A Study on the Association of Depression and Functional Disability Among the Elderly in Mukim Sepang, Sepang, Selangor, Malaysia

Transcription

1 Ili ORIGINAL PAPER A Study on the Association of Depression and Functional Disability Among the Elderly in Mukim Sepang, Sepang, Selangor, Malaysia Sherina MS*, Mustaqim A* * Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Puma Malaysia. Depression is the most common psychiatric disorder in the elderly. Another common problem among the elderly is functional disability. Depression has been found to be significantly associated with functional disability in the elderly. However, such findings have not been previously established in Malaysia. The prevalence of depression among the elderly in Mukim Sepang, Sepang District, Selangor, Malaysia was determined using the Geriatric Depression Scale. The presence of functional disability was determined using the Barthel Activities of Daily Living Index. The prevalence of depression among the elderly was 7.6%. Depression was found to be significantly associated with functional disabilities such as urinary incontinence, problems in transferring to their beds and problems in using the toilet among the elderly. Primary health care personnel need to be aware of the prevalence and association of depression and functional disabilities among the elderly and address these problems accordingly. Key-words : Depression, functional disability, association, elderly, community Malaysian Journal of Psychiatry September 2002, Vol.10, No. 2 Introduction In 1997, the Malaysian population aged 60 years and abovewas proximated to be l million. In the year 2000, this particular group has increased to 1.5 million and will further increase to 4 million by the year 2025 (1). A nation is said to be aging when 10% or more of its population is aged 60 years and above (2). By the year 2020, the elderly population is expected to make up 9.8% ofthe overall Malaysian population (3). Elderly people aged 60 years and above in the world will reach 1.2 billion by the year 2025, the majority ofwhomwill be in developing countries (1). Increasing age is associated with an increased risk to disease and lessening adaptability (4). Depression is the most common psychiatricdisorderinthe elderly. Depression decreases an individual's quality of life and increases dependence on others (5). Diagnosing depression in the elderly is often difficult. This is why it is commonly misdiagnosed and under treated. Presence ofcognitiveimpairment, reluctance and denial Correspondence: Sherina Mohd Sldlk, Lecturer, Department of Community Health, Faculty ofmediclne and Health Sciences, Universiti PutraMalaysia,43400 Serdang, Selangor Darul Ehsan. by the elderly and their family members as well as atypical manifestations of depression in the elderly make eliciting history difficult and complicate the doctor's assessment (6). Studies show a wide range of prevalence of depression among the elderly. In Spain, 4.8% of the elderly suffer from depression (7). However, in Turkey and Hong Kong, the prevalence ofdepression is as high as 35% (8,9). In Malaysia, two studies done at primary health care clinics have shown a high prevalence of depression among the elderly, ranging from 14%to 18%(10,11). There are many screening instruments available to detect depression among the elderly. One ofthe most widely used instrument is the Geriatric Depression Scale which has high sensitivity and specificity. It has been proven to be a valid instrument for evaluating depression in the elderly (12,13). Another common problem among the elderly is functional disability. Functional disabilities and handicap are found to be significantly associated with age (14). In Singapore, it was reported that 17% of the 28

2 A STUDY ON THE ASSOCIATION OF DEPRESSION AND FUNCTIONAL DISABILITY AMONG THE ELDERLY IN MUKIM SEPANG, SEPANG, SELANGOR, MALAYSIA elderly have problems in at least one function of their Activities ofdaily Living (ADL). The most common type of problem (functional disability) is urinary incontinence (14.5%), followed by bowel incontinence (2.57%), problems with climbing stairs (2.25%), poor mobility (1.75%) and problems with transferring from bed to chair or chair to bed (1.5%) (15). In Malaysia, a study on functional status of the elderly found that 80% ofmen between 65 to 74 years old could perform all the Activities of Daily Living. However after the age of 75, only 64% of men could perform all the Activities of Daily Living. As for women, 71% between 65 to 74 years of age could perform all the Activities ofdaily Living, while 68% over the age of 75 could perform all the Activities of Daily Living. This shows that the proportion of elderly who can do all the Activities of Daily Living decrease with age (16). Studies have reported that depression is significantly associated with functional disability (8,9). Depression is most disabling when it coexists with a physical illness (17). Another study by Woo eta[ among an elderly Chinese population also found that various indices of functional disability were associated with depression (9). As both depression and functional disability are common among the elderly, this study was undertaken to determine the prevalence of depression among the elderly in acommunity and to determine its association with functional disability. Materials and Methods A cross sectional study was conducted in Mukim Sepang, Sepang District, Malaysia. It covers an area of 20,441 hectares. Five out of nine kampungs in Mukim Sepang were selected using table of random numbers. All elderly residents aged 60 years old and above were selected as respondents. Data was collected using the Geriatric Depressi on Scale (GDS) and Barthel Activities ofdaily Living Index (BA!) questionnaires. The GDS and BAI questionnaires were pre-tested in another locality not included in the study area. The Geriatric Depression Scale consisted of 30 questions, which were scored as 0 or 1. The total scores ranged from 0 to 30. Based on the GDS guidelines, a predetermined cut offscore ofmore than 10 was used to identify depression. The Barthel Activities of Daily Living Index (BAI) was used to assess physical functional ability in the elderly respondents. A respondent's ability to function independently was determined by their ability to complete their daily living activities on personal care, continence and mobility. If a respondent was able to perform a function independently, they were graded as normal functional ability. However, if a respondent was not able to perform a function independently, they were graded as having problems in functional ability (functional disability). Data was analysed using the Statistical Package for Social Sciencesprogrammeversion The level of significance used for the above data was p<0.05. Chi-square testwas used to determine the relationship between depression and each functional disability such as feeding, dressing, grooming, bathing, urinary continence, bowel continence, using the toilet, transferring from chair to bed, mobility on level surfaces and climbing stairs. Results Out of the 263 elderly residents, 223 agreed to participate giving a response rate of 84.8%. The mean GDS score was 4.34± SD 3.76 and the median score was The scores ranged from 0 to 27. Based on the GDS scores, 17 of the respondents were found to have depression. Therefore, the prevalence ofdepression among the elderly in Mukim Sepang was 7.6%. The prevalence was 15.7% for elderly respondents who had at least one problem (functional disability) in performing their activities of daily living based on the BAI. All respondents could perform activities such as feeding, dressing and grooming without any problems. The most common problems was urinary incontinence (9.9%). Otherproblems were in climbing stairs (9.0%), mobility (7.6%), transferring to their beds (5.4%),usingthetoilet(5.4%),bowel incontinence (3.6%) and bathing (0.4%). (Table 1) Table 2 shows the association between depression and functional disability. In this study, depression ;']

3 SHERINA MS eta? Table 1: Activities of Daily Living (based on the Barthel Activities of Daily Living Index / BAI ) among the elderly respondents in Mukim Sepang Activities of Daily Living Problems with Functioning Normal Functional (Functional Disability) (%) Ability (%) Feeding 0 (0.0) 223 (100.0) Dressing 0 (0.0) 223 (100.0) Grooming 0 (0.0) 223 (100.0) Bathing 1 (0.4) 222 (99.6) Bladder control 22 (9.9) 201 (90.1) Bowel control 8 (3.6) 215 (9C.4) Transfer to bed 12 (5.4) 211 (94.6) Using the toilet 12 (5.4) 211 (94.6) Mobility on level surfaces 17 (7.6) 206 (92.4) Climbing stairs 20 (9.0) 203 (91.0) was more common among respondents with one or more functional disability (11.4%) compared to respondentswithoutany functional disability (6.9%). Further analysis was carried out to determine the association between depression and each functional disability. Theprevalence ofdepression was higher in respondents who had urinary incontinence (18.2%) compared to those without urinary incontinence (6.5%), respondents who had bowel incontinence (12.5%) compared to those without bowel incontinence (7.4%), respondents with problems in transferring to their beds (25.0%) compared to those withoutproblems in transferring (6.6%), respondents with problems in using the toilet (25.0%) compared to those without problems in using the toilet (6.6%), respondents with problems in mobility (17.6%) compared to those without problems in mobility (6.8%) and respondents with problems in climbing stairs (15.0%) compared to those without problems in climbing stai s(6.9%).functionaldisabilitieswhich were found to be significantly associated with depression were urinary incontinence, problems in transferring to their beds and problems in using the toilet. However, only one respondent had problems inbathing and thiswas not found to be associated with depression. Discussion Studies have shown that depression affects 8% to 20%ofelderly inthe community (18). Theprevalence of depression among the elderly in the community in this study was 7.6%. Two local studies on depression among the elderly carried out in primary health care clinics showed higher prevalence of 14% and 18% (10,11). The prevalence of depression among the elderly inprimary care settings in othercountrieswere reported to range from 5% to 37% (19). Physical disabilities and handicap are found to be significantly associated with age (14). In our study, the prevalence was 15.7%of the elderly respondents who had at least one functional disability among the activities of daily living (ADL). The most common functional disability was urinary incontinence. This was followed by problems in climbing stairs, mobility, transferring to bed, using the toilet,bowel incontinence and bathing. This finding is consistent with a study by Chan etal amongelderly in Singapore, which reported that 17% of the elderly had at least one functional disability in their activities of daily living. The most common type of functional disability was urinary incontinence (15). 30

4 A STUDY ON THE ASSOCIATION OF DEPRESSION AND FUNCTIONAL DISABILITY AMONG THE ELDERLY IN MUKIM SEPANG. SEPANG, SELANGOR, MALAYSIA Table 2 : Association between depression and functional disability among the elderly in Mukim Sepang Activity of Daily Livings Depression (n=17) No depression (n=206) Prevalence (%) Disability > 1 functional disability No functional disability Bladder control Normal Problem * Bowel control Normal Problem Transfer to bed Normal Problem * Toilet use Normal Problem * Mobility Normal Problem Climbing Stairs Normal Problem Bathing Normal Problem *Significant at p<0.05 Studies have also found that there is an association between depression and functional disabilities (8,9). Depression is most disabling when it coexists with a physical illness (17). In this study, there was a higher prevalence of depression in the elderly having at least one functional disability compared to those without any functional disability. There was significant association between depression and physical disabilities such as urinary incontinence, problems with using the toilet and problems in transferring. In his study on an elderly Chinese population, Woo et al. found that depression was also associated with functional disabilities such as urinary incontinence, feeding problems and inability to do housework (9). The prevalence of depression among the elderly respondents was 7.6% and the prevalence of the elderly respondents having at least one functional disability was 15.7%. There was significant association between depression and functional disabilities such as urinary incontinence, problems with using the toilet and problems in transferring. In conclusion there is a significant association between depression and functional disabilities in the elderly. As both the Geriatric Depression Scale and Barthel Activities ofdaily Living Index are screening instruments, further studies should be done where elderly who are found to be depressed and functionally disabled are referred to psychiatrists and physicians for further assessment and diagnosis. Primary health care personnel need to be aware of the presence and association of these two common problems in the elderly to facilitate early detection and treatment. This 31

5 SHERINA MS et rl is to enable the elderly to have a better quality of life. Acknowledgement We would like to express our gratitude to Professor Madya Dr Lekhraj Rampal and Professor Dr Azhar Md Zain for all their help and support. We also thank the State Director ofhealth, Selangor forhis permission to publish our findings. References 1. Arokiasamy JT. Malaysia's Ageing Issues (Editorial). Medical Journal of Malaysia 1997: 52: Nazileh R. Senario Penuaan di Malaysia: Kesannya Kepada Negara. In: Seminar on "Ke Arah Had Tua yang Gemilang', Department of Statistics. Demographic Data, Ebrahim S. Public Health Implications ofageing. In Srinivas P. (Eds) : Proceedings of the First National Symposium on Gerontology 1995; Blanchard MR, Waterraus A, Mann AH. The Nature of Depression Among Older People in Inner London and the Contact with Primary Care. British Journal of Psychiatry 1994; 164: VanDerPol CA, Setter SM, Hunter KA, et al. Depression in Community Dwelling Elders. Postgrad. Med 1998; 103 (3): Lobo A, Saz P, Marcos G,et al. The Prevalence of Dementia and Depression in the Elderly Community in a Southern European Population. Archive of General Psychology 1995; 52: Bekaroglu M, Uluutku N, Tanriover S, et al. Depression in an elderly population in Turkey. Acta Psychiatrica Scandinavica 1991; 84: Woo J, Ho SC, Lau J, et al. The Prevalence of Depressive Symptoms and Predisposing Factors in an Elderly Chinese Population. ActaPsychiatr Scandinavica 1994; 89: Norsiah MN. Prevalence of Depression Among the Elderly Attending Klinik Kesihatan Pokok Sena and Who Do They Go For Help? MSc Thesis.Universiti Kebangsaan Malaysia; (Unpublished). 11. Sherina MS. The Prevalence of Depression Among ElderlyPatients Attending a Government Primary Care Clinic. Asia-Pacific Journal of Public Health, 12 ih Asia Pacific Regional Conference. Special issues 2002: Koenig HG, Meador KG, Cohen HJ, et al. Selfrated depression Scales and Screening for Major Depression in the Older Hospitalized Patient. J Am Geriatr Soc 1998 ;36(8): Yesavage JA, Brink TL, Rose TL, et al. Development and Validation of a Geriatric Depression ScreeningScale: ApeliminaryReport. Journal ofpsychiatric Research 1983; 17: Yadav SS. Disabilty and handicap among elderly Singaporeans. Singapore Medical Journal 2001; 42(8): Chan KM, Pang WS, Be CH et al. Functional Status of the Elderly in Singapore. Singapore Medical Journal 1999; 40 (10): Chia YC. Primary Care in the Elderly. In Srinivas P. (Eds) : Proceedings of First National Symposium on Gerontology 1995; Jeremy AS, Laura BD, Sidney Z. Late Life Depression: How to Identify Its Symptoms and Provide Effective TreatmentGeriatrics 57;2002: Rockville MD. Mental Health: A Report of The Surgeon General, U.S. Department ofhealth and Human Service 1999; Miller MD. Recognizing and Treating Depression in the Elderly. Adapted from Diagnosis and Treatment of Late Life Depression: Making a Difference. American Association of Geriatric Psychiatry 1996; pp