Prevalence of Depression Among Elderly Patients Attending a Primary Health Care Clinic

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1 ORIGINAL PAPER Prevalence of Depression Among Elderly Patients Attending a Primary Health Care Clinic Introduction Sherina MS*, Jefferelli SB*, NoorZurani MHR**, Noorlia Yahaya*** Department of Community Health, F}culty of Medicine and Health Sciences, Unive rsiti Putm Malaysia ' Department of Primary Care Medicine, Faculty or Medicine, Universiti Malaya. Kulim Health District, Ministry of Health Depression Is the most common psychiatric disorder among the elderly. It is an important problem in primary care practice. The objective of this study was to assess the prevalence of d pression among the elderly patients a ttending a primary health care clinic in Malaysia and to identify its associated factors. The Geriatric Depression Scale questionnaire was used as a screening Instrument. 18% of the patients were found to have significant depressive symptoms. The associated factors identified were gender, marital status, educational level, total Income, occupation, living arrangement, place of residence and ethnicity. Further clinical evaluation using the DSM IV Criteria for major depression revealed that two-thirds of the patients with significant depressive symptoms were suffering from major depression. In conclusion, the prevalence of depression among the elderly primary care patients was 12%. Therefore, prima ry care doctors should take extra care to detect depression when managing elderly patients. Key words : Depression, Depressive symptoms, Elderly, Primary Care, Associated factors Malaysian Journal of Psychiatry September 2002, Vol.10, No. 2 Rapid socioeconomic development and improved health services in our country has resulted in declining mortality and improved life expectancy leading to an aging population in Malaysia (1). Apart form the drop in mortality, the decreased fertility also contributes to an aging population (2). Prom the year 1957 to the year 2001, there has been a drop in the crude death rate from 12.4 to 4.4 and a drop in infant mortality rate from 76 to 7.9. The crud a^ birthrate and the total fertility rate reduced over the same period of time from 46 to 23.5 and 6.7 to 3.2 respectively, have resulted in an overall decrease in mortality rates (3). Besides having a longer life expectancy, these changes will also lead to a smaller expected number ofchildren per couple and hence a smal^er population in the younger age group (4). Increasing age is associated with iperease risk to diseases and lessening adaptability.' Therefore in anticipation ofthis shift in population demographics, Correspondence: Sherina Mohd Skills, Lecturer, Department of eommunity Health, Faculty utmedlcine and HealtbSciences, nniversltl PgtraMalaysla, Serdang, Selangor DE primary health care providers need to be alert and informed ofthe special needs ofthis group ofpatients (1). In older adults, depression is the commonest psychiatric disorder. Unfortunately it is commonly misdiagnosed and under treated. This could be due to the misconception that depression is part of aging rather than a treatable condition. As depression could decrease an individual's quality of life and increase dependence on others, the untreated depressed elderly patients have significant clinical and social implications (5). The manifestations of depression in the elderly are different from depression in other periods of adulthood. Older patients often present with atypical, non-specific or somatic symptoms. Furthermore, the presence ofcognitive impairment, reluctance or denial by the patient or care providers, unavailability or over protectiveness of family members may make eliciting history difficult or complicate the physician's assessment (6). Primary Care doctors play an important role in the early detection and treatment of the depressed elderly, as most of these patients are 23

2 SHERINA MS et al seen at primary care level and not by the psychiatrists (7). There are many screening instruments and rating scales available to aid the primary care doctor to detect depression among the elderly (8). The Geriatric Depression Scale (GDS) which has high sensitivity and specificity has been provento be avalid instrument and is widely used for evaluating depression in the elderly (9,10). In this study we actively attempt to identify elderly patients with depressive symptoms. National figures on depression are often based on cases admitted to hospital. For every case of depression admitted to hospital there are many more undiagnosed cases of depression in the community. We hope this study will provide a better picture of the burden of depression in the community at large. To do so we will determine the prevalence of depression among attendees of a community clinic. We feel it is important to identify which socio demographic groups among the elderly are at greater risk of depression, where more detailed and thorough assessment should be carried out. The objective of this study was to determine the prevalence of depression among the elderly and the associated socio demographic factors. Materials and Method The study was conducted in Klinik Kesihatan Table 1: The association between sociodemographic factors and depressive symptoms among the elderly attending Klinik Kesihatan Butterworth Depressive symptoms No Depressive symptoms Prevalence p value Race Chinese % Indian % Malay % Gender Female % Male % Marital Status Married % Single/Widowed % Living Arrangement Living alone %, Living with family % Place of Residence Rural % Urban % Education level No formal education % Formal Education % Occupation Pensioner % Unemployed % Employed % Family Income Less than RM % RM300 or more % 24

3 PREVALENCE OF DEPRESSION AMONG ELDERLY PATIENTS ATTENDING A PRIMARY HEALTH CARE CLINIC Butterworth (Butterworth Health Clinic) in the Health Districtof Seberang Perai Utara, which covers an area of km 2 and a population of 252,000. This cross sectional study was conducted over a period of six months, from April to September In this study we defined elderly as males and females aged 60 and above. The socio demographic factorsincludedinthisstudywere age, gender, ethnicity, marital status, living arrangement, place ofresidence, occupation, education and family income. The inclusion criteria in this study was elderly patients who attended the health clinic during the study period, whereas the exclusion criteria was severe cognitive impairment and difficulty in communicating. The Geriatric Depression Scale was used as the study instrument. The patients' answers were scored by summing up the positive and negative responses. A predetermined cut off score of more than 10 was used to identify depression. GDS scores of 10 or less were considered to be negative for depressive symptoms, whereas scores of 11 and more were considered to be positive. This classification was based on the GDS guidelines. Information was collected by personal interview, conducted by the principal author using a structured questionnaire and the GDS. If the GDS scores were positive for depression, these patients were then assessed by a psychiatrist using the DSM IV criteria for Major Depression. Those with major depression were given treatment and followed up. Data was analysedusing the Statistical Package for Social Sciences programme version 7.5. Results A total of2 10 respondents ful filled the study inclusion criteria. Two respondents were excluded because of severe cognitive impairment and communication difficulties. GDS score The score of the GDS ranged from 0 to 19. The mean score was 6.32 and the median score was Based on the GDS scores, 37 (18%) ofthe respondents were found to have depressive symptoms. These patients were then referred to a psychiatrist for further assessment. Using the DSM IV Criteria, the psychiatrist diagnosed that 22 out ofthis 37 patients were suffering from major depression. Socio demographic factors In this study, depressive symptoms were more commonamongfemales(26.4%)than inmales (11.1%), the unmarried (32.3%) than the married (12.1%), thosewithoutanyfomtal education (29.6%) compared to those with fomtal education (5.0%), the unemployed (27.4%) compared to the employed (9.3%) or the retired (10.2%). Depressive symptoms were also more common in those with monthly family income less than RM 300 (27.5%) compared with those with family income more than RM 300 (4.5%) and the elderly who lived in urban areas (25.3%) compared to those who lived in rural areas (13.2%), those living alone (36.4%) compared to those living with family (16.8%) and among Indians (25.8%) compared to Malays (18.2%) and Chinese (14.1%). The differences were all statistically significant except for living arrangements and ethnicity. Discussion Studies of late life depression consistently show an increase of depressive symptoms in the elderly compared with other age groups (11). In this study, the prevalence ofdepressive symptoms in the elderly attending Klinik Kesihatan Butterworth was 18% where two third of them were subsequently found to have major depression. The findings ofthis study is consistent with other studies done overseas which reported the rate of depression in primary care setting to range from 5% to 37% (12). The factors found to be significantly associated with depressive symptoms among the elderly were gender, marital status, education status, occupation, income level and place ofresidence. Elderly females were found to be more depressed compared to elderly men. This could be explained by the fact that women in the older age group had frequently loss their spouse and were widowed. A widower often remarries, but widows tend to maintain their widowhood(13,14,15). An elderly female also experiences loss ofincome and change in living environment once they are widowed (13,16). In developing countries like Malaysia, the 25

4 SHERINA MS eta( situation is even worse since most elderly women are financially dependent on their spouses and are from the lower socioeconomic group (17). The prevalence of depressive symptoms was more than double among the unmarried (widow or single) compared to those who are married in this study. We believe this is due to the lack ofsupport and loneliness among the elderly who remain unmarried. Other studies have found that elderly who are married lead a better quality of life compared to elderly who are single, divorced or widowed (14,15). In this study otherfactors significantly associated with depressive symptoms among the elderly were no formal education, unemployment and low family income. These factors are commonly found in the lower socioeconomic groups ofthe community. Other studies have also found that among the lower socioeconomic groups, there is an increased rate of depression among the elderly. This is due to multi factorial elements such as inadequate diet, poor housing, poor health and medical care and the combination offamily and community disorganization (13,18). In Malaysia the elderly are generally lesswell off financially compared to the rest of the adult population due to their inability to earn. The elderly depend on theirpension, savings, investments oreven money from theirchildren to meettheirfinancial needs, which include seeking health care (19). This study also found theprevalence of depressive symptoms among the elderly who lived in urban areas double than those who live in the rural areas. This could be attributed to the fact that those living in urban areas were more likely to be socially isolated, compared to those in the rural areas. Furthermore, rural community folks tend to be more supportive and help one another (20). Although depressive symptoms were found more frequently among the Indians compared to other races in this study, this was not statistically significant. This could be due to the small representation of Indians in our study. Among the limitations of this study is that it was conducted in only oneprimary care government clinic. It did not include elderly patients from clinics in the private sector. It also did not include patients who could not attend the clinic due to severe physical disabilities or who were bed-ridden. Therefore, even though this study provides an insight into the preval ence ofdepression among the elderly, it does not represent the Malaysian elderly population at large. Conclusion Primary Care providers need to be vigilant when treating elderly patients in their care as depressive symptoms are commonly found in this age group. The failure to detect and treat these depressive symptoms have serious clinical and public health consequences. Early detection and treatment will significantly improve the patients quality of life and reduce dependence on other. Factors found to be positively associated with depression are the female sex, those who are unmarried, those with lower education, those with income less than RM 300/per month, the unemployed and the rural residence. Acknowledgements We thank Drs Lai Fong Hwa, Shamsul Azhar Shah, Norsiah MatNoor and Professor Dr Azhar Md Zain, Dean ofthe Faculty ofmedicine and Health Sciences, Universiti Putra Malaysia for all their help and support. We also thank the State Director of Health Pulau Pinang, Dr Azmi Shapie for his permission to publish. References Ebrahim S. PublicHealth Implications ofageing. In Srinivas P. (Eds) : Proceedings of the First National Symposium on Gerontology Faculty ofmedicine, University Malaya, Kuala Lumpur. 1995; Arokiasamy, J.T. Demography and Epidemiological Aspects of Ageing in the Developing World : Focus on Malaysia. Department of Social & Health Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Department of Statistics. Demographic Data, United Nations. Health of the Elderly. Report of

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