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PREVALENCE OF DEPRESSION WITH MEDICAL CO-MORBIDITIES AMONG THE ELDERLY

1Ajay krumar Singh, 2T. B. Singh, 3Sanjay Gupta, 4Jay Singh Yadav

Junior resident1, Professor3, Assistant Professor4 Department of Psychiatry, Professor Department of Biostatistics 2IMS, BHU, Varanasi, UP, India.

Abstract

Background-Depression is the most common psychiatric disorder among the elderly. The hallmark of depression in the elderly is its co-morbidities with medical illness.

Aim-To determines the prevalence of depression and its association with medical co-morbidities among the elderly in a rural & sub-urban community setting.

Methods-A cross sectional study design was used. A 15-item Geriatric Depression Scale questionnaire was used as a screening instrument.

Results-The overall prevalence of depression was 27.5%, with a higher prevalence among females (30.7%) as compared to males (23.9%). Depression was more prevalent in rural vs urban population (31.0% vs. 24.0%). Prevalence of depression was higher among elderly with medical co-morbidities (37.1%) compared to without medical co-morbidities (5.0%). Depression among the elderly was significantly associated stroke and hypothyroidism.

Conclusion-The prevalence of depression among the elderly with medical co-morbidities in the community is high. Primary care providers need to be vigilant when treating elderly patients in their care as depression is commonly found in this group.

Key words: Medical co-morbidities, Depression, Elderly, Prevalence.

 

Introduction

Depression is an affective illness characterized by symptoms such as disturbance in mood, cognition, and behavior 1. It is the most common psychiatric disorder among the elderly which can manifest as major depression or as minor depression characterized by a collection of depressive symptoms.2 It accounts more than half the psychiatric morbidity in Indian elderly3. It has been observed to be more common in immigrant population, females, low socio economic status, uneducated and unemployed4,5,6 With the growing number of elderly in the Indian population, the burden of depression is rising to be enormous on the society. Depression is commonly associated with many medical illnesses.7 It is also linked to increased morbidity and mortality as it can worsen underlying medical disorders.8Untreated depression in elderly is associated with a poor quality of life, difficulty with social and physical functioning and poor adherence to treatment.9 Various studies worldwide have reported increased disability, poor health care utilization and increased cost of health services among depressed individuals.10,11 Depression is an independent predictor of mortality in older adults. Depressive symptoms are a significant risk factor for cardiovascular as well as non-cancer, on-cardiovascular mortality.12Depression in elderly is an under diagnosed and under treated entity.9, 13 Symptoms of late onset depression like agitation, anxiety and irritability are often ignored by the primary care physician. The diagnosis of depression may be complicated by pain, cognitive impairment, and alcohol or substance misuse.6

The aims of the present study were (a) to determine the prevalence of depression with medical co-morbidities illness among the elderly (b) to determine the association of various risk factors with depression.

Materials and Methods

Study area: Out of 8 blocks of Varanasi district, a block was selected randomly (i.e. Kashividyapeeth) then a rural area (i.e. Tikari) and a suburban area (i.e. Sunderpur) were selected randomly. 

Research design Cross sectional descriptive research design was used.

Selection of subjects All elderly were sought out by house – to – house visit. All the persons of aged 55 years and over have been included in the study. Each who were agreed to participate in the study. The written informed consent was obtained from the respondents. And we excluded subjects who refused to participate, who are severely demented and/or were not available during visits. A structured interview schedule was prepared after an initial pre testing to assess the elderly.

Sample Size

Reliability of the estimates depends largely on the sample size and its representiveness of the target population. However resources and time availability for the study also play a very significant role in fixing the sample size. Thus one is forced to make a choice somewhat between the minimum and maximum sample sizes. It was prior decided to screen individuals of 25% of the total households in each of the study areas. Therefore, 200 households Total population of Varanasi is 3,682,194 as per latest provisional figures released by Directorate of Census Operations in Uttar Pradesh14. The population was 5,024 in Tikari as reported by Census 2011.Of the total population 13,706 in the area, taking the national average of 6.8% elderly (60 years and above), expected number of elderly came to be approximately 940. A total of 200 elderly comprised the study subjects, which is 21% of the elderly residing in that area.

Methodology A Comprehensive Geriatric Assessment was carried out from each participant including socio-demographic profile, medical history, and clinical examination by using Semi structured interview schedule (SSIS). A Semi structured interview schedule was prepared after an initial pretesting the social class of the subject was determined by modified Kuppuswamy’s Socioeconomic Status Scale suited equally for rural and urban subjects15, 16. Morbidities in major organ systems were looked for keeping in mind the common medical disorders in the elderly. A provisional checklist looking at the major organ systems included: hypertension, diabetes mellitus, stroke, arthritis, Cataract, Gastrointestinal, and hypothyroidism. These diagnoses were made by the physician based on the reported illness, clinical examination, and cross-checking of the medical records and the drug prescriptions. Depression & depressive symptoms were screened by using the Hindi version of the Geriatric Depression scale–15 items (GDS-15)17, 18, 19.The study was duly cleared by the Institutional Research and Ethics Committee.

Statistical analysis

Data collected were revised, checked, coded, tabulated, & introduced to PC for statistical analysis. All data manipulation and analysis were performed using the 16th version of SPSS (Statistical Package for Social Sciences). Statistical tests used included; Chai- square test with Yates correction, independent-sample T test and Pearson correlation.

Results

A total of 200 elderly (55 years or more) were enrolled in the study with 96 (48.0%) males and 104 (52.0%) females. 22 (11.0%) were between 55-60 years, 128 (64.0%) 61-70 years, and 35 (17.5.0%) 71- 80 years of age. The last group had 15 (7.5%) elderly more than 80 years of age. The mean age of the population studied was 69.75 ± 5.57 years. The minimum and the maximum age were 55 and 90 years respectively. Of the 200 subjects, 100 (50%) individuals had an urban background, 161 (80.5%) individuals were literate, 142 (71.0%) had a living spouse, 160(80%) elderly had a family support, 48 (24.0%) were employed, 131(65.5%) individuals had a joint family and 49(49.0%), 49(49.0%), 2(2.0%) individuals were in middle, lower and upper socioeconomic status. Study showed that the depressive disorder was more in individuals who had medical co-morbidities (37.1%) as compared who do not have medical co-morbidities (5%). The study also observed that 70% of the old population was suffering from medical Co morbidities.  (Table 1).

 

Table 1. Association of socio-demographic variables with the prevalence of depression

 

Socio-demographic

variable

Number of

subjects (n=

200) (%)

Number of

subjects with

depression (n=55)

Prevalence (%)

P value

Age group(yrs.)

55-60

22

(11.0)

3

13.63

c2  

=43.08

p < 0.001

61-70

128(64.0)

22

17.18

71-80

35(17.5)

17

48.57

>80

15(7.5)

13

86.66

Sex

Male

96(48.0)

23

23.95

z =1.078

p>0.05

Female

104(52.0)

32

30.76

Locality

Rural

100(100)

31

31.00

Z =1.109

p>0.05

Sub-urban

100(100)

24

24.00

Education

Illiterate

39(19.5)

21

53.8

Z =4.107

p<0.01

Literate

161(80.5)

34

21.11

Living spouse

Yes

142(71.0)

19

13.38

Z =6.997

P<0.001

no

58(29.0)

36

62.06

Economic status

upper

5(2.5)

1

20.00

c2  

=1.13

p>0.05

middle

128(64.0)

28

21.87

lower

67(33.5)

26

38.80

Occupation

Unemployed

152(76.0)

46

30.26

Z =2.557

P<0.01

Employed

48(24.0)

9

18.75

Family type

Nuclear

69(34.5)

11

15.94

Z =2.657

P<0.01

joint

131(65.5)

44

33.58

Family support

Yes

160(80.0)

43

26.87

Z =0.396

p>0.05

no

40(20.0)

12

30.00

Medical co-morbidities

Present

140(70.0)

52

37.1

 

absent

60(30.0)

3

5.0

 

Arthritis was found to be the most common medical illness (14.5%), followed by gastrointestinal dysfunction (13.0%), cataract (9.0%), hypertension (7.5), diabetes mellitus (5.0%), stroke (3.5%), and hypothyroidism (1.5%)  (Table 2) . 32 of the 200 (16.0%) elderly had 2 or more coexisting chronic medical diseases while the others had <2 medical disorders.

 

Table 2. Prevalence of depression according to number of medical co-morbidities.

Medical

Co-morbidities

 

No. of

subjects

(n=200)(%)

No. of

subjects with

depression

(n=55)(%)

Z & P value

Number medical

Co-morbidities

2 or more

32(16.0)

21(65.6)

Z =3.797

P<0.001

<2

108(54.0)

31(28.7)

Hypertension

yes

15(7.5)

6(4.0)

Z =1.127

p>0.05

no

185(92.5)

49(26.5)

Arthritis

Yes

29(14.5)

8(27.6)

Z =0.011

p>0.05

no

171(85.5)

47(27.5)

Diabetes

yes

10(5.0)

7(70.0)

Z =3.088

P<0.01

no

190(95.0)

48(25.3)

Hypothyroidism

Yes

3(1.5)

2(66.7)

Z =1.531

p>0.05

no

197(98.5)

53(26.4)

Stroke

Yes

7(3.5)

5(71.4)

Z =2.65

P<0.01

no

193(96.5)

50(26.0)

cataract

Yes

18(9.0)

4(22.2)

Z =0.526

p>0.05

no

182(91.0)

51(28.0)

Gastrointestinal dysfunction

Yes

26(13.0)

7(27.0)

Z =0.071

p>0.05

no

174(87.0)

48(27.6)

 

55 of the 200 elderly had scores 05 or more on the GDS-H-15. Thus the overall prevalence of depression among the elderly was 27.5%. More females were depressed (32 of 104; 30.7%) as compared to the males (23 of 96; 23.9%) although the difference did not reach statistical significance. Depression was more prevalent in the rural population (31.0%) in contrast to suburban population (24.0%). Illiterate individuals were more depressed (53.8%) than their literate counterparts (21.1%). Elderly with a living spouse perceived less depression (13.4%) than those who had lost their life companions (62.1%).Employed individuals experienced less depressive symptoms (18.75%) than unemployed (30.2%). Elderly staying with their children had a slightly lower evidence of depression (26.8%) than those staying alone (30%) (Table 1). The prevalence of depression was significantly more in elders suffering from 2 or more chronic diseases (65.6%) than those with <2 diseases (28.7%). This difference was highly significant statistically (p<0.001) (Table 2). Prevalence of depression was the highest among the stroke patients (71.4%), followed by hypothyroidism (66.7%), diabetes mellitus (30.0%), arthritis (27.6%), gastrointestinal dysfunction (26.9%), cataract (22.2%), and hypertension (6.7%)  (Table 2). When we looked at the number of medical morbidities in those depressed according to our screening method, the result was informative. We found that 21 of the 55 (38.2%) depressed individuals had 2 or more medical illnesses coexisting simultaneously, while 11 of 108 (10.2%) suffered from < 2 medical conditions. This difference was highly significant statistically (p<0.005) (Table 3).

 

Table 3. Prevalence of medical co-morbidities in depressed elderly.

Depression

 

Number of subjects (%)

 

Number of subjects with 2 or more physical problem (%)

 

p-value

 

Present

55(27.5)

21(38.2)

P<0.005

Absent

145(72.5)

11(10.2)

Discussion

In the total study population overall crude prevalence rate of depressive disorders was found to be 27.5% .The study findings were consistent with the observation made by  many authors who had determined the prevalence of depressive disorder in the elderly population to be 22.0%, 24.1%, 13.5%, 23.6%, 21.7% & 25.4% respectively. 20, 21,22,23,24,25 However, a high prevalence of depressive disorders of 52.2% among elderly ≥ 60years was observed in the study conducted in rural area of West Bengal 26. One study from the urban slums of Mumbai reported depression in up to 45.9% elderly6. In a systematic review, reported that the prevalence of depression varied from 2.8% -35% among the elderly population.27 Such broad differences may be due to multiple factors, including differences in diagnostic criteria, administrative procedures, assessment measures, sampling, and response rates, the age of the cohort, and gender ratios.

In our study, most of the study sample was in the age group of 60 to 70 years, followed by the age groups of 71 to 80 years and >80 years. This could be due to the fact that there will be a gradual decline in the number of persons surviving with increasing age (life expectancy – 63.4 years in India, according to 2002)28.  in another study which the youngest age group accounted for high sample size, with decreasing number of people with advancing age. The present study shows that there was an increasing trend in the prevalence of depression with increasing age with lowest (13.63%) prevalence in age group (55 -60) and highest (86.7%) in oldest old (>80yrs. age group) and this finding is statistically significant. large population based studies observed that there is a linear rise in self reported symptoms of depression with age.29,30This may be attributed to age- related decline in central serotonergic function, which might make older individuals more vulnerable to depression.

The results from our study reported higher prevalence in females (30.7%) as compared to males (23.9%). Several Indian community studies and their meta analysis reported higher prevalence of depression in women than men (20,21,22,24,31). In an extensive review32, the effect of gender was explained in terms of methodology (report bias - women being more apt to report symptoms), psychopathology (women being more vulnerable and more exposed to etiological factors) and socialization (women's conflicting and unrewarding roles in society).

In our study depressive disorders were found to be more in single (widow, widower , divorced and unmarried ) as compared to married .Many Indian community surveys were also consistent with our finding and had shown consistent association of depression with widowed and divorced marital status (6,20,21,22,32).

The present study found significant association of depressive disorder with lower socioeconomic status consistently in both rural and suburban area. This is consistent with Studies 21,35,33 which reported a significantly higher prevalence of depression in geriatric population belonging to the low socioeconomic status group compared to those in the middle and high income status. Some studies have shown that economic hardship is a significant cause of depression. Our data showed that there was a relationship in prevalence of depression with income and education. The association was however, found to be statistically non significant. It has also been shown that illiterate people have higher prevalence of depression compared to their more educated counterparts. Several studies had reported a significantly high prevalence of depression among individuals with lower level of education and among the unemployed individuals (6, 20, 21 ,22,32,33,34). The present study also observed similar findings. The association was however, found to be statistically significant (p=0.01).

Our study figures had higher rate of depressive disorder in rural (31%) population than sub urban (24%), but it was statistically insignificant. Murrell et al., (41) reported more depressive symptoms among older men in rural areas than in cities. The effect of urban living had been studied less widely. Our study reemphasizes that depression affects rural elderly more in comparison to their urban counterparts (35, 36).

Many studies done in subjects with depression have shown high level of co morbidity of both psychiatric and physical illnesses, especially in elderly individuals with depression (37, 38). On the other hand studies on the prevalence of psychiatric morbidity in medical disorders have shown that depression is quite prevalent in these conditions. The importance of detecting physical illnesses is even greater because medically associated depression have a different prognosis and management implications then others kind of depression. Commonly, the hallmark of depression in the elderly is its co morbidity with medical illness (33). The present study showed that the depressive disorder was more in individuals who had medical co-morbidities (37.1%) as compared who do not have medical co-morbidities (5%). The study also observed that 70% of the old population was suffering from medical Co morbidities. Previous studies from various parts of India had also shown that more than 50% of the old populations were suffering from one or more chronic diseases (3, 25, and 39). This is an important issue and we should think more about the quality of life of old people with chronic diseases.

The elderly often suffer from multiple chronic illnesses (3).The mean number of morbidities among elderly may vary from 2.5-6.1(3, 40) Depression is commonly associated with many medical illnesses and vice versa. The common medical illnesses associated with depression are cardiovascular diseases. (8, 13) end stage renal disease, diabetes, hypothyroidism, hyperparathyroidism, chronic obstructive airway disease, tuberculosis, Vitamin B 12 deficiency and cancer.8, 13,41. In the present study the prevalence of depression varied from 22.2%-71.4% in various medical illnesses.

In the present study, 65.6% of the elderly with 2 or more medical illnesses were depressed where as only 28.7% of elderly with <2 diseases were depressed. These results strongly indicate that depression is directly linked to the number of chronic medical illnesses. This positive correlation has also been examined in previous studies.42,43 This implies that depression should be positively screened for in elderly suffering from multiple medical morbidities. We have also observed that the vice-versa is also true.

In India although the social and family network is partly intact, there are still limitations in the care of aged. A qualitative study to investigate the concepts of late-life depression and dementia reveals that these could be attributed to abuse, neglect, or lack of love on the part of children towards a parent. Fear for the future and in particular 'dependency anxiety' was commonplace among elders.45 it is therefore the moral duty of the youth to improvise ways to resolve the conflicts and agony experienced by their parents. It has been observed that supportive relationships are associated with lower illness rates, faster recovery rates and better health care behavior.44, 45

Untreated late-life depression is associated with a poor quality of life, poor social interaction, physical disability, and poor compliance with treatment. Fortunately elderly persons respond to antidepressants and other therapies as well as the young. They should not be denied treatment because of the notion that it is natural condition of old age. A holistic approach to treatment including practice of yoga may benefit elderly with depression 46.

Conclusion

With this prevalence of depression among the elderly with medical co-morbidities, programs need to be implemented to help the elderly. This can be done through coordination with support groups in the voluntary sector to promote detection and treatment of depression in the elderly. Patients with medical co-morbidities especially stroke also need to be screened for early detection of depression.

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