectively. Prevalent anxiety symptoms were associated independently with female, rented housing, more
stressful life event and medical illness, physical inactivity, depression, insomnia, and lower cognitive function.
Incident anxiety symptoms were predicted by older age, female gender, depression, and insomnia; persistent
anxiety symptoms were predicted by older age, more medical illness, and baseline depression.
Conclusions: Since depression was associated with prevalent, incident, and persistent anxiety symptoms,
effective detection and management thereof is important in older adults to reduce anxiety. Furthermore,
preventive collaborative care should be considered, particularly for older, female, insomniac patients.

Key words: anxiety, depression, insomnia, aged, longitudinal study

Introduction their association with distress and medical illness

such as coronary heart disease, limited mobility,
In recent years, interest in the prevalence, course, and interference with daily activities (Wetherell
and etiology of mental disorders in later life has et al., 2003; Mehta et al., 2007). Although growing
grown, commensurate with current demographic evidence suggests that, in the absence of treatment,
aging. Late-life anxiety is highly prevalent, anxiety symptoms are unlikely to fully remit
surpassing the incidence rate of depression and (Schuurmans et al., 2005), it is estimated that
other mood disorders (Bryant et al., 2008). approximately 70% of older adults with mood and
Elderly anxiety disorder predicts increased physical anxiety disorders do not use mental health services
disability, memory difficulties, decreased quality- (Byers et al., 2012). Therefore, identifying anxiety
of-life, increased service utilization, and mortality in the elderly individuals is a concern for clinicians.
(Carrière et al., 2013). Sub-threshold anxiety Furthermore, identifying high-risk patients, and
symptoms that do not satisfy anxiety disorder improving the management of such individuals,
criteria are also important in older adults, given could increase well-being in older people.
In previous studies, the prevalence rate of
Corresponding should be addressed to: Prof. Jae-Min Kim, Department of late-life anxiety ranges between 1.2% and 52.3%
Psychiatry, Chonnam National University Medical School, 160 Baekseoro, (Bryant et al., 2008). In longitudinal studies, the
Dong-Ku, Gwangju, 501-746, South Korea. Phone: +82-62-220-6143; Fax: rate of incident anxiety and persistent anxiety
+82-62-220-2351. Email: jmkim@chonnam.ac.kr. Received 4 Mar 2015;
revision requested 29 Apr 2015; revised version received 17 Jul 2015; accepted was between 4.3% and 19.4% (de Beurs et al.,
24 Jul 2015. First published online 24 August 2015. 2000; Chou et al., 2011) and 16.3% and 58.6%

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 424 H.-J. Kang et al.
(de Beurs et al., 2000; Schuurmans et al., 2005),
respectively. Factors associated with elderly anxiety
disorder or symptoms have been investigated in
several cross-sectional and longitudinal studies,
with equivocal results. Poor physical health and
social support (living alone and/or infrequent social
contact), socio-demographic variables (female
gender, lower education status), and recent stressful
life events are associated with anxiety disorder
or symptoms (de Beurs et al., 2000), as are
chronic physical disease and functional limitation
(de Beurs et al., 2000; Smit et al., 2007).
However, the association between anxiety and
chronic disease and functional limitation was
not supported by a previous longitudinal study
(Schuurmans et al., 2005). In a recent review,
biological (chronic disease, functional limitation),
psychological (personality traits, inadequate coping
strategies, previous psychopathology), and social
(reduced social network, stressful life events) factors
were all associated with anxiety disorders and
symptoms in elderly patients (Vink et al., 2008), but
chronic disease and functional limitation were only
cross-sectionally associated with anxiety. However,
the studies included in the cited review, similar
to other, subsequent longitudinal studies, were
mainly conducted in Western countries. Only
two previous studies on late-life anxiety in Asian
countries (Vietnam and India; Prina et al., 2011;
Leggett et al., 2012) have appeared; these employed
cross-sectional design and a limited range of
predictors and culture-specific measures. Anxiety
disorder is among the most common mental
disorders in adult Asian population (Demyttenaere
et al., 2004). In one study, anxiety disorder
(6.2%) was rated as the second-most prevalent
mental disorder among Korean adults (Cho et al.,
2007), who exhibited a slightly higher prevalence
compared with other East-Asian countries (2.5–
5.3%; Demyttenaere et al., 2004). Therefore,
a comprehensive, longitudinal study on late-life
anxiety in Asian countries is required to identify
whether the risk factors for anxiety are similar to or
different from those of Western countries.
Using data from a longitudinal community study
of an older Korean population, we herein estimated
the prevalence, incidence, and persistence of anxiety
symptoms over a two-year period, and investigated
associated psychosocial factors.
Methods
Study overview and participants
This analysis is a component of a prospective
community-based study of late-life psychiatric mor-
bidity carried out in Gwangju, South Korea between
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2001 and 2003. The study has been outlined
previously (Kim et al., 2013). At baseline, com-
munity dwellers aged 65 years living within two
geographic catchment areas (one urban and another
rural) were systematically surveyed using national
registration lists, and were subsequently invited
to participate. No particular inclusion/exclusion
criteria were applied. All participants were
approached for follow-up after two years (mean
value ± SD interval: 2.4 ± 0.3 years). Anxiety
was evaluated at both baseline and follow-up; all
other data were gathered at baseline. All participants
for all examinations provided written informed
consent; moreover, we obtained written informed
consent from the family members of participants
with moderate-to-severe cognitive impairment. The
Chonnam National University Hospital Institu-
tional Review Board granted ethical approval.
Anxiety
The community version of the Geriatric Mental
State Schedule (GMS-B3) together with diagnostic
algorithm, the Automated Geriatric Examination
for Computer-Assisted Taxonomy (AGECAT)
were used to estimate baseline and follow-
up anxiety (Copeland et al., 1986). These are
structured diagnostic instruments used extensively
in international epidemiological research on older
age population. Anxiety patients were defined as
having the AGECAT scores of 3, intended to
correspond to clinical levels of anxiety warranting
clinical intervention. AGECAT scores of 1 or
2 were considered indicative of sub-threshold
anxiety, which would not routinely warrant drug
intervention, but was considered meaningful due
to its association with disability in elderly adults
(Prina et al., 2011).
Demographic, socio-economic, and clinical
characteristics
Data on the demographic, socio-economic, and
clinical characteristics potentially associated with
anxiety symptoms were collected (Vink et al.,
2008). The following variables were included in
the analyses: demographic factors such as age,
gender, living area (rural or urban), and marital
status (married or unmarried); socio-economic
factors, including years of education, housing status
(owned or rented), past occupation (manual or non-
manual), current occupation (employed or not),
monthly income (more or  US$200), stressful
life events, and social support deficits, and clinical
factors, such as the number of chronic medical
illnesses, physical inactivity, depression, insom-
nia, cognitive function, and drinking problem.
Home-based interviews were conducted, in which

data were obtained primarily from participants
and corroborated, where possible, by caregiver
reports to provide more accurate information. The
following stressful life events over the past year
(previously recognized as affecting late-life mood
and anxiety disorder; Prince et al., 1997) were
evaluated: serious illness (self or close relative),
bereavement (immediate family member or other
relative or close friend), marital separation, end
of a relationship, problem with a close friend or
relative, and theft or property loss. To calculate
total scores, positive responses were summed and
divided into four groups (0, 1, 2, 3+). Social
support deficits were estimated using the following
six binary variables (Prince et al., 1997): living
alone, seeing a relative for less than once a
month, seeing a friend for less than once a month,
having no close friends, seeing a neighbour for
less than once a month, and having no close
neighbours. Items were summed and classified into
four groups (0, 1, 2, 3+). The following common,
generally chronic medical illnesses were considered
(Lindesay, 1990): arthritis or rheumatism; eyesight
problems; hearing difficulty or deafness; persistent
cough; breathlessness, difficulty in breathing or
asthma; high blood pressure; heart disease or
angina; gastric or intestinal problems; faints or
blackouts; paralysis, weakness or loss of power
in one leg or arm; and skin disorders such as
pressure sores, leg ulcers, or severe burns. The
number of illnesses was summed and classified
into four groups (0, 1, 23, 4+). Daily physical
activity was estimated by measuring both work
and leisure activities, with “sedentary lifestyle”
serving as a binary variable. Depression was also
assessed using the GMS-B3 (Copeland et al., 1986)
with computerized algorithm (AGECAT); clinically
relevant depressive symptoms were quantified using
AGECAT scores on the basis of the conventional
3 confidence level, as per the anxiety assessment.
Insomnia was assessed by the following questions,
which were used in the previous publication (Kim
et al., 2009): (i) Do you experience any difficulties
falling asleep?; (ii) Do you experience any problems
remaining asleep, including early waking?; (iii) How
often do you experience these problems per week?;
and (iv) How long have these problems persisted?
Using these questions, insomnia was characterized
as difficulty in initiating or maintaining sleep for
3 nights per week for at least one month.
The Mini-Mental State Examination (MMSE)
was used to measure cognitive function (Folstein
et al., 1975), with participants subsequently divided
into three groups on the basis of their scores
(−20, 2124, 25+). In terms of lifetime alcohol
consumption data, problem drinkers were classified
as males taking more than 14 drinks per week, and
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Anxiety disorder in Korean elderly individuals 425
females taking more than seven drinks per week,
based on consumption during the previous three
months (National Institute of Alcohol Abuse and
Alcoholism, 1995).
Statistical analysis
Considering the importance of sub-threshold
anxiety later in life, a single category labeled
as “anxiety symptoms,” which combined anxiety
cases and sub-threshold anxiety, was analyzed
in our study, consistent with previous studies
(Wetherell et al., 2003; Prina et al., 2011). Three
dependent variables – “prevalence,” “incidence,”
and “persistence” – were included in analyses.
The prevalence of baseline anxiety symptoms was
estimated. We defined “incidence” as the rate of
anxiety symptoms at follow-up in those without
baseline anxiety symptoms, and “persistence” as
the rate of anxiety symptoms at follow-up in
those with baseline anxiety symptoms. Univariate
analyses of the three outcome measures were
initially performed, followed by multivariate logistic
regression models after adjusting for potentially
relevant factors (p < 0.05 in χ2 tests) in
the previously unadjusted analyses, to assess
independent association with the three dependent
variables. In the interest of including a broader
significance cut-off for inclusion in the multivariate
analysis and thereby allowing for “negative”
confounding, multiple comparison testing was not
considered in the analyses. Additional sensitivity
analyses were performed to investigate the risk
factors of anxiety patients separately. Analyses were
performed using the SPSS for Windows software
package (version 21.0; IBM Inc., New York, USA).
Results
Recruitment, follow-up, and anxiety
symptoms
The recruitment process and anxiety symptom
rates are summarized in Figure 1. We found
no difference between participants (n = 1,204)
and non-participants (n = 362) in terms of age
(mean value ± SD, 72.2 ± 5.9 years and 72.4
± 6.6 years, respectively; p = 0.302) or gender
(58% female of participants and 62% female of
non-participants) at baseline. Anxiety symptoms
(both anxiety cases and sub-threshold anxiety)
were present in 459 (38.1%) participants. At
follow-up, 909 (75.5%) participants were re-
examined. Compared with participants who were
not analyzed at follow-up (n = 295), the data from
the analyzed participants (n = 909) did not exhibit
baseline differences in terms of age (mean value
 426 H.-J. Kang et al.

Table 1. Changes in anxiety from baseline to follow-up (n = 909)

AT FOLLOW-UP (N, %)

SUB-
NO THRESHOLD ANXIETY
ANXIETY ANXIETY CASENESS
AT BASELINE (N = 602) (N = 231) (N = 76)
.....................................................................................................................................................................................................................................................................

No anxiety (n = 566) 400 (66) 128 (55) 38 (50)

Sub-threshold anxiety (n = 264) 168 (28) 78 (34) 18 (24)
Anxiety caseness (n = 79) 61 (6) 25 (11) 20 (26)

1566 inhabitants in registration lists

362 excluded
181 contact could not be established
71 refused to participate
55 no fixed abode
28 changed address
18 data insufficiency
9 died before the visit

1204 completed the baseline evaluation

459 had anxiety symptoms 745 had no anxiety symptoms

116 (25.3%) excluded 179 (24.0%) excluded

42 contact could not be established 60 contact could not be established
18 died 43 died
15 refused to participate 42 refused to participate
9 changed address 37 changed address
7 too unwell to participate 12 too unwell to participate
3 data insufficiency 7 data insufficiency

343 completed the follow-up evaluation 566 completed the follow-up evaluation

141 had persistent anxiety symptoms 166 had incident anxiety symptoms

Figure 1. Flow diagram for baseline recruitment and sample follow-up.

± SD, 72.4 ± 5.7 and 73.0 ± 6.9 years, evaluation (thus at the time of follow-up). Changes
respectively; p = 0.394), gender (58% female in anxiety symptoms during follow-up are presented
of follow-up participants and 59% female of no in Table 1. Anxiety symptoms were observed in
follow-up participants; p = 0.711), or prevalence 166 (29.3%) of the 566 followed-up participants
of baseline anxiety symptoms (39.3% and 37.7%, without baseline anxiety symptoms, and persisted
respectively; p = 0.626). A total of 307 (33.8%) in 141 (41.1%) of the 343 followed-up participants
of the 909 followed-up participants experienced with baseline anxiety symptoms. Anxiety cases
anxiety symptoms two years after baseline were present in 108 (9.0%) participants. Anxiety

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developed in 56 (6.7%) of the 830 followed-up
participants without baseline anxiety, and they
persisted in 20 (25.3%) of the 79 followed-up
participants with baseline anxiety.
Univariate associations with anxiety
symptoms
Table 2 shows the associations determined by
univariate analysis between baseline characteristics
and anxiety symptoms. The baseline factors
significantly correlated with prevalent anxiety
symptoms were increased age, female gender, urban
residence, unmarried status, no previous education,
rented housing, not in current employment,
lower monthly income, increased number of
stressful life events and social support deficits,
higher number of chronic medical illnesses,
physical inactivity, depression, insomnia, and lower
cognitive function. Incident anxiety symptoms (in
participants without baseline anxiety symptoms)
were significantly associated with the following
subsequent features: older age, female gender,
unmarried status, no previous education, increased
number of chronic illnesses, depression, insomnia
and lower cognitive function. Variables associated
with anxiety symptoms persistence (for participants
with baseline anxiety symptoms) included urban
residence, unmarried status, rented housing, not
in current employment, increased number of
stressful life events and physical disorders, physical
inactivity, and depression at baseline.
Multivariate associations with anxiety
symptoms
Multivariate associations between baseline char-
acteristics (simultaneously entered into regression
models) and anxiety symptoms, derived from
logistic regression models, are summarized in
Table 3. Baseline anxiety symptoms were sig-
nificantly associated with female gender, rented
housing, higher number of stressful life events
and chronic medical illnesses, physical inactivity,
depression, insomnia, and lower cognitive function
after adjusting for all covariates. Older age, female
gender, depression, and insomnia were significantly
associated with incident anxiety symptoms after
adjusting for all potential covariates. Persistent
anxiety symptoms were significantly predicted by
older age, chronic medical illnesses, and depression
after adjusting for all covariates.
Sensitivity analyses of baseline characteristics
and anxiety cases
Univariate associations between baseline char-
acteristics and anxiety cases exhibited baseline
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Anxiety disorder in Korean elderly individuals 427
features identical to those associated with anxiety
symptoms such as older age, female gender, urban
residence, unmarried status, no previous education,
rented housing, not in current employment, lower
monthly income, increased number of stressful life
events and social support deficits, higher number
of chronic medical illnesses, physical inactivity,
depression, insomnia, and lower cognitive function.
Incident anxiety cases were significantly associated
with physical inactivity and insomnia. Variables
associated with persistent anxiety cases included
urban residence, increased number of social
support deficits, and depression at baseline. Table 4
describes adjusted associations derived from logistic
regression models between baseline characteristics
(simultaneously entered into regression models)
and anxiety cases. Baseline anxiety cases were
independently associated with rented housing,
physical inactivity, depression, insomnia, and lower
cognitive function. Incident anxiety cases were
predicted by physical inactivity and insomnia,
whereas persistent anxiety cases were predicted
by rented housing, higher stressful life events,
and depression. In summary, factors associated
with anxiety cases were similar to those associated
with anxiety symptoms, although the number
of significantly associated factors was reduced
commensurate with lower statistical power.
Discussion
The major finding of this two-year longitudinal
community study of older people was that the
prevalence, incidence, and persistence rates of
anxiety symptoms (both anxiety cases and sub-
threshold anxiety) were 38.1%, 29.3%, and 41.1%,
respectively, compared with 9.0%, 6.7%, and
25.3% for anxiety patients. Furthermore, baseline
anxiety symptoms were independently associated
with female gender, rented housing, greater number
of stressful life event and medical illnesses, physical
inactivity, depression, insomnia, and lower cognit-
ive function, whereas incident anxiety symptoms
after two years were predicted by older age,
female gender, depression, and insomnia; persistent
anxiety symptoms were predicted by older age,
chronic medical illnesses, and depression. The rate
of late-life anxiety in South Korea was similar to
those found in Western studies, and Korean elderly
individuals with risk factors, such as rented housing
and physical inactivity, which were first evaluated
in South Korea, are more likely to be anxious.
Anxiety symptoms were highly prevalent in our
sample; the rate was in line with previous studies
conducted in Western countries (Smit et al., 2007;
Prina et al., 2011). In terms of the baseline
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428
Table 2. Univariate associations of baseline characteristics with prevalent, incident, and persistent anxiety

H.-J. Kang et al.

a b
PREVALENCE ANALYSIS INCIDENCE ANALYSIS PERSISTENCE ANALYSIS

SOURCE N ANXIETY (%) OR (95% CI) N ANXIETY (%) OR (95% CI) N ANXIETY (%) OR (95% CI)
........................................................................................................................................................................................................................................................................................................................................................................................................................................................

Total 1,204 38.1 566 29.3 343 41.1

Demographic factors
Age (years)
65–69 451 31.9 1.0 229 23.6 1.0 106 34.0 1.0
70–74 349 36.7 1.24 (0.92–1.66) 178 30.9 1.45 (0.93–2.25) 97 36.1 1.10 (0.62–1.96)
75–79 248 43.5 1.65 (1.20–2.26)† 107 31.8 1.51 (0.91–2.51) 88 54.5 2.33 (1.31–4.17)
80+ 156 50.6 2.19 (1.51–3.17)‡ 52 44.2 2.57 (1.37–4.81)† 52 42.3 1.43 (0.72–2.82)
Gender
Male 505 28.9 1.0 275 21.1 1.0 109 40.4 1.0
Female 699 44.8 1.99 (1.56–2.54)‡ 291 37.1 2.21 (1.52–3.21)‡ 234 41.5 1.05 (0.66–1.66)
Living area
Rural 746 34.5 1.0 387 29.5 1.0 205 35.1 1.0
Urban 458 44.1 1.50 (1.18–1.91)† 179 29.1 0.98 (0.66–1.45) 138 50.0 1.85 (1.19–2.87)†
Marital status
Married 698 32.8 1.0 368 24.7 1.0 170 34.7 1.0
Not married 506 45.5 1.71 (1.35–2.16)‡ 198 37.9 1.86 (1.28–2.69)† 173 47.4 1.70 (1.10–2.62)∗
Socio-economic factors
Duration of formal education
1+ year 630 34.0 1.0 312 24.4 1.0 157 36.3 1.0
0 year 574 42.7 1.45 (1.15–1.83)∗ 254 35.4 1.70 (1.18–2.45)† 186 45.2 1.45 (0.94–2.23)
Housing
Owned 1,096 35.8 1.0 541 29.0 1.0 294 38.4 1.0
Rented 108 62.0 2.94 (1.95–4.41)‡ 25 36.0 1.38 (0.60–3.18) 49 57.1 2.14 (1.16–3.94)∗
Past occupation
Non-manual 121 30.6 1.0 60 26.7 1.0 21 47.6 1.0
Manual 1,083 39.0 1.45 (0.97–2.17) 506 29.6 1.16 (0.63–2.12) 322 40.7 0.75 (0.31–1.83)
Current employment
Yes 542 30.4 1.0 301 27.9 1.0 128 32.8 1.0
No 662 44.4 1.83 (1.44–2.32)‡ 265 30.9 1.16 (0.81–1.66) 215 46.0 1.75 (1.11–2.76)∗
Monthly income (US$)
>200 433 33.0 1.0 215 28.8 1.0 105 41.0 1.0
<200 771 41.0 1.41 (1.10–1.80)† 351 29.6 1.04 (0.72–1.51) 238 41.2 1.01 (0.63–1.61)
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Table 2. Continued
a b
PREVALENCE ANALYSIS INCIDENCE ANALYSIS PERSISTENCE ANALYSIS

SOURCE N ANXIETY (%) OR (95% CI) N ANXIETY (%) OR (95% CI) N ANXIETY (%) OR (95% CI)
........................................................................................................................................................................................................................................................................................................................................................................................................................................................

Stressful life events

No 303 31.7 1.0 158 25.3 1.0 68 32.4 1.0
1 476 36.8 1.25 (0.92–1.70) 233 30.0 1.27 (0.80–2.00) 138 41.3 1.47 (0.80–2.71)
2 306 40.8 1.49 (1.07–2.08)∗ 136 29.4 1.23 (0.74–2.06) 91 41.8 1.50 (0.78–2.89)
3+ 119 52.9 2.43 (1.57–3.74)‡ 39 41.0 2.05 (0.99–4.27) 46 52.2 2.28 (1.06–4.93)∗
Social support deficit
No 363 35.3 1.0 177 25.4 1.0 104 34.6 1.0
1 505 32.9 0.90 (0.68–1.20) 271 29.9 1.25 (0.82–1.92) 126 39.7 1.24 (0.73–2.13)
2 223 42.6 1.36 (0.97–1.92) 88 33.0 1.44 (0.83–2.52) 67 49.3 1.83 (0.98–3.43)
3+ 113 61.9 2.99 (1.93–4.63)‡ 30 36.7 1.70 (0.75–3.84) 46 47.8 1.73 (0.86–3.51)
Clinical factors
Chronic medical illness
No 193 18.1 1.0 117 22.2 1.0 24 20.8 1.0
1 301 32.6 2.18 (1.41–3.38)‡ 163 27.6 1.36 (0.77–2.33) 75 32.0 1.79 (0.60–5.36)
2–3 450 40.7 3.09 (2.05–4.67)‡ 199 31.7 1.62 (0.96–2.75) 137 42.3 2.79 (0.98–7.91)
4+ 260 55.0 5.52 (3.19–8.57)‡ 87 36.8 2.04 (1.10–3.77)∗ 107 50.5 3.87 (1.35–11.13)∗
Physical activity
Active 852 30.2 1.0 454 27.5 1.0 199 33.7 1.0
3.12 (2.41–4.03)‡ 2.08 (1.34–3.23)†

Anxiety disorder in Korean elderly individuals

Inactive 352 57.4 112 36.6 1.52 (0.98–2.35) 144 51.4
GMS-Depression
No 1,044 31.3 1.0 547 28.5 1.0 245 33.7 1.0
Yes 160 82.5 10.34 (6.74–15.86)‡ 19 52.6 2.79 (1.11–6.98)∗ 98 61.2 3.20 (1.97–5.20)‡
Insomnia
No 879 31.9 1.0 448 23.4 1.0 203 36.9 1.0
Yes 325 55.1 2.62 (2.02–3.40)‡ 118 51.7 3.50 (2.29–5.33)‡ 140 47.1 1.52 (0.98–2.36)
MMSE-K
25+ 590 31.5 1.0 307 23.5 1.0 143 38.5 1.0
21–24 338 37.6 1.31(0.99–1.73) 172 34.3 1.70 (1.13–2.57)∗ 101 39.6 1.05 (0.62–1.77)
20- 276 52.9 2.44 (1.82–3.27)† 87 40.2 2.20 (1.33–3.63)† 99 46.5 1.39 (0.83–2.33)
Drinking problem
No 945 39.5 1.0 430 30.7 1.0 273 40.3 1.0
Yes 259 33.2 0.76 (0.57–1.02) 136 25.0 0.75 (0.49–1.17) 70 44.3 1.18 (0.69–2.00)

Notes: a Sample restricted to participants with no anxiety symptoms at baseline.

b Sample restricted to participants with anxiety symptoms at baseline.
WHODAS = World Health Organization Disability Assessment Schedule; GMS = Geriatric Mental State schedule, MMSE-K = Mini-Mental State Examination – Korean version.
∗ p < 0.05; † p < 0.01; ‡ p < 0.001.

429
 430 H.-J. Kang et al.

Table 3. Multivariate associations with prevalent, incident, and persistent anxiety. Data are ORs (95% CIs)
ASSOCIATIONS WITH ANXIETY SYMPTOM OUTCOMES

INDEPENDENT VARIABLE PREVALENCE INCIDENCE PERSISTENCE

............................................................................................................................................................................................................................................................................................................................

Demographic factors
Age (5-year increase) NS 1.32 (1.09–1.60)† 1.28 (1.03–1.59)∗
Gender (female) 1.42 (1.06–1.89)∗ 2.18 (1.47–3.23)‡ NS
Living area (urban) NS NS NS
Marital status (not married) NS NS NS
Socio-economic factors
Previous education (absent) NS NS NS
Housing (rented) 1.91 (1.19–3.07)† NS NS
Current employment (not employed) NS NS NS
Monthly income (<US$200) NS NS NS
Stressful life event (higher) 1.16 (1.00–1.34)∗ NS NS
Social support deficit (poorer) NS NS NS
Clinical factors
Chronic medical illness (more) 1.32 (1.43–1.52)‡ NS 1.45 (1.11–1.88)†
Physical activity (inactive) 1.77 (1.31–2.39)‡ NS NS
Depression (present) 6.52 (4.16–10.24)‡ 3.19 (1.21–8.44)∗ 2.86 (1.74–4.69)‡
Insomnia (present) 2.11 (1.57–2.82)‡ 3.78 (2.44–5.86)‡ NS
MMSE-K (lower) 1.24 (1.04–1.47)∗ NS NS

Notes: The categories in parentheses are the comparator categories.

MMSE-K = Mini-Mental State Examination – Korean version.
∗ p < 0.05; † p < 0.01; ‡ p < 0.001.

Table 4. Multivariate associations with prevalent, incident, and persistent anxiety caseness. Data are ORs (95%
CIs)
ASSOCIATIONS WITH ANXIETY CASENESS OUTCOMES

INDEPENDENT VARIABLE PREVALENCE INCIDENCE PERSISTENCE

............................................................................................................................................................................................................................................................................................................................

Demographic factors
Age (5-year increase) NS NS NS
Gender (female) NS NS NS
Living area (urban) NS NS NS
Marital status (not married) NS NS NS
Socio-economic factors
Previous education (absent) NS NS NS
Housing (rented) 2.22 (1.06–4.66)∗ NS 15.44 (1.73–137.64)∗
Current employment (not employed) NS NS NS
Monthly income (<US$200) NS NS NS
Stressful life event (higher) NS NS 6.80 (1.91–24.22)†
Social support deficit (poorer) NS NS NS
Clinical factors
Chronic medical illness (more) NS NS NS
Physical activity (inactive) 2.72 (1.68–4.41)‡ 3.21 (1.59–6.49)† NS
Depression (present) 11.04 (6.09–20.01)‡ NS 5.80 (1.20–28.07)∗
Insomnia (present) 3.23 (1.99–5.27)‡ 2.95 (1.40–6.19)† NS
MMSE-K (lower) 1.58 (1.18–2.11)† NS NS

Notes: The categories in parentheses are the comparator categories.

MMSE-K = Mini-Mental State Examination – Korean version.
∗ p < 0.05; † p < 0.01; ‡ p < 0.001.

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prevalence of anxiety symptoms, a recent systematic
review reported that prevalence of anxiety disorder
in community samples ranged between 1.2% and
15%; but the prevalence of symptoms was markedly
higher, ranging between 15% and 52.3% (Bryant
et al., 2008). Incident and persistent anxiety rates
have been reported in previous longitudinal studies
to be between 4.3% and 19.4% (de Beurs et al.,
2000; Chou et al., 2011) and between 16.3% and
58.6% (de Beurs et al., 2000; Schuurmans et al.,
2005), respectively. In spite of relative scarcity of
data on late-life anxiety (compared with depres-
sion), previous studies have suggested consistently
that anxiety is more prevalent than mood disorders
(Byers et al., 2012), although the prevalence
declines with age (Forlani et al., 2014). Our results
indicate that Korean elderly individuals experience
anxiety symptoms as frequently as do Caucasians.
However, considering the low prevalence of mental
illnesses (including anxiety disorder) in the adult
Korean population, based on a Korean epidemiolo-
gical study (Cho et al., 2007), our data suggest that
Korean elderly individuals are relatively more likely
to suffer from anxiety symptoms than Caucasians,
although direct comparisons are impossible because
of differences in the study design. The result can be
partially explained by the fact that South Korea has
the highest elderly poverty rate among the countries
of Organization for Economic Cooperation and
Development (OECD) due to rapid aging
population and an immature pension system
(OECD, 2013).
Baseline depressive symptoms were associated
with incident and persistent anxiety symptoms after
two years, and with baseline anxiety symptoms.
An association between depressive and anxiety
symptoms has been consistently reported in cross-
sectional studies. There are several plausible
mechanisms underlying the correlation between
anxiety and depressive symptoms: First, anxiety
and depression are highly comorbid in later life; in
previous studies, between 23% and 84% of elderly
individuals with a primary diagnosis of depression
also experienced anxiety, and 25–54% of those with
a primary diagnosis of anxiety also suffered from
depression (Prina et al., 2011). Furthermore, the co-
occurrence of anxiety and depression is frequently
associated with increased severity and a more
persistent course of disease (Andreescu et al., 2007).
According to such data, depression might be a risk
factor for the occurrence and persistence of anxiety
symptoms during two-year follow-up. Second,
certain criteria of depression (e.g. sleep, appetite,
and concentration disturbances) are also common
to anxiety. Thus, elderly individuals experiencing
depressive symptoms should be closely monitored
and offered appropriate treatment, considering their
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Anxiety disorder in Korean elderly individuals 431
prospective association with the occurrence and
persistence of anxiety symptoms (in addition to the
fact that depressive symptoms are distressing in and
of themselves).
Baseline anxiety symptoms were independently
associated with female gender, rented housing,
higher number of medical illnesses, physical
inactivity, insomnia, and lower cognitive function.
Our cross-sectional associations are similar to
those reported in a previous review (Vink
et al., 2008). Rented housing, a rarely examined
variable that serves as a proxy for low socio-
economic status (e.g. low income), was associated
with baseline anxiety symptoms in prior studies
(van Zelst et al., 2003).
Older age, female gender, and insomnia
predicted anxiety symptoms after two years,
whereas older age and chronic medical illness
predicted anxiety persistence during the two-year
period. Female gender was strongly and consistently
associated with the incidence of anxiety in the
elderly individuals in previous longitudinal studies
(de Beurs et al., 2000; Chou et al., 2011). Females
appear to be more prone to anxiety, attributed to
genetic and biological factors (such as hormonal
changes) and to psychological and social factors
(World Health Organization, 2001). Females may
also experience greater stress associated with social
roles and exhibit higher degrees of interpersonal
sensitivity and emotional involvement when facing
life’s adversities. Data on the association between
older age and anxiety incidence and persistence
are equivocal. Numerous cross-sectional studies
have suggested that anxiety prevalence decreases
in older age groups (Forlani et al., 2014), but no
such association was reported in several longitudinal
studies in spite of the existence of univariate
associations between older age and anxiety (de
Beurs et al., 2000; Smit et al., 2007). In contrast with
the findings of Western countries, Korean elderly
adults are more likely to experience the occurrence
and persistence of anxiety symptoms as they get
older. In our present study, insomnia predicted both
present and incident anxiety symptoms in elderly
individuals. To the best of our knowledge, this is the
first report of the longitudinal association between
insomnia and anxiety symptoms later in life. In
previous studies on adult populations, insomnia
increased the risk of future anxiety in line with
our data (Neckelmann et al., 2007). Insomnia is
common in older adults, with prevalence rates of
20–40% (Liu and Liu, 2005). Considering the
role of insomnia in predicting anxiety later in
life, insomnia in elderly individuals should not be
considered as part of the normal aging process;
rather efforts should be made toward detection
and management thereof. Our results contrast with
 432 H.-J. Kang et al.
those of a previous review (Vink et al., 2008) that
found chronic medical illness to be associated with
baseline and persistent anxiety. We postulated that
chronic medical illness might precipitate concern
regarding loss of independence later in life, thereby
leading to anxiety symptoms and their persistence
(Schulz et al., 2000). However, chronic illness
was not associated with an increased incidence of
anxiety symptoms in the present study (both of
which were highly prevalent in our sample).
Our study is the first to define factors predicting
the incidence and persistence of anxiety symptoms
in an older Asian cohort. The prevalence, incidence,
and persistence of anxiety symptoms in our cohort
were high, similar to the studies conducted in
Western countries. Furthermore, Korean elderly
adults who live in rented housing and who are
less active physically are more likely to be anxious;
neither of these factors was evaluated in previous
Western studies. Moreover, we used standardized
assessment scales; our follow-up rate of 75.5%
was adequate, and participants who were followed
up did not differ from those who were not
followed up with respect to the risk factors of
interest. However, our study also had several
limitations. First, anxiety measurement was limited
in nature, and specific anxiety subtypes were not
distinguished, limiting the inferences that can be
drawn from our data. Furthermore, the GMS
diagnostic instrument is less well validated in the
context of anxiety assessment than dementia or
mood disorder assessment (Copeland et al., 1986).
Nevertheless, the GMS has proven to be useful
in characterizing the psychopathology of anxiety,
including at sub-threshold levels (Prina et al.,
2011). Second, data on general physical health
and insomnia were evaluated based on self-report
measures. Medical records, including information
regarding mental health treatment, were not
available, and certain factors, such as personality
traits, were not included in the evaluation. However,
numerous other risk factors were evaluated, with
the determinants of anxiety symptoms identified
via multivariate analyses. Further studies evaluating
multidimensional risk factors are required because
anxiety is a complex disorder (Blay and Marinho,
2012). Third, we did not consider multiple
comparisons in the analysis, which may increase
the chance of type I error. However, we feel that
it is an acceptable practice to include a broader
significance cut-off for inclusion in multivariate
analysis to allow for “negative” confounding (i.e.
which obscures rather than exaggerates the effects).
Finally, our prospective analysis considered anxiety
symptoms to be an “incident” outcome – i.e. absent
on one occasion and present on another. Such an
approach has only a limited ability to reflect anxiety
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trajectories (although the approach is commonly
used in epidemiological research); for example,
episodes occurring and then disappearing between
examination points would not be included in the
analysis, which might result in underestimation of
anxiety incidence and persistence.
In conclusion, anxiety symptoms are common
in later life. As depressive symptoms are associated
with increased risks of both incidence and
persistence of anxiety, effective detection, diagnosis,
and treatment of depression are all clearly important
to reduce anxiety in elderly populations. Based on
these findings, further study is needed to examine
the reciprocal relationship between anxiety and
depression in later life. Furthermore, particularly
close monitoring of female, older age, and
insomniac patients is required due to their increased
risk of incident anxiety symptoms. Clinicians and
community-based social service providers should
seek to identify patients with anxiety, although
further research is required on the most feasible,
effective, and acceptable interventions.
Conflict of interest
Dr. J-M Kim has received research support from
the Ministry of Health & Welfare and National
Research Foundation of Korea. Drs. H-J Kang, K-
Y Bae, S-W Kim, I-S Shin, and J-S Yoon report no
additional financial or other relationships relevant
to the subject of this paper.
Description of authors’ roles
Drs. H-J Kang and J-M Kim conducted the data
analysis and drafted the paper. Drs. K-Y Bae, S-W
Kim, I-S Shin, and J-S Yoon Yoon helped to analyze
the data, draft the paper, and revise it critically. All
authors approved the final version of the paper to
be published.
Acknowledgments
This study was supported by a grant of
the Korean Health Technology R&D Project,
Ministry of Health & Welfare, Republic of Korea
(HI12C0003).
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