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Prevalence and predictors of depression and anxiety among the elderly population living in geriatric homes in Cairo, Egypt

Ahmed, Daliaa; El Shair, Inas Helmic; Taher, Emana; Zyada, Fadiab

The Journal Of The Egyptian Public Health Association: December 2014 - Volume 89 - Issue 3 - p 127–135
doi: 10.1097/01.EPX.0000455729.66131.49
Original articles
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Background Anxiety and depression are common in the elderly and affect their quality of life. The rates of depression and anxiety are higher among those living in institutional settings and are usually undiagnosed.

Aim The aim of the study was to determine the prevalence and predictors of depression, anxiety and mixed form (i.e. depression and anxiety) in the elderly living at geriatric homes.

Participants and methods A cross-sectional study was conducted on 240 elderly participants from four randomly selected geriatric homes in Cairo. A pretested interview questionnaire was used to collect data. A short version of the Geriatric Depression Scale (GDS-15), the Hamilton Anxiety Scale, the Katz scale for Activity of Daily living, the three-item loneliness scale and the Personal Wellbeing Index Scale were used.

Results The prevalence of depression, anxiety and mixed disorder among the studied group were 37.5, 14.2 and 30%, respectively. Old age and the presence of comorbidities were predictors for depression and/or anxiety. Female sex, a lower social class, insufficient income, partial independence and loneliness feeling are significant predictors for depression. Being married and loneliness feeling are significant predictors for anxiety, whereas the functional status is a significant predictor for mixed depression and anxiety.

Conclusion and recommendations Depression and/or anxiety were found in more than 80% of the studied group. An older age, female sex, insufficient income, a lower social class, a partially independent functional status, the presence of comorbidities, more frequent loneliness feeling and being married or divorced were found to be significant predictors for these problems. This study reflects the need for the screening of the elderly in geriatric homes for depression and/or anxiety, especially among high-risk groups, and developing interventions to prevent and control such problems.

Departments of aPublic Health and Community Medicine

bPsychiatry, Faculty of Medicine

cCommunity Nursing Department, Faculty of Nursing, Cairo University, Cairo, Egypt

Correspondence to Dalia Ahmed, MD, Department of Public Health and Community Medicine, Faculty of Medicine, Cairo University, 11513 Cairo, Egypt Tel: +20 102 099 4957; e-mail: dalia_ams@yahoo.com

Received August 17, 2014

Accepted September 22, 2014

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Introduction

The number of persons aged 60 years or older in the world was estimated to be 629 million in 2000. This number is projected to grow to nearly two billion by 2050. Persons aged 60 or older currently comprise 10% of the world population, and by 2050, it is projected to reach 21% 1.

In Egypt, the percentage of older people (defined as ≥60 years) was 4.2 of the total population according to the last Egyptian census in 1995; this percentage reached 5.8% in 2006 and may reach 8.9% in 2016 and 10.9% in 2026 2–4.

Older people are exposed to different health problems, including mental problems such as depression and anxiety 5. Depression is considered as a major public health problem and the most common mood disorder among the elderly 6. It is predicted to be the second leading cause of disability by the year 2020 according to the WHO 7. It may be associated with serious sequelae including a decrease in all dimensions of the quality of life, increased mortality and increased service utilization. Moreover, it is undiagnosed in about 50% of the cases 8.

On the basis of previous studies of geriatric depression in many countries, the prevalence of depressive disorders is 12.9–21.2% in the community setting 9 and 26.0–37.7% in geriatric homes 10. Egyptian studies reported a prevalence ranging between 31.4% 11 and 36% 12.

Although some studies have shown a relatively low prevalence of anxiety disorders in older individuals, 13,14 others have reported anxiety disorders to occur two to seven times more often than depression problems. This suggests that anxiety disorders are real and relatively common problems among the elderly 15. This discrepancy among different studies regarding the prevalence of anxiety is due to the difference in how anxiety is defined and measured and the type of sampling used, whether community based or institutional based.

The co-occurrence of anxiety and depression in elderly patients is a fact with very strong association between them as detected by Brenes et al. 16. Moreover, a considerable symptomatic overlap between anxiety and depressive disorders exists, with frequent progression of anxiety to depression over time 17.

Advanced age and socioeconomic variables such as low education, poor income, manual occupation and a decreased standard of living can be considered as important predictors for mental health problems 18.

There is a strong correlation between depression and anxiety, and the occurrence of comorbidities, loneliness, functional decline, and impairment in activities of daily living (ADL) 19.

Although the rates of depression and anxiety disorders are higher in older people, especially those living in institutional settings 20, most of them remain undiagnosed and untreated due to a lack of adequate knowledge. Also, studies conducted to evaluate such psychiatric illnesses among this population are still limited 21.

The present study was conducted to investigate the prevalence and predictors associated with geriatric depression, anxiety and mixed form among residents of geriatric homes.

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Participants and methods

A cross-sectional study was conducted to study the prevalence of anxiety and depression among the elderly from both sexes, aged 60 years or more, who are living in geriatric homes. Four geriatric homes (Omkalthoom in Helwan, HadyaBarakat in Eldoki, ElGamayaElkhairia in El-Sayeda Zienab, and Alhabaib in Almaadi) were randomly selected from the 65 geriatric homes present in Cairo, and all the elderly in the selected homes who fulfilled the inclusion criteria (i.e. elderly from both sexes, aged ≥60, and free from dementia) and who agreed to participate were included in the study. Geriatric homes are residential homes where the elderly live with their peers and are helped in their ADL and instrumental ADL by trained workers 15. Elderly individuals with dementia (i.e. elderly who achieved a score of more than 25 on the Mini-Mental Status Examination Test 22 indicating no cognitive impairments), and completely dependent individuals were excluded from this study.

Using the WHO/STEPS sample size calculator program 23, at 95% confidence level, margin of error 0.05, and frequency 81% 15, a sample size of at least 237 individuals would be necessary. A sample of 240 elderly from geriatric homes was collected during a period of 3 months from the beginning of January 2014 to the end of March 2014.

Study tools included a pretested interview questionnaire covering the following sections:

  • Sociodemographic characteristics included age, sex, education, previous occupation, marital status and income sufficiency and source. Social score: the social class of the family was determined according to the husband’s education (score 2–10), the wife’s education and work (scores 1–10) and the crowding index (scores 1–5). The total score calculation was as follows: a score from 19 to 25 indicates a high social class, a score from 12 to18 indicates a middle social class and a score below 12 indicates a low social class 24.
  • The shorter version of the Geriatric Depression Scale (GDS-15) was used to screen for depression. It is a depression assessment tool specifically designed for older people. The scale consists of 15 items that can be answered by yes/no with a range of scores from 0 to 15. Impairment is indicated by a score of 5 or higher. According to the GDS score, 5–7 indicates mild depression, 8–12 moderate depression, and 13 or higher severe depression 25. The validated Arabic version of the GDS-15 was used 26.
  • The validated Arabic version of the Hamilton Anxiety Scale 27 was used in this study. It is a scale used for the detection of anxiety. It consists of 14 items, each defined by a series of symptoms. Each item is rated on a five-point scale, ranging from 0 (not present) to 4 (severe). The total score is 0–17 for normal individuals, 18–24 for mild anxiety, 25–29 for moderate anxiety, and at least 30 for severe anxiety.
  • The Katz scale for ADL was used to assess the degree of dependency in performing basic ADL including bathing, dressing, toileting, transfer, urinary and fecal continence, and feeding 28. Each of the six functions is measured and categorized into three levels of dependency scored from 0 to 2, where 2=full independence without need for human assistance, 1=partial dependence with the need for some help, and 0=total dependence with an inability to perform the task even with assistance. The total score of the scale is from 0 to12. According to the scale, patients are classified into three categories: totally independent (score 9–12), partially dependent (score 5–8), or totally dependent (score 0–4). The Katz scale was translated into the Arabic language and the reliability was tested using internal consistency, and a Cronbach’s α of 0.84 was found.
  • The three-item loneliness scale 29 was used to measure loneliness feeling. Response categories were coded as 1 (hardly ever), 2 (some of the time), and 3 (often). Each person’s responses to the questions were summed, with higher scores indicating greater loneliness. According to the scale, patients were classified into three categories: rare (score 1–3), sometimes (score 4–6), or often (score 7–9). The scale was translated into the Arabic language, and the reliability was tested using internal consistency, and a Cronbach’s α of 0.89 was found.
  • The Personal Wellbeing Index 30 was used to measure both personal wellbeing and satisfaction with life as a whole. In each item, the elderly was asked how satisfied they feel on a scale from 0 to 10, where 0 indicates no satisfaction at all and 10 indicates complete satisfaction. It consists of two parts:
    • Part one: about satisfaction with life as a whole.
    • Part two: the Personal Wellbeing Index Scale contains eight items of satisfaction, each one corresponding to a quality of life domain including health, the standard of living, his/her achievement in life, personal relationships, feeling safe, feeling part of the community, future security, and spirituality and religion (optional).
  • The total score is the sum of the eight items. Then, the raw scores are converted into the standard 0–100 scale format for the purpose of creating results that can be compared simply with other scales. Then, the percent score is classified into below 50% or equal to and more than 50%. The scale was translated into Arabic and validated by five experts. The required corrections and modifications were carried out accordingly. The reliability was tested using internal consistency, and a Cronbach’s α of 0.71 was found for the eight items of the scale.
  • The presence and numbers of diagnosed comorbidities was ascertained by asking if the participant had been diagnosed by physicians and were currently receiving any treatment.
  • Perceived health status: older adults responded to the following question about their health status: ‘In general terms, how would you describe your health status: very good, good, fair, poor?’ No health-related questions that could influence the response were asked before telling the respondents to rate their health status 31.
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Statistical analysis

Data were coded and entered using the statistical package SPSS for Windows, Version 15.0 (SPSS Inc., Chicago, Illinois, USA) Data were summarized using descriptive statistics: mean, SD, range values for quantitative variables and number and percentage for qualitative values. Statistical differences between groups were tested using the χ 2-test for qualitative variables. Correlations were determined to test for linear relations between variables. Logistic regression analysis was performed to test for significant predictors of depression and/or anxiety. A P-value less than or equal to 0.05 was considered to be statistically significant.

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Ethical consideration

All the participants included were treated according to the Helsinki Declaration of biomedical ethics 32; verbal consent was obtained after proper orientation of the participants regarding the objectives of the study, data confidentiality and the impact of the study. The researchers emphasized that participation in the study was entirely voluntary. An official permission was obtained from the ministry of social solitary to carry out this study.

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Results

Table 1 describes the basic sociodemographic, clinical and psychological characteristics of the studied group. About 65% of the 240 studied elderly were female and more than half were less than 65 years old. Their mean age was 64.8+2.5 years, ranging from 60 to 74 years.

Table 1

Table 1

The prevalence of depression, anxiety and mixed disorder among the studied group were 37.5, 14.2, and 30%, respectively (Fig. 1).

Figure 1

Figure 1

As shown in Figs 2 and 3, the prevalence of depression (both depression alone and mixed depression and anxiety) was 67.5% (51.7% mild, 15.8% moderate), whereas the prevalence of anxiety (both anxiety alone and mixed depression and anxiety) was 44.2% (25.4% mild, 9.2% moderate, and 9.6% severe).

Figure 2

Figure 2

Figure 3

Figure 3

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.

Table 2

Table 2

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.

Table 3

Table 3

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.

Table 4

Table 4

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.

Table 5

Table 5

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Discussion

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.

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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.

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Study limitations

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.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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Keywords:

anxiety; depression; elderly; geriatric home

© 2014 Egyptian Public Health Association