Authors:
Prof. Moatassem S Amer MD (1),
Dr. Hoda MF Wahba MD(1),
Dr. Enas Ramadan Abdel-Hafez M.B., B.CH (1),
Dr. Reem Sabry El Bedewy MD (1),
Assist. Prof. Heba Hamed El-Shehawy MD (2)

(1) Geriatric Medicine and Gerontology Department, Ain shams University,
(2) Neuropsychiatry Department, Ain Shams University

Correspondence:
Prof. Motassem Salah Amer,
Department of Geriatric Medicine and Gerontology, Ain Shams University.
Ramsis St., Abbassia, Cairo, Egypt,
Tel: 0020123100373,
FAX: 0020224826726
Email: drmoatassem@yahoo.com
or
Dr. Hoda Mohamed Farid Wahba,
Department of Geriatric Medicine and Gerontology, Ain Shams University.
Ramsis St., Abbassia, Cairo, Egypt,
Tel: 0020111864167,
FAX: 0020224826726
Email: farida_mf@yahoo.com

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INTRODUCTION
Depression is a common and disabling psychiatric disorder particularly in later life and particularly in frail nursing home patients (1).

The prevalence of depression in the nursing home population is 46%, which is three to four times higher than in the community dwelling elderly (1). Yet, it appears to be less prevalent in the community aged 65 years or older when compared with younger groups (2).
Stephene et al (2003) stated that depression is a major contributor to the burden of illness in the older population. Its effect on function, quality of life and use of medical services is severe. Moreover, among it's consequences are reduced life satisfaction and quality, social deprivation, loneliness, cognitive impairment, impairments in activities of daily living, increased non-suicide mortality (4), and somatic symptoms (5). Depression in late life is a multifactorial illness, where social risk factors predominate (6). The risk factors are:

1) Demographic e.g. age and gender (7)
2) Psychosocial factors e.g. life events (8), marital status (9), social support (10), socio-economic factors (11).

Although their extent remains unclear, major and minor depression are widespread in the nursing home population. Decline in functional competence, loss of personal autonomy and unavoidable confrontation with the process of death and dying that are associated with nursing home placement are probably the most common risk factors (12).

Recognition of what the nursing home resident has lost is often the key to developing plans for management.

METHODS
Design:
The study is a case-control study.

Sample:
100 elderly >60 years, males and females

1- Group I: 50 elderly with depression and co-morbid medical conditions (cases)
2- Group II: 50 elderly with depression only (controls)

Three nursing homes in Cairo, Egypt
Exclusion of elderly with cognitive impairment

Methods:
Every subject will undergo:
1- Informed oral consent
2- Comprehensive geriatric assessment
3- Diagnosis of depression via DSM IV criteria (13), and Hamilton depression scale was used to rate the severity (14).

Statistical analysis using SPSS 13 (mean, standard deviation, analysis of variance using ANOVA test and lastly Chi square).

RESULTS
The prevalence of depression in the nursing homes was 45.5%. The age range was 60-89 years. The mean age in the case group was 70.34+/-7.37, and in the control group 70.68+/-7.79 with no statistical difference. The males constituted 48% of the case group and 38% of the control group, while the females constituted 52% of cases and 62% of controls.

As for marital status the largest group in the cases was 48% widowed while the smallest group was 14% divorced, compared to 46% widowed in the control group and 14% married.

The cases were mainly of low social class while the controls were mainly of moderate social class.

56% of the cases had diabetes mellitus, 58% were hypertensive, 6% suffered renal disease, 18% had heart disease, 16% had COPD and 30% suffered other co-morbidities.

There was no significant statistical difference regarding the core symptoms of depression between the two groups. The three most common symptoms in the cases were depressed mood, insomnia and hypochondriasis, while in the controls was depressed mood, insomnia and anxiety.

Almost half of both groups suffered mild depression (53% of cases and 55% of controls). Most of the other half (41% of cases and 39% of controls) suffered moderate depression.

Studying risk indicators of depression revealed that 86% of controls suffered loneliness compared to 56% in cases, retirement in 32% of cases and 8% of controls, and visual impairment in 64% of cases and 84% of controls with a strong significant difference. On the other hand other indicators such as pain, no visit from family, inadequacy of care and death of a child showed insignificant statistical difference between the two groups.

The study found no significant statistical affect of the demographic variables on the severity of depression in the case group, while the female controls mainly suffered mild depression as did smokers.

Co-morbidities according to this study don't necessarily co-exist with severe depression. On the contrary, COPD patients mainly suffered moderate depression (71%), as did the hypertensive patients (52%), while in the diabetic patients 39% suffered severe depression and an equal percentage suffered moderate depression. The rest of the subjects suffered mild depression.
The risk indicators also showed a significant correlation to severity of depression where 50% of cases suffering loneliness suffered moderate depression.

69% of cases suffering pain were diagnosed with moderate depression while 78% of those complaining of inadequacy of care suffered moderate and severe depression in equal numbers. 56% of retired cases suffered severe depression and 50% of cases with visual impairment suffered moderate depression.

As for controls there was no single risk indicator linked to severity of depression.

Table 1: Comparison between the two groups regarding depressive symptoms according to the DSM IV criteria

DISCUSSION
The current study recruited subjects in the age range 60-89 years of which 57% were females and 43% males. This agrees with many authors such as Hussaini et al (1991) who stated that females tend to become more depressed due to increased life events and diminished level of contact with relatives and friends and additionally due to hormonal effects.

The prevalence of depression in the widowed subjects confirms the findings by Richard et al (2004) that stated that up to 15% of widowed adults have potentially serious depression for a year or longer after the death of a spouse.

Murata et al (2008) stated that there is a higher rate of depression among lower socioeconomic classes and this is evident in this study, where the cases were mainly of low socioeconomic class and controls mainly belonged to moderate socioeconomic class.

Nöel et al (2004) stated that patients with chronic medical illness are known to have a high prevalence of co-morbid depression and major depressive disorder. This study also shows a significant statistical correlation between severity of depression and co-morbid medical conditions.

As for the risk indicators this study found that loneliness was higher in the controls. This may be due to more social support received by cases with co-morbid medical conditions. Moreover these individuals are more occupied with their illnesses rather than being lonely. Jongenelis et al in a (2004) study revealed that lonely patients in particular need to be screened for depression. Hence it is important to identify these subjects.

Jongenelis et al (2004) also stated that retirement, death of a child, visual impairment and functional impairment are significant negative life events that may increase the risk of depression in elderly in nursing homes. Our study also showed that 74% of all subjects suffered visual impairment. On the other hand, only 20% of our subjects were retired. This may be as usually low socioeconomic class subjects don't have a job with formal retirement age but rather freelance jobs.

REFERENCES
1- Jongenelis K, Pot AM, Eisses AM, et al. Prevalence and risk indicators of depression in elderly nursing home patient. J Affect Discord 2004: 83(2-3):135-42.
2- Blazer DG, Kessler RC, McGonagle KA et al. The prevalence and distribution of major depression in a national community sample: the national comorbidity survey. Am J Psychiatry 1994: 151: 979-86.
3- Stephene CK, Sambamoorthi U, James TW et al. Diagnosis and treatment of depression in the elderly Medicare Population: Predictors, Disparities and trends. J Am Geriatr Soc 2003: 51(12):1718-1728.
4- Steffens DC, Skoog I, Norton MC et al. Prevalence of depression and its treatment in elderly population: The Cache County Study. Arch Gen Psychiatry 2000: 57:601-607.
5- No?l PH, Williams JW, Unützer J et al. Depression and comorbid illness in elderly primary care patients: Impact on multiple domains of health status and well-being. Ann Fam Med 2004: 2(6):555-562.
6- McCallum J, Simons L, Simons J et al. Low serum cholesterol is not associated with depression in the elderly: data from an Australian community Study. Aust NZJ Med 1994: 24(5):561-4.
7- El-Banooby MH, Mortagy AK, Ghanem M, et al. Prevalence of depression among Egyptian Geriatric Community: Thesis at Geriatric Department Library, Ain Shams University, 1998.
8- Madianos MG, Gournas G, Stefanis CN. Depressive symptoms and depression among elderly people in Athens. Acta Psychiatrica Scandinavica. 1992; 86:320-326.
9- Stephenson-Cino P, Steiner M, Krames L et al. G. Depression in elderly persons and its correlates in family practice: A Canadian study. Psychol Rep 1992; 70: 359-368.
10- Murphy E. Social origin of depression in old age. B J of Psychiat 1982: 141:135-42.
11- Woo J, Ho SC, Lau J et al. The prevalence of depressive symptoms and predisposing factors in an elderly Chinese population. Acta Psychiatrica Scandinavica 1994: 89:8-13.
12- Abrams RC, Teresi JA and Butin DN. Indicators of depression in nursing home patients. Clin Geriatr Med 1992: 8(2):309-22.
13- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Washington DC, APA, 1994, pp147-171.
14- Hamilton M. Rating depressive patients. Journal of Clinical Psychiatry 1980: 41: 21-24.
15- Hussaini BA, Moore ST, Castor RS, et al. Social density, stressors and depression: gender differences among the black elderly. J Gerontol 1991: 46(5): 236-42.
16- Richard BB and Vemuri SP. Depression in later life a diagnostic and therapeutic challenge: Current direction. Am Fam Physician 2004: 15:69(10): 2375-2382.
17- Murata C, Kondo K, Hirai H et al. Association between depression and socioeconomic status among community-dwelling elderly in Japan: The Aichi Gerontological Evaluation Study (AGES). Health and place 2008; 14(3): 406-14.

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