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ORIGINAL ARTICLE

Acta Medica Indonesiana - The Indonesian Journal of Internal Medicine

Risk Factors for Depressive Symptom Changes in Indonesian Geriatric Outpatient

Edy R. Wahyudi, Siti Setiati, Kuntjoro Harimurti, Esthika Dewiasty, Rahmi IstantiDepartment of Internal Medicine, Faculty of Medicine, University of Indonesia - dr. Cipto Mangunkusumo Hospital. Jl. Diponegoro No. 71 Jakarta 10430, Indonesia. Correspondence mail: er_wahyudi@yahoo.com.

ABSTRAK Tujuan: mendapatkan faktor risiko perubahan gejala depresi pada pasien geriatri rawat jalan.

Metode: penelitian dengan metode kohort prospektif dilakukan terhadap 106 pasien geriatri yang berobat jalan di Poliklinik Geriatri Terpadu RS dr. Cipto Mangunkusumo Jakarta pada tahun 2010. Kuesioner terstruktur digunakan untuk mendapatkan data variabel independen, seperti usia, jenis kelamin, tingkat pendidikan, penyakit-penyakit kronik (diabetes mellitus, penyakit ginjal kronik, hipertensi, dislipidemia, dan osteoarthritis), status fungsional (Skor WHO-Unescap), status gizi (indeks massa tubuh), kualits hidup terkait kesehatan (skor Eq5D), total asupan kalori, dan kejadian rawat inap dalam 6 bulan masa pengamatan, Gejala depresi sebagai variabel dependen diukur dengan menggunakan kuesioner Geriatric Depression Scale (GDS). Hubungan antara beberapa faktor risiko dengan perubahan gejala depresi danalisis menggunakan regresi logitik. Hasil: sebagian besar subjek adalah wanita (63,2%), berusia 70 tahun atau lebih (71,0%), dan menderita hipertensi (82,1%). Terdapat 22,6% subjek yang mengalami peningkatkan skor GDS selama 6 bulan pengamatan. Analisis bivariat menunjukkan bahwa diabetes mellitus dan penyakit ginjal kronik berhubungan bermakna dengan perubahan gejala depresi. Hasil analisis regresi logistik menunjukkan adanya hubungan yang bermakna antara perubahan gejala depresi dengan penyakit ginjal kronik yang tidak terkontrol (OR 3,39; 95% CI 1,07-10,76). Kesimpulan: penyakit ginjal kronik yang tidak terkontrol merupakan faktor risiko perubahan gejala depresi pada pasien geriatri rawat jalan.

Kata kunci: status mental, geriatri, gejala depresi.

ABSTRACTAim: to determine risk factors for depressive symptom changes in geriatric outpatients. Methods: a prospective

cohort study was conducted on 106 geriatric outpatients at Integrated Geriatric Clinic Cipto Mangunkusumo Hospital, Jakarta in 2010. A structured questionnaire was applied to obtain independent variable such as age, sex, educational level, chronic diseases (diabetes mellitus, chronic kidney diseases, hypertension, dyslipidemia, and osteoarthritis), functional status (WHO-Unescap score), nutritional status (body mass index), health related quality of life (Eq5D score), hospitalization within 6 months, and total calorie intake. Depressive symptom as dependent variable was assessed using Geriatric Depression Scale. The association between aforementioned various factors with depressive symptom changes were analyzed using multiple logistic regression analysis. Results: most of subjects were women (63.2%), aged 70 years old and older (71.0%) and had hypertension (82.1%). There were 22.6% subjects with increase in GDS score during 6-month follow-up. Bivariable analysis showed that diabetes mellitus and chronic kidney diseases were significantly associated with depressive symptom changes. Multiple logistic regression showed that variable which independently associated with depressive symptom changes was uncontrolled chronic kidney disease (OR 3.390; 95% CI 1.07–10.76. Conclusion: uncontrolled chronic kidney disease is risk factor for depressive symptom changes in geriatric outpatients.

Key words: mental status, geriatric, depressive symptom.

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INTRODUCTION Elderly populations in Asia is estimated

will reach 1.2 billion (59% of the total elderly population in the world) by the year 2050.1 Elderly population in Indonesia is also estimated increasing, by the year 2020 it will reach 29 million (11.2% of the total population in Indonesia). As the elderly population increasing, the health related problems will also increase in this population. Depression is common health condition among elderly, which is adversely affects the lives of this population.2,3

Prevalence of depression in elderly ranging from 8 to 15% in community settings and 40% in hospitalized patients.4 Other study found the point prevalence of major depression was estimated 4.4% in elderly women and 2.7% in elderly men in community.5 Prevalence of susceptibility to depression and depression was 17.2% in an Indonesian community dwelling elderly population.6 Elderly with depression commonly have more functional impairment, poorer well-being and quality of life, and cognitive decline.7-9 Studies showed that depressive disorders among elderly in primary care setting have poor prognosis and increased mortality.10-11 It has been projected that by 2020, depression will be the second leading cause of disability worldwide.12

Chronic diseases, poor health status, cognitive disorders, and functional impairment are a risk factor for depression among elderly and high prevalence of comorbid depression is also found in patients with chronic medical illness.13-16 Depression is also influence the cost of health care among individuals with chronic diseases.17,18As an elderly population increase in Indonesia, it is predicted that the number of chronic diseases and depressive elderly will also increase, which will lead to higher risk to socioeconomic burdens. Indonesian Geriatric outpatients are commonly having more than 2 comorbidities. Considering the specific characteristics of Indonesian geriatric outpatients such as such as high prevalence of illness, lower level of education, higher economic burden, and limited access to health services, which contribute to psychological condition of this population, it is important to identify risk factors for depressive symptom in Indonesian elderly. Information about risk factors for depressive symptom changes in Indonesian elderly is important to give direction to health professional in the management and care of

Indonesian geriatric outpatients. We, therefore, conducted this study to determine risk factors for depressive symptom changes.

METHODS

Design, Setting, and Study Population A prospective cohort study with 6 months

follow-up was conducted among 106 geriatric patients who visited geriatric clinic at Cipto Mangunkusumo Hospital. The inclusion criteria were those who have at least two of these following diseases (hypertension, diabetes mellitus, chronic kidney diseases, malnutrition, osteoarthritis, and dislypidemia), have no inability to answer the assessment questionnaire due to serious hearing problems or severe communication disorders and not refused to participate in the study. All subjects were informed about the objectives and contents of the study, and verbal informed consents were obtained. Subjects were follow-up for 6 months in this study.

Assessment of Factors Associated with Depressive Symptom

A structured questionnaire was applied to collect demographic data such as age, sex, and educational status, chronic diseases (hypertension, diabetes mellitus, chronic kidney diseases, malnutrition, osteoarthritis, and dislypidemia), functional status, nutritional status, quality of life, calorie intake, history of hospitalization within 6 months of the study, and mental status. All subjects were evaluated by face to face interview technique done by a trained staff. Data collections for all variables were done two times, at baseline and at 6 month after follow up.

Chronic diseases (hypertension, diabetes mellitus, chronic kidney diseases, malnutrition, osteoarthritis, and dislypidemia), were categorized into no diseases, controlled diseases and uncontrolled. Hypertension, diabetes mellitus, and chronic kidney diseases were categorized based on systolic-diastolic blood pressure, HbA1C value, and glomerulus filtration rate respectively. Osteoarthritis and dislypidemia were categorized based on VAS and total cholesterol value. Controlled diseases were defined if there was a positive value change within 6-months follow-up.

Functional status was measured by WHO-Unescap questionnaire, which was consisted

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of 6 questions. Nutritional status was measured by body mass index (BMI). We defined normal nutritional status as BMI score 18.5–22.9, underweight as BMI score less than 18.5, and overweight/obese as BMI score 23.0 or more. Quality of life was assessed by Euroqol-5D (Eq-5D) which describes health status according to five dimensions (mobility, self care, usual activity, pain/discomfort, and anxiety/depression). Calorie intake was assessed by 24-hour food recall. Depressive symptom was measured by geriatric depression scale (GDS) questionnaire, which was consisted of 15 questions.

Data Analysis Characteristics of subjects are presented

as number and percentage; including age, sex, education, and chronic diseases. Bivariable analysis using Chi square test were done between each independent variable and depressive symptom. Multivariable analysis using logistic regression was performed. A 2-sided p-value less than 0.05 was considered to indicate statistical significance. Data were analyzed using statistical package software.

RESULTS Table 1 summarizes subject characteristics.

Most of subjects were women (63.2%), aged 70 years old and older (71.0%) and had hypertension (82.1%). There were 22.6% subjects with increase in GDS score during 6-month follow-up. Prevalence of depression in this study was 2.8%.

Table 2 shows the results of Chi-square test using GDS score as dependent variable and other variables as independent variables. Significant associations were found in diabetes mellitus and chronic kidney diseases (p<0.05). Table 3 shows the results of multiple logistic regression. We found uncontrolled chronic kidney diseases significantly associated with depressive symptom changes (OR 4.30; 95% CI 1.26 – 14.68).

DISCUSSION Geriatric depression scale is commonly used

to assess mental status of elderly. The current study used the changes in GDS score to indicate depressive symptom changes which represent the mental status of the geriatric patients in this population. We found that chronic diseases such as diabetes mellitus and chronic kidney disease were associated with depressive symptom which

is represented by the change in GDS score within 6 months follow-up among geriatric outpatient. This result is in line with meta-analysis study which found that the presence of chronic disease was a risk factor for development of depression.19

Diabetes mellitus are common health condition among geriatric patients. Comorbid depressive symptoms are prevalent among older adults with diabetes.20 Study done by Sandra found that 31.1% of the older diabetic individuals reported high levels of depressive symptoms.3 Bivariable analysis showed that subjects with diabetes mellitus have a higher risk of increase GDS score compare to subjects without diabetes mellitus in this study. This result is in line with longitudinal study done by Maraldi et al which found diabetes mellitus was associated with a depressed mood (OR 1.31).18 Groot also reported that depression is twice as common in diabetic people that it is in non-diabetic people. As diabetes complication worsen, it will increase the chances of becoming depression.21

Elevated prevalence of depression among diabetic subjects was related to poor glycemic

Table 1. Characteristic of subjects

Characteristics n (%)

Sex

- Men 39 (36.8)

- women 67 (63.2)

Educational level

- No school 1 (0,9)

- Elementary school 15 (14,2)

- Junior high school 16 (15,1)

- Senior high school 25 (23,6)

- University 49 (46,2)

Age group

- 60-69 year 35 (33.0)

- > 70 year 71 (67.0)

Chronic diseases

- Diabetes Mellitus 39 (36.8)

- Hypertension 87 (82.1)

- Dyslipidemia 48 (45.3)

- Osteoarthritis 55 (51.9)

- Chronic kidney disease 34 (31.1)

- Malnutrition 77 (72.6)

Mental status

- Normal 85 (80.2)

- Succeptibility to depression 18 (17.0)

- Depression 3 (2.8)

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Table 2. Bivariable analysis on factors associated with depressive symptom changes

GDS ScoreOR (95% CI) p value

Decrease/steady Increase

Sex

- Men 28 (71.8) 11 (28.2)

- Women 54 (80.6) 13 (19.4) 0.61 (0.24 - 1.54) 0.29

Age group

- 60-69 years 27 (77.1) 8 (22.9)

- > 70 years 55 (77.5) 16 (22.5) 0.98 (0.37 – 2.58) 0.97

Educational level

- Junior high school or less 55 (74.3) 19 (25.7)

- Senior high school or higher 27 (84.4) 5 (15.6) 0.54 (0.18 – 1.59) 0.25

Hypertension

- No hypertension 15 (78.9) 4 (21.1)

- Controlled hypertension 44 (80.0) 11 (20.0) 0.94 (0.26 – 3.39) 0.92

- Uncontrolled hypertension 23 (71.9) 9 (28.1) 1.47 (0.38 – 5.64) 0.57

Chronic kidney diseases

- No chronic kidney diseases 61 (84.7) 11 (15.3)

- Controlled chronic kidney diseases 10 (66.7) 5 (33.3) 2.77 (0.79 – 9.67) 0.11

- Uncontrolled chronic kidney diseases 11 (57.9) 8 (42.1) 4.03 (1.32 – 12.29) 0.01

Diabetes mellitus

- No diabetes mellitus 57 (85.1) 10 (14.9)

- Controlled diabetes mellitus 5 (55.6) 4 (44.4) 4.56 (1.04 – 19.96) 0.04

- Uncontrolled diabetes mellitus 20 (66.7) 10 (33.3) 2.85 (1.03 – 7.86) 0.04

Dyslipidemia

- No dyslipidemia 46 (79.3) 12 (20.7)

- Controlled dyslipidemia 20 (76.9) 6 (23.1) 1.15 (0.38 – 3.49) 0.81

- Uncontrolled dyslipidemia 16 (72.7) 6 (27.3) 1.44 (0.46 – 4.46) 0.53

Osteoarthritis

- No osteoarthritis 39 (76.5) 12 (23.5)

- Controlled osteoarthritis 30 (73.2) 11 (26.8) 1.19 (0.46 – 3.07) 0.72

- Uncontrolled osteoarthritis 13 (92.9) 1 (7.1) 0.25 (0.03 – 2.11) 0.20

Nutritional status

- Normal (BMI 18.5 – 22.9) 21 (72.4) 8 (27.6)

- Underweight (BMI < 18.5) 4 (80.0) 1 (20.0) 0.66 (0.06 – 6.79) 0.72

- Overweight/obese (BMI > 23) 57 (79.2) 15 (20.8) 0.69 (0.26 – 1.87) 0.47

Hospitalized history within 6 months

- No 49 (73.1) 18 (26.9)

- Yes 22 (78.6) 6 (21.4) 0.74 (0.29 – 2.13) 0.58

Total calorie intake

- Increase 45 (81.8) 10 (18.2)

- Decrease 37 (72.5) 14 (27.5) 1.70 (0.68 – 4.28) 0.25

Functional status (WHO-Unescap score)

- Decrease 72 (78.3) 20 (21.7)

- Increase 10 (71.4) 4 (28.6) 1.44 (0.41 – 5.08) 0.52

Quality of life (Eq5d score)

- Increase 73 (79.3) 19 (20.7)

- decrease 9 (64.3) 5 (35.7) 2.14 (0.64 – 7.12) 0.21

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control, diabetes mellitus related complications, and obesity.22-24 Subjects with diabetes mellitus also have a higher risk for physical disability and cognitive impairment which can also contribute to the development of depression.18 Depression or impairment of mental status in elderly with diabetes mellitus will have a bad impact on treatment adherence such as diet and exercise which may lead to increasing severity and complications of the diseases. This will increase the use of health care service which will lead to higher health care cost.18,25

Depression is affecting up to 21% of patients with chronic kidney diseases (CKD). One in 5 patients with CKD had depression.26 Brian et al found 45% subjects with end stage kidney diseases positive for depression.27 Our study found lower prevalence, 42.1% subjects with uncontrolled CKD had increased GDS score, which is indicate decreased mental status. Subjects with uncontrolled CKD had higher risk for having decreased GDS score in this study (OR 3.39; 95% CI 1.07-10.76).

Depression in CKD patients was associated with an increased risk of poor outcomes, such as hospitalization, higher kidney diseases severity, and death.28 Some medical aspects of diseases can be affected by depression in CKD patients, such as limiting utilization of health care, adherence of treatment (dialysis regimen or compliance with prescribed medication), nutritional status (probably through eating disorders), changes in immune function or inflammatory responses.29,30 Survival of the CKD patients could also be influenced by depression through the use of medication or effect of underlying diseases.29

Mental management such as depression is considered to be important to maintain a high level of quality of life in geriatric patients.31 It

Table 3. Multivariable analysis on factors associated with depressive symptom changes in elderly

Variables Coefficient OR (95% CI)

Pvalue

Controlled chronic kidney diseases 0.99 2.45

(0.67–9.52) 0.17

Uncontrolled chronic kidney diseases

1.22 3.39 (1.07–10.76) 0.04

Controlled Diabetes Mellitus 1.44 4.24

(0-.9–19.90) 0.06

Uncontrolled Diabetes Mellitus 0.81 2.24

(0.77–6.52) 0.14

is important for health care workers to screen geriatric patients routinely for depression in order to prevent the incidence of chronic disease complications. Screening alone does not improve outcomes, but screening in combination with monitoring of adherence to therapy of the chronic diseases may be useful. This study emphasizes the importance of maintaining chronic medical conditions and screening routinely for depression. Need for multidisciplinary care and the role of geriatric team for geriatric patients care is apparent.

One of the limitation of the present study was time of the observation was 6 month which only can see the change in the GDS score. It is important to do the same study with a longer time observation to see the incidence of depression in geriatric patients with chronic medical condition.

CONCLUSION Uncontrolled chronic kidney diseases was

risk factors for depressive symptom changes in geriatric patients.

ACKNOWLEDGEMENTThis study was supported by University of

Indonesia

REFERENCES1. Population Division of The Department of Economic

and Social Affairs of the United Nations Secretariat (2007). World Population Prospects: the 2006 revision. New York: United Nations.

2. Polly-Hitchock N, John WW, Jurgen U, Shuko Lee, Cornell J, Katon W, Linda HH, Enid H. Depression and comorbid illness in elderly primary care patients:impact on multiple domains of health status and well being. Ann Fam Med. 2004;2:555-62.

3. Black SA. Increased health burden associated with comorbid depression in older diabetic Mexican American. Diabetes Care. 1999;22:56-64.

4. Leon FG, Ashton AK, Mello DA, Dantz B. Depression and comorbid medical illness: therapeutic and diagnostic challenges. J Fam Pract. 2003;19-23.

5. David C S, Ingmar S, Maria CN, Andrea DH, JoAnn TT, Brenda LP, Bonita WW, Kathleen AWB, John CSB. Prevalence of depression and its treatment in an elderly population. Arch Gen Psychiatry. 2000;57:601-7.

6. Setiati S, Harimurti K, Dewiasty E, Istanti R. Predictors and scoring system for health-related quality of life in an Indonesian community dwelling elderly population. Acta Med Indones. 2011;43(4):237-42.

7. Blazer D. Depression in the elderly. N Engl J Med. 1989;320:164-6.

8. Unutzer J, Patrick DL, Simon G, Grembowski D, Walker E, Rutter C, et al. Depressive symptoms and

Edy R. Wahyudi Acta Med Indones-Indones J Intern Med

52

the cost of health services in HMO patients aged 65 and over: a 4-year prospective study. JAMA. 1997;277:1618-23.

9. Palsson S, Skoog I. The epidemiology of affective disorders in the elderly: a review. Int Clin Psychopharmacol. 1997;12:S3-S13.

10. St Jhon PD, Montgomery PR. Do depressive symptoms predict mortality in older people. Aging Men Health. 2009;13:675-81.

11. Licht-Strunk E, Van Marwijk HW, Hoekstra T, Twist JW. De Haan M, Beekman AT. Outcome depression in later life in primary care:longitudinal cohort study with three years follow-up. BMJ. 2009;338:a3079.

12. Murray CJL, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet. 1997;349:1436–42.

13. Blay SL, Andreoli SB, Fillenbaum GG, Gastal FL. Depression morbidity in later life: prevalence and correlates in a developing country. Am J Geriatr Psychiatry. 2007;15:790-9.

14. Katon W. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003;54:216-26.

15. Cole MG, Dendukuri N. Risk factors for depression among elderly community subjects: a systematic review and meta analysis. Am J Psychiatry. 2003;160:1147-56.

16. Djernes JK. Prevalence and predictors of depression in populations of elderly: a review. Acta Psych Scand. 2006;113:372-87.

17. Hurkeler EM, Spector WD, Fireman B, Weisner C. Psychiatric symptoms, impaired function, and medical care cost in an HMO setting. Gen Hosp Psychiatry. 2003;25:178-84.

18. Cinzia Maraldi, Stefano Volpato, Brenda W, et al. Diabetes mellitus, glycemic control, and incident depressive symptoms among 70- to 79-year-old persons. The health, aging, and body composition study. Arch Intern Med. 2007;167:1137-44.

19. Huang CQ, Zhang XM, Dong BR, Lu ZC, Yue JR, Liu QX. Health status and risk for depression among the elderly: a meta-analysis of published literature. Age and Ageing. 2010;39:23-30.

20. Konen JC, Curtis LG, Summerson JH. Symptoms and complications of adult diabetic patients in a family practice. Arch Fam Med. 1996;135-45.

21. De Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association of depression and diabetes complications: a meta-analysis. Psychosomatic Med. 2001;63:619-30.

22. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001; 24:1069-78.

23. de Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association of depression and diabetes complications: a meta-analysis. Psychosom Med. 2001; 63:619-30.

24. Roberts RE, Deleger S, Strawbridge WJ, Kaplan GA. Prospective association between obesity and depression: evidence from the Alameda County Study. Int J Obes Relat Metab Disord. 2003;27:514-521.

25. Roberts RE, Kaplan GA, Shema SJ, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: a 4-year prospective study. JAMA. 1997;277:1618-23.

26. Hedayati SS, Minhajuddin AT, Toto RD, Morris DW, Rush AJ. Prevalence of major depressive episode in CKD. Am J Kidney Dis. 2009;54(3):424-32.

27. Brian AJW, Ron DH, Karen LS, Moshe F, William BC. Helath-related quality of life, depressiove symptoms, anemia, and malnutrition at hemodialysis initiation. Am J Kidney Dis. 2002;40:1185-94.

28. Hedayati SS, Minhajuddin AT, Afshar M, Toto RD, Trivedi MH, Rush AJ. Association between major depressive episodes in patients with chronic kidney disease and initiation of dialysis, hospitalization, or death. JAMA. 2010;303:1946-53.

29. Paul LK, Samir SP, Rolf AP. Depression in African-American patients with kidney disease. J Nat Med Assoc. 2002;94(8):92S-103S.

30. Kimmel PL. Depression in patients with chronic renal disease:what we know and what we need to know. J Psychosom Res. 2002;53(4):951-6.

31. Demura S, Sato S. Relationship between depression, lifestyle, and quality of life in the community dwelling elderly: A comparison between gender and age group. J Physiol Anthropol. 2003;22(3):159-66.