Prevalence of Depression and Associated Factors in Non-institutionalized Older Adults With a Previous History of Falling

Archives of Psychiatric Nursing 31 (2017) 493–498

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Prevalence of Depression and Associated Factors in Non-institutionalized Older Adults With a Previous History of Falling Begoña Pellicer-García a,⁎, Isabel Antón-Solanas a, Sergio Moreno-González a, Enrique Castro-Sánchez b, Raúl Juárez-Vela a a b

Faculty of Health Sciences, Universidad San Jorge, Zaragoza, Spain Imperial College London, United Kingdom

a r t i c l e

i n f o

Article history: Received 10 November 2016 Revised 21 March 2017 Accepted 4 June 2017 KEYWORDS: Depression Elderly Falls Prevalence Risk factor

a b s t r a c t The purpose of this paper was to estimate the prevalence of depression and associated factors in people aged 65 or older with a history of falling in the last 12 months. A cross-sectional descriptive study was performed involving a random sample of 213 participants from two social centers for older adults in the city of Zaragoza (Spain). The mean age of the participants was 77.3 years (SD ± 7.0). Our findings reveal a prevalence of depression of 28.2% in the study sample, with older adults who were at a high risk of falling being more susceptible to developing depression. In conclusion, one in three elderly people who were at risk of suffering a fall in the 12 months prior to data collection had symptoms of depression. This is in agreement with the results from previous studies, which confirm that there is a high prevalence of depression in elderly patients with a previous history of falls. © 2017 Elsevier Inc. All rights reserved.

INTRODUCTION According to the World Health Organization (WHO), 37.3 million falls that occur worldwide every year are severe enough to require medical attention (World Health Organization, 2012), and represent a loss of N19 million dollars per disability-adjusted life year. More specifically, 30% of people over 65 living in the community fall at least once a year (Petridou et al., 2008; Swift & Iliffe, 2014), and approximately half of the elderly who suffer a fall end up falling again in the following year. This has a considerable impact on this population at physical, psychological and socioeconomic levels, which in most cases leads to disability, hospitalization (Gill, Murphy, Gahbauer, & Allore, 2013; Rubenstein, 2006) and even to institutionalization (Evitt & Quigley, 2004; Stel, Smit, Pluijm, & Lips, 2004). In 2012 the World Health Organization estimated that there had been around 424,000 fatal falls worldwide, which makes falling the second leading cause of death from unintentional injuries. The highest mortality rates due to falls were in people aged 60 or over (Fig. 1). Depression is another very frequent geriatric syndrome, and has often been associated with falls in the elderly (Iaboni & Flint, 2013).

⁎ Corresponding author at: Facultad de Ciencias de la Salud, Campus Universitario Villanueva de Gállego, Autovía A-23 Zaragoza-Huesca, Km. 299; 50830 Villanueva de Gállego, Zaragoza, Spain. E-mail addresses: [email protected] (B. Pellicer-García), [email protected] (I. Antón-Solanas), [email protected] (S. Moreno-González), [email protected] (E. Castro-Sánchez), [email protected] (R. Juárez-Vela).

http://dx.doi.org/10.1016/j.apnu.2017.06.006 0883-9417/© 2017 Elsevier Inc. All rights reserved.

According to various studies in different countries, the prevalence of depression in non-institutionalized elderly people is between 13 and 23% (Anstey, Von Sanden, Sargent-Cox, & Luszcz, 2007; Braam et al., 2010; Hamer, Bates, & Mishra, 2011). In particular, depression is more frequent in women, in people with a medium-low socioeconomic status, and in those individuals with higher disability and comorbid conditions (German et al., 2011; Nicolosi et al., 2011). An increased risk of both falls and depression has been associated with the elderly population (older than 65 years) (Anstey, Burns, Von Sanden, & Luszcz, 2008; Biderman, Cwikel, Fried, & Galinsky, 2002; Wada et al., 2008). Usually, neither syndrome is easily detected in primary care, which means that this population may not always receive adequate and timely treatment (Banazak, 1996). There may be three different ways in which depression and falls can be related. Firstly, depression may be a risk factor for falls; secondly, falls may be a cause leading to a depressive symptomatology in elderly individuals (Whooley et al., 1999); finally, both syndromes may be the result of a third condition or set of factors that adversely affect health in the elderly population (Biderman et al., 2002). However, the mechanism underlying this association is not yet clear as there is a significant bidirectional relationship between depression and falls. Approximately, 25–55% of non-institutionalized people over 65 are able to identify the causes of falling or fall risks (Tinetti, Mendes de Leon, Doucette, & Baker, 1994). This may sound like a positive but it is possible that, in some cases, the fear of suffering recurrent falls may become excessive and disabling, to the point of experiencing agoraphobia, thus increasing the risk of future falls. Additionally, it is

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Fig. 1. Study design. Cross-sectional study about the prevalence of depression and associated factors in non-institutionalized older adults with a previous history of falling.

known that both depression and fear of falling are associated with deterioration in gait and balance (Iaboni & Flint, 2013). So far, very few studies have analyzed the prevalence of depression in non-institutionalized subjects, older than 65 years, with a previous history of falling. Furthermore, it is still unclear why depression is associated with falling in the elderly population. Thus, it is necessary to conduct further research that may contribute to shed light on the relationship between depression and falls in this population (Van den Berg et al., 2011). Based on the above, the aim of this study was to estimate the prevalence of depression and associated risk factors in people aged 65 or over with a history of falling in the last 12 months.

for participation: 1) being under 65, 2) not having experienced at least one fall in the last 12 months, 3) being unable or refusing to be interviewed, and 4) scoring 3 or more in the Short Portable Mental State Questionnaire (SPMSQ). The final sample consisted of a total of 213 participants. Sample size was calculated with SPSS© (version 21 for Windows) for a 30% prevalence of falls in the chosen population, a confidence level (1- α) of 95%, an accuracy (d) of ± 0.5, a variance (S2) of 13.72 and an estimated 5% drop out rate. The data were collected from May 2014 to June 2015.

METHODS

This study was approved by a Clinical Research Ethics Committee, and all subjects gave informed consent prior to participation.

ETHICAL CONSIDERATIONS

DESIGN ASSESSMENT TOOLS A cross-sectional descriptive study was performed. Four assessment tools were used for data collection. STUDY SETTING AND PARTICIPANTS Participant recruitment took place in two social centers for older adults in the city of Zaragoza. These community-based social centers provide a common space where older adults may partake in leisurely and other activities which promote healthy aging. Our participants were selected from a total sample of 16,000 registered members. The final random sample included participants who: 1) were aged 65 or over, 2) had suffered at least one fall in the last 12 months prior to the commencement of the study, 3) were registered members of one of the selected social centers, 4) were not institutionalized in social or health centers, 5) did not have a cognitive impairment, and 6) accepted to sign the informed consent form after being informed of the study purpose, procedures and risks. The following were exclusion criteria

The Pfeiffer's Short Portable Mental State Questionnaire (SPMSQ) (Pfeiffer, 1975) is a brief screening tool for the assessment of organic brain deficiency in elderly patients. In its Spanish version, it consists of 11 items that assess short and long term memory, orientation to surroundings, knowledge of current events and the ability to perform simple mathematical tests. Its scoring ranges from 0 to 11, with a score ≥ 3 indicating cognitive impairment. The SPMSQ has been tested for validity and reliability, and its psychometric characteristics have been tested also in the Spanish population (GonzálezMontalvo, Rodríguez, & Ruipérez, 1992). The questionnaire of the World Health Organization for the study of falls in the elderly (WHO, 1989) (Vidán et al., 1993) was

B. Pellicer-García et al. / Archives of Psychiatric Nursing 31 (2017) 493–498

administered by the researcher due to its complexity. It is one of the few instruments which has been validated in our country and provides information about the circumstances of the fall, including personal data, data about the patient's home and immediate surroundings, physical activity, both functional and clinical capabilities, clinical history, current medication, and cause and consequences of the fall. The Geriatric Depression Scale (GDS), Spanish version (Martínez et al., 2002; Yesavage et al., 1983) is a 15-item instrument that assesses depression in elderly people. All questions have a dichotomous response (yes/no). A score ≤ 4 indicates absence of depressive symptoms, whereas a score ≥ 5 is suggestive of depression. The Tinetti Gait and Balance Assessment Tool (Tinetti, 1986). This test is designed to determine an elderly person's risk of falling within the next year. Administered by the researcher, the Tinetti Gait and Balance Assessment Tool consists of two parts, namely the gait scale (12 points) and the balance scale (16 points), with a total maximum for the overall instrument of 28 points. The higher the final score, the better the patient's functionality and the lower the risk of suffering a fall. Scores under 24 points indicate risk of falls. In addition to the above, we measured the following sociodemographic variables: gender, age, marital status, level of education, living conditions and weekly physical exercise; Body Mass Index (BMI) (where an index from 18.5 to 24.9 was considered normal; an index between 25 and 26.9 was considered overweight grade I; an index between 27 and 29.9 was considered overweight grade II; an index between 30 and 34.9 indicated obesity type I; and an index from 35 to 39.9 indicated obesity type II) (Spanish Society for the Study of Obesity SEEDO, 2000). The participants' current medication was also recorded; data about the type, dose and duration of the prescribed medication were collected using the OMIap© software programme for Primary Care of the Aragon Health System (Spain). Subsequently, these medications were classified according to the Guidelines for Anatomical, Therapeutic, Chemical (ATC) classification system and Defined Daily Dose (DDD) assignment 2013 (WHO, 2012). DATA ANALYSIS All statistical tests were conducted using SPSS© (version 21 for Windows) (confidence interval 95%). We performed a univariate statistical analysis (mean and standard deviation) and a bivariate analysis (Chi-square and T-test), in order to analyze the factors potentially associated with depression in the chosen population. In order to identify the variables independently associated with depression, a multivariate analysis was performed using the unconditional logistic regression model including sociodemographic, clinical-functional and pharmacological variables. RESULTS The sociodemographic characteristics of the sample are presented in Table 2. The final sample was composed of 213 older adults, after 11 participants (5%) declined or were unable to participate in the study. Approximately one third of the subjects who had a history of falls in the last 12 months were also depressed according to the GDS cut-off score. The risk of falls was assessed through the Tinetti Gait and Balance Assessment Tool, and we found that approximately a third of the participants were at risk of further falls (31.9%). In people with depression the risk of falls increased significantly (68.3%), while it was found to be substantially lower in those with a negative screening for depression (17.6%). These data are presented in Table 1.

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Table 1 Risk falling characteristics of the total sample and according to GDS scores. GDSa, nb (%) Risk of falling, n (%) Risk No risk a b c

GDS ≤ 4 153 (71.8)

GDS ≥ 5 60 (28.2)

Total n = 213 213 (100)

Statistic significancec

27 (17.6) 126 (82.4)

41 (68.3) 19 (31.7)

68 (31.9) 145 (68.1)

50.948 p ≤0.001

GDS: Geriatric Depression Scale. Absolute frequency. Qualitative variables Chi-square test χ2.

Table 2 presents a comparison of the sociodemographic characteristics in depressed and non-depressed older adults. The mean age of the participants was 77.3 years, with the vast majority being women, with a basic level of education and living alone. There was a high overall prevalence of depression, and more than half of the participants said that they practiced physical exercise regularly. Having said this, it was observed that depressed participants were significantly older and exercised less that those who were not depressed. Regarding the clinical functional assessment, it was observed that 29.6% of the total sample had a normal BMI. Similarly, 31.7% of people with a positive screening for depression were also found to have a normal BMI. The percentages found in the use of assistive devices for ambulation in elderly patients with depression were 23% in the use of a walking stick, 11.5% in the use of crutches, 10% in the use of a walking frame and 2.5% in the use of a wheelchair, while 85.6% of those without depression claimed they did not use any type of support for ambulation. Nearly half of the participants with a positive screening for depression said they were suffering from urinary incontinence, although there was no significant association between these variables. The prevalence of fear of future falls in subjects with a positive screening for depression was higher (71.7%) than in those without depression (56.2%). When asked about their emotional state, about two thirds of all the participants admitted that they felt sad (66.2%), with some claiming that they felt sad constantly. Three out of four participants (74.6%) said they suffered 2 or more falls in the 12 months prior to data collection. These figures were very similar for people with a positive screening for depression (78.3%) and those without depression (73.2%). In addition, 83.6% of the participants complained of having suffered an injury after the fall. No significant association was found between depression and the occurrence of a fall Table 2 Sociodemographic characteristics of the total sample and according to GDS scores.

Sex, nb (%) Male Female Age (years) Mean (±SD) CI of 95% Marital status, n (%) Single Married Widower Separated Divorced Level of education, n (%) Basic studies Medium level University studies Living alone, n (%) Exercise, n (%) a b c

GDSa ≤4

GDSa ≥5

Total n = 213

Statistic significancec

33 (21.6) 120 (78.4) 76.7 (± 6.8) 75.4–78.0

11 (18.3) 49 (81.7) 78.8 (±7.3) 76.7–80.9

44 (20.7) 169 (79.3) 77.3 (± 7.0) 76.2–78.4

0.275 p = 0.708

8 (5.2) 63 (41.2) 74 (48.4) 1 (0.7) 7 (4.6)

8 (13.0) 21 (35.0) 26 (43.0) 1 (1.7) 4 (6.7)

16 (7.5) 84 (39.4) 100 (46.9) 2 (0.9) 11 (5.2)

117(76.5) 25 (16.3) 11 (7.2) 67 (43.8)

46 (76.7) 11 (18.3) 3 (5.0) 28 (46.7)

163 (76.5) 36 (16.9) 14 (6.6) 95 (44.6)

112 (73.2)

26 (43.3)

138 (64.8)

−1.991 p = 0.048

5.254 p = 0.262

0.416 p = 0.812 0.144 p = 0.760 16.855 p ≤0.001

GDS: Geriatric Depression Scale. Absolute frequency; ±SD: standard deviation; CI: confidence interval. Qualitative variables Chi-square test χ2; quantitative variables T-Student test.

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and related injuries. The clinical functional characteristics of the sample are presented in Table 3. Regarding the pharmacological characteristics of the sample (Table 4), it was found that participants with a positive screening for depression took more medications in general, and medications that act on the nervous system in particular (ATC system group N), than those who were not depressed. Mean medication intake per person per day was 5.38 (SD ± 3.50) (CI from 4.2 to 6.5), ranging from 0 to 17 drugs daily. In people with a negative screening for depression the average number of drugs taken per person per day was 5.03 (SD ±3.56) (CI from 3.7 to 6.4), whereas people who were depressed reached an average of 6.25 drugs per person per day (SD ± 3.20) (CI from 4.1 to 8.4). The clinical and pharmacological characteristics of the sample are shown in Table 4. A bivariate analysis of the variables depression and risk of falls rendered a highly significant association between both variables (χ2 = 50.948; p b 0.001, with CI from 56.6 to 80.1) (Table 1). Additionally, two sociodemographic variables were related to a higher prevalence of depression for this population: age (t = − 1991; p = 0.048) and physical exercise (χ2 = 16.855; p b 0.001, with CI from 44.1 to 69.2) (Table 2). A significant association was found between depression and three clinical functional characteristics of the sample, namely the use of assistive devices for ambulation (χ2 = 28.460; p b 0.001), the feeling of perceived sadness (χ2 = 7.112 own; p = 0.010 with CI from 69.9 to 90.1), and the fear of falling (χ2 = 4.312; p = 0.043). Despite the high prevalence of fall related injuries, it was not significantly associated with depression (χ2 = 0.003; p = 1.000) (Table 3). Regarding drug intake, all the participants with a positive screening for depression reported taking at least one medicine daily (χ2 = 4.549; p = 0.037). Similarly, a significant association was found between depression and the number of daily consumed drugs (t = − 2.306; p = 0.022 with CI from 4.1 to 8.4). Interestingly, whereas no significant association was established between the intake of cardiovascular drugs (ATC system group C) and depression, a significant correlation was found between depression

and the intake of drugs that act on the nervous system (ATC system group N) (χ2 = 4.340; p = 0,043 with CI from 71.9 to 91.5) (Table 4). Taking the variable depression as a dichotomous qualitative variable, we proceeded to carry out a multivariate analysis by the logistic regression model presented in Table 5. The independent variables were chosen by the researchers given that the automatic model would select only two variables, namely risk of falls and feeling of sadness. According to the linear logistic regression model presented in Table 5, the only variable that represented a risk factor for developing depression in our chosen population, and with a statistically significant coefficient, was the risk of falling. No significant relationship was found between the remaining variables and depression in people with a previous history of falls. Our data therefore suggest that those people aged 65 or older, who had at least one fall in the last 12 months, and who were at risk of falling, were more susceptible of developing depression than those subjects who were not at risk of falling. DISCUSSION The prevalence of depression in people over 65 and with a history of falls resulting from our study is consistent with the results from similar studies in different countries (Murphy, Williams, & Gill, 2002; Patel et al., 2014). A study conducted by Byers et al. (2008) reported a prevalence of depression much higher than ours. However, the purpose and characteristics of the sample were different (they included participants aged 60 or over), as they focused on determining whether depression was a factor to be considered when designing preventive interventions for falls in individuals who were receiving home health care. It is likely that the difference between this and our study is due to the fact that our participants were not institutionalized. The results from our bivariate analysis are in agreement with other published studies, which found a statistically significant relationship between depression and lack of physical exercise, type of drugs consumed (N group), and poor gait and balance (Eggermont, Penninx, Jones, &

Table 3 Clinical functional characteristics of the sample. GDSa ≤4

GDSa ≥5

Total n = 213

Statistic significancec

GDSa, nb (%) BMI, n (%) Normal weight Overweight grade I Overweight grade II Obesity type I Obesity type II Assistive devices for ambulation, n (%) None Walking stick Crutches bWalker Wheelchair Urinary incontinence, n (%)

153 (71.8)

60 (28.2)

213 (100)

–

44 (28.8) 36 (23.5) 36 (23.5) 29 (19.0) 8 (5.2)

19 (31.7) 7 (11.7) 10 (16.7) 17 (28.3) 7 (11.7)

63 (29.6) 43 (20.2) 46 (21.6) 46 (21.6) 15 (7.0)

131 (85.6) 14 (9.2) 2 (1.3) 4 (2.6) 23 (5.3) 60 (39.2)

32 (53.3) 14 (23.3) 7 (11.7) 6 (10.0) 1 (2.6) 29 (48.3)

163 (76.5) 28 (13.1) 9 (4.2) 10 (4.7) 24 (5.1) 89 (41.8)

Fear of falling, n (%)

86 (56.2)

43 (71.7)

129 (60.6)

The subjective perception of sadness, n (%)

93 (60.8)

48 (80)

141 (66.2)

First fall n (%)

41 (26.8)

13 (21.7)

54 (25.4)

Fall-related injuries, n (%)

128 (83.7)

50 (83.3)

178 (83.6)

Visual impairment, n (%)

122 (79.7)

48 (80.0)

170 (79.8)

Hearing impairments, n (%)

67 (43.8)

30 (50.0)

97 (45.5)

a b c

GDS: Geriatric Depression Scale. Absolute frequency. Qualitative variables Chi-square test χ2.

8.360 p = 0.079

28.460 p ≤0.001

1.473 p = 0.280 4.312 p = 0.043 7.112 p = 0.010 0.559 p = 0.488 0,003 p = 1.000 0.002 p = 1.000 0.670 p = 0.447

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Table 4 Pharmacological characteristics of the sample. GDSa ≤4

GDSa ≥5

Total n = 213

Statistic significancee

Take at least one drug, nb (%)

142 (92.8)

60 (100)

202 (94.8)

4.549 p = 0.037

Number of medications, mean (±SD)

5.03 (3.56)

6,25 (3.20)

5,38 (3.50)

c

Drug intake group C , n (%) Drug intake group Nd, n (%) a b c d e

115 (75.2)

44 (73.3)

159 (74.6)

103 (67.3)

49 (81.7)

152 (71.4)

−2.306 p = 0.022 0.076 p = 0.861 4.340 p = 0.043

GDS: Geriatric Depression Scale. Absolute frequency; ±SD: standard deviation. Drugs for the cardiovascular system. Drugs for the nervous system. Qualitative variables: Chi-square test χ2; quantitative variables: T-Student test.

Leveille, 2012; Gill et al., 2013). The use of assistive devices such as walking sticks and walkers, the perception of sadness and the intake of 4 or more drugs daily were also identified as risk factors for depression in older adults with a previous history of falls. Having said this, the prevalence rate of depression in our study population is lower than that of similar studies (Van den Berg et al., 2011). Fear of falling is a common health problem in the elderly population and has previously been described in the literature (Howland et al., 1998; Murphy et al., 2002). Several researchers have suggested that fear of future falls is strongly associated with depression (Arfken, Lach, Birge, & Miller, 1994; Austin, Devine, Dick, Prince, & Bruce, 2007; Lachman et al., 1998), although our findings reveal a higher prevalence of this phenomenon than other published studies. The results from a logistic regression analysis revealed a statistically significant relationship between being at risk of falling and screening positive for depression in the study population. Our data confirm what has already been published in the literature, where it is suggested that the risk of falling is twice as high in elderly people with symptoms of depression as in those without depression (Stalenhoef, Diederiks, Knottnerus, Kester, & Crebolder, 2002). Having said this, our data do not allow the establishment of a causal relationship between both variables. Instead, a bidirectional relationship may exist between a risk of falling and depression. This is based on the fact that many of the risk

Table 5 Variables related to the presence of depression, final logistic regression model. Independent variables

Coefficient Odds ratio

CI of 95%

Wald

pc

Sex Age Level of education Living alone? Do you do any exercise? Assistive devices for ambulation Urinary incontinence Fear of falling Feeling sad Risk of falling Was it your first fall? Fall-related injuries Number of drugs consumed Drug intake group Ca Drug intake group Nb Constant

0.140 −0.043 0.173 0.429 −0.803 0.121

1.150 0.958 1.189 1.536 0.448 1.128

0.399–3.315 0.896–1.025 0.479–2.950 0.704–3.355 0.198–1.012 0.329–3.865

0.067 1.565 0.139 1.161 3.729 0.037

0.796 0.211 0.709 0.281 0.053 0.848

0.193 0.581 0.505 2.097 0.101 0.150 −0.010 −0.291 0.040 0.682

1.212 1.787 1.656 8.143 1.106 1.162 0.990 0.747 1.041 1.978

0.555–2.650 0.764–4.181 0.685–4.008 3.070–21.600 0.451–2.710 0.419–3.221 0.852–1.151 0.274–2.036 0.388–2.790 –

0.233 1.793 1.253 17.752 0.049 0.084 0.016 0.324 0.006 0.063

0.629 0.181 0.263 b0.001 0.825 0.772 0.899 0.569 0.937 0.801

factors associated with depression are very similar to those associated with falls. LIMITATIONS The main limitation of this study relates to the study design: a crosssectional study. Such methodological design did not allow us to establish a causal relationship between the variables depression and risk of falling, even if this was not one of the aims of this study. CONCLUSION In conclusion, one in three elderly people who were at risk of suffering a fall in the 12 months prior to data collection had symptoms of depression. Our study confirms that there is a high prevalence of depression in elderly patients with a previous history of falls. However, it is important to emphasize that there are multiple factors, including the perception of sadness and the number of medications consumed daily, which may interact together, and thus contribute to an increased risk of developing depressive symptoms in this population. This represents an important public health problem, requiring health professionals to evaluate both the clinical functional and psychosocial characteristics of patients who are at risk of falling, or who have previously had a fall. This is due to the fact that both abnormal gait and balance are strongly related with depression and falls. Our recommendations for future research in this area include longitudinal studies combining the variables depression and risk of falling in a similar population. SPONSORSHIP

Dependent variable: depression (no = 0/yes = 1). Hosmer – Lemesshow test, p = 0.002. a Drugs for the cardiovascular system. b Drugs for the nervous system; CI: confidence interval. c Statistic significance.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. CONFLICT OF INTERESTS The authors declare that they have no conflicts of interest in the research. SOURCES OF FUNDING No sources of funding were used to assist in the preparation of this article. ACKNOWLEDGMENT Castro-Sánchez, Enrique is affiliated with the National Institute for Health Research, Health Protection Research Unit in Healthcare

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