Introduction

Anxiety disorders are the most common mental health problem across all age groups, including in later life. In both community and clinical settings, the prevalence of anxiety disorders amongst older adults varies, and is estimated to range from 1.2% to 17% and 1% to 28%, respectively [1]. Symptoms of anxiety and anxiety disorders, such as generalized anxiety disorder, may have onset in early life and persist throughout the life course, or can be of late onset [2, 3]. Anxiety disorders are more prevalent than depression in later life and can significantly disrupt an older adult’s health, leading to functional impairments, diminished social engagement, increased risk for cognitive impairment, and decreased overall well-being [4, 5].

There are notable barriers to detecting clinically important anxiety in older adults [5]. Despite its prevalence, anxiety in older adults is often overlooked or misattributed to aging (e.g., sleep disturbances, change in cognitive abilities), or conflated with other medical conditions and medication use [6]. Older adults who experience anxiety may exhibit diverse symptoms, ranging from generalized worry, apprehension, and restlessness to lesser recognized age-related concerns focused on health, disability and specific fears, like fear of falling [1, 6, 7]. Fear of falling is particularly pertinent as it can restrict mobility, reduce physical activity, and consequently heighten the risk of falls and related injuries [8]. While older adults (≥ 65) are more likely to correctly recognize the physical symptoms of anxiety, including restlessness and heart palpatations, they are less likely to correctly identify psychological symptoms comapred to younger adults [6, 9]. Furthermore, older adults may downplay psychological symptoms of anxiety and articulate them in different ways than their younger counterparts. Consequently, many older adults living with anxiety go undiagnosed or untreated [10]. This is important, because early detection and treatment of anxiety, either of new anxiety or with the purpose to reduce the intensity of existing anxiety, has been found to increase quality of life and prevent unfavourable outcomes [10].

One way to improve the detection of anxiety in older adults is to recognize those who may be at risk. This includes a need to identify those demographic, health, and psychosocial factors that can increase risk, or may be protective of anxiety and anxiety symptoms in this population. Previous reviews on these factors have provided valuable insights into the complex interplay between various determinants and the development or exacerbation of anxiety in older adults. However, many recent reviews have focused on specific anxiety disorders or have limited their scope to distinct subpopulations of older adults (e.g., those with specific chronic illness or cognitive decline). Given the breadth of literature, an overarching synthesis is needed to identify commonalities across these individual reviews and provide a more comprehensive understanding of the risk and protective factors for anxiety in older adults. Considering the large body of literature available, there is a need for a synthesis of this literature to identify commonalities in these factors for anxiety across older adult populations.

This rapid review of reviews responds to this gap by synthesizing findings from multiple systematic reviews to offer a high-level overview of patterns across diverse studies. This approach is valuable because it consolidates fragmented evidence, highlights areas of agreement and inconsistency, and addresses the limitations of traditional systematic reviews that often focus narrowly on specific disorders or populations. This review aims to support clinicians in more effective case finding and intervention for anxiety in older adults.

The aim of this review of reviews was to synthesize the available evidence on risk factors for anxiety in older adults. This rapid review was completed as part of the development of guidelines for the assessment and treatment of anxiety [11]. A rapid review is a sub-type of the systematic review in which some components are either simplified or omitted with the purpose of producing a synthesis of available evidence [12, 13]. This review was guided by the question, “What are the factors associated with anxiety in older adults?”

Methods

Our rapid review approach followed the recommendations outlined by Tricco et al. [13]. No protocol for this rapid review was registered. Streamlined methods used in this review included: limiting the literature search to peer-reviewed articles in 3 databases (PsycInfo, Embase, and Medline), no hand searching, limiting inclusion criteria to English and French language, and presenting results in a narrative summary. The Canadian Coalition for Seniors’ Mental Health Anxiety Guidelines working group guided the development of the research question, search terms, and extraction plan. This manuscript follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist (see S1 Table. PRISMA checklist).

Study selection

The database search was completed in February 2023 and updated in April 2024 (see S1 File. Search strategy and terms). The search strategy was developed in consultation with a health sciences librarian and informed by the clinical expertise of the authorship team. Published articles were included if: they were systematic reviews, specific to an older adult population, including if 80% of the studies include a sample aged ≥65 or results specific to older adults are presented separately, reported modifiable or non-modifiable factors associated with increased or decreased frequency of anxiety, and reported on anxiety disorders or symptoms of anxiety including fear or fear of falling. Studies were excluded from this review if: they were interventional or qualitative in nature, not specific to an older adult population, or reported on factors associated with mental health conditions that are no longer categorized as anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; e.g., post-traumatic stress disorder, obsessive compulsive disorder).

Screening and exclusion was completed by two independent reviewers using Distiller SR. Full-text articles were similarly reviewed by two independent reviewers. Disagreements were resolved through consensus and reasons for exclusion were recorded. A summary of study selection and PRISMA diagram is provided (Fig 1).

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Fig 1. PRISMA diagram.

https://doi.org/10.1371/journal.pone.0315185.g001

Results

Characteristics of included studies

Of the 27 reviews included in this rapid review, 10 included a meta-analysis (see Table 1). Many included reviews described the population of interest using an age-based definition (n = 14), including adults aged 60 and older (n = 12), or those that simply described their sample as “older adults” (n = 2). Further definitions of the sample included a focus on a specific disease or health condition, such as cognitive impairment or dementia (n = 2), or cancer (n = 4), while others had a geographical or location-based definition like residential care (n = 1) or a community-dwelling sample (n = 2). Most reviews focused on identifying factors associated with anxiety disorders or symptoms of anxiety (n = 19), while some focused on death anxiety (n = 2) or fear of falling (n = 8). However, these foci were not mutually exclusive.

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Table 1. Summary characteristics of the 27 reviews included in the rapid review.

https://doi.org/10.1371/journal.pone.0315185.t001

Risk and protective factors

In the 27 included papers, 77 unique risk and protective factors for anxiety and fear of falling were identified (see Table 2). These factors spanned diverse categories, including demographic variables, objective health measures, physical function outcomes, medication use, social and environmental factors, sleep outcomes, psychological, and neurological factors. While some of the 77 factors were only reported once in a single review, some commonly reported risk factors included: female sex (n = 9); functional limitations (n = 8); multimorbidity (n = 7); history of falls (n = 5); impaired balance (n = 5); pain (n = 5); cognitive impairment (n = 4); low self-rated health (n = 4); loneliness or social isolation (n = 5); low social support (n = 4); depression (n = 3); and sleep disturbance or insomnia (n = 3).

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Table 2. Synthesis of risk factors, protective factors, and factors reported to have no association with anxiety.

https://doi.org/10.1371/journal.pone.0315185.t002

In addition to these broad factors, there were a number of discrepant findings reported in the included reviews, with some of these factors overlapping with those which were commonly reported. This included age, cognitive impairment, the presence of functional limitations, including gait challenges, level of education, polypharmacy, worry about falls, and the presence of multiple chronic conditions. For example, in the reviews by Cheng et al. (2019), Ciuffreda et al., (2021), Creighton et al. (2017), and Silva (2022), age had no association with anxiety. Two studies of older adults with cancer found that older age was associated with less risk of anxiety (Lee et al., (2023); Parpa et al., (2015). Whereas in the reviews by Scheffer et al., (2008), Vo et al., (2023), and Xiong et al. (2024), older age was a risk factor for fear of falling, specifically.

Only one factor, older age, was described to be protective of anxiety in this population and was reported more than one time across the included reviews. Of the protective factors identified, many can be considered psychological factors, including life satisfaction, positive affect, positive attachment, better quality of life, and reporting meaning in life. There were also a number of spiritual or religious factors, including high spirituality, intrinsic religiosity, and religious affiliation that were reported to be protective of anxiety in this population.

Discussion

In this rapid review of reviews, we have comprehensively summarized a wide array of factors associated with anxiety and fear of falling in older adults, culminating in the identification of 77 unique risk and protective factors. These findings, particularly the number of factors as well as the discrepancies noted, underscore the multifaceted nature of anxiety in this demographic, shaped by demographic, health, environmental, and psychosocial influences. Contrary to common misconception, anxiety in older adults is not solely a consequence of aging, rather, it is influenced by a complex interplay of factors that demand nuanced consideration [43].

Anxiety and fear of falling in older adults may be present as a result of a combination of factors rather than one single factor. Female sex, functional limitations, multimorbidity, history of falls, impaired balance, pain, cognitive impairment, low self-rated health, loneliness or social isolation, low social support, depression, and sleep disturbance or insomnia were among those risk factors recurrently identified. These factors may heighten feelings of vulnerability and risk (e.g., loneliness, pain), amplify concerns about independence and ability (e.g., functional limitations, gait challenges), or even further intensify feelings of existing anxiety or fear of falling (e.g., sleep disturbance). These findings align with previous research and suggest that interventions for anxiety in older adults may need to target multiple domains of health and wellbeing.

Importantly, many of the factors identified can be considered modifiable. Considering that most older adults living with anxiety and anxiety symptoms have been doing so for most of their lives, understanding the ways that these multifaceted factors present is critical in designing comprehensive interventions and support systems that address the needs of this population. Integrative approaches focusing on social support, healthcare accessibility, behavioral modifications, and mental health management can significantly improve the well-being of these older adults.

Screening for anxiety is most effective when it is targeted at those older adults who are at a higher risk [3, 6, 11]. The presence of the factors described in this paper may prompt further consideration of a screening tool to support timely case finding or to further inquire about symptoms that meet diagnostic criteria. Recognizing and acting upon these factors through more fulsome assessment and testing can lead to tailored interventions that better support and enhance the mental health of older adults affected by anxiety [44]. Moreover, there’s a clear need for further research, employing standardized methodologies and assessments, to deepen our understanding of the intricate relationship between these multifarious factors and anxiety in older adults, enabling more targeted and effective interventions.

When considering the high prevalence of anxiety in older adults, acknowledging the multifaceted nature of anxiety and fear of falling in older adults presents an opportunity to promote equity, implement tailored and personalized biopsychosocial intervention, and foster a more holistic approach to well-being [6, 8]. One way to do this is to consider these broad and multifarious factors in the context of the social and structural determinants of health and the ways that these factors span various domains of life [45–47]. This includes socioeconomic factors (e.g., low income, level of education); psychosocial factors (e.g., marital status or living arrangement, social support, caregiving status), biological and genetic factors (e.g., age, sex, presence of chronic disease), and identity and experiential factors (e.g., experience of discrimination, racism, or sexism). While the biological determinants of health may continue to dominate in certain spaces, there is an opportunity for health and social care providers and professionals to act upon these social and structural determinants of health. A comprehensive understanding of the impact of these factors on health can ultimately result in more effective treatment, improved screening, and timely referrals [47]. There is a need for further research to explore upstream public health interventions that aim to address social and structural determinants of health, enhance protective factors, and prevent anxiety in older adults.

Conclusion

This rapid review provided a foundational step in the development of key clinical practice guidelines to treat and manage anxiety in older adults. Through identifying factors described as associated with anxiety and fear of falling in this population, this rapid review lays the groundwork for informed and targeted interventions. The comprehensive insights gleaned from the diverse range of risk and protective factors identified, provides valuable guidance for healthcare professionals, policymakers, and researchers. Future research should build on these findings by developing theoretical models that further explore the interplay between these factors and by testing interventions that address both clinical and social determinants of anxiety in older adults.

Supporting information

Acknowledgments

This review was completed as part of the development of a guideline for the assessment and treatment of anxiety in older adults. As such, the authors wish to acknowledge the Canadian Coalition for Seniors Mental Health.