Factors Affecting Depression and Quality of Life in the Elderly

Aim: This study was conducted to assess depression and quality of life in the elderly and the factors influencing these methods. Methods: The sample of this descriptive study consisted of 450 individuals, 65 years of age and older, who presented to the Family Healthcare Centers in the provincial center of Erzincan between October 2010 and March 2011. The data were collected using a descriptive questionnaire, Geriatric Depression Scale (GDS), World Health Organization Quality of Life Instrument-Older Adults Module (WHOQOL-OLD) and Europe Health Impact ScaleWorld Health Organization Quality of Life Scale (EUROHIS-QOL.8-WHOQOL-8.Tr). Results: It was determined that 62.2% of older people suffer from depression. The mean WHOQOLOLD subdomain scores of older people were moderate and their overall scores were low. As the study participants’ mean WHOQOL-OLD and EUROHIS-QOL.8 scores increased, the mean GDS score declined, and the difference in between was statistically significant (p<0.001). Conclusion: Our study results showed that the majority of older people were at risk for depression, and as the mean depression risk score increased, the mean quality of life score decreased. *Corresponding author: Rabia Hacıhasanoğlu Aşılar, Department of Nursing, Erzincan University School of Health, Erzincan, Turkey, Tel: +90 (446) 226 58 61; E-mail: rabia_hhoglu@hotmail.com Received June 12, 2015; Accepted November 19, 2015; Published November 25, 2015 Citation: Bakar N, Aşılar RH (2015) Factors Affecting Depression and Quality of Life in the Elderly. J Gerontol Geriatr Res 4: 249. doi:10.4172/2167-7182.1000249 Copyright: © 2015 Bakar N, Aşılar RH. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
Aging is an inevitable physiologic fact and a natural process causing physical, mental and social deterioration [1]. The World Health Organization (WHO) has defined old age as being 65 years old and older [2]. The number of older people in the world is growing rapidly and the population of those 60 years of age and older is expected to double from 11% to 22% between 2000 and 2050. Furthermore, their number is projected to increase from 605 million to 2 billion [3]. According to the data of the Turkish Statistical Institute (TSI) for the year 2012, individuals 65 years old and older comprised 7.5% of the total population. Population projection estimates indicate that this ratio will reach 10.2% in 2023, 20.8% in 2050 and up to 27.7% in 2075 [4].
The physiological changes caused by aging bring about chronic diseases; psychosocial problems and inactivity-related problems and can result in a vicious circle [5]. Depression is an important mental health concern that is seen most frequently in the elderly [6,7]. This disease leads to significant loss of abilities, adversely affects the progress of a physical disease, increases deaths due to suicide and physical diseases, and increases the use and cost of healthcare services. Older people with depression lose social harmony, struggle in managing their self-care activities, and their quality of life deteriorates considerably as a result of all these [5]. The Pennix et al [8] reported that chronic depression significantly decreased physical performance for communitydwelling older people (>70 years). Wada et al [9] study found that older individuals with depression experienced a lower quality of life and negative effects on their daily living activities. All of these issues highlight the great need to evaluate the physical, psychological and social dimensions present in the lives of the elderly [10].
Depression is an important mental health issue which needs to be addressed in a primary care setting. In order to provide optimal health services and an improved quality of life for the elderly, health professionals need to become more aware of depression and its effects on the lives of the elderly.

Data Collection
The study data were collected by Nihal Bakar through face-to-face interviews with the elderly in the FHCs in Karaağaç, İnönü and Mimar Sinan in the provincial center of Erzincan. The completion of forms took about 20-25 minute.

Statistical analysis
The data were analyzed using numbers, percentages and mean calculations; the Kruskall Wallis Variance Analysis and one-way variance analysis (ANOVA) were used to compare the descriptive characteristics of individuals, the mean scores of Quality of Life and GDS, and the t-test was used for independent groups; the relationship between the scales was assessed with a correlation analysis and the level of significance was set at p<0.05.

Ethical Principles of the Study
In order to carry out the study, written permission was obtained from the Erzincan Provincial Health Directorate together with the ethical approval from Erzincan University, Health Sciences Ethics Committee. To protect their rights, participants were informed of the objective and duration of the study, the procedures involved during the study, and those who volunteered and met the required criteria were included in the study. The participants were also informed that they had the prerogative to withdraw from the study at any time, and their personal information would be protected after having been shared with the investigator. In addition, both the information and the identity of the responder would be kept confidential.

Results
The results indicated that 62.2% of older people have depression. The GDS average scores of all older people and the older people have depression were 23.06 ± 4.40 and 17.31 ± 8.43, respectively (Graphic 1).
Forty percent of the study participants were in the 65-69 age group; 51.3% were male, 66.9% married, 47.6% literate/graduates of primary school, 59.3% perceived their health as being poor, 86.4% had a chronic disease, 56.7% did not smoke (Table 1), and all the individuals included in the study had some kind of a social security.
Being at an advanced age, female, single or widowed, a low education level, a low income level, not living in a city, living alone, not receiving social support from associates, poorly perceived health, and having a chronic disease negatively affected the mean depression score in statistical terms (p<0.001), whereas smoking positively affected the mean depression score in statistical terms (p<0.001). The Intimacy domain of the WHOQOL-OLD had the highest mean score with 13.10±3.15 and the Death and Dying domain had the lowest mean score with 10.06±3.53 (Table 2).
Being female, having a low education level, a low income level, perceiving health status as poor, and having a chronic disease affected all the WHOQOL-OLD subdomains, and overall and mean EUROHIS-QOL.8 scores statistically in the negative direction (p<0.05, p<0.001), whereas smoking affected them in the positive direction, respectively (p<0.05, p<0.001).
With advancing age, the mean scores of WHOQOL-OLD had a statistically significant decrease (p<0.001), except for the autonomy subdomain. The elderly aged 80 and over had higher scores than those of the 75-79 age group in all domains except social participation and death and dying. They also had a higher overall score. As age advanced, the mean EUROHIS-QOL.8 score significantly decreased (p<0.001). Being single or widowed, not living in a city, living alone, and not receiving social support from associates had a statistically negative effect on all the mean WHOQOL-OLD subdomain scores, except autonomy and the mean overall and mean EUROHIS-QOL.8 scores (p<0.001). With the exception of the living condition intimacy subdomain (p<0.05), all the other quality of life subdomains did not affect significantly the mean overall and EUROHIS-QOL.8 scores in statistical terms (p>0.05) ( Table 3). The correlation analysis made between the mean scores of WHOQOL-OLD and EUROHIS-QOL.8 and the mean score of the GDS showed that as the mean scores of WHOQOL-OLD and EUROHIS-QOL.8 increased, the mean score of GDS declined markedly and the difference in between was significant (p<0.001) ( Table 4).

Discussion
Depression is a mental disorder commonly seen in older people [15]. This study determined that 62.2% of older people have depression. Other studies [16][17][18][19] conducted in Turkey of the elderly living at home found the prevalence of the risk for depression to be between 24.3% and 61.1%. Studies [9,[20][21][22][23] carried out in other countries have shown the risk for depression to be between 6.4% and 44.3%.
The mean WHOQOL-OLD subdomain scores of the elderly study participants were found to be moderate and above moderate and their mean overall scores were low. This result was lower than that of the Eser et al [13] study. This difference can be explained by the influence of different socioeconomic and cultural factors.
The results of the study indicated that the mean score of depression risk significantly increased as the age advanced and this increase was higher in the 75-79 age group. The Zunzunegui et al. [24] found age to be a risk factor for depression; in particular; it was a risk factor in women in another study [20]. In the Pennix et al [8] chronic depression was seen more frequently in individuals 70 years old and older. Also we found that the mean scores of all the subdomains of WHOQOL-OLD except for autonomy, the mean overall and EUROHIS-QOL.8 scores significantly decreased as age advanced, and according to the Tukey analysis, this significance originated from the 65-69 age group. Other studies have also found that as one ages, the quality of life significantly decreases in statistical terms [25][26][27][28].
In this study we found the mean score of depression was significantly higher in women than in men. Other studies have reported similar findings [17-20, 24,29,30]. Besides women had significantly lower mean scores than men in all the WHOQOL-OLD subdomains except sensory abilities and in mean overall and EUROHIS-QOL.8 scores.
Other studies have also reported that the quality of life scores of women are significantly lower than those of men [26,28,[31][32][33].
The mean score of depression was found significantly higher in single and widowed individuals than in married individuals. Other studies have also reported similar findings [18,19,29,[34][35][36]. These results indicate that marriage, with its aspects of sharing and support, may play a protective role in preventing depression. Furthermore when compared to those who were married, widowed and single older people had significantly lower mean scores in all the subdomains of WHOQOL-OLD except autonomy, mean overall, and EUROHIS-QOL.8 scores. The Sonmez et al. [31] study also reported that being married significantly increased the quality of life score for study participants.
Our study results also found that as the education level of older people increased, their mean scores of depression decreased significantly. Other studies have also found that being illiterate or having a low education level significantly increases the risk of depression [17,19,24]. Although no statistically significant difference was reported, another study determined that as a person's education level increased, the mean depression score decreased [37]. Likewise it was found that as the education level went up, the mean WHOQOL-OLD sub-dimension, overall and EUROHIS-QOL.8 scores decreased  significantly. Many other studies have also found that education level is an important factor influencing quality of life. Individuals who had a higher education level had significantly higher quality of life scores [38,[26][27][28]32]. Penniks et al. [8]. reported that physical function in older people who have lower education level was lower.
Having children did not significantly affect the mean score of depression. This result is similar to the result of the study made by Bingöl et al. [37]. Moreover whether or not a person had children did not affect the mean WHOQOL-OLD subdomain, overall and EUROHIS-QOL.8 scores. No statistically significant difference was found in the mean quality of life scores of the elderly with children and without children. The same result was also found in the study made by Ercan in a nursing home [39].
In this study, a low income level was found as a factor which increased the mean score of depression. This result supports those of other studies [17,20]. In addition, income level is an important factor influencing health, well-being and quality of life. Individuals who had a low income level had significantly lower mean WHOQOL-OLD subdomain, overall and EUROHIS-QOL.8 scores than individuals who had their income equal to their expenses. Other studies have also reported that older individuals with a low income status have a diminished quality of life [26,31,33].
The mean scores of depression of individuals living in provincial centers were found to be lower than those living in other settlement areas. More difficult living conditions, hardship in accessing healthcare and other institutional services, distant shopping centers, and other similar reasons may negatively affect the mental conditions of the elderly living outside provincial centers. As well individuals living in provincial centers had higher mean scores in the WHOQOL-OLD

Autonomy (Mean ± SD)
Past, present and future activities (Mean ± SD)

EUROHIS-QOL.8 (Mean ± SD)
Family Support P 0.000* 0.000* 0.000* 0.000* 0.000* 0.019** 0.000* 0.000* *p<0.001, **p<0.05, ***p>0.05 Table 3B: Descriptive characteristics of individuals according to the WHOQOL-OLD and EUROHIS-QOL.8 comparison of average score (n=450).  subdomains except for the autonomy and mean overall and EUROHIS-QOL.8 scores. The reasons for a lower quality of life in villages and boroughs/small towns than in provinces may be due to difficult working conditions, inadequate access to healthcare facilities, a lack of knowledge about health matters, and no tangible opportunities or possibilities to improve the quality of life.

WHOQOL-OLD
Loneliness may play an etiological role in the development of physical and mental health problems in older people. Prolonged loneliness may jeopardize mental well-being of an individual and increase the risk of suicide [40]. We found in this study that living alone significantly increased the mean score of depression. The other studies have also reported depression symptoms to be significantly high [15,24]. It has been also found in a study made in Lithuania with middleaged and aged persons that depressive symptoms are seen less often in those living with less crowded families at home [36]. One study found the mean score of depression symptoms to be high, although not at a significant level [34]. Besides our study indicated that individuals who lived with their spouses or with their spouses and their child/children in a family atmosphere had higher mean WHOQOL-OLD subdomain, overall and EUROHIS-QOL.8 scores than those living alone or only with their children. This result is similar to that of the study conducted by Çalıştır et al. [26].
The emotional support given by children to the elderly in their families is vitally important to their mental and physical health [24]. However, this study found that family support or living without any support did not have any significant impact on depression scores. Another study reported similar results between perceived social support from the family and depressive symptoms [41]. Ejem et al. [42]. have reported in their study that the caregivers of the elderly with depressive symptoms have a higher mean emotional stress score than those giving care to the elderly with no depressive symptoms. The result of the present study can be explained by the fact that the family members may have perceived the burden of care as well as emotional stress and this situation may have affected their provision of sufficient and effective support.
The presence of social support is an important factor in sustaining and improving the psychosocial status and well-being of the elderly [43]. In this study we found that the mean scores of depression were significantly lower in the elderly with social support from associates (friends, neighbors, relatives) than in those who did not receive such support. The study [43] of found a significant relationship between perceived social support and depression in the negative direction, and another study found that the social support received from neighbors and friends was significantly lower in individuals who were at risk for depression [25]. In addition, those living with support from their family had higher mean scores from the WHOQOL-OLD subdomains except the autonomy subdomain and mean overall and EUROHIS-QOL.8 scores than those living without any support. However, a statistically significant difference showed only in the intimacy subdomain. Older people with social support had higher mean WHOQOL-OLD subdomain, overall and EUROHIS-QOL.8 scores than those who did not have it. This difference was statistically significant in all the WHOQOL-OLD subdomains except the autonomy subdomain and in the mean overall and EUROHIS-QOL.8 scores. Studies conducted in nursing homes have reported that there is a positive correlation between social support and life satisfaction [44] and between social support received from the family and quality of life [32].
The mean scores of depression were higher in older individuals who perceived their health as being poor than in those who did not. This result is similar to the results of other studies [15,20,34,37] . In this study, individuals who perceived their health as being poor had significantly lower mean WHOQOL-OLD subdomain, overall and EUROHIS-QOL.8 scores than those who perceived their health as being well. Another study made with older people found that those who perceived their health as "poor" tended to have a higher level of dependency in daily living activities [45]. In another study made with middle-aged and aged subjects, perceived health and quality of life were significantly low in those with depressive symptoms than in those with no depressive symptoms [36].
Depression in the elderly has been reported to increase comorbidities, mortality, cognitive disorders, and weakness [46]. In this study the mean scores of depression of the elderly without any chronic disease were significantly lower than those with a chronic disease. Many studies have reported a significant correlation between chronic disease and depression [19,20,34,38,47,48]. Individuals have a chronic disease had significantly lower mean WHOQOL-OLD subdomain, overall and EUROHIS-QOL.8 scores than those without a chronic disease. Other studies have also found that presence of a concomitant disease is a risk factor resulting in a lower quality of life [27,31,49,50].
In this study, the mean scores of depression of individuals who had never smoked were significantly higher than for those who smoked and those who had smoked and quit. The sensation of touching a cigarette, the taste and smell it leaves in the mouth and the stimulus of the chemicals in smoke on the lung tissue give a psychological satisfaction to the person. This is the major factor in developing a smoking habit [51]. The lower risk for depression in smokers may be attributed to their belief that smoking relaxes them and enables them to control their emotions. Then again in this study, the mean WHOQOL-OLD subdomain, overall and EUROHIS-QOL.8 scores were found significantly high in those who smoked. In another study, older people with a smoking habit had a high quality of life in all subdomains except the general health subdomain, and this was significant in the emotional role and physical pain subdomains [28]. This can be explained by smokers' insistence on the relaxing psychological effects of smoking which subsequently improves their quality of life.
Over time, depression plays an important role in a person's decline in physical activity [8]. We found in this study that the mean GDS scores decreased as the mean WHOQOL-OLD subdomain, overall and EUROHIS-QOL.8 scores increased, and the difference in between was significant. There was a moderate correlation in the negative direction between individuals' mean scores of WHOQOL-OLD subdomains of sensory abilities, past, present and future activities, social participation, death and dying and intimacy and their mean overall scores, and their mean GDS scores. There was a weak correlation in the negative direction between the mean WHOQOL-OLD autonomy subdomain score and the mean GDS scores, and there was a moderate correlation in the negative direction between the mean EUROHIS-QOL.8 scores and the mean GDS scores. Other studies have also reported that presence of depression significantly influenced quality of life in the negative direction [38,31,50].
The strength of the study was the results of the study were reported from one center which has a wide variety of patients from different socioeconomic states while the weaknesses of the study was the study sample did not include all the elderly living in the province of Erzincan, the results of the study can be generalized only to this group.

Conclusion
Our study results determined that the majority of older people were at risk for depression and as the mean depression risk score increased, the mean quality of life score decreased. The mean score of depression risk increased with being at an advanced age, being female, being single or widowed, having a low education level, a low income level, not living in a city, living alone, not receiving social support from associates, health being perceived as poor, and having a chronic disease, whereas smoking decreased it. Being female, having a low education level, low income level, poorly perceived health and having a chronic disease decreased all the WHOQOL-OLD subdomain, overall and mean EUROHIS-QOL.8 quality of life scores. Being at an advanced age, being single or widowed, not living in a city, living alone, and not being able to receive social support from associates negatively affected all mean WHOQOL-OLD subdomain scores except autonomy, mean overall scores and mean EUROHIS-QOL.8 scores, whereas living conditions negatively affected the mean score of the WHOQOL-OLD intimacy subdomain.
As for the future, if we are committed to improving the quality of life for our elderly, we highly recommend that they be acknowledged as a priority risk group for the disorder of depression. They should be screened routinely not only for general health but also for depression. In addition, more geriatric hospitals and outpatient clinics need to be established, and home care projects should be developed to help improve the quality of life for our elderly. Lastly, training programs pertaining to gerontology should be developed to increase the knowledge, skills, and awareness of health professionals, families and communities at large. In these ways, we hope to be able to improve the health and lives of our very vulnerable elderly citizens.