Table 2 shows the prevalence of depression and/or anxiety among the elderly with different sociodemographic characteristics. By comparing depression, anxiety and mixed disorder groups with the normal group, the following was found: depression was significantly more common among women, the elderly with insufficient income or income from sons or social support, housewives and individuals belonging to lower social classes.
However, anxiety was significantly more frequent among women, in older age groups and among the married elderly. Regarding mixed disorder, it was significantly more frequent among older age groups.
Table 3 shows the association between depression and/or anxiety among the elderly with different clinical and psychological characteristics. The following was found on comparing depression, anxiety and mixed disorder groups with the normal group: depression was significantly associated with loneliness feeling, a partially independent functional status, a poor perceived heath status, the presence and the number of diagnosed comorbidities, a low (<50%) well-being index and being unsatisfied with family support, geriatric home working team support, and recreational activities.
Anxiety was significantly associated with loneliness feeling, the presence and the number of diagnosed comorbidities, a low (<50%) well-being index and being unsatisfied with family support, geriatric home working team support and recreational activities.
Mixed disorder was significantly associated with a partially independent functional status, a poor perceived heath status, a low (<50%) well-being index and being unsatisfied with family support, geriatric home working team support and recreational activities.
Table 4 shows the correlation results between depression and anxiety scores among the elderly with the studied quantitative variables. The depression score was positively correlated with the loneliness feeling score and the number of diagnosed comorbidities, whereas it was negatively correlated with the functional status score and some components of well-being scores (satisfaction scores with health, the standard of living, future security and spirituality or religion) and the well-being score.
The anxiety score was positively correlated with age and the number of diagnosed comorbidities, whereas it was negatively correlated with some components of well-being scores (satisfaction scores with the standard of living and safety feeling) and the well-being score.
Table 5 shows the results of the logistic regression analysis to test for significant predictors of depression, anxiety or mixed disorder. Age, sex, the marital status, education, occupation, income sufficiency, the social score, the functional status, comorbidities, and loneliness feeling were assessed in the three regression models. Regarding depression, an older age, female sex, insufficient income, a lower social class, a partially independent functional status, the presence of comorbidities and more frequent loneliness feeling were found to be significant predictors for the presence of depression. Regarding anxiety, an older age, being married or divorced, the presence of comorbidities and more frequent loneliness feeling were found to be significant predictors for the presence of anxiety. Regarding mixed disorder, an older age, a partially independent functional status and the presence of comorbidities were found to be significant predictors.
Depression and anxiety in the elderly are common problems that are often not diagnosed and consequently not treated 8. The co-occurrence of anxiety and depression in elderly patients is strongly associated with symptomatic overlap and frequent progression of anxiety to depression over time 17.
The prevalence of depression among our studied population was 37.5%. This figure matches other previous studies such as those of Shehatah et al.11, who reported 31.4% among 86 elderly participants in a suburban community in Egypt, and Wada et al.33, who reported 33.5% in their study on 5363 community-dwelling elderly. A low prevalence were reported in China and in Western Europe (3.9 and 12% consequently) owing to the difference in cultures as reported by a meta-analysis conducted by the University of Liverpool 34.
The prevalence of depression and combined depression with anxiety was 67.5% in this study. A similar high rate was also noticed in some Egyptian studies such as that of Hamza et al.35, who reported a rate of depression of 64% among 100 elderly patients recruited from the inpatient unit, Ain Shams University hospitals. In contrast, the study conducted by Abdul Rahman 15 including 168 elderly recruited from two geriatric homes found that 81% of their participants were suffering from depressive manifestations. This high prevalence can be explained by the difference in the age distribution as participants above 70 years of age constituted 42.3% of the sample. Also, a study in Alexandria reported a higher prevalence of depression among hospitalized elderly (79%) compared with institutionalized (36%) and community-dwelling (24%) elderly 12. Higher rates of depression among hospitalized inpatients may be explained by the fact that the patients may be depressed by being ill, being away from their families, being unable to work and facing a risk of death.
The prevalence of anxiety was 14.2% in this study. This is in concordance with Ritchie et al.36, who reported a rate of 14% among 1873 noninstitutionalized persons aged 65 years and above. The prevalence of anxiety and anxiety mixed with depression was 44.2%, which is in agreement with Kvaal et al.37, who reported a prevalence of 44%. A higher rate was reported by Abdul Rahman 15 (58.3%) owing to the age composition difference.
The co-occurrence of anxiety and depression in elderly patients is a true fact with very strong association between them as detected by Brenes et al.16. Our study demonstrated that 30% of the participants had the mixed form of anxiety and depression, whereas the study conducted by Abdul Rahman 15 reported a higher rate of 57.1%.
Similarities in some risk factors were detected among cases with depression, anxiety, and combined cases. This can also be explained according to Beekman et al.38, who reported that the categories of anxiety disorders, major depressive disorder, and major depressive disorder plus anxiety disorders represent the same disorder, but at a different level of severity or at a different stage of development. With respect to the severity, it was shown that anxiety disorders and major depressive disorder were very similar and that major depressive disorder plus anxiety disorders represented a group with more severe symptoms.
Age is a common predictor for depression, anxiety, and mixed form. This study revealed that the occurrence of depression and anxiety increases with age. This may be attributed to the fact that with increasing age, people experience a greater loss of physiological, psychological, and social functioning and become increasingly prone to mental disorders 12. Depression and/or anxiety manifestations commonly start at the age of 60 as it is the age of retirement in Egypt, and it is accompanied with a shrinkage of social activities and the role of the elderly in the community.
The presence of depression was found to be significantly related to the sex. This study revealed that women were more likely to experience such symptoms than men. This finding is in line with Shehatah et al.11, who reported a higher prevalence of depression among women compared with men (42.2 against 19.2%, respectively), and explained this by the fact that elderly women were more likely to be widows and living alone. Also, they have a lower level of education, are prone to financial difficulties and have poor social support, in addition to suffering from more chronic diseases. In contrast, the results reported by Abdul Rahman 15 revealed that male sex is a significant predictor for depression, and this was explained by the fact that 70% of the male participants were above the age of 70 years.
Being married was detected as a significant predictor for anxiety, and this can be explained by more worry that exists among them towards their spouse, who is usually elderly and suffer from chronic health problems. Added to this are the multiple role demands within a marriage. The current study found no association between the marital status and depression or mixed depression (depression and anxiety), and this was in contrast to other studies that demonstrated that a divorced/ separated marital status was associated with geriatric depression in both sexes and also in the overall sample 5.
A significant association was observed between depression and an insufficient income status as well as with a lower social classes compared with higher social classes. The same finding was reported by El Kady and Ibrahim 12.
Loneliness is a subjective, negative feeling related to the person’s own experience of deficiency in social relations, and it is one of the most significant predictors of depression and anxiety 39. Many people experience loneliness either as a result of living alone, a lack of close family ties, reduced connections with their culture of origin or an inability to participate actively in local community activities 39. This study revealed a positive correlation between depression and anxiety and loneliness feeling. A similar correlation was reported by Aylaz et al.19.
Physical illness is a risk factor for psychiatric illness: it affected 86.1% of our sample. Depression and/or anxiety were more prevalent among chronically ill elders, especially those with two or more diseases. Also, the perceived health status was significantly associated with depression; a similar finding was reported by Kim et al.8, who found it to be the most important predictor for depression, and highlighted that focusing on improving perceived health through encouraging social and physical activities is an important strategy to alleviate depressive manifestation.
Greater physical activities had a preventive effect on the occurrence of depression 40. This study demonstrated a significant association between depression per se, anxiety per se and the mixed form with lacking satisfaction with and enjoying recreational activities (P=0.002, P<0.001, and P=0.002, respectively).
The present study also revealed that there was an inverse relationship between the functional status for ADL and depression. Participants who were partially independent had five times the risk to be depressed and nearly four times the risk to have mixed depression and anxiety than totally independent individuals. This is in accordance with El Kady and Ibrahim 12, who reported a negative correlation of depression with functional decline and impairment among the elderly. This is due to the fact that physical dependence brings about marked feelings of dependency on others, limited usefulness, loss of self-actualization, and a general lack of mastery or sense of control.
It is well known that depression and anxiety has a negative impact on the well-being score and life satisfaction 39. In this study, a negative correlation was found between depression and anxiety scores and some component scores of the well-being index including the standard of living, safety and security feeling and satisfaction with spiritually and religion. There was a significant association between depression and/or anxiety with poor satisfaction with the geriatric home team support and with family support, which was also confirmed with Abdul Rahman 15, who recommended supervising geriatric homes in Egypt with geriatricians, geriatric psychiatrists, social workers qualified in this field and social agencies, and enhancing the importance of family support for the elderly.
Conclusion and recommendations
Depression and/or anxiety were found in more than 80% of the studied group. An older age, female sex, a lower socioeconomic level, partial independence, the presence of comorbidities, loneliness feeling and being married or divorced were significant predictors for these psychological problems. Depression and anxiety were associated with the perceived health status, low well-being total scores and most of its components and a lack of satisfaction with family support, geriatric home personnel support and recreational activities. On the basis of these findings, there is a need for integrated medical, psychological and social activities to improve physical and psychological health among the elderly living in geriatric home, such as periodic screening for depression and/or anxiety, especially in high-risk groups. Also, modifiable factors (such as loneliness feeling, family support, the perceived health status and recreational activities) affecting the psychological health can be considered in conducting interventions for improving the mental health in the elderly, for example training and increasing the awareness of geriatric home personnel, available trained nurses, recreational activities and encouraging families visit and family counseling.
The cross-sectional design prevents clear causal inferences between geriatric depression and related risk indicators. Second, as the participants were limited to geriatric home residents in Cairo, generalization of the conclusions to elderly people in the community setting needs further confirmation.
Conflicts of interest
There are no conflicts of interest.
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Keywords:© 2014 Egyptian Public Health Association
anxiety; depression; elderly; geriatric home