O R I G I N A L P A P E R
Quality of Life, Family Support, and Comorbidities
in Institutionalized Elders With and Without Symptoms
of Depression
Aurigena Antunes de Arau´jo1•
Rosa Ange´lica Silveira Rebouc¸as Barbosa2•
Marı´lia Stefani Souza de Menezes2•
Ingrid Iana Fernandes de Medeiros3•
Raimundo Fernandes de Arau´jo Jr.4•
Caroline Addison Carvalho Xavier de Medeiros5,6
Published online: 21 July 2015
Ó Springer Science+Business Media New York 2015
Abstract The institutionalization of elders can decrease the health status and quality of life in this population. The aim of this study was to analyze the socio-demographic, quality of life, family support, and comorbidities variables in institutionalized elders with and without symptoms of depression. This was a cross-sectional study in institutions for long
Aurigena Antunes de Arau´jo and Rosa Ange´lica Silveira Rebouc¸as Barbosa have contributed equally to this work.
& Caroline Addison Carvalho Xavier de Medeiros carolineaddisonfarma@yahoo.com.br
Aurigena Antunes de Arau´jo aurigena@ufrnet.com
Rosa Ange´lica Silveira Rebouc¸as Barbosa angelica_farmacia@msn.com
Marı´lia Stefani Souza de Menezes marilia_stefani@hotmail.com Ingrid Iana Fernandes de Medeiros ingrid_iana@hotmail.com Raimundo Fernandes de Arau´jo Jr. araujojr.morfologia@gmail.com
1 Post Graduation Program of Public Health and Pharmaceutical Science, Department of Biophysics and Pharmacology, Center of Biosciences, Federal University of Rio Grande do Norte UFRN, Senador Salgado Filho Avenue, S/N - Lagoa Nova, Natal, RN 59078-900, Brazil
2 Student of the Post Graduation Program in Health and Society, Rio Grande do Norte State University/UERN, Mossoro´, RN, Brazil
3
Student of Physician, Rio Grande do Norte State University/UERN, Mossoro´, RN, Brazil 4
Post Graduation Program in Functional and Structural Biology/Post Graduation Program Health Science, Department of Morphology, Federal University of Rio Grande do Norte/UFRN, Natal, DOI 10.1007/s11126-015-9386-y
permanence for the elderly in the State of Rio Grande do Norte, Brazil. Two institution-alized elderly groups were compared (138 elders: 69 with and 69 without depressive symptoms). The instruments used were: mini-mental state examination, geriatric depres-sion scale in the reduced verdepres-sion, socio-demographic questionnaire, quality of life (World Health Organization Quality of Life abbreviated-WHOQOL-bref), and inventory of per-ception of family support. Elders with depressive symptoms had inferior quality of life than those without depressive symptoms. Other factors that negatively influenced the quality of life in this population include: low economic conditions, occurrence of comorbidities, and deficient family assistance. These results have important implications in the decision making process with regard to strategies for improving the health status of institutionalized elders.
Keywords Depression Institutionalized elderly Quality of life
Background
The growth of the elderly population is a worldwide phenomenon that results from increased life expectancy and reduction in birth rates [1]. In developing countries such as Brazil, elders are those who are over 60 years old. According to the 2013 National Survey by Household Sampling (PNAD), there are 26 million elders in Brazil, with 405,000 in the State of Rio Grande do Norte [2].
As people age, psychological and social functions decrease and the number of chronic degenerative diseases increase, factors that expose the elderly to physical and emotional vulnerability are observed [3]. The prevalence of depressive symptoms is difficult to evaluate due to epidemiological problems such as the various definitions of ‘‘depression’’, which often prevent comparisons between studies. The second major difficulty is related to selection bias due not only to differences in studied populations, but also the fact that a large percentage of depressed patients refuse to participate in these studies. The prevalence of major depression in the general population is estimated to be from 1 to 4 % according to the DSM-IV criteria, and from 8 to 16 % for depressive symptoms that may require treatment. The heterogeneity of the symptomatology of depression with atypical clinical feature in the elderly leads to the underestimation in diagnosis and lack of proper medical care [4].
The study of Yaka et al. [5] revealed that depression was significantly higher in elders who had cerebrovascular, neurodegenerative and psychiatric disease, COPD, or organ failure, and was dependent on someone for daily life needs.
The prevalence of depressive symptoms elders in the general population of elders is estimated to be 10–15 % [6], but increases to 46.5 % in institutionalized elders [7]. The institutionalization of elders is a significantly traumatic event that requires adaptability. According to Del Duca [8], the loss of independence and space are only two notable difficulties that may trigger symptoms of depression and lower self-esteem, well-being, and quality of life.
5 Department of Biophysical and Pharmacology, Federal University of Rio Grande do Norte/UFRN, Natal, RN, Brazil
6
Although the Brazilian laws ensure the rights of elders in family and community life, many will depend on care in Long Permanence Institutions due to cultural factors, weakness in family arrangements, and availability of alternative services [9].
Based on this context, the objective of this study was to analyze the socio-demographic, quality of life, family support, and comorbidity variables in institutionalized elders with and without symptoms of depression.
Methods
Study Population and Data Collection
This was a cross-sectional study with institutionalized elders. Inclusion criteria include: age C60 years, residence in a philanthropic Institution of Long Permanence for Elders, and cognitive ability. The elderly who were under 60 years old, and did not reside in the institutions, showed low cognition, and did not respond to all questionnaires through the interviews were excluded from the study. The research was approved by the Ethics Committee from the Rio Grande do Norte State University under protocol number 363 858. The participants signed a Volunteer and Informed Term of Consent.
The data presented in this article are based on a sample of 138 institutionalized elders in the State of Rio Grande do Norte, Brazil. Data were collected between November 2013 and July 2014 through interviews with elders who responded to questions assessing their cognitive status, symptoms of depression, demographic variables, quality of life, and family support.
Instruments Used
The following validated and standardized instruments were used in this study: the Mini-mental state examination cognitive assessment scale (MMSE), geriatric depression scale in the reduced version (GDS-15), a questionnaire addressing socio-demographic variables, an assessment of quality of life (World Health Organization Quality of Life abbreviated-WHOQOL-bref), and inventory of perception of family support (IPFS).
Socio-demographic variables (gender, age, education, religion, marital status, children, income, reason and time of institutionalization, and family visits) were evaluated through a structured adapted questionnaire [10].
The cognitive assessment scale (MMSE), developed by Folstein et al. [11], was used to evaluate the cognitive functions in the institutionalized elders and was useful for selecting the participating sample. The instrument was adapted by Ganguli et al. [12] for use in Brazil. The score can vary from a minimum of zero to up to a maximum of 30 points.
The GDS-15 was used to detect symptoms that are indicative of depression. The scale presents 15 questions with Yes or No answers. A score of 0–4 score is considered normal; a score of 5–15 is indicative of depression. GDS-15, the instrument-of-choice for evaluating depressive symptoms in geriatric populations in research and clinical contexts was created by Yesavage et al. [13] and became a scale considered with satisfactory reliability and validity properties for tracing depression in the elderly.
The instrument to assess quality of life was the WHOQOL-bref translated and validated in Brazil by Vagetti et al. [14] and elaborated by the World Health Organization. It contains 26 items: two general questions about quality of life and 24 divided into four
domains consisting of physical, psychological, social, and environmental questions. Scores for questions in the four domains range from 1 to 5. The final scores for each domain are calculated by a syntax based on the criteria proposed that ranks the overall quality of life, and the respective domains were based on percentage scores ranging from 0 to 100. Scores closer to 100 indicate better elderly quality of life.
The IPFS evaluates elderly perception of family support in terms of affectivity, autonomy, and adaptation. It consists of 42 items divided into three factors: affective-consistent (21 items), family adaptation (13 items), and autonomy (8 items) [15]. Comorbidities were identified from the data in medical records of institutionalized elders.
Data Analysis
The socio-demographics, quality of life, family support, and comorbidity variables were compared between institutionalized elderly groups, with and without depressive symptoms, using the analysis of variance (ANOVA) and Chi squared test. The p \ 0.05 value was considered significant.
Results
The study sample contained 138 elders, divided into two groups: 69 with depressive symptoms and 69 without depressive symptoms. The socio-demographic, quality of life, family support, and comorbidity variables were compared. Most of the elderly in both groups were females (68 and 54 %); the predominant age was [80 years (42 % in both groups); literate (52 and 64 %), catholic (75 and 85 %), single (38 and 44 %). Addition-ally, the study sample had children (64 and 59 %). Significant differences in relation to these variables were not observed between the groups (Table1). Groups of elders with and without depressive symptoms showed a statistically significant difference in the income variable (p = 0.026). In the group of elders with symptoms of depression, 93 % were receiving up to one minimum wage (Table1).
The reason for institutionalization generated different answers between the groups: most of the depressed elders were institutionalized as the result of a family option (59 %), while the majority of those without depressive symptoms were institutionalized by their own free will (49 %). Most elders in both groups lived there for less than 5 years (70 and 68 %), and a large number were receiving visits from family members (71 and 67 %).
Table2presents quality of life data assessed by the WHOQOL-BREF. The results in the four domains of quality of life (physical, psychological, social, and environmental) were significantly lower in the group with depressive symptoms. The global domain showed that elders with depressive symptoms had lower QOL in relation to those without depressive symptoms (p = 0.02).
Results for perception of family support were demonstrated by the IPFS (Table3). Results demonstrated that both groups had a perception of low family support. A larger number of elders with symptoms of depression had a total perception of lower family support in relation to those without symptoms (p = 0.001), with the most affected factor being family adaptation for the elderly with depressive symptoms in relation to those without these symptoms (p = 0.003).
The prevalence rates of comorbidity between elderly groups are presented in Table4. The group without symptoms of depression showed significantly lower prevalence of
diseases than those with symptoms of depression (p = 0.002). Among the non-associated diseases in the group of elderly with depressive symptoms (16 %), hypertension was the most prevalent followed by psychiatric diseases (11.6 %). Hypertension and psychiatric and endocrinological diseases were prevailing comorbidities in both groups. The elderly with symptoms of depression presented more associated diseases.
Table 1 Socio-demographic variables in institutionalized elders - Rio Grande do Norte, Brazil, 2014 Variables With depression symptoms Without depression symptoms p
Gender 0.081 Female 47 (68 %) 37 (54 %) Male 22 (32 %) 32 (46 %) Age 0.168 60–70 12 (17 %) 12 (17 %) 71–80 28 (41 %) 28 (41 %) [80 29 (42 %) 29 (42 %) Schooling 0.168 Illiterate 33 (48 %) 25 (36 %) Literate 36 (52 %) 44 (64 %) Religion 0.266 Catholic 52 (75 %) 59 (85 %) Evangelical 8 (12 %) 6 (9 %) Other 9 (13 %) 4 (6 %) Marital status 0.691 Single 26 (38 %) 30 (44 %) Married 6 (9 %) 5 (7 %) Divorced 15 (22 %) 10 (14 %) Widower 22 (31 %) 24 (35 %) Children 0.600 Yes 44 (64 %) 41 (59 %) No 25 (36 %) 28 (41 %) Income 0.026* Up to 1 MWa 64 (93 %) 55 (80 %) [1 MWa 5 (7%) 14 (20 %)
Reason for institutionalization 0.099
Self-will 22 (32 %) 34 (49 %) Family option 41 (59 %) 29 (42 %) Others 6 (9 %) 6 (9 %) Time of institutionalization 0.854 Up to 5 years 48 (70 %) 47 (68 %) [5 years 21 (30 %) 22 (32 %) Family visits 0.581 Yes 49 (71 %) 46 (67 %) No 20 (29 %) 23 (33 %) * p\ 0.05—statistically significant a MW minimum wage
Discussion
In Brazil, The Long Permanence Institutions are public or private institutions that promote comprehensive care for functionally dependent or independent elders who cannot be with their families or in their own home [16]. According to Damian et al. [17], older individuals living in institutions have certain characteristics that distinguish them from others who live within a community: frequent inactivity, emotional deficiency, high prevalence of func-tional dependency, cognitive problems, lack of support for self-care, and insufficient financial support.
In the present study, elder females prevailed in both with depression symptoms and without depression symptoms groups, being the higher percentage in the group with depression (68 %). Some authors have demonstrated a larger ratio of female to male elders, with percentages ranging from 55.5 to 86 % [18]. Most of the studied elderly were over 80 years old (42 % in both groups). Similarly, some authors also found higher proportions of depression among elders over 80 years old [19,20]. With regard to education, a higher
Table 2 Quality of life in institutionalized elders (WHOQOL-bref)
Elderly Physical domain Psychological domain Social domain Environmental domain Global domain M p M p M p M p M p With depression symptoms 40.1 0.002* 48.4 0.000* 51.6 0.005* 42.9 0.007* 46 0.02* Without depression symptoms 62.7 72.5 62.8 63.0 65.0 * p \ 0.05—statistically significant
Table 3 Inventory of perception of family support in institutionalized elders (IPFS)—Rio Grande do Norte, Brazil, 2014
Elderly Consistency in affectivity Family adaptation Family autonomy Total
N % p N % p N % p N % p
With depression symptoms
Low 40 58 44 64 28 41 48 70
Medium-low 18 26 11 16 10 15 10 14
Medium-high 6 9 7 10 8 11 9 13
High 5 7 7 10 23 33 2 3
0.098 0.003* 0.664 0.001*
Without depression symptoms
Low 28 41 24 35 23 33 29 42
Medium-low 19 27 14 20 15 22 19 28
Medium-high 9 13 9 13 7 10 7 10
High 13 19 22 32 24 35 14 20
percentage of literate elders was observed in both groups. In contrast, other studies showed a greater tendency to elderly illiteracy or with low education level [21,22].
Catholics predominated in regards to religion. Single elderly prevailed in both groups (38 and 44 %); most claimed to have children (64 and 59 %). The elderly with symptoms of depression received more visits (71 %) than those without symptoms of depression (67 %).
Family income was the statistically significantly different socioeconomic variable (p = 0.026) between the elderly with and without depressive symptoms. A total of 93 % of elders with depression received up to one minimum wage compared to 80 % in the group without depression. Studies have detected that the economic condition is a risk factor for the development of depression in the elderly [21,22].
Upon entering the institution, elders leave their families and homes, lose autonomy, and become dependent on third parties [23]. Institutionalized elderly generally remain isolated and idle, and unable to exercise their physical, psychological, and social functions. Therefore, institutionalization is a strong risk factor for the emergence and aggravation of depression by interfering with quality of life (QOL) [1]. In addition, it is well known that depression has a high impact on the QOL of patients in the general population.
We compared elders with and without symptoms of depression using a generic tool for QOL (WHOQOL-BREF). QOL scores in four areas were different in the two groups and in favor of the group without depressive symptoms. Such results indicate that older people with symptoms of depression have less control over physical, psychological, social, and environmental variables when compared to the group without depressive symptoms,
Table 4 Comorbidities in institutionalized elders—Rio Grande do Norte, Brazil, 2014
Comorbidities With depression
symptoms Without depression symptoms N % N % p Absence of comorbidities 4 5.8 18 26.1 0.002** Hypertension 3 4.3 11 16 Endocrinological 1 1.4 1 1.4 Psychiatric 8 11.6 2 3.0 Neurological 1 1.4 0 0 Hypertension ? psychiatric 5 7.2 1 1.4
Hypertension ? psychiatric ? others 8 11.6 1 1.4
Hypertension ? endocrinological 5 7.2 9 13
Hypertension ? endocrinological ? others 6 9.0 9 13 Hypertension ? endocrinological ? psychiatric 4 6.0 4 6.0 Hypertension ? endocrinological ? psychiatric ? others 7 10.1 1 1.4
Psychiatric ? others 3 4.3 2 2.9
Endocrinological ? psychiatric 9 13 9 13
Endocrinological ? psychiatric ? others 1 1.4 0 0
Endocrinological ? others 1 1.4 0 0
Other associationsa 3 4.3 1 1.4
* p \ 0.05—statistically significant a
suggesting lack of support and appropriate adaptation when facing the presence of depressive symptoms. In other words, institutionalized elderly with depressive symptoms had lower quality of life than those without depressive symptoms. These results corrob-orate results from other studies showing that the symptoms of depression are important predictors for poor QOL [24].
In the present study, when questioned about the reason for institutionalization, most elders without depressive symptoms stated that they were voluntarily institutionalized (49 %), while most of those presenting depressive symptoms were institutionalized by family members’ choice (59 %). A study [25] showed that family choice was the main reason for institutionalization (62.84 %).
In relation to the time of institutionalization, most elderlies, with and without symptoms of depression, were residing at the institution for less than 5 years (70 and 68 %), which is a result similar to results reported in other study [26]. A study in the United States showed that the percentage of elders with depressive symptoms was higher among the recently admitted: 54 % were diagnosed with depression during the first year of institutionalization. These data may be correlated to the fact that the first year is marked by changes and adaptations. Another factor is the presence of hope on the part of the institutionalized elderly: they hope that their families will assume their care at home [27].
In this study, the total perception of family support was low. A higher number of elders with symptoms of depression presented lower perception of affective-consistency, adap-tation, and family autonomy factors than those without depressive symptoms; family adaptation was the factor most affected for elders with depressive symptoms. From this result, we can infer that deficient family assistance may have contributed to both the symptoms of depression and to the poor quality of life found in the institutionalized elderly with symptoms of depression. According to Soares et al., family becomes essential to the elderly and lack of family support or perceived lack of family support constitutes a relevant factor for the occurrence of depression in the elderly [28].
The evaluation of the influence of family function on depression in a sample of elderly Chinese, with and without depression, found that elderly patients with depression showed worse family functioning and lower social support than elders without depression [29]. According to a Brazilian study, familial dysfunction was higher among elders with depressive symptoms and, therefore, that family abandonment is a risk factor for depres-sion. The family has a fundamental role for the elder, and may aid in treatments and strengthen ties. Thus, the family must be inserted in the daily life of elders [25].
Although, the National Policy for the Elderly and the Elderly Statute reinforce the constitutional guidance that ‘‘programs of support for the elderly will run primarily in their homes’’ and always aiming at strengthening family and community links, that coexistence is regrettably not always possible. Institutionalization occurs when the elderly person has no family, is unable to provide for his own housing, food, health and social needs, or, is a victim of domestic violence [30,31].
Although long-stay institutions are of great importance for the care of this population, they effectively separate family members, a situation that may negatively affect elderly by generating feelings of insecurity, loneliness, and abandonment which, in turn, may lead to depression, social exclusion, and poor quality of life [32].
In this study, elders with symptoms of depression showed significantly higher preva-lence of isolated and associated comorbidities in relation to elders without these symptoms. Another interesting finding was the high number of elders without depressive symptoms or diseases. Hypertension and psychiatric and endocrinological diseases were comorbidities that prevailed in both groups. A similar result was found in other studies [32,33].
Considering that depression is a disabling disease that exposes the elderly to the risk of increased morbidity and chronicity, it is important to know the conditions that may prevent or minimize it. Early diagnosis is the best strategy to reduce the possible consequences of depression in the elderly. Therefore, it is essential that health professionals are trained to recognize the characteristics of depression in the elderly and to use scales of depression for evaluation purposes [34].
Literature data show that medical comorbidities and depression exert negative syner-gistic effects on the quality of life of elders. The bidirectional relationship between chronic physical ailments and depression is a possible mechanism. The deterioration of health causes emotional stress and may precipitate depression [35]. Conversely, depression can directly affect and worsen the evolution of physical disease through biological mecha-nisms, such as inflammation and cardiovascular responses to stress, or indirectly by engagement in unhealthy habits [36]. In addition, depression can impair the ability to develop physical conditions, affect perception of and tolerance to pain [37], and reduce the functionality and quality of life. A second possible mechanism is that both conditions have common underlying physiological pathways such as those involving the neuroendocrine system (hypothalamic–pituitary–adrenal axis) and autonomous system (sympathetic-adrenal-medullary axis). Thus, the malfunctioning of these systems leads to increased levels of glucocorticoids and catecholamines that are associated with depression [38] and a series of medical conditions mediated by the cardiovascular, metabolic, and immunolog-ical systems [39].
The results of this study have important implications for preventive strategies and health promotion with the main objective of improving the quality of life of institutionalized elders.
Conclusion
Our study showed that depressive symptoms are closely related to low quality of life in institutionalized elders. Other factors that also negatively influenced the quality of life in this population include: low socioeconomic conditions, unsatisfactory family assistance, and occurrence of comorbidities. These results have important implications in the decision making process regarding strategies for maintaining and improving the health status of institutionalized elders, suggesting the need for improved health and opportunities of interaction among individuals.
Authors Contribution Have made substantial contributions to Acquisition of data: RAR, IIM, AAA. Statistical analysis and interpretation of data: AAA, RAR, MSM, RFA, CACXM. Participated in the preparation of the manuscript and critical review of the intellectual content: AAA, RAR, RFA, CACXM. Compliance with Ethical Standards
Conflict of interest None.
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Aurigena Antunes de Arau´ jo, PhD graduated in Dentistry, Federal University of Rio Grande do Norte, is an Associate Research Scientist at the Program for Public Health and Pharmaceutical Science, Federal University of Rio Grande do Norte. She completed her postdoctoral at University of San Luis Potosi, Mexico, has experience in pharmacology, with emphasis on Pharmacokinetics, Pharmacoepidemiology and Experimental Phamacology.
Rosa Ange´lica Silveira Rebouc¸as Barbosa graduated in Pharmacy and Biochemistry, is an Associate Research Scientist at the Program for Health and Society – UERN. She has experience in pharmacology, with emphasis on polypharmacy and Pharmacoepidemiology.
Marı´lia Stefani Souza de Menezesgraduated in nursing, is an Associate Research Scientist at the Program for Health and Society of the University of Rio Grande do Norte State – UERN. She has experience in pharmacology, with emphasis on polypharmacy and Pharmacoepidemiology.
Ingrid Iana Fernandes de Medeiros is an Associate Research Scientist at the School of Medicine, University the Rio Grande do Norte State – UERN. She has experience in pharmacology, with emphasis on polypharmacy and Pharmacoepidemiology.
Raimundo Fernandes de Arau´jo Jr., PhDgraduated in Dentistry, is an Associate Research Scientist at the Program for Health Sciences and Studies in Structural Biology and Functional of the Federal University of Rio Grande do Norte. He is Professor at the Department of Morphology of the Federal University of Rio Grande do Norte (UFRN). He completed his postdoctoral at School of Medicine, University of Sa˜o Paulo, Brazil. He has experience in Pathology and Experimental Oncology.
Caroline Addison Carvalho Xavier de Medeiros, PhDgraduated in Pharmacy, is an Associate Research Scientist at the Program for Health and Society of the University of Rio Grande do Norte State – UERN. She is Professor at the Department of Biophysics and Pharmacology of the Federal University of Rio Grande do Norte (UFRN). She completed her postdoctoral at University of Federal University of Ceara´ Brazil, Works in Pharmacology with an emphasis on experimental models of inflammation, and has developed research in pharmacoepidemiology and rational use of medicines.
