SUMMARY
This study aimed to determine the effects of daily living activities and self-care capacity on depression of the elderly in northern Turkey. The study was conducted with participation of 451 voluntary elderly individuals. Data were collected via a questionnaire, Geriatric Depression Scale, Exercise of Self-care Agency Scale, Daily Activities Index, and Instrumental Activities of Daily Living Index. The mean Exercise of Self-care Agency Scale score and Geriatric Depression Scale score was 91.44±16.32 and 11.87±5.01, respectively. Negative and highly statistically significant correlations (p=0.000) were found between depression scores and self-care capacity scores (r=-0.470), daily activities scores (r=-0.351), and Instrumental Activity of Daily Life scores (r=-0.270). Study results showed that depression scores of the elderly increased as their daily life activities and self-care capacity scores decreased.
Key words: Activities of daily living, Depression, Aged, Nursing, Self care, Turkey
Introduction
In 2000, 600 million people were aged 60 and over, and by 2050, there will be 2 billion (1). As in the world (2), in Turkey, the aged population is gradually increasing. According to Turkish State Institute of Statistics census findings, the proportion of the population aged 65 and above was 4.3% in 1990, 4.7% in 1997, and 5.6% in 2000. This curve is anticipated to reach 7.7% in 2020 (3). Based on the State Institute of Statistics data, it is clear that Turkey will soon be one of the old countries in the world.
Elderly people need to possess sufficient self-care capacity. Self-care capacity involves the activities conducted by individuals to maintain their independence, lifestyle, and state of health and wellness. Changes in age, health, physical and psychological factors, environmental conditions, and socio-economic factors can influence the self-care capacity of individuals (4, 5). The literature suggests that physical health, functional limitations and disability are affected by many factors, one of which is depression (6-8).
Depression has been documented as one of the most prevalent mental health problems in the elderly (9, 10). The literature also indicates that depression increases disability (11, 12), morbidity, mortality, and healthcare utilization (11). Studies have determined that the following factors are related with the development of depression: being female; being single, divorced, or separated (10); having a low income or socio-economic level (10); and having many chronic diseases, insufficient social support, and unexpected negative life events (13). It has also been reported that depression is an important risk factor for dependency in the elderly (14-17). In spite of the availability of studies on the factors affecting daily life activities and self-care capacity of the elderly (5, 18-21), no comprehensive study determining the effect of daily life activities and self-care capacity levels on depression in the elderly was found.
Aims
This descriptive study aimed to determine the effect of daily life activities and self-care capacity levels on depression in the elderly. The questions posed in the study were the following:
What is the mean level of depression among elderly individuals?
In terms of activities of daily living, are elderly dependent on others?
Do daily life activities and self-care capacity levels of the elderly affect depression levels?
Subjects and Methods
Study design
This study was conducted between July 1, 2013 and December 31, 2013. The authors aimed to recruit the entire population of those presenting to internal medicine and surgical outpatient clinics at Ondokuz Mayıs University due to various health problems. A total of 608 elderly individuals were admitted to outpatient clinics during the study period. However, elderly people who were not willing to participate in the study and who did not complete the questionnaire were excluded from the research (n=157). The study was carried out with voluntary participation of 451 elderly individuals. The response rate was 74.2%.
Instruments
Study data were collected via a questionnaire, Geriatric Depression Scale, Exercise of Self-Care Agency Scale, Daily Activities Index, and Instrumental Activities of Daily Living Index. Both depression and dementia affect activities of daily living (ADLs) and self-care agency in the elderly. For these reasons, distinction between dementia and depression symptoms was made by questioning the year, season, month, day, country, and city orientations among the elderly.
The Geriatric Depression Scale is an assessment tool introduced by Yesavage et al. (22). Its validity and reliability for Turkish population has been verified by Ertan and Eker (23). The scale consists of 30 self-report questions aimed at enabling the elderly to respond easily with ‘yes’ or ‘no’. The minimal and maximal number of points that can be obtained on the scale is 1 and 30, respectively. The Geriatric Depression Scale Cronbach Alpha reliability coefficient was determined to be 0.77.
The validity and reliability of the Exercise of Self-Care Agency Scale developed by Kearner and Fleischer (24) were tested in Turkey by Nahçivan (25). The scale employs self-evaluations of self-care activities. Each statement is rated from 0 to 4, and the ratings are based on a five-point Likert-type scale. A higher score obtained using the scale indicates greater self-care potential (25). The Exercise of Self-Care Agency Scale Cronbach Alpha reliability coefficient was determined to be 0.81.
The Daily Activities Index was used to detect problems in performing ADLs. Clients receive a score of yes/no for independence in bathing, dressing, toileting, transferring, continence, and feeding (26, 27). The Daily Activities Index Cronbach Alpha reliability coefficient was determined to be 0.89.
The Instrumental Activities of Daily Living Index includes preparing meals, shopping, taking medicine, traveling out of walking distance, doing housework, performing repairs in the house, managing money, and using telephone. The activities of the participants are evaluated as independent, semi-independent or dependent. The Instrumental Activities of Daily Living Index Cronbach Alpha reliability coefficient was determined to be 0.91.
Data collection
Data were collected from the elderly over a period of six months by the researcher during face-to-face interviews. This study was conducted in accordance with the principles of the Helsinki Declaration (WMA Declaration of Helsinki, 2008) (28). The questionnaire was tested on a group of 10 elderly individuals in a pilot study. The response time was 20-25 min.
Data analysis
Data were analyzed using SPSS for Windows (v. 15.0). Descriptive statistics and Student’s t-tests were used to summarize data. Multiple regression analysis was used to determine whether there was a difference between depression scores of the elderly regarding self-care capacity, daily life activity, and instrumental activities of daily living. The values of p<0.05 were considered statistically significant.
Results
In this study, 35.9% of all participants were between 60 and 66 years of age, 44.8% were females and 55.2% were males (Table 1). According to the distribution of clinical characteristics, 65.0% of all participants suffered from chronic diseases. Moreover, daily life activities were affected by chronic diseases in 94.2% of the participants, 21.3% exercised, 10.4% smoked, and 28.4% attended social activities (Table 2). The mean participants’ Exercise of Self-Care Agency Scale score and Geriatric Depression Scale score was 91.44±16.32 and 11.87±5.01, respectively. Additionally, 25.5% of the participants were dependent in terms of Daily Life Activities and 8.0% in terms of Instrumental Activities of Daily Living.
Table 1. Distribution of elderly subjects according to socio-demographic characteristics (N=451).
| Characteristic | n | % |
|---|---|---|
| Age group (yrs, mean±SD) | 69.1±6.7 | |
| 60-66 | 162 | 35.9 |
| 67-73 | 147 | 32.6 |
| 74-80 | 95 | 21.1 |
| 81-87 | 47 | 10.4 |
| Gender | ||
| Female | 202 | 44.8 |
| Male | 249 | 55.2 |
| Marital status | ||
| Married | 395 | 87.6 |
| Single | 56 | 12.4 |
| Education level | ||
| Literate | 270 | 59.9 |
| Elementary school | 143 | 31.7 |
| Intermediate school | 19 | 4.2 |
| High school | 9 | 2.0 |
| University | 10 | 2.2 |
| Socioeconomic status | ||
| Income less than expenses | 212 | 47.0 |
| Income equal to expenses | 229 | 50.8 |
| Income greater than expenses | 10 | 2.2 |
| Social insurance | ||
| Present | 417 | 92.5 |
| Absent | 34 | 7.5 |
| Occupation | ||
| Homemaker | 185 | 41.0 |
| Worker | 99 | 22.0 |
| Officer | 9 | 2.0 |
| Retired | 90 | 20.0 |
| Self-employed | 68 | 15.0 |
| Place of residence | ||
| City | 109 | 24.2 |
| Town | 134 | 29.7 |
| Village | 208 | 46.1 |
| Family type | ||
| Large | 186 | 41.2 |
| Small, nuclear | 265 | 58.8 |
| Number of children | ||
| 1-3 | 162 | 35.9 |
| 4-6 | 221 | 49.0 |
| 7-9 | 64 | 14.2 |
| None | 4 | 0.9 |
| Lives with | ||
| Spouse | 166 | 36.8 |
| Family member(s) | 280 | 62.1 |
| Alone | 5 | 1.1 |
Table 2. Distribution of elderly subjects according to clinical characteristics and health behavior (N=451).
| Characteristic | n | % |
|---|---|---|
| Perceived health | ||
| Good | 153 | 33.9 |
| Fair | 250 | 55.4 |
| Poor | 48 | 10.7 |
| Satisfied with medical treatment | ||
| Yes | 393 | 87.1 |
| No | 58 | 12.9 |
| Satisfaction level related to medical treatment (n=393) | ||
| Low | 8 | 2.0 |
| Middle | 281 | 71.5 |
| High | 104 | 26.5 |
| Chronic disease condition | ||
| Yes | 293 | 65.0 |
| No | 158 | 35.0 |
| aHas chronic illness (n=293) | ||
| Coronary arterial disease | 148 | 50.5 |
| Diabetes | 116 | 39.6 |
| Hypertension | 169 | 57.7 |
| Osteoporosis | 14 | 4.8 |
| Asthma | 10 | 3.4 |
| Renal failure | 36 | 12.3 |
| Rheumatism | 8 | 2.7 |
| Herniated disc | 3 | 1.0 |
| Hepatitis | 3 | 1.0 |
| Epilepsy | 4 | 1.4 |
| Goiter | 8 | 2.7 |
| Cataract | 4 | 1.4 |
| Daily activities affected by chronic illness (n=293) | ||
| Yes | 276 | 94.2 |
| No | 17 | 5.8 |
| Previous hospitalization | ||
| Yes | 389 | 86.3 |
| No | 62 | 13.7 |
| Frequency of hospitalization (n=389) | ||
| At least once a month | 68 | 17.5 |
| Once in three months | 51 | 13.1 |
| Once in six months | 50 | 12.9 |
| Once a year | 111 | 28.5 |
| Other | 109 | 28.0 |
| Has an attendant while hospitalized (n=389) | ||
| Yes | 267 | 68.6 |
| No | 122 | 31.4 |
| Has regular health check-ups | ||
| Yes | 288 | 63.9 |
| No | 163 | 36.1 |
| Exercises | ||
| Yes | 96 | 21.3 |
| No | 355 | 78.7 |
| Smoking | ||
| Yes | 47 | 10.4 |
| No | 404 | 89.6 |
| Attending social activities | ||
| Yes | 128 | 28.4 |
| No | 323 | 71.6 |
aMore than one answer was given.
The current study revealed that the mean self-care capacity scores were relatively higher in married (t=2.881, p=0.004), regular health check-up receiving (t=4.174, p=0.000) and exercising (t=6.088, p=0.000) elderly individuals. The mean depression scores were also higher in women (t=4.915, p=0.000), singles (t=5.123, p=0.000), chronic disease sufferers (t=4.849, p=0.000) and those that did not attend social activities (t=4.857, p=0.000). There was a significant negative relationship between the depression scale score and educational status (r=-0.176), perception of health (r=-0.423) and satisfaction with medical treatment received (r=-0.286), and a significant positive relationship between the state of having a chronic disease (r=0.095) and the depression scale score (p<0.000) for the elderly. In other words, the mean score of depression decreased with increase in the level of education, level of health perception and level of satisfaction with medical treatment. Nevertheless, having a chronic disease increased the depression score.
The present study also revealed a statistically significant correlation (p<0.000) between the participants’ mean scores on the Daily Life Activities and Instrumental Activities of Daily Living Indexes and certain socio-demographic and clinical characteristics. The Daily Life Activities Index scores were higher in men (t=7.777, p=0.000), married individuals (t=3.425, p=0.001), individuals receiving regular health check-ups (t=3.488, p=0.001), individuals attending social activities (t=3.179, p=0.002) and individuals who exercised (t=5.857, p=0.000). Moreover, the Instrumental Activities of Daily Living Index scores were higher in men (t=7.374, p=0.000), married individuals (t=2.432, p=0.015), individuals without a chronic disease (t=2.344, p=0.020), individuals attending social activities (t=2.143, p=0.033) and individuals who exercised (t=6.991, p=0.000).
In the regression analysis concerning the effect of the Daily Life Activities and Self-Care Agency and Instrumental Activity of Daily Life on depression (Table 3), a statistically highly significant negative relationship was found between depression scores and self-care capacity of the elderly (r=-0.470), daily life activities (r=-0.351), and Instrumental Activity of Daily Life scores (r=-0.270). Study results showed that depression scores of the elderly increased as their daily life activities and self-care capacity scores decreased.
Table 3. Multiple regression analysis of factors (self-care capacity, daily life activities and instrumental activities of daily living) affecting depression levels in the elderly.
| Coefficientsa | t | Sig. | |||
|---|---|---|---|---|---|
| Unstandardized coefficients |
Standardized coefficients | ||||
| B | SE | Beta | |||
| (Constant) | 25.823 | 1.235 | 20.910 | 0.000 | |
| Self-care capacity | -0.128 | 0.013 | -0.417 | -10.154 | 0.000 |
| Daily life activities | -0.708 | 0.143 | -0.293 | -4.943 | 0.000 |
| Instrumental activities of daily living | 0.039 | 0.055 | 0.042 | 0.701 | 0.484 |
aDependent variable: depression total points; SE = standard error; Sig. = significance
Discussion
While the extent of depression varies with the characteristics of the elderly group involved in the study, the location of the study, and the selected methods, it has been asserted in the literature that many different factors affect development of depression (10, 11, 29-33). This study revealed that the mean depression scores were higher in women, singles, chronic disease sufferers, and individuals who did not attend social activities. Additionally, according to some studies, it has been asserted that depression, in line with the current research findings, is more common among women (10, 21, 31, 32). However, according to other studies inconsistent with the current research findings, depression is more common among individuals with low education levels (10, 31, 32) and those living in city centers, having serious illnesses or physical disabilities, physically inactive individuals and smokers (31, 32).
The current study revealed that two-thirds of the elderly had chronic diseases and that depression scores of such individuals were higher. Consistent with the results obtained in this sample, findings of other studies (34, 35) conducted in Turkey on this issue have revealed that elderly individuals with chronic diseases have higher levels of depression. However, in other studies (36) that have yielded findings inconsistent with the present ones, it has been asserted that having a chronic disease does not have any effect on the level of depression.
The present study found that almost all daily activities in the elderly chronic-disease sufferers were affected by their conditions and one-third of the elderly were dependent on the others in terms of continuing their daily life activities. Relevant studies from other countries (37, 38) have shown that between 4.3% and 8.6% of the elderly depend on the others to maintain their activities of daily living. Performing activities of daily living and self-care as part of personal care without any assistance is quite important in the eyes of the elderly.
In this study, it was determined that Daily Life Activity Index scores were relatively lower (and, consequently, dependency levels were higher) in the following: women, singles, and individuals not receiving regular check-ups, not attending social activities, and not exercising. In some studies, it has been asserted that dependency in terms of activities of daily living, in line with the current research findings, is more common among women (20, 21, 39, 40). However, according to other studies presenting findings inconsistent with those of the current research, dependency in terms of activities of daily living is more common among the following: homemakers (20), advanced age groups (19-21), individuals with low education levels (19), individuals without any social security (20), individuals with low socio-economic status (20), chronic-disease sufferers (20, 21), individuals who constantly use medicine (20), and individuals who perceive their health status as poor (21). Jiang et al. report that some demographic subgroups appear to be at a higher risk of impaired ADLs (41). Almedia and Rodrigues found that women and 75-84 age group were more dependent (37). Also, Konno et al. report that the prevalence of ADL disability increases with aging (38).
The present study demonstrated that the mean self-care capacity scores of the elderly were relatively higher in married individuals and among those who received regular health check-ups and exercise. On the other hand, other studies carried out on this issue have asserted that self-care capacity decreases as age and disease duration increase in the elderly (20), and that decreased self-care capacity has an important effect on the mood state of elderly individuals (42).
We found negative correlation between Geriatric Depression Scale scores and self-care capacity and daily life activity scores. That is, as daily life activities and self-care capacity decreased, depression levels in the elderly increased. During the aging process, the elderly may find it difficult to carry out the daily activities they were able to perform previously, and they may become dependent on the others. This may affect the elderly at many levels and hence decrease their self-care capacity. According to the findings of this study, a decrease in both daily life activities and self-care capacity levels of the elderly had a negative effect on depression. Therefore, reduction of depression prevalence in the elderly is of utmost importance.
Conclusion
In this study, depression scores of the elderly increased as their daily life activities and self-care capacity scores decreased. Therefore, the following is proposed: support to the elderly people’s maintaining daily life activities and self-care capacity independently; carrying out routine depression screenings among the elderly; referring elderly people at risk to psychiatric services and monitor them; and strengthening psychological counseling and guidance services focused on the elderly.
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