UMEÅ UNIVERSITY MEDICAL DISSERTATIONS
New Series No. 1132 – ISSN 0346-6612 – ISBN 978-91-7264-423-6
From the Department of Community Medicine and Rehabilitation, Geriatric Medicine and the Department of Clinical Sciences, Division of Psychiatry,
Umeå University, Sweden
DEPRESSION AMONG THE VERY OLD
ELLINOR
BERGDAHL
Department of Community Medicine and Rehabilitation,
Geriatric Medicine and the Department of Clinical Sciences, Division of Psychiatry, Umeå University, SE-901 87 Umeå, Sweden
©Ellinor Bergdahl
New Series No. 1132 – ISSN 0346-6612 – ISBN 978-91-7264-423-6 Printed in Sweden by Larsson & Co:s Tryckeri AM, Umeå 2007
To my parents,
Maja-Lisa and Jackie,
in whose vocabulary the word
“impossible” does not exist.
C
ONTENTABSTRACT 5
SAMMANFATTNING/SWEDISH SUMMARY 6
ABBREVIATIONS 7
ORIGINAL PAPERS 8
INTRODUCTION 9
DEPRESSION 9
PREVALENCE OF DEPRESSION 9
PHYSICAL,COGNITIVE AND SOCIAL FACTORS ASSOCIATED WITH DEPRESSION 11
TREATMENT OF DEPRESSION 12
OUTCOME OF DEPRESSION 12
DEPRESSION IN URBAN AND RURAL AREAS 12
DEMENTIA 18
RATIONALE FOR THIS THESIS 20
AIMS OF THIS THESIS 21
SPECIFIC AIMS 21 METHODS 22 PARTICIPANTS 22 PROCEDURE 26 SOCIODEMOGRAPHIC DATA 26 ASSESSMENTS 26 DEPRESSION 26 COGNITION 27 PSYCHOLOGICAL MEASUREMENTS 27
EXPERIENCED SYMPTOMS AND SOCIABILITY 27
PHYSICAL MEASUREMENTS 27 BLOOD ANALYSES 28 MORTALITY 28 STATISTICAL METHODS 28 ETHICS 29 RESULTS 31 PAPERI 31 PAPERII 34 PAPERIII 36 PAPERIV 40 PAPERV 44 DISCUSSION 47 PREVALENCE OF DEPRESSION 47 TREATMENT OF DEPRESSION 47 OUTCOME OF DEPRESSION 48
DEMENTIA AND DEPRESSION 48
PHYSICAL,COGNITIVE AND SOCIAL FACTORS ASSOCIATED WITH DEPRESSION 48 OTHER DISEASES ASSOCIATED WITH DEPRESSION 49 MEDICATIONS ASSOCIATED WITH DEPRESSION 49
ETHICAL CONSIDERATIONS 50
METHODOLOGICAL CONSIDERATIONS 50
STUDY POPULATION AND DATA COLLECTION 51
PARTICIPATION RATE 51
STATISTICAL CONSIDERATIONS 51
CLINICAL IMPLICATIONS 51
IMPLICATIONS FOR FURTHER RESEARCH 51
CONCLUSIONS 53
ACKNOWLEDGEMENTS 54
A
BSTRACTEmotional suffering in old age is largely caused by various psychiatric conditions, of which depression is the most common. Depression is associated with a decline in both well-being and daily functioning and reduces both morale and social capacity among the very old, which may produce high health and social costs for society.
The overall aim of the thesis was to study the prevalence of depression among the very old, to identify factors associated with depression and to evaluate the prognosis of depression among the very old.
In total, 363 people were evaluated for depression, 242 from an urban municipality in the year 2000 and 121 from five rural municipalities in 2002. In 2005, those still alive in the urban municipality were asked to participate again, and were therefore re-evaluated. The prevalence of depression was 27% in the urban municipality, 34% in the rural municipalities and 29% in the total sample. Of those depressed, about 67% were receiving antidepressive treatment, and of those, approximately 50% had responded to treatment. In the rural municipality, the depressed were less often treated with Selective Serotonin Re-uptake Inhibitor medications, receiving instead Tri-Cyclic Antidepressants. In the rural municipalities, only 38% of the depressed had responded to treatment. A higher proportion of women were diagnosed as depressed, 33% vs. 19%, p=0.006, although the response rate was the same for men and women. Depression was twice as common among those with dementia, 44% vs. 23%. There were discrepancies concerning associated factors between the depressed participants with dementia and those without.
Experiencing the death of a child during the preceding ten years was associated with depression and independently associated with depression among men and participants with dementia. In all the studies, the depressed were less often able to go outside independently and to visit others. They also received fewer visits from others and often experienced loneliness.
The great majority of those who were depressed in 2000 died during the subsequent five years, only 13 out of 65, 22%, were still alive in 2005, compared to 41% of those who were not depressed, p=0.003. Of 13 who survived, only two had recovered. Twenty-four out of 70 non-depressed people, 34%, had developed depression during the five years (2000-2005), and the total prevalence in year 2005 was 42% (35 out of 83 participants). Ten out of the 24 who had developed depression were prescribed antidepressants. Of those ten, four were regarded as responders. In the group with persistent depression, nine out of eleven were receiving antidepressants and 67% were responders.
In conclusion, a large proportion of the very old suffer from diagnosed and under-treated depression. The response rate to treatment seems to be low, and the quality of treatment and follow-up also seems to be poor. The mortality rate among the depressed was high. The spectrum of factors associated with depression in people with dementia is different from that associated with depression among non-demented. Depression among the very old clearly emerges as a common and serious public health problem, with probably the most serious impact on quality of life. More efforts have to be made to improve the quality of assessments, treatment and research regarding depression among the very old.
S
AMMANFATTNING/S
WEDISH SUMMARYEmotionellt lidande i hög ålder beror i stor utsträckning på olika psykiatriska sjukdomar, varav depression anses vara den vanligaste. Att drabbas av en depression är associerat med en nedgång i såväl välbefinnande som funktionsnivå i det dagliga livet och minskar även den sociala kapaciteten bland dem som drabbas, vilket i sin tur leder till höga sociala och hälsomässiga kostnader för samhället.
Det övergripande syftet med denna avhandling var att undersöka förekomsten av depression bland personer äldre än 85 år, att identifiera faktorer associerade med depression i denna åldersgrupp samt att utvärdera prognosen vid depression bland de allra äldsta.
Totalt utvärderades 363 personer med avseende på depression, 242 boende i en tätort år 2000 samt 121 personer från fem glesbygdskommuner under år 2002. År 2005 tillfrågades de som fortfarande var i livet från undersökningen år 2000 om de ville delta i en ny studie och de som då tackade ja utvärderades ånyo med avseende på depression. Förekomsten av depression var 27% i tätorten, 34% i glesbygdskommunerna samt 29% totalt. Av de deprimerade hade cirka 67% en pågående behandling med antidepressiva läkemedel, och av dem hade cirka 50% svarat på behandlingen. I glesbygdskommunerna behandlades de deprimerade mer sällan med så kallade Serotonin-återupptagshämmande mediciner, i stället behandlades fler med tri-cykliska antidepressiva mediciner. En högre andel kvinnor var deprimerade, 33% gentemot 19%, p=0.006, dock svarade en lika stor andel kvinnor som män på den antidepressiva
behandlingen. Depression var dubbelt så vanligt bland studiedeltagare med en
demenssjukdom.
Att ha upplevt ett eget barns död under de senaste tio åren var associerat med depression och oberoende associerat med depression bland män och dementa deltagare. I alla studier gick personer med depression mer sällan ut oberoende av andra, de fick färre besök och besökte också andra mer sällan. Fler personer med depression upplevde sig ensamma.
Majoriteten av de deprimerade deltagarna år 2000 hade dött under de efterföljande fem åren, endast 13 av 65, 22% av de deprimerade var fortfarande i livet år 2005, jämfört med 41% av de icke deprimerade deltagarna, p=0.003. Av de 13 som fortfarande var i livet hade enbart två personer tillfrisknat. Tjugofyra personer av 70 utan depression, 34%, hade utvecklat depression under åren 2000-2005 och den totala prevalensen år 2005 var 42% (35 utav 83 deltagare). Av dem som hade utvecklat depression var 10 av 24 förskrivna antidepressiva mediciner. Av dessa tio hade fyra svarat på sin behandling. I gruppen med kvarstående depression var nio av elva behandlade med antidepressiv medicinering och 67% hade svarat på sin behandling.
Sammanfattningsvis lider en stor andel av de allra äldsta av depressioner som varken är diagnostiserade eller behandlade. Behandlingseffekten av antidepressiv medicinering tycks vara låg, och kvaliteten på behandling och uppföljning av denna förefaller även den vara dålig. Mortaliteten bland dem med depression var hög. Depression bland de allra äldsta förefaller vara ett vanligt och allvarligt folkhälsoproblem, med stor inverkan på livskvalitet och välbefinnande. Större ansträngningar måste göras för att förbättra kvaliteten på såväl bedömning som behandling och forskning inom detta område då den i dagsläget förefaller bristfällig.
A
BBREVIATIONSAD Alzheimer’s Disease
ADL Activities of Daily Living
BMI Body Mass Index
DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4thedition
GDS Geriatric Depression Scale
GDS-15 Geriatric Depression Scale (15-item version)
GQL Gothenburg Quality of Life
MADRS Montgomery-Åsberg Depression Rating Scale
MMSE Mini Mental State Examination
MNA Mini Nutritional Assessment
NSAID Non-Steroid Anti-Inflammatory Drug
OBS scale Organic Brain Syndrome scale
PGCMS Philadelphia Geriatric Centre Morale Scale
S- Serum- (used in blood analyses)
SD Standard Deviation
SNRI Serotonin-Norepinephrine Re-uptake Inhibitor
SSRI Selective Serotonin Re-uptake Inhibitor
TCA Tri-Cyclic Antidepressant
TSH Thyroid Stimulating Hormone
O
RIGINAL PAPERSThis thesis is based on the following papers, which in the text will be referred to by their Roman numerals:
I Bergdahl E, Gustavsson JMC, Kallin K, von Heideken Wågert P, Lundman B, Bucht G,
Gustafson Y.Depression among the oldest old: the Umea 85+ study.
Int Psychogeriatr. 2005 Dec;17(4):557-75.
II Bergdahl E, Allard P, Lundman B, Gustafson Y. Depression in urban and rural municipalities. Aging Ment Health. 2007 Sep;11(5):570-8.
III Bergdahl E, Allard P, Alex L, Lundman B, Gustafson Y. Gender differences in depression
among the very old. Int Psychogeriatr. 2007 Jul 26;:1-16(Epub ahead of print).
IV Bergdahl E, Allard P, Gustafson Y. Depression among the very old with dementia. Submitted.
V Bergdahl E, Allard P, Gustafson Y. Long term outcome of depression in a very elderly population. Manuscript.
I
NTRODUCTIONInternationally, the definition of being old is to be aged 60 years or older and to be very old is being aged 80 years and above. People aged 80 years and older were earlier termed the oldest old, but the World Health Organization has recently changed the nomenclature to the very old (2).
Worldwide, 10% of the population are above 60 years of age, and this proportion is expected to double by 2050. The very old is the fastest increasing age group in the western world. At
the beginning of the 21stcentury they accounted for about 12% of those aged 60 years and
above, and this proportion is expected to rise to about 19% by 2050. Sweden today has over 9 million inhabitants, 2.1 million (25%) are 60 years old or above, approximately 500 000 are 80 years and older (3).
DEPRESSION
PREVALENCE OF DEPRESSION
Depression is a common cause of emotional suffering. The lifetime prevalence of depression is 10-25% among women and 5-12% among men (1).
Depression is the most common psychiatric condition in old age (4-6). It is associated with a decline in both well-being and daily functioning and reduces both morale and social capacity among the very old (7), which may incur high health and social costs for society (8).
Despite the fact that age per se does not constitute a predisposition for depression (6, 9, 10), many studies report that the prevalence of depressive symptoms is high in old age (11, 12), although the DSM-IV criteria for depression are not met in full in many cases. Depression and depressive symptoms are more prevalent among the very old than among the younger old. The predominant explanation is that the former group contains a higher proportion of women and that the frequency of physical and psychiatric disabilities (e.g. dementia) in this group is increased (5). Depression is more prevalent among women than among men throughout the whole life cycle, including the old (5, 13-15). However, it has been suggested that depression might be under-diagnosed to a greater extent among men (16). Depression in old age differs between men and women, both regarding the reporting of symptoms and investigation of risk factors. Women more often report mood-related symptoms, while men report more motivation-related symptoms and agitation (17, 18). Feelings of loneliness and poor self-perceived health are common among women who are developing depression. Among men, declining health, chronic diseases, becoming a widower and other social factors are known risk factors for depression (11, 19-21).
DSM IVCRITERIA FORMAJORDEPRESSION:
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
(1) Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others.
(2) Markedly diminished interest or pleasure in all, or almost all activities, nearly every day.
(3) Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
(4) Insomnia or hypersomnia nearly every day.
(5) Psychomotor agitation or retardation nearly every day. (6) Fatigue or loss of energy nearly every day.
(7) Feelings of worthlessness or excessive or inappropriate guilt nearly every day. (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (9) Recurrent thoughts of death, recurrent suicidal ideation, or a suicide attempt or a
specific plan for committing suicide. B. The symptoms do not meet criteria for mixed episode.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance or a general medical condition.
E. The symptoms are not better accounted for by Bereavement.
DSM IVCRITERIA FORMINORDEPRESSIVEDISORDER: A. A mood disturbance, defined as follows:
(1) at least two (but less than five) of the following symptoms has been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) or (2):
(1) Depressed mood most of the day, nearly every day.
(2) Markedly diminished interest or pleasure in all, or almost all activities, nearly every day.
(3) Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
(4) Insomnia or hypersomnia nearly every day.
(5) Psychomotor agitation or retardation nearly every day. (6) Fatigue or loss of energy nearly every day.
(7) Feelings of worthlessness or excessive or inappropriate guilt nearly every day. (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (9) Recurrent thoughts of death, recurrent suicidal ideation, or suicide attempt. (2) the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
(3) the symptoms are not due to the direct physiological effects of a substance or general medical condition
(4) the symptoms are not better accounted for by Bereavement.
B. There has never been a Major Depressive Episode, and criteria are not met for Dysthymic Disorder.
C. There has never been a Manic Episode, a Mixed Episode or a Hypomanic Episode, and criteria are not met for Cyclothymic Disorder.
D. The mood disturbance does not occur exclusively in Schizophrenia, Schizophreniform Disorder, Schizoaffective Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
As the different DSM-IV criteria are known to be less applicable among the old, in the present thesis all the diagnoses are used without distinctions.
PHYSICAL,COGNITIVE AND SOCIAL FACTORS ASSOCIATED WITH DEPRESSION
The clinical presentation of depression differs between the young and the old. Changes in diurnal rhythm, anxiety and different cognitive symptoms (e.g. confusion and difficulties in concentrating) are common symptoms among the old (22). Comorbidity, with both somatic disorders and dementia, often renders the depressive symptoms difficult to recognize and also complicates the treatment (5, 23, 24). Older people also seem to have a different spectrum of risk factors for depression compared to younger age groups. Heredity and previous episodes of depression do not seem to be as important among the old as among younger age groups (25, 26). Instead, disability in activities in daily living (ADL) and declining physical health have been reported as important risk factors for developing depression among the old (11, 27-33). Previous studies have found depression in old age to be associated with a variety of physical and psychiatric conditions: states post myocardial infarction and hip fracture, suffering from diabetes (5), stroke (5, 34) or dementia (27). Psychosocial factors have also been shown to contribute to the development of depression among the old: inadequate social networks (27, 35-37) and feelings of loneliness (30, 38-40). Experiencing the death of an adult child has been shown to be associated with depression, both among young people and old women (38, 41). The loss of a spouse, common among the very old, is an important risk factor among young men and women with depression but seems to be of less importance among old people according to some studies (11, 38, 41, 42). Although, bereavement is commonly associated with depression among old people (39, 43, 44). It is also known that the
DSM IVCRITERIA FORDYSTHYMICDISORDER:
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account for or observation by others, for at least 2 years.
B. Presence, while depressed, of two (or more) of the following: (1) Poor appetite or overeating
(2) Insomnia or hypersomnia (3) Low energy or fatigue (4) Low self-esteem
(5) Poor concentration or difficulty making decisions (6) Feelings of hopelessness
C. During the 2-year period of the disturbance, the person has never been without the symptoms in Criteria A and B for more than two months at a time.
D. No Major Depressive Episode has been present during the first 2 years of the disturbance. E. There has never been a Manic Episode, a Mixed Episode or a Hypomanic Episode, and criteria
has never been met for Cyclothymic Disorder.
F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder. G. The symptoms are not due to the direct physiological effects of a substance or a general medical
condition.
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
DSM IVCRITERIA FORMOODDISORDER DUE TO A GENERAL MEDICAL CONDITION:
A. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following:
(1) Depressed mood or markedly diminished interest or pleasure in all, or almost all, activities
(2) Elevated, expansive or irritable mood
B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
adverse effects of drugs (e.g. dopamine-blockers, anti-epileptics, corticosteroids, digoxin, certain calcium channel blockers, NSAID), might produce depressive symptoms among older people (45, 46).
TREATMENT OF DEPRESSION
The aims of depression treatment among old people are to reduce the symptoms of depression, to prevent relapse or recurrence of symptoms and to improve cognitive and functional status. Antidepressant treatment is regarded as effective when given to elderly individuals as when given to younger adults (47, 48). SSRIs and SNRIs are the antidepressants of choice. Although the initial doses should be low, the final doses should be similar to those used among younger adults, and the same doses should be used for maintenance as for treatment (47). Underdosage, discontinuing treatment too soon and not aiming for full remission and recovery are the most frequent errors that occur in the treatment of depression among very old people (49). Very few old people are referred to a psychiatrist, although other therapies have been shown to have a good treatment effect (e.g. Electro-Convulsive Therapy, Behavioural Treatment), equally as effective as in younger adults (47, 48). It is a commonly held opinion, that depression among the old is difficult to treat, but these difficulties are often due to the complications of comorbidity (24, 50).
OUTCOME OF DEPRESSION
Many studies have shown a high prevalence of depression and/or depressive symptoms, but despite such findings, depression is often both underdiagnosed and inadequately treated (5, 8, 25, 51). The prognosis for a total recovery from depression among the old is poor (52, 53) when the symptoms of depression are severe and when depression is related to cognitive impairment, physical illness (12, 54, 55) and to poor subjective social support (55, 56). Depression has also been shown to be associated with increased mortality, even when controlling for potentially confounding variables such as sociodemographic factors, somatic diseases and behavioural risk factors (5, 57-62).
DEPRESSION IN URBAN AND RURAL AREAS
Few studies have compared old people with depression in urban versus rural areas. No differences in prevalence between rural and urban areas were found by (63-65). Differences have been shown between rural and urban areas in the association between depression and factors such as higher age, ethnicity, marital status, low socio-economic status and low educational level (63, 65-67). Depression among the old is known to be associated with an inadequate social network, which might differ between rural and urban areas and hence possibly influence the prevalence of depression.
Ta b le 1 A. A sel ect io n o f cr o ss-sect ional st udi es concer ning depr es si on among the o ld and the ver y ol d. 1 st author , year , countr y Des ign N A ge Pr evalence R es u lts C onclus ion C arpinie llo, 1989, It aly Cr o
ss-sectional study, ur
ban-ru ra l 317 6 5 17% vs . 1 6 % . 15% women v s. 11% men T h e h ighes t pr evalence was found among widowed people. T h e p er centage of depr es si on was always h igher among ur ban res idents (N S) . Female gender , widowhood , abs ence o f conf idant, poo r educat ional level , fi n anci al diffic u ltie s (only among u rba n elder ly) , phys ical impair m ent and di sease s wer e al l associ at ed wi th depr es si on. Beekm an, 1995, Eu rope Cr o ss-sectional study 646 55-85 M ajor depr es si on: 2. 02% M inor depr es si on: 12. 9% Depr essi on pr eval ence in cr ease s wi th age. M ar ri ed, phys ical function, subjective h ealth, social suppor t, lonelines s, contr o l and ber eavement wer e al l associ at ed wi th depr essi on. It appear s that m ajo r depr es si on is m o re of te n an exacer bat io n o f a chr onic m ood dis tur bance w ith roots in longs tanding vulne ra bility factor s; while mino r depr es si on is more ofte n a re ac tion to the st re ss co mmonly expe rie n ce d in la te r life . Beekm an, 1997, Eu rope Cr o ss-sectional study 646 55-85 M ajor depr es si on: 2. 02% M inor depr es si on: 12. 9% In multiva ria te an al ys is minor depr es si on was related to phys ical health but major d epr es si on was not. Gener al as p ects o f phys ical health had st ronger as so ciations with depr es si on th an speci fi c d is ease cat egor ie s. M ajor but not minor depr es si on was as so ciated with phys ical he alth. Fors ell, 1998, Sw eden Surve y des ign, demented 1101 7 5 M ajor depr es si on: 3. 9% among the non-demented, 11. 8% among the demented. Some de pre ss ive sy mptoms we re more com m o n am ong th e d em ent ed (i .e. lack of ener gy, thinking /concentr ation diffic u ltie s) . A h igher p re valence w as found am ong th e d em ent ed. In cr eased dis ability wa s as so ci at ed with an in cr ease in d epr essi on bot h in demented and nondemented per sons .
Pä ivä rinta , 1999, Finland Cr o ss-sectional study 339 8 5 M ajor depr es si on, women: 8. 1% M en: 4. 9% M inor depr es si on, Women: 18. 5% M en: 18. 9% F act or s associ at ed wi th m aj o r depr es si on: M en: Poor phys ical health. W o me n: R are conta ct with fa mily an d fr iends and poor phys ical health. M inor depr es si on: M en: Poor phys ical health, p re vious MCI . Women: Poor phys ical health , poo r ab ility to wa lk , smoking. A h igh p re valence w as found . T he sam e fact or s w er e associ at ed wi th major and mino r depr es si on. Li , 2001, US Cr o ss-sectional study 248 Mean age: VAD: 75. 2 year s AD: 77. 1 year s Non- demented: 72. 6 y ear s Depr es si ve sy mptoms in VAD: 31. 4% AD: 13. 2% Non-demented: 13. 2% VAD, AD and a his tor y o f d epr es si on wer e al l associ at ed wi th depr essi on. De pre ss ion wa s as soc ia te d w ith dementia, independent of cognitive le v el . Os bor n, 2003, USA Cr o ss-sectional study 14217 7 5 y ear s D epr es si on (m easur ed as GDS <6/ 6 +) 7. 7% M o re depr es si on among the v er y o ld, si ngles , n egative lif e events , sm oking , phys ical illnes s, conf iding relations hips , living Social is olation and age but not sex w as asso ci at ed wi th depr es si on.
Ta b le 1 B. A selection o f longitudinal studies concer ni ng depr es si on among the o ld and the ver y o ld. 1 st author , year , countr y Des ign N A ge R es u lts C onclus ion Beekm an, 1995, Eu rope L ongitudinal st udy (5 year s) 238 55-85 at inc lus ion time 52% wer e never d epr es se d; 16% su ff er ed an inc ide nt de pre ss ion, ha lf o f whic h re mitte d dur ing the st udy; 14% we re chr onically depr es se d and in 10% the cour se was v ar iable. Of thos e d ep re ss ed at b as eline , 32% re mitte d without re laps e, 25% re laps ed and 43% wer e chr onically depr es se d. Demogr aphic v ar iables wer e not pr edi ct iv e, heal th -r el at ed var iabl es w er e pr edictive o f b o th the ons et and the cour se of depr es si ve syndr omes . C hr onicity was associ at ed wi th recent v is it s to gener al pra ctitione rs , indic ating tha t tre atme nt coul d h ave b een pr ovi ded rel at iv el y easi ly in m any cases. R ober ts , 1997, US L ongitudinal st udy (1 year ). 2219 M ean age=64. 7 year s (50-95) M ajor d epr es si on: 1994: 8. 7 % , 1995: 9 .0% . Gender , chr onic h ealth conditions , p roblems with activities o f d ai ly li fe , cognit ive pr oblems , neighbour hood pr oblems and so cial is olation in 1994 wer e as so ciated with depr es si on in 1995. Healthy, nor mally functioning older adults ar e at n o g reat er ri sk of depr essi on th an younger p eople. What seem to be age-re lated ef fects ar e att ributable to phys ical he alth proble m s and re la te d d is ab ility. Fors ell, 1999, Sw eden L ongitudinal st udy (3 year s) 875 Mean age: 85 year s M ajor d epr es si on: 4. 1% Dementia , unsat is fact or y n et wor k and m o re than 2 depr es si ve sy mptoms at bas eline p re dicted depr es si on. Female: m ale ratio as in younger p eople but a lower pr eval ence th an am ong th e young. Fors ell, 2000, Sw eden L ongitudinal st udy (3 year s) . 894 Mean age: 84. 5 y ear s 29 out of 894 had d epr es si ve sy mptoms . P er sons who h ad a h is tor y of ps ychos is , w er e af fected with de me ntia an d h ad an ins u ffic ie n t soc ia l networ k h ad an inc reas ed fr equency o f p sy chotic sy mptoms . A his tor y o f d epr es si on/anxiety incr eas ed the fr equency o f suf fe ri ng anxiety and depr es si on. An ins u ff icient social n etwor k was associ at ed wi th anxi et y. In this st udy anxiety , depr es si on and ps yc hotic sy mptoms in the v er y elde rly seem to be linked to a li fe long ps yc hologic al vulne ra bility, sinc e al l w er e re lated to a p revious ps ychiatr ic h is tor y . Pa te rniti, 2002, France L ongitudinal st udy (4 year s) . 1003 59-71 B as eline d epr es sive symptoms incr eas ed the ris k of cognitive impa irme n t at four ye ar s. Pe rs is te nt de pre ss ion wa s as soc ia te d w ith a lower ed cognition.
Beekm an, 2002, Ne the rla nds L ongitudinal st udy (6 year s) 277 55-85 Per sis tence o ccur re d in 32% . 23% re mis si on. Unf avour able but fl uctuating cour se : 4 4 % . 14% short-live d sy mptoms . T h e n atur al h is tor y o f late-li fe depr es si on in the community is poor . D SM af fective dis o rde r is re la tive ly ra re b u t doe s ide ntify thos e w ith the w or st p rognos is . Subthr es hold d epr es si on is se ri ous and chr oni c in m any cases. Ste k , 2002, Ne the rla nds L ongitudinal st u d y (6 -8 year s) 105 >55 40% dead. 24% re laps ing cour se . 22% re si dual symptoms . 11% still de pre ss ed. 9% dementia. T h e m orta lity ra te is high in clinic ally tre at ed olde r elde rly with ma jor depr es si ve dis o rd er . Schoever s, 2003, Ne the rla nds L ongitudinal st udy (3 year s) 236 65-84 A p er sonal h is tor y of depr es si on, bas eline func tiona l limita tions an d inc ide n t anxie ty syndr ome p re dicted depr es si on. Without ear lier de pre ss ion: func tiona l d is ab ility, m al e g ende r and ins tr umental suppor t. T h e impact o f ri sk factor s o n the cour se of depr es si on is modif ied by longs tanding vulne ra bility ch ar ac te ris tic s, su ch as a per sonal h is to ry and g ender . Mor e recent lif e str es so rs ar e as so ciated with pr ognos is in subjects w ithout a p er sonal h is tor y of depr es si on and in m en. L einonen, 2004, Finland L ongitudinal st udy (1 0 year s) . 150 Mean age, 73. 2 (ma jo r depr es si on) 75. 8 y ear s (d ep re ss iv e dis o rd er ) T w en ty-five pe rc en t o f the pa tie nts w ith ma jor depr es si on and 28% of pa tients w ith depr es si ve dis o rd er developed o rg anic dementia dur ing fo ll o w-up. T h er e w as no di ff er ence in th e ri sk between thes e g roups . Ps ychoger iatr ic p atients admitted due to ma jor m en ta l d is orde r m ay ha ve an in cr eased ri sk of or gani c d em ent ia in th e n ea r fu tu re . Heikkinen, 2004, Finland L ongitudinal st udy (1 0 year s) . 337 222 131 75 year s W omen 36. 6% vs . 2 7 .4% among men at bas eline. Af ter 1 0 y ear s: 44. 7 % among women vs . 29. 7% among men . An inc re as e in d ep re ss ive sy mptoms with age is found among women. L onelines s, ch ronic d is ea se s, poor se lf-ra te d h ea lth , poor functional capacity, poo r v is ion, per ceived n egative changes in lif e w er e all associ at ed wi th depr essi on.
Adams on, 2005, UK Pr os pective longitudinal study. 1309 7 5 M or bidity, d is ability and li fe cycle can explain mos t of the obs er ved relations hip b etween sy mptoms of depr es si on and m or tali ty, subjects who repor t 6 symptoms o f d ep re ss ion ar e 27% more like ly to h av e d ie d . Depr es si on conf er s a sm all ris k o f morta lity in olde r p eople , not expla ine d so lely by poor health . T he re su lts suppor t the encour agement o f ef fective d iagnos is , tr eatment, and suppor t fo r ind ividuals with depr es si on. Ander sen, 2005, Denmar k C ohor t study: 5-year fo llow-up 3346 65-84 Per sons with a h is tor y of dep res si on had an in cr eased ri sk fo r A lz hei m er ’s D is ease bot h at bas eline and at fo llow-up . De pre ss ion wa s as soc ia te d w ith an in cr eased ri sk of AD. Bal d wi n , 2006, UK L ongitudinal st udy (3 year s) 85 6 0 S ev en pa rtic ipa n ts ha d d ie d (a ll from the depr es se d g roup) and six developed d ementia (a ll but one fr o m the depr es se d g roup) . L ate ons et depr es si ve dis o rd er is as so ci at ed with a h igh ra te o f m o rta lity and possi bl y d em ent ia . H arris , 2006, UK L ongitudinal st udy (2 year s) . 1164 6 5 Incidence 8. 4% . Per sis tence 61. 2% . P redi ct o rs : g reat er basel in e scor e, com pr om is ed so cial suppor t. Focus ing on older p er sons with incr eas ing dis ability, phys ical ill health and compr o mis ed so cial suppor t should h elp in both p re venting and recognizing the ons et of later lif e d ep re ss ion.
DEMENTIA
Dementia is a progressive and chronic disorder and the prevalence increases with age, from around 2-4% among those above 65 years old, up to more than 20% among those aged 85 and above (1). In Sweden, about 150 000 people suffer from dementia (2005) (68). Alzheimer’s Disease is the most common type of dementia and accounts for about 50% of the total number of people with dementia.
Dementia and depression often co-occur but the relationship between them remains obscure, despite several studies (69-72). Depression constitutes an established risk factor for dementia (69, 72-75), although other studies have shown that depression and depressive symptoms are to be considered as prodromal stages to dementia rather than independent risk factors (71, 76, 77). It has also been suggested that depression is a reaction to a subjective or early cognitive decline (70, 77).
The symptoms of depression, especially in the elderly, resemble the symptoms of an early dementia with apathy, lack of both interest and motivation, loss of energy, difficulties in concentrating, psychomotor agitation and retardation (78). These are symptoms that complicate the differentiation between depression and dementia. The risk factors for depression in those who have a dementia disorder seem to differ from those among the elderly without dementia. Among those with dementia, a higher risk of depression is found among those who have recently experienced stressful life events (79), but no association has been found with the most common factors associated with depression in old age, i.e. gender, living alone and functional decline (80, 81).
A previous study has suggested that a false reduction in depression prevalence may occur when the dementia disease deteriorates, since individuals with dementia may have difficulties recognizing and expressing their depressive symptoms (82). An alternative explanation has been presented in other studies showing that depression occurs during the early stages of
DSM IVCRITERIA FORDEMENTIA OFALZHEIMER’STYPE ANDVASCULAR DEMENTIA: A. The development of multiple cognitive deficits manifested by both
1. Memory impairment 2. At least 1 of the following:
(a) Aphasia. (b) Apraxia. (c) Agnosia.
(d) Disturbance in executive functioning.
B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social and occupational functioning and represent a significant decline from a previous level of functioning. C. Absence of occurrence exclusively during the course of Delirium.
In dementia of Alzheimer’s Type, the course is characterized by gradual onset and continuing cognitive decline. In Vascular Dementia, focal neurological signs and laboratory evidence of vascular disease judged to be related to the dementia are present. The clinical course of vascular dementia is variable and typically progresses in a stepwise manner (1).
dementia and decreases as the dementia disorder deteriorates (77, 83, 84), suggesting that when the person’s knowledge and awareness of the dementia disease decreases, the prevalence of depression also decreases.
Previous studies have reported that the prevalence of depression in people with dementia is higher than in people without dementia (81, 82, 85, 86). The difference in the prevalence of depression between women and men, which is seen among non-demented elderly people, seems to disappear among people with dementia (80, 81).
R
ATIONALE FOR THIS THESISDepression is common among the very old. Little is known about the factors associated with depression in this age group or whether there are different factors associated with depression in people with dementia compared with people with depression without dementia. Social factors are known to have an impact on depression and depressive symptoms, although little is known regarding this among the very old. Gender differences in depression prevalence are known among the young, but very few studies consider this issue among the very old. Earlier research has shown inconclusive results regarding differences in prevalence and factors associated with depression, in comparisons between depopulated rural municipalities with growing urban areas.
The outcome of depression in old age is known to be poor, with increased mortality and a high rate of chronicity, although the long-term outcome of depression among the very old is little studied. Depression among the very old is under-diagnosed and under-treated. It is therefore of great importance to develop knowledge about depression and its treatment among the very old.
A
IMS OF THIS THESISThe overall aim was to study the prevalence of depression, to identify factors associated with depression among the very old and to evaluate the prognosis of depression among the very old.
SPECIFIC AIMS:
I - to study the prevalence of depression and factors associated with depression among the oldest old regardless of living conditions. A second aim was to study the impact of depression on well-being and mortality.
II - to compare the prevalence, the treatment and the factors associated with depression among the oldest old, in an expanding urban city and in five depopulated rural communities in northern Sweden.
III - investigate the social, medical and psychological factors associated with depression among men and women aged 85 and above, and to investigate possible differences between men and women with depression.
IV - to investigate the prevalence of depression among very old individuals with dementia compared to those without dementia and to examine the factors associated with these conditions.
M
ETHODS PARTICIPANTSA total sample was selected for participation (n=348), by randomly selecting half the population born in 1915 (85-year-olds) and the total population born in 1910 (90-year-olds) and 1905 or earlier (range 95-103 years), living in an urban municipality in northern Sweden, on the 1 January 2000. Similarly, a total sample was selected for participation (n=179), by randomly selecting half the population born in 1917 (85-year-olds) and the total population born in 1912 (90-year-olds) and 1907 or earlier (range 95-103), living in five rural municipalities in northern Sweden, on the 1 January 2002. All those who participated in the urban study in 2000 and were alive on the 1 January 2005 were asked to participate in a follow-up study.
The names, addresses and personal identification numbers of the eligible participants were obtained from the National Tax Board. The randomisation of 85-year-olds was carried out by randomly selecting every second person from the National Tax Board lists, where people are listed in order of date of birth.
In the urban municipality, 29 people, 8%, died before they could be asked to participate. They did not differ regarding sex, age or living conditions from the remaining 319 but a greater proportion were single (p=0.002). Of the remaining 319, 29 people, 9%, who were alive at the time of inclusion declined to participate. These 29 people did not differ from the others regarding sex, age, civil status or living conditions. Of the remaining 290 participants, 48, 16%, could not be assessed for depression. The reasons for this were functional limitations such as e.g. dysphasia, hearing difficulties, and severe cognitive impairment. They did not differ from the others regarding age, sex, civil status or living conditions. The final urban sample consisted of 242 participants.
In the rural municipalities, 15 people, 8%, died before they could be asked to participate. They did not differ from those remaining regarding age, sex, civil status or living conditions. The remaining 164 people were asked to participate. During the inclusion period 23 people, 14%, declined to participate. They did not differ from the remaining sample regarding age, civil status or living conditions, but a higher proportion were men (p=0.025). The remaining sample consisted of 141 people, of whom 20, 14%, could not be assessed for depression. The reasons for this were functional limitations such as e.g. dysphasia, hearing difficulties, and severe cognitive impairment. They did not differ from the others regarding age, sex, civil status or living conditions. The final rural sample consisted of 121 participants.
In 2005, 90 of the 242 people in the urban sample in the 2000 study, were alive on 1 January. Of those 90, 2 people, 2%, died before they could be asked to participate. Of the remaining 88, all but five, agreed to participate. The sample from 2005 consisted of 83 people, i.e. 94% of those still alive at the time of inclusion.
Figure 1. Flow chart of the urban population in 2000 (Papers I, II, III, IV). 85-year-olds: n=143 90-year-olds: n=117 95-year-olds: n=88 26% men, 74% women
Asked to
participate
n=319
Selected
participants
n=348
Declined participation n=29 9.1% of 319 85: n=130 90: n=106 95: n=83 25% men, 75% women Died before request n=29 8.3% of 348In the study
n=290
Not possible to evaluate for depression n=48 17% of 290 85: n=118 90: n=96 95: n=76 25% men, 75% womenFinal sample
n=242
85: n=95 90: n=82 95: n=65 25% men, 75% women
Figure 2. Flow chart of the rural population in 2002 (Papers II, III, IV).
Asked to
participate
n=164
Selected
participants
n=179
Declined participation n=23 14% of 166 85: n=70 90: n=61 95: n=33 40% men, 60% women Died before requestn=15 8% of 179
In the study
n=141
Not possible to evaluate for depression n=20 14% of 141 85: n=61 90: n=54 95: n=26 36% men, 64% womenFinal sample
n=121
85: n=51 90: n=49 95: n=21 35% men, 65% women 85-year-olds: n=74 90-year-olds: n=65 95-year-olds: n=40 40% men, 60% women
Figure 3. Flow chart of the study population in the urban municipality in 2005 (Paper V). Participated year 2000 n=242 Not depressed year 2000 N=177 In the study 2005 N=70 In the study 2005 N=13 Declined participation (year 2005) N=5 Depressed year 2005 N=24 Not depressed year 2005 N=46 Died (years 2000-2005) N=102 Declined participation (year 2005) N=1 Recovered from depression N=2 Still depressed year 2005 N=11 Depressed year 2000 N=65 Died (years 2000-2005) N=51
PROCEDURE
Initially, the participants received a letter containing information about the study and two weeks later, they were informed about the home-visit procedure and gave their informed consent. The oldest participants were asked first to participate. Assessments were carried out during one to three home visits and included structured interviews and measurements. Data were also collected from medical charts, relatives and caregivers. Trained interviewers administrated all assessments, questions and scales. Each home visit took about two hours, with a space of one to two weeks between visits.
SOCIODEMOGRAPHIC DATA
A structured interview was conducted concerning the participant’s current living conditions. Housing was classified as ordinary if s/he lived in a house or apartment with or without help from the homecare services. Residential care consisted of private apartments with 24-hour daily access to staff in the same building. A skilled nursing home, comprised rooms for up to four people with shared dining and living rooms. In a group dwelling for the demented, each person had a single room but shared dining and living rooms. Those who lived in nursing homes and shared sleeping wards were classified as living alone unless they had previously resided with at least one of their co-habitants.
ASSESSMENTS
Diagnoses were collected from the participants and staff, and from medical charts at the hospital and/or the institutional care facility. Both prescribed and privately purchased drugs were registered. Participants with assessments that indicated undiagnosed and untreated conditions were either further assessed by a specialist in geriatric medicine or referred for further assessments. Finally, a specialist in geriatric medicine evaluated all the documentation concerning the diagnoses, drug treatments and measurements before the final diagnoses was made according to the same criteria for all participants.
DEPRESSION
Depression was diagnosed after an evaluation of previously documented diagnoses and current treatment with antidepressants. Depressive symptoms were also screened for using the Geriatric Depression Scale-15 (GDS-15), where scores of between five and nine indicate mild depression, and a score of ten or more indicates moderate to severe depression (87, 88). The GDS-15 has recently been evaluated in a sample of the very old and has been found to have high sensitivity and specificity in diagnosing depression (89). To validate the depression diagnosis, a specialist in geriatric medicine further assessed participants with a GDS-score of five or more using the 30-points Montgomery-Åsberg Depression Rating Scale (MADRS) (90) (Paper I-IV). The rating for the MADRS is based on a clinical interview including 10 symptoms of depression. The ten ratings use 0 to 3 severity scales, with the higher scores reflecting more severe symptoms. As it focuses only on the psychiatric symptoms of depression, the MADRS is valuable for assessing depression in physically ill people (91). Depressive and other psychiatric symptoms were also rated according to the Organic Brain Syndrome scale (OBS scale) (92). Depression was diagnosed according to DSM-IV criteria but, in addition, anyone who had a previously diagnosed depression with ongoing treatment with antidepressants, despite a GDS score <5, was diagnosed as having depression. Those who were receiving ongoing antidepressant treatment and had a GDS score below five were regarded as responders to treatment.
COGNITION
Cognition was screened for using the Mini Mental State Examination (MMSE) which has a maximum score of 30. Any score below 24 indicates impaired cognition (93). Dementia was diagnosed according to DSM-IV criteria based on assessments including MMSE, OBS scale, and previously diagnosed dementia, and in uncertain cases a complete dementia assessment was performed at an outpatient clinic.
PSYCHOLOGICAL MEASUREMENTS
Psychological well-being or morale was assessed using the Philadelphia Geriatric Centre Morale Scale, (PGCMS) (94). The scale consists of 17 questions and according to its designer, scores of between 17 and 13 indicate high morale, 12 to 10 middle range and 9 to 0 low morale. Morale is often used synonymously with psychological well-being, which is the expression of choice for the measurement in this study. The British Geriatric Society has recommended the PGCMS for measuring subjective well being among old people (95). The Organic Brain Syndrome scale (OBS scale) (92) is an instrument used to determine a person’s orientation and awareness and to rate and register various symptoms. The OBS scale consists of two subscales; the disorientation subscale, which consists of a questionnaire containing 12 items, and the confusion subscale which is an observation schedule covering 39 clinical features. The disorientation subscale measures patient orientation to time, place and their own identity. The confusion subscale describes various cognitive, perceptual, emotional and personality changes and fluctuations in the clinical states and is based on observing and interviewing the participant as well as interviewing the caregivers. The OBS scale has been found to be clinically useful for describing a person’s mental state. In comparisons with other assessment scales it has shown reasonably good concurrent validity (92, 96-98). In the present thesis, the total OBS scale containing both subscales was only used in the urban sample from 2000; in the rural sample and the urban sample from 2005 only the confusion subscale was used.
EXPERIENCED SYMPTOMS AND SOCIABILITY
The Gothenburg Quality of Life instrument (GQL-instrument), a symptom questionnaire about experienced symptoms was used to gain information about symptoms experienced in the last three months (99). The participants were asked about the most common symptoms selected from this instrument, as given in the Lund 80+ study (100), and answered yes or no. For assessment of security and loneliness, we developed questions concerning feeling safe at home (“Do you feel safe at home?”), receiving the help one needs (“Do you get the help that you think you need?”), feeling lonely (“Do you ever feel lonely?”) and having a good friend or family to talk to (“Do you have a good friend/family member to talk to if you need to?”). The participants were also asked how many visits they had received from friends and relatives and how often they had visited someone else during the previous week. Relatives and caregivers were also asked to confirm the number of visits and phone calls participants with dementia had received.
PHYSICAL MEASUREMENTS
Activities of Daily Living (ADL) were rated using the Barthel ADL Index (101, 102), which consists of 10 items concerning personal (p-) ADL. The maximum score is 20, indicating total independence in p-ADL. The participants answered one question about how often they walked outdoors independently of others. The participants were also asked whether they had been outdoors during the preceding week and if they had sustained any falls during the past year.
Reading vision was rated as unimpaired when the participant, with or without spectacles, could read a word printed in four mm capital letters at reading distance. Hearing was rated as unimpaired if the participant, with or without a hearing aid, could hear a normal speaking voice from a distance of one metre.
Height and weight were measured using a folding ruler and a digital bathroom scale and Body
Mass Index (BMI) was calculated (kg/m2) from these figures. Nutritional status was assessed
using the Mini Nutritional Assessment (MNA) scale, a screening instrument for nutritional status among the very old (103). The MNA has a maximum score of 30 indicating good nutritional status. Scores between 23.5 and 17 indicate risk of malnutrition and scores below 17 indicate the presence of malnutrition.
Hypertension was diagnosed if the patient had a documented diagnosis of hypertension with ongoing treatment or if the person’s blood pressure was 160/95 without ongoing treatment for hypertension. The blood pressure was taken after five minutes’ bed rest and immediately after standing up.
BLOOD ANALYSES
In the urban sample in 2000, for further assessment of medical and physical status, blood samples were collected and analysed for s-haemoglobin, s-B12, s-folate, plasma-homocysteine, s-albumin, s-TSH, s-free T3, s-free thyroxin and s-creatinine by Umeå University Hospital laboratory, accredited by SWEDAC (Swedish Board for Accreditation
and Conformity Assessment) since May 9th1995, ref no 1937. All analyses were made within
one hour or centrifuged within thirty minutes, to ensure that no hemolysis or coagulation occurred before analysis. For photometric analysis of haemoglobin Sysmex FC 9000 was used. B12 and folate were analysed using Biorad quantaphaseII RIA and p-homocysteine using the immunological method, Abbot IMX. Creatinine and albumin were analysed in J&J Vitros, creatinine with enzymatic J&J Vitros and albumin with BCG. Thyroid status (s-TSH, s-free T3 and s-free thyroxin) was analysed using Microparticle Enzyme Immunoassay with Abbot’s AXSYM. The blood samples were not routinely drawn after fasting, but since they were taken at the end of the interview, more than two hours had elapsed since the most recent food intake in most cases.
MORTALITY
One-year and five-year mortality data were collected from the Swedish Tax Board. STATISTICAL METHODS
All calculations were made using the Statistical Package for Social Sciences (SPSS). The
chi-square and Student’s t-tests were used to analyse differences between groups. Multicolinearity was controlled for by correlation analyses. Variables with a statistically significant association with depression were included in logistic regression models to find independent factors associated with depression. The variables that best explained the differences between people with depression and those without were chosen in the final model. The Kaplan-Meier product limit method was used to estimate mortality as a function of time and the log rank test to find differences between groups. A p-value of <0.05 was regarded as statistically significant.
ETHICS
The study was approved by the Ethics Committee of the Medical Faculty of Umeå University (§ 99-326 and §05-063M).
Table 2. Participants and assessment instruments in the five papers.
Paper I Paper II Paper III Paper IV Paper V
Urban population X X X X X
Rural population X X X
Blood analyses X
Barthel ADL index X X X X X
BMI X X X X X Mortality data X X X Five-year follow-up X GDS X X X X X GQL X MADRS X X X X MMSE X X X X X MNA X X X X X OBS scale X X X X X PGCM X X X
Table 3. Overview of the studied samples.
Paper I Papers II-IV Paper V
N, total 242 363 83 85, n 95 146 -90, n 82 131 47 95, n 65 86 36 Age, mean±SD 90±0.3 90±0.2 93±0.4 Female gender, n/% 182/75% 261/72% 65/78% Depression, n/% 65/27% 106/29% 35/42% Dementia, n/% 69/29% 103/28% 37/45% Institutional care, n/% 102/42% 149/41% 39/47% Antidepressant treatment, n/%
R
ESULTSPAPERI
Sixty-five out of the 242 participants (27%) were diagnosed as suffering from depression. The 85-year-olds had a significantly lower prevalence of depression than the older age groups, 17% of the 85-year-olds versus 34%, p=0.008 of the 90 year-olds and 32%, p=0.023 of the 95-year-olds. No differences in prevalence of depression between men and women were found in any age group (data not shown). Of the 65 people diagnosed as having depression, 69% were receiving ongoing treatment for depression. Of these 65, 29 people, 45%, could be evaluated using the GDS and, according to that scale, 17, 59%, were still depressed i.e. measured as having a GDS score of five or more.
A description of the variables associated with depression in late life in this study is presented in Tables 4 and 5. Sociodemographic variables associated with depression apart from age group were, living in institutional care, feeling unsafe, feeling lonely and having experienced the death of one or more children during the last ten years (Table 4).
Among the diagnoses, constipation, osteoporosis and impaired reading vision were associated with depression among the very old in this study. Those who were depressed also experienced more symptoms than those who were not depressed. Other associated factors were dependency in ADL and a lower score on the MMSE. Those suffering from depression more often had an impaired walking ability and they were less often able to go outside independently than those without depression (Table 4).
The very old who were depressed used a larger number of medications even when antidepressant treatment was excluded from the analyses. An association was found between depression and analgesics (e.g. opioids and paracetamol), bensodiazepines, corticosteroids and laxatives. Beta-blockers had an adverse association.
Participants with depression had a poorer nutritional status, measured with the MNA than non-depressed participants (Table 5).
Regression analyses resulted in the model shown in Table 6. Living in institutional care and number of medications were the factors which, in the final regression model, remained independently associated with the diagnosis of depression.
Participants with diagnosed depression had a statistically significant reduced well-being, according to the PGCMS, than those without depression (Table 5).
The one-year mortality was higher among those suffering from depression than among the non-depressed (Figure 4). Twice the proportion among the depressed had died after one year, 23%, compared to 11%, of those without depression, p=0.014. Dementia and impaired ADL-ability were also associated with increased one-year mortality (data not shown).
Table 4. Factors significantly associated with depression.
Variable Depression (n=65) No depression (n=177) P-value Social factors, % Female gender 81.5 72.9 .167 Dead children (n=203)* 29.1 16.4 .045 After 1991 18.2 7.5 .027 Institutional care 63.1 34.5 <.001 Experienced loneliness 64.6 45.8 .023 Feeling unsafe† 10.9 3.2 .037
Barthel Index of ADL, Mean±SD 16.7±5.6 13.4±6.9 .001
Going outside independently 29.2 62.1 <.001
Walking difficulties 62.0 39.0 .004
Clinical characteristics, %
Impaired reading vision 39.1 21.1 .005
Constipation 64.6 31.6 <.001
Dementia 41.5 23.7 .007
Osteoporosis 53.8 31.6 .002
Number of symptoms according to
GQL-instrument‡, Mean±SD 7.8±3.6 5.9±3.5 .001 Medications, % Analgesics 67.7 50.8 .019 Opioids 27.7 13.6 .010 Paracetamol 56.9 42.4 .044 Antidepressants 69.2 0.6 <.001 SSRI§ 64.6 0.6 <.001 Bensodiazepines 50.8 28.2 .001 Against anxiety 15.4 6.8 .039 For sleeping 44.6 27.1 .010 Beta-blockers 16.9 31.1 .028 Laxatives 60.0 28.8 <.001 Steroids (systemic) 10.8 4.0 .044
Number of medications (Mean±SD) 8.9±4.5 5.9±3.7 <.001
*Of those who have had children. †42 cases missing. ‡Gothenburg Quality of Life-Instrument. §Selective
Table 5. Measurements. Variables Depression, (n=65) Mean±SD No depression, (n=177) Mean±SD P-value
Mini Mental State Examination (MMSE) 18.4±9.0 22.5±7.7 .003
Mini Nutritional Assessment (MNA) 20.4±5.2 23.4±4.6 <.001
Malnutrition (MNA<17), % 20.0 9.9 .043
Malnutrition or risk of malnutrition (MNA<24), %
63.3 41.0 .003
Philadelphia Geriatric Centre Morale Scale (PGCMS)
9.2±3.1 12.1±2.9 <.001
Table 6. Multiple logistic regression model of variables associated with diagnosed depression.
Variable B 95% Confidence Interval for B P-value
Number of medications 1.162 1.074 to 1.257 <.001
Institutional care 2.260 1.093 to 4.672 .028
Age .997 .926 to 1.074 .936
Sex 1.272 .595 to 2.718 .534
Chi-square for the model 31.85, p-value: <0.001, concordant 74%.
400 300 200 100 0 1,0 ,9 ,8 ,7
Figure 4. One-year mortality, p=0.011
Depressed Non-depressed
PAPERII
In total, 106 people, 29%, were diagnosed as suffering from depression. In the urban municipality, 65 people, 27%, were diagnosed as having depression while the prevalence for the rural municipalities was 34%, 41 persons, p=0.165. Depression was more common among women (data not shown), but the proportion of participants with depression who were women was similar in the rural and urban municipalities, 83% vs. 82%, p=0.856. The 85-year-old participants in the rural municipalities had a higher prevalence of depression than those in the same age group in the urban municipality, 37% vs. 17%, p=0.006. No differences in prevalence could be found for the 90-year-old participants, 33% vs. 34%, p=0.861. Among those aged 95 years and above the participants in the urban municipality had a higher prevalence than those in the rural municipality, 32% vs. 15%, p=0.042.
Among the depressed in the total population, 61% were receiving ongoing treatment with antidepressants. There was a tendency for the participants in the rural municipalities to receive treatment for their depression less often than those in the urban municipality 51.3%, vs. 69.2% p=0.067. In the rural municipalities, the depressed were less often treated with SSRI medications but instead there were participants receiving ongoing treatment with TCAs. The rates of participants who were regarded as successfully treated for depression among those who could be assessed using the GDS were 38% in the rural municipalities vs. 59% in the urban municipality, p=0.175.
The participants with depression in the rural municipalities went outdoors independently more often than those in the urban municipalities. They also had more children born alive and more living children, but they had fewer children in their home municipality. The participants with depression in the rural municipalities had fewer diagnosed eye-diseases and less osteoporosis than the depressed participants in the urban municipality. The depressed participants in the rural municipalities used more analgesics than the depressed participants in the urban municipality (Table 7).
In the final regression models younger age was associated with depression only in the rural municipalities, as was the use of analgesics and a low MNA score. Loss of a child was associated with depression in the urban municipality, as was not going outdoors independently. Experienced loneliness was independently associated with depression in both groups (Table 8).
Table 7. Significant characteristics of the population according to diagnosed depression:
rural municipalities and urban municipality*.
Variables Rural Municipalities
(n=41)
Urban Municipality (n=65)
Total P-value
n % n % N %
Experienced symptoms and sociability Female gender 34 82.9 53 81.5 87 82.1 .856 Going outside independently 20 52.6 19 29.2 39 37.9 .018 Diagnoses Eye diseases 16 39.0 46 70.8 62 58.5 0.001 Osteoporosis 12 29.2 35 53.8 47 44.3 0.013 Prescribed drugs Analgesics 37 94.9 44 67.8 81 77.9 0.001 SSRI 14 35.9 42 64.6 56 53.8 0.004 TCA 4 10.3 0 0 4 3.8 0.018 Mean±SD Mean±SD Age 88.7±4.2 90.8±4.3 0.015 Number of children alive† 2.7±1.9 1.9±1.1 0.034 Number of children in the same municipality† 0.3±0.6 1.2±1.1 0.09 Number of living born children 3.17±1.84 2.27±1.34 0.009
*Single items of data are missing in different variables.†Of those who have/had children.
Table 8. Logistic regression models for depression: rural municipalities and urban municipality.
Rural Municipalities (n=87) Urban Municipality (n=197)
OR 95% CI P-value OR 95% CI P-value Age 0.76 0.59-0.98 0.032 0.96 0.88-1.06 0.421 Analgesics 6.39 1.05-38.98 0.044 1.07 0.49-2.33 0.865 Experienced loneliness 4.53 1.24-16.53 0.022 2.42 1.14-5.13 0.021 Female sex 3.97 0.82-19.36 0.088 1.18 0.47-2.94 0.722 Heart failure 3.67 0.86-15.58 0.078 1.07 0.46-2.48 0.873 Loss of a child 4.20 0.65-27.15 0.132 2.88 1.15-7.21 0.024 Mini Nutritional Assessment 0.78 0.61-0.98 0.035 0.91 0.83-1.00 0.056
Not going outside independently
4.13 0.65-26.26 0.133 3.53 1.43-8.68 0.006
Chi-square for the model 46.89 (rural municipalities), 33.99 (urban municipality), p-value: <0.001 (rural municipalities), 0.001 (urban municipality), concordant 82.8 (rural municipalities), 79.2 (urban municipality)
PAPERIII
In the final sample of 363 participants, 106, 29%, were diagnosed as suffering from depression. Among the women 33% were depressed compared with 19% of the men, p=0.006. Of those treated with antidepressants, 44% of the men and 51% of the women, p=1.000, had a GDS score of less than five points, implying that more than half of those being treated for depression were still depressed.
Depression among both men and women was significantly associated with an experienced loneliness, not going outside independently and few visits to others/week. The depressed participants were prescribed more medications, even when treatment with antidepressants was excluded from the analysis. More symptoms were reported among the depressed, both men and women, and more depressed participants suffered from osteoporosis. A higher proportion of the depressed were at risk of malnutrition, which was also indicated by a lower MNA score.
Among men, depression was associated with the absence of a good friend to talk to, of having somebody who could help if necessary, and seldom or never receiving telephone calls from close relatives. The loss of a child during the preceding ten years was also associated with depression in men. Depressed men more often had impaired reading vision and suffered more often from incontinence than men without depression.
Among women, depression was associated with living conditions, e.g. being in institutional care and seldom or never visiting others. Women with depression, compared with those without depression, also wanted to see their family more often than they did. Concerning somatic diagnoses, depression among women was associated with constipation, dementia and heart failure. Depression was also associated with various kinds of medication, analgesics, benzodiazepines, laxatives and nitroglycerine. Women with a depression scored lower on the Barthel ADL index and on the MMSE than those without depression. They also had a lower systolic blood pressure (Tables 9 and 10).
The final regression showed that depression among men was associated with loss of a child/children during the last ten years (OR=30.0), not going outside independently (OR=26.0) and experienced loneliness (OR=7.0). Among women, experienced loneliness (OR=3.4), not going outside independently (OR=2.6) and treatment with nitroglycerine medications (OR=2.5) remained statistically significant (Table 11).
Table 9. Significant characteristics of the female population with and without depression (N=261). Depressed (n=87)* Not depressed (n=174)* N % N % P-value Social factors Experienced loneliness 44 69.8 68 46.6 .002 Going outside independently 30 35.7 105 61.0 <.001 Institutional care 54 62.1 64 36.8 <.001 Visits to others† 49 80.3 77 54.2 <.001
Wish to meet family more
often 46 74.2 72 51.4 .002 Clinical characteristics Constipation 57 65.5 60 34.7 <.001 Dementia 38 43.7 46 26.4 .005 Heart failure 31 35.6 38 22.0 .019 Osteoporosis 41 47.1 60 34.5 .048 Risk of malnutrition 38 46.9 52 31.1 .015 Medications Analgesics 69 81.2 100 58.5 <.001 Antidepressants 54 63.5 1 0.6 <.001 Benzodiazepines 38 44.7 47 27.5 .006 Against anxiety 13 15.3 12 7.0 .036 For sleeping 32 37.6 44 25.7 .049 Laxatives 53 62.4 55 32.2 <.001 Nitroglycerine medications 33 38.8 36 21.1 .003 Mean±SD Mean±SD
Barthel ADL index 13.2±6.9 16.1±6.0 .001
GDS score 6.1±2.7 3.1±2.1 <.001
Mini Mental State
Examination (MMSE) 18.7±8.3 22.3±7.9 .001 Mini Nutritional Assessment (MNA) 20.9±5.2 23.1±4.8 .001 Number of medications§ 8.9±5.0 5.7±3.7 <.001 Number of symptoms** 8.3±3.4 6.3±3.4 <.001 Number of visits to others/week 0.5±1.1 1.3±2.0 .001
Systolic blood pressure (mmHg)
141.8±20.9 151.5±25.4 .003
*
Statistics measured on number of valid cases (different numbers of cases missing in different variables).
†Friends and family. Seldom/never.§
Antidepressants are not included in this group.**
Gothenburg Quality of Life-Instrument
Table 10. Significant characteristics of the male population with and without depression (N=102). Depressed (n=19)* Not depressed (n=83)* N % N % P-value Social factors Experienced loneliness 11 64.7 27 35.1 .024
Going outside independently 9 47.4 69 83.1 .001
Good friend to talk to 10 58.8 61 81.3 .046
Having someone that can help if necessary 12 70.6 70 94.6 .010
Loss of child
During the last ten years 7 43.8 6 8.5 <.001
Loss of spouse
During the last ten years 10 83.3 18 48.6 .047
More than ten years ago 2 16.7 19 51.4 .047
Telephone calls† 3 42.9 2 6.7 .040
Clinical characteristics
Impaired reading vision 6 31.6 8 9.8 .013
Urinary incontinence 7 36.8 11 13.3 .015 Osteoporosis 6 31.6 10 12.0 .035 Risk of malnutrition 9 52.9 18 22.5 .011 Medications Antidepressants 11 57.9 0 0 <.001 Benzodiazepines 8 42.1 13 15.9 .011 For sleeping 8 42.1 14 17.1 .017 Mean±SD Mean±SD GDS score 6.4±3.0 2.5±1.6 <.001
Mini Nutritional Assessment (MNA) 22.3±3.2 25.4±2.7 <.001
Number of medications§ 7.8±4.4 4.7±3.8 .002
Number of symptoms 8.5±4.0 5.2±3.2 <.001
Number of visits to others/week 0.18±0.39 1.65±2.17 <.001
*
Statistics measured on number of valid cases (different numbers of cases missing in different variables).†
Every month or more seldom.‡Friends and family. Seldom/never,§Antidepressants are not included in this group.
Table 11. Logistic regression model: women*and men.
Women (n=204) Men (n=81) OR 95% CI P-value OR 95% CI P-value Age 0.9 0.86-1.03 0.177 0.8 0.57-0.98 0.038 Experienced loneliness 3.4 1.63-7.10 0.001 7.0 1.28-38.2 0.025 Institutional care 2.3 0.99-5.30 0.054 Living children 0.2 0.06-0.80 0.022 Loss of child/children† 30.0 4.04-222.7 0.001 MMSE 0.9 0.85-0.99 0.023 Nitroglycerine medications 2.5 1.23-5.19 0.011
Not going outside independently
2.6 1.18-5.87 0.018 26.0 3.39-199.7 0.002
*
Corrected model compared with the published paper.†After 1991
Chi-square for the model 48.12 (women) 31.99 (men), p-value <.001 (women), <.001 (men), concordant 73.5 (women), 90.1 (men).
