COMPETENCIAS GERENCIALES (14.65 PTOS) VALORACIÓN

6.2.1 Prevalence of depression

The prevalence of depression in this study using Geriatric Depression Scale (GDS) was found to be 11.7% of which 10.6% had mild depression and 1.1% had severe depression. The community based longitudinal comparative study

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conducted in Ibadan and Indianapolis among African-American elderly by Baiyewu et al⁵⁸ employed the GDS and reported comparable prevalence rates in the cohort of the Indianapolis elderly. Abhishekh et al²²⁰, in another community based study in a rural population in India reported similar findings using Hamilton Depression Rating Scale. Similar finding was obtained in the U.K in a population based community study where an automated screening instrument was employed⁵⁶. Olutoki et al² in their own study in a mixed urban community employed the use of GDS and found a higher prevalence rate (26.3%) while Papadopoulos et al⁶ did a population based study in a rural setting in Greece using a 15-GDS instrument and also found higher prevalence rate of 27 percent.

When the diagnostic instrument (MINI) was applied in this study, the prevalence of major depressive episode (current) was found to be 7.7% while the prevalence of recurrent depressive disorder was 3.7%. Gureje et al⁹ in their community based survey in Ibadan using the WHO Composite International Diagnostic Interview (CIDI) reported a 12-month prevalence rate of 7.1% which is comparable with the finding of this study.

Prevalence of depression in rural population tends to be lower than results obtained from urban population²⁵⁰. Gureje et al⁹ had reported that urbanization strongly increases the risk of depression in the elderly. Lower prevalence rate of depression in rural area could be attributed to joint family structure which is widely prevalent in rural areas²²⁰. Stress and nuclear family pattern are some of the important psycho-social risk factor for the development of depression which differs grossly between urban and rural areas.

6.2.2 Severity of depression

Severity of depression ranges from mild to moderate to severe. The prevalence rate of mild depression in this study was found to be 10.6%. This is comparable with findings of 12.3% prevalence rate obtained by Baiyewu et al⁵⁸ among their African-American cohort but slightly higher prevalence rate of 19.8% was obtained among their Nigerian cohort. On the other hand, our finding is at variance with the result obtained by Papadopoulos et al⁶. They reported a prevalence rate of 27% for mild depression in their study. The GDS was the instrument employed in all the surveys. Our finding that mild depression is commoner than severe depression is consistent with the findings of most other studies^2,6,7,9,58.

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The prevalence rate of severe depression in this study was found to be 1.1%. This is similar to the estimated severe depression rate found among African-American cohort in Indianapolis (2.2%) and the Nigerian cohort in Ibadan (1.6%) reported by Baiyewu⁵⁸. Similar but slightly higher prevalence rate of 4.3% was found among rural dwelling Chinese elderly²⁵¹. Conversely, Papadopoulos et al⁶ reported a higher prevalence rate of 12% for severe depression in their study. The GDS was the instrument employed in all these studies. The survey on geriatric depression studies in the community indicates that only a minor percentage of the cases are severe depression.

In most studies, women were reported to have a higher prevalence of depression than men^5,227. In this study, the prevalence rate of depression using GDS was higher in females which was 6.0% compared to 5.7% in males.

However, applying the diagnostic instrument (MINI), the prevalence of major depressive episode (current) among male respondents (4.9%) was higher than that of female respondents (2.9%). Similarly, the prevalence of recurrent depressive disorder in males (2.0%) was also higher than in females (1.7%).

6.2.3 Depression and socio-demographic variables

Marital status was found to be an important factor in this study. Most of the respondents with major depressive episode (current) were either separated, divorced or widowed suggesting that separation or loss of spouse may be associated with depression. This is similar to the observation of Gureje et al⁹ in which they reported that being widowed, separated, or divorced was strongly associated with increased lifetime risk for major depressive disorder.

Similarly, Sikorski et al²²⁸ in their longitudinal German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe) reported that experiencing a loss of spouse was predictive of mild and moderate depression even after adjusting for age and gender. However association with severe depression was not significant. Numerous previous studies6,224,225,229 also found living alone as risk factor for depression in the elderly. However, some other studies reported no association between marital status and depression in the elderly^2,58,230. Further studies are therefore needed to clarify the nature of the relationship of marital status with depressive illness.

In this study, bereavement was found to be strongly associated with depression in the elderly. This is consistent with the observation reported by Hashim²³¹ that bereavement is strongly associated with late life depression.

Bereavement in the elderly can be as a result of spousal loss, loss of a close relative or significant others.

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Prigerson²³² established and reported bereavement-related depression in the elderly as a distinct disorder different from complicated grief. Bereavement (spousal or otherwise) may eventually lead to loss of required social support for the elderly. Olutoki² reported significant association between low social support and the development of depression in the elderly. The higher the subjects’ perceived social support the lower the risk of being depressed.

This is similar to the findings of Gureje et al¹⁸² among a sample of Nigerian elderly subjects. The authors established that low available social support was associated with the development of depression in the elderly.

Similarly, this observation is consistent with the findings of Kim and Geistfeld²³³ among elderly Koreans. They reported a significant independent relationship between reduced social support and depression. A previous study among elderly Japanese urban residents by Kawakami et al²³⁴ also reported significant association between low social support and major depressive episodes. Other earlier studies reported that lower social support was highly related to a decrease in life satisfaction and an increase in the rate of depression²³⁵. Newsom and Schulz²³⁶ reported that fewer friends, fewer family contacts, a lower level of perceived belonging and support which are measures of perceived support predicted depressive symptoms. Thus, the present observation conforms with previous reports and suggests the importance of providing support for the elderly when they are bereaved. The present level of support for the elderly within the community where they live needs to be strengthened. Government involvement in the care of the elderly should be instituted as part of provision of social services to the people.

In the elderly, suicidal ideations, suicide attempts, and completed suicides occur most frequently in the context of major depression232,237,238. Psychological autopsy studies have found depression to be the most common psychiatric diagnosis in elderly suicide victims and in suicide attempters²³⁸. Depression has been said to be the principal risk factor for suicide in late life and for suicide’s clinical precursor, suicidal ideation²³⁹. In this study, suicide risk was found to be strongly associated with depression in the elderly and also an independent risk factor (p<0.001). This is similar to the result obtained by Wongpakaran et al²⁴⁰ in their study of the elderly in a long term facility in Northern Thailand. They reported that a quarter of the facility residents suffered from major depressive disorder and suicide risk was reported for one-third (of which most were depressed), though most were in the low-risk category. The same result was obtained by Mezuk²⁴¹ in their systematic review of suicide risk in long-term care facilities where

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they reported that most studies indicate that suicidal thoughts (active and passive) are common among residents and that major depression is mostly associated. All available reports indicate that depression is the single most important risk factor for suicidality in the elderly²⁴¹.

The subjects in this study live in rural communities with poor access to health care services. Provision of health care in this community is mainly through middle level care providers such as community health officers and assistants who operate at the primary health care level. These health care providers will need to be trained to acquire the knowledge required for the recognition of mental health problems among the elderly, particularly depressive illness. They should also acquire adequate knowledge required for the suspicion of suicide risk in depressed elderly so that such can be promptly referred for proper management. The result also suggests that the depressed elderly should be routinely screened for suicide risk.

Age and cognitive impairment have been associated with increase in the risk of depression in previous reports^8,242. Mean cognitive function has been observed to decline with increasing age²⁴³ and cognitive impairment was observed to be associated with higher risk of depression⁶. In this study, depression was observed to be strongly associated with cognitive impairment (p<0.001). Similarly, Ortiz et al²⁴⁴ in their study of elderly cohort in a metropolitan area in Mexico reported that cognitive impairment and depression are significantly associated.Also, a previous study has reported a wide range of cognitive impairment in late-life depression including decreased central processing speed, executive dysfunction and impaired short term memory²⁴⁵.

The cross-sectional surveys of older people in the English Longitudinal Study of Ageing consistently found associations between higher levels of depressive symptoms and poorer cognitive performance. It was also observed that better cognitive function was associated with lower severity of depression up to the age of 80 years and that greater severity of depression was associated with a slightly faster rate of cognitive decline but only in people aged 60-80 years. However it was noted that the trend in the trajectory was inconclusive and that the reciprocal dynamic influences was inconsistent²⁴³. Other studies have observed further that in certain subsets of elderly patients, late-life depression, mild cognitive impairment and dementia could represent a possible clinical continuum^246,247. In this

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study, it was found that the prevalence of cognitive impairment increases significantly with age. This observation is also consistent findings among the Chinese²⁴⁸ and Swedish²⁴⁹ elderly.

In this study, there is no significant association between education and depression in late life. Some earlier studies in Nigeria^9,58 reported similar findings. On the contrary, in two studies of depression conducted among the elderly in urban setting in Nigeria² and China²²⁶ reported that lower educational level was significantly associated with major depressive disorder in later life. Further studies on the relationships are therefore necessary.