CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND TO THE STUDY
Depression in the elderly is also known as late-life depression or geriatric depression.
Depression in the elderly is defined as depression occurring for the first time or recurrence of past depression in old age.
Sadness or low mood in the elderly can be assumed to be an expected phenomenon in the elderly, but depression is not a normal part of the aging process. 1-3 Formal diagnoses of depression are less common in older people, with prevalence rates considerably lower than those in younger populations. 1-3 Depression is of devastating consequences with pervading effects.
Depression as a disorder can be missed by the individual, family, healthcare providers and even physicans.
Depression is a mood disorder involving disturbances in emotional, cognitive, behavioural and somatic regulation. 1,6 Depression is characterized by major symptoms which are: low mood and energy with loss of interest in previously pleasurable activities, with other depressive symptoms. Minor depression is also referred to as sub-threshold depression or sub-syndromal depression. 1,6 International Classification of Diseases (ICD) for Mental and Behavioural disorders –10 and American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) – IV or V are the most commonly used classifications. 6-8 The DSM-5 has tried to harmonize the DSM –IV and ICD classification of
The World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The healthcare needs of the elderly are better achieved with great benefits, by holistic use of the bio-psychosocial model of healthcare that reconciles physical, biological and psycho- social aspects of the individual in disease and health.
The recognition of depression as part of healthcare for the elderly is crucial because of the impact of depression on other aspects of that individual‘s health, even if the elderly person has only low mood or sadness or minor
Definition of the elderly: WHO defines the elderly as individuals chronologically above 60 years of age.
In most informal and traditional African societies, individuals who are 50 – 55 years in age are regarded as elderly, which is based not only on chronological age, but having adult children and grandchildren, a change in social role, onset of menopause, change in work pattern due to retirement and even presence of grey hair.
The Nigerian demographic census of 2006 uses cut-off age of 65years to define elderly.
The age of the elderly in Nigeria is usually an estimation due to poor birth register records. The lack of proper birth records has led to the use of age estimation using historical events, age of first child or the person’s age at marriage. In developed countries, most studies and surveys use the age of 65 years for definition of the elderly, because of longer life expectancy with most individuals working beyond 70 years by choice.
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The United Nation Population Fund (UNPF) and other international agencies use a general cut off of 60years which is increasingly being adopted.
The age of 60years is also the retirement age used by most formal employers of labour in Nigeria. Various studies in the elderly use 60 or 65years, depending on the investigators. For the purpose of this study, the elderly individual is a person equal or older than 60years as recommended by WHO.
Definition of social support: Social support can be conceptualized as the structure, quality, utilization, and availability of and satisfaction with one’s support network.
Social support includes the structure and function of the existing social networks of an individual.
Social support is widely understood and accepted, but with varying ideas about the definition and concepts.
The definition of social support varies widely among researchers and authors. Social support in various studies is operationalized in several different ways. Social support has been associated with increased physical and psychological well-being while low support could be associated with depression among older adults. 12,13-16 Social support in the elderly
is best explained from the life-span perspective as proposed by Uchino with changes in the form or amount of support with aging,
which also explains the development of depression in the elderly.
Historical perspective on depression in elderly Depression is an age-long problem with earliest documented depression in second millennium BC (before Christ) time period. There was separation of management of depression and other mental health issues by priests, with attribution of depressive mood disorder to spiritual causes only. Hippocrates, the Greek Father of modern medicine suggested imbalance in body humors, with predominance of black bile leading to melancholy. 1,6 This was superseded by a bio-psychosocial model of illness.
The bio- psychosocial model of depression is the most widely accepted by professionals. The bio- psychosocial model suggests multiple pathways of biological, psychological and social factors leading to depression, all of which are inter-linked; with depression having significant contributions to health or disease. 4,6 This model encourages physicians to examine all relevant biological, psychological and social factors that could contribute to the development, maintenance and remission of depression. 4,6 Hence, the complexity and interdependence of depression in elderly is best explained by the bio-psychosocial model. 4,6
Diagnosis of depression International Classification of Diseases (ICD) – 10 classifies depression into: primary mood disorders which are categorized into depressive (unipolar) and manic depressive (bipolar) conditions. Unipolar depression is further divided into major depressive disorder, persistent depressive disorder and depression not otherwise specified. 6,7 The ICD -10 requires four out of ten symptoms while DSM-V requires five of nine symptoms for diagnosis of major depression of clinical importance. 6-8 The ICD-10 diagnosis of major depression must have two of major symptoms of depressed mood, anhedonia (loss of interest in previously
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pleasurable activities) or low energy as major criteria in addition to the other symptoms. The DSM criteria definition must have one of these major criteria: Depressed mood or diminished loss of interest or pleasure in all or almost all activities; in addition to other minor criteria such as- insomnia or hypersomnia; fatigue and loss of energy; dramatic appetite change resulting in a 5% weight gain or loss in a month; feelings of worthlessness; self -hate or inappropriate guilt; loss of concentration and difficulty making decisions; suicidal ideation or suicide; feelings of helplessness and hopelessness; psychomotor agitation; restlessness and irritability. 6,7 In DSM-5, unlike previous editions, grief after the death of a loved one is not considered to be exclusionary.
The symptoms should be present for at least 2 weeks and for most of the day. The DSM criterion is the most widely used criteria and includes more of somatic symptoms of depression.
The association between somatization and depression is common at all ages, even more so in the elderly. 1,4,6 Multiple or unexplained symptoms may signal a mood disorder, especially in the elderly. 3,4
Depression in the elderly is a spectrum from minor (sub-threshold or sub-syndromal depression) to major depressive illness arising for the first time in elderly. 1,4,17 Depression is the commonest mental health morbidity among patients seeking treatment in primary care. 3,5
1.2 Magnitude of the problem
Elderly depression is commonly associated with somatic symptoms which could be the reason for clinical encounter.
The level of major depression among older Nigerians is high, as seen in the study carried out in Nigeria by Gureje et al, which showed the lifetime prevalence for major depression and 12 month prevalence was 26.25% and 7.1% respectively.
A cross-sectional study by Olagunju et al found the prevalence of depression among community-dwelling Nigerians in Lagos state to be 26.4%, especially prevalent among the young elderly.
The 12 month prevalence was found to be 4.0% among South
Africans older than 50 years.
The incidence rate was 10.4 per 100 person years in the Ibadan study on ageing.
In the United States (US), incidence rate was 6.8 per 100 person years, though the age cut-off was 70years in the Buchtemann et al study.
The prevalence of depression in the elderly is about 7.2 - 49% of all elderly depending on place of study, classification, study participants age, and instrument used to assess depression. 22-24 Studies have found that minor depression was generally at least 2-3 times more prevalent than major depression among older adults. 1,4,24 Depression in the elderly occurs mainly in sub- threshold (minor) levels such that, depression is not clinically recognized and those affected are still able to cope in society. 4,17 Sub-threshold depression which is the commonest type of depression in elderly does not fulfill the ICD- 10 or DSM-IV criteria for depression of low mood, anhedonia and low energy for at least 2weeks.
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Minor depression is the most common form of depressive disorder in older adults, accounting for 62.9% in the Ibadan study on Ageing.
Minor depression is observed more often than major depression in numerous settings, especially by Family Physicians. 3,25 Minor depression has the same disease burden, impact and yet has more positive outcomes than other forms of depression, with recognition and treatment. 17,25,26 The elderly seem to have a higher risk of recurrent depressive episodes with varying periods of remissions. 25,26 Furthermore, minor depressive conditions in elderly patients elevate the risk of major depression. 17,26 In the study by Goar et al in Jos, it was found that, depression if untreated is associated with increased healthcare utilization and costs.
Depression in the elderly, further worsens the health care expenditure with both direct and indirect costs.
The presence of depression in the elderly has also been associated with care giver distress and even depression.
Depression could be an earlier feature of other disorders such as dementia,
elder abuse,
or worsening of pre-existing conditions.
Uwakwe‘s study showed association of depression in the elderly with increasing dependence.
Depression is also an early feature of mild
cognitive impairment, a major cause of insomnia and somatization among the elderly,
worsening of existing morbidity
and mortality
and poorer quality of life.
There is also a high risk of progression of mild or sub-threshold depression to major depression.
The development, aetiology and management of depression and decline in social support in the elderly follows a bio-psychosocial model. 4,14 Changes in traditional care for the elderly by immediate family members are becoming more evident in the elderly as seen in the study by Okumagba.
Lack of insight into geriatric health issues in Sub-saharan Africa has also contributed to low response and priority level with false assumption of availability of the security net of family support and social support, pension payment and comparably affordable healthcare expenditure. 36,37 These are occurring in the face of increasing health expenditure. Possible catastrophic health expenditure, was found by Adisa in Nigeria to occur in 9.6% of elderly household.
It is obvious that not only do developing countries have less time to adjust to a growing population of older persons; they are at much lower levels of economic development and will experience greater challenges in meeting the needs of the elderly.
The Family Physician provides for majority of the health-care needs of the elderly.
Older primary-care patients prefer to receive treatment from their primary-care provider in the primary-care clinic, with preference for continuity of care by their primary care physician.
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Most of the mental health problems are attended to in the primary care setting. 42,43 Primary care clinicians detect major depression in only one-third to one-half of their patients, even those with major depression. 3,42 The recognition and management of elderly depression is an important responsibility for Family Physicians providing primary care and specialized care for the elderly in the vacuum of geriatric medicine. 42-43 Family Physicians are better equipped to do so with patient centred care using bio-psychosocial model and various family medicine tools. 43,44 WONCA (World Organization of Family Doctors) and WHO are
collaborating to increase the focus on and improve mental health care by Family Physicians, while promoting greater integration of mental health care into general care.
Primary care as a context to address health disparities in geriatric depression care is being promoted by WHO mGAP (mental health Gap Action Programme) since the patients seen are undifferentiated and more inclusive.
Targeting interventions for patients with minor (sub-threshold) depression, which is the most prevalent form of depression encountered in our environment, may prove useful as both primary and secondary prevention strategies can be instituted by Family Physicians.
The recognition and treatment of depression has the potential to improve functioning and quality of life in spite of the presence of other medical co-morbidities. As the population of elderly continues to grow older, the necessity for increased focus to provide assistance with the physical, mental and social health needs associated with later life will become a critical issue. 39,40,43 Of urgent importance, is recognizing the inevitability of population ageing and the need to adequately prepare all stakeholders (governments, civil society, private sector, communities, and families) for the growing numbers of older persons. Family Medicine worldwide since 1989 is increasing capability and skills to care for older patients, in view of few available geriatricians or psychiatrists in relation to high present and projected population of elderly requiring access to care. 40,43-44 Availability of physicians and changing patterns of specialist training have created gaps which can be adequately filled by Family Physicians, who deal with issues that define public health as a major part of daily clinical work, and have great potential to evolve appropriate health strategies. 43,44 In Nigeria, with no specialty training and low interest in geriatrics medicine, this gap can be filled adequately by Family Medicine Specialty. Pharmacological and psychological interventions can be made available and used to manage depression in elderly at the primary level of care, while using available resources.
There is an urgent need to re-focus on
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depressive illness in the elderly as part of holistic care for the elderly due to our unique place and position in geriatric medicine.
1.3 Aim
To investigate the pattern of depression and social support among elderly patients seen in General Outpatient Clinic (GOPC) in Federal Medical Centre (FMC), Owo, with a view to increasing the quality of comprehensive care in geriatric patients. Objectives 1. To determine prevalence of depression among elderly patients seen in the General Outpatient Clinic in Federal Medical Centre, Owo. 2. To determine the level of perceived social support of the elderly patients attending General Outpatient Clinic of Federal Medical Centre, Owo. 3. To determine predisposing factors for depression in the elderly patients seen in the GOPC of Federal Medical Centre, Owo. 4. To determine the association between depression and the perceived social support of the elderly patients attending the General outpatient clinic in FMC, Owo.
1.4 Rationale for the study
Research question: The significance of depression recognition in the elderly in a Nigerian health care setting, especially in a semi-rural based environment needs to be explored. The social risks for depression are assumed to be minimal. Social support especially in the dimension of family support context is presumed to be adequate, due to availability of family social networks in the predominantly traditional family and household structure still existing in semi-rural areas. It would be important to determine if there is a need to increase focus on elderly depression and incorporate it into geriatric care in Family Medicine practice in Nigeria. The prevalence of depression in the elderly in a primary care setting,
which cares for most of the health needs of the elderly patients seen in FMC Owo, needs to be determined while, searching for possible contributors to elderly depression.
1.5 Justification for research
Depression is a treatable condition with medications or psychotherapy. Yet, care for depression in the primary care setting has resulted in only about half of depressed adults getting treated. 24,25 Individuals could refuse to be identified as depressed due to denial, fear of stigmatization, low financial capability coupled with inability to access care where available. 4,45 Stigmatization would be more prominent in our environment due to prevailing socio-cultural and spiritual beliefs. Also primary care physicians are claimed to have difficulties and little familiarity with handling mental health problems, coupled with inadequate consultation time.
These mitigating drawbacks which are especially so in our environment, can be reduced with access to care by a Family Physician, who provides continuity of care from cradle to old age. 44,46
There have been strides in research and understanding of elderly depression worldwide. Various research on social support and it’s impact on health have also been carried out in developed countries. There had been few studies until recently in Nigeria, and fewer still by Family Physicians. There is a need to increase the recognition of depression in clinical encounters with elderly patients receiving care, while searching out possible risk factors and predisposing factors for depression in the elderly.
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Inadequate recognition and treatment of depression at the individual level has important implications for the use of social, medical, and mental health services, and for the allocation of scarce health care resources. Family Physicians provide care that is not only hospital based, but could include home and community based care, collaborative and coordinated care with advocacy, while remaining patient centred and evidence based, which is especially important in this age group. 41,46 This study is being motivated by the presence of depressive symptoms seen among our patients,
who tend to present with somatic symptoms in a study area with changing socio- demographics due to rural – urban migration. Most of the studies have been carried out in urban based hospital settings. Exploration of possible risk factors and social support has been given slightly more focus in recent times, so as to develop possible interventions for depression in the elderly. This study would help to determine the level of depression and the social support among elderly patients seen in the General Outpatient Clinic (GOPC) of FMC, Owo which is a semi-rural area. This study would help explore possible predisposing factors for elderly depression in this setting.
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