Abstract
Objectives:
Determine the association between depression and SCD-related outcomes by age and gender.
Methods:
Using 2018 Behavioral Risk Factor Surveillance System survey data, crude and multivariable logistic regression were used to determine the associations between depression and SCD-related outcomes by age and gender.
Results:
Among respondents 45 to 69, depression was associated with SCD [adjusted OR (aOR): 4.36; 95% CI: 3.24–5.86]; needing assistance with activities due to confusion/memory loss (aOR: 2.38; 95% CI: 1.26 – 4.51); needing help with activities and the help is not available (aOR: 4.46; 95% CI: 1.31 – 15.2); and having discussed confusion/memory loss with a health care professional (aOR: 1.87; 95% CI: 1.09 – 3.23). However, among respondents 70 and older, depression was associated with SCD (aOR): 3.52; 95% CI: 2.06 – 6.02); needing help with activities and the help is not available (aOR: 0.09; 95% CI: 0.01 – 0.56); confusion/memory loss interfering with work/social activities (aOR: 2.44; 95% CI: 1.03 – 5.79); and having discussed confusion/memory loss with a health care professional (aOR): 2.99; 95% CI: 1.20–7.40). Depression was positively associated with SCD among men (aOR): 3.68; 95% CI: 2.52–5.38) and women (aOR): 4.76; 95% CI: 3.29 – 6.87; and was positively associated with all SCD-related outcomes among men except for confusion/memory loss interfering with work/social activities and given up chores. Depression was positively associated with the latter among women (aOR): 2.10; 95% CI: 1.09 – 4.06).
Discussion:
SCD interventions should include assessment of and intervention for depression, and consider age and gender differences.
Keywords: cognitive function, cognitive status, depression, mental health, disparities
Introduction
Depression continues to be a common mental health disorder (National Institute of Aging, 2020) and a major public health challenge among older adults (Allan, Valkanova, & Ebmeier, 2014; Cheruvu & Chiyaka, 2019). In the US, the prevalence of depressive symptoms among older adults in the US was 6.1% (Cheruvu & Chiyaka, 2019) while depressive symptoms can be found in 15% of community-dwelling populations of older adults (Blazer, 2003; Fiske et al., 2009). Higher estimates have been found among specific healthcare-related subgroups including 18% among older adults who report medical cost as a barrier to seeking healthcare (Cheruvu & Chiyaka, 2019); 14% among those who require home healthcare (Centers for Disease Control and Prevention, 2020a); 5 to 10% among outpatients (Blazer, 2003; Djernes, 2006; Fiske et al., 2009); 12% among inpatients (Centers for Disease Control and Prevention, 2020a); and 14 to 42% among older adults living in long-term care (Blazer, 2003; Djernes, 2006; Fiske et al., 2009). Older adults are at an increased risk of depression due to additional comorbidities and limited functioning, and tend to be misdiagnosed and undertreated for depression (Centers for Disease Control and Prevention, 2020a). Among older adults, depression has been linked to a variety of adverse health outcomes including suicide (Centers for Disease Control, 2020a), morbidity (Centers for Disease Control and Prevention, 2020a), impairments in physical, social, and cognitive functioning, and mortality (Blazer, 2003; Fiske et al., 2009).
Research has also shown an association between depression and subjective cognitive decline (SCD), a potential precursor for Alzheimer’s disease (AD), in older adults (Zlatar, Muniz, Galasko, & Salmon, 2018). Cognitive symptoms (e.g., difficulty concentrating) are included in the core diagnostic criteria for major depressive disorder and present in up to 90% of depressive episodes (Conradi, Ormel, & de Jonge, 2011). Indeed, such symptoms complicate the distinction between early AD-related cognitive changes and depression in older adults, particularly given the association between depressive symptoms and increased AD risk (Ownby, Crocco, Acevedo, John, & Loewenstein, 2006; Palmer et al., 2010). SCD specifically, or the perception of a decline in memory or thinking over time, is also associated with depression in older adults, including Hispanic populations, after adjusting for sociodemographic characteristics and objective cognitive performance (Zlatar, Muniz, Galasko, & Salmon, 2018; Zlatar, Muniz, Espinoza, et al., 2018). A previous systematic review found that SCD was consistently associated with concurrent depressive symptoms, with longitudinal evidence suggesting an increased risk of developing depression among older adults with SCD (Hill et al., 2016). Recent work has identified a temporal relationship such that SCD tends to precede higher depressive symptoms over time, rather than vice versa (Bhang, Mogle, Hill, & Bhargava, 2020; Mogle, Hill, Bhargava, Bell & Bhang, 2020). Both SCD and depression can negatively impact an older adult’s ability to perform instrumental daily activities such as managing finances or medications (Ormel, Rijsdijk, Sullivan, van Sonderen, & Kempen, 2002), but little is known regarding how SCD impacts such activities in the context of depression. For example, depressive symptoms have been linked to medical help-seeking due to SCD (Espenes et al., 2020), but depression may be associated with other SCD-related outcomes such as interference with instrumental activities of daily living (IADLs), specifically due to memory problems or confusion. Retirement, a major life event, may also play a role in the association between depression and SCD. For example, retirement has been linked to a decrease in cognition among women, but not among men (Oi 2019).
Gender differences also exist in SCD and depression. For example, previous research has shown that men are twice more likely to report SCD compared to women (Brown & Patterson, 2020b) and the prevalence of SCD is also higher among men (Centers for Disease Control and Prevention, 2020b). However, depression tends to be more prevalent among women compared to men (Albert 2015) and specifically among older women compared to older men (Fiske et al., 2009) with a narrow gender gap compared to that seen at other ages (Djernes et al., 2006).
Although the link between depression and SCD is relatively well-established (Hill et al., 2016), how this relationship may differ by age group (among middle-aged and older adults) and by gender is not as clear. In addition, the association between depression and SCD-related outcomes has not been examined. Therefore, the aim of this study was to determine the association between depression and SCD and SCD-related outcomes by age group among adults aged 45 and older, and by gender. Findings will help to inform intervention programs geared towards improving cognitive outcomes throughout aging by reducing SCD through assessment and treatment of depression, as well as targeting these interventions based on age groups, gender, and specific SCD-related outcomes.
Methods
Data Source and Study Population
Data were obtained from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), a survey established by the Centers for Disease Control and Prevention (Centers for Disease Control and Prevention, 2019). BRFSS collects data on US residents’ health behaviors, health conditions and use of healthcare services. Data collection occurs each year, and the questionnaire consists of a core module, optional modules, and state-added questions. Research participants are identified through telephone-based methods using random sampling techniques and include noninstitutionalized adults aged 18 and older. Participants complete surveys via phone interviews. Although the BRFSS collects data in all US states, three states (New Jersey, Oregon, and Pennsylvania) included the SCD module (combined land line and cell phone data in the LLCP2018 dataset), which was an optional module in 2018. This module was asked of respondents aged ≥45 and are, therefore, included in the study. The stratum weight considers the differences of the probability of being selected among strata, which are subsets of area codes or combinations of prefixes. More details on the sampling methodology can be found here (Centers for Disease Control and Prevention, 2019)
Measures
SCD was operationalized by the question: “During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?” (Yes vs. no). SCD-related outcomes were asked of participants who answered yes to SCD and were operationalized by: 1) “During the past 12 months, as a result of confusion or memory loss, how often have you given up day-to-day household activities or chores you used to do, such as cooking, cleaning, taking medications, driving, or paying bills?” (Always, usually, sometimes vs. rarely, never); 2) “As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities?” (Always, usually, sometimes vs. rarely, never); 3) “When you need help with these day-to-day activities, how often are you able to get the help that you need?” (Rarely, never vs. always, usually, sometimes); 4) “During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home?” (Always, usually, sometimes vs. rarely, never); and 5) “Have you or anyone else discussed your confusion or memory loss with a health care professional?” (Yes vs. no). SCD-related outcomes on a five-point scale (Always, usually, sometimes, rarely, never) were dichotomized to determine if these outcomes were a challenge (assigned as 1) vs. if they rarely or never happened (assigned as 0).
Depression was operationalized by the question “(Ever told) you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?”
(Yes vs. no).
Statistically significant differences in SCD by income, education, and employment have been found using BRFSS data (Brown & Patterson, 2020a). Age, gender, and racial differences have been found in SCD where older, male and Other populations report higher odds of SCD compared to younger, female and White populations (Brown & Patterson, 2020b; Taylor, Bouldin, & McGuire, 2018). Marital status and diabetes have also been considered risk factors of SCD. With regards to depression, differences by age (Kessler et al., 2010), income (Niranjan, Corujo, Ziegelstein, & Nwulia, 2012), education (Niranjan et al., 2012), employment (Niranjan et al., 2012), race/ethnicity (Niranjan et al., 2012), and marital status (Niranjan et al., 2012) have been reported. In addition, diabetes and depression are considered a syndemic clinical challenge (Holt, de Groot, & Golden, 2014). Therefore, gender (male, female), race/ethnicity (White, Black, Other, Hispanic), income (<$15000, $15,000–<$50,000, ≥ $50,000), education (< high school, high school graduate, some college, college graduate), employment (employed, unemployed, retired), marital status (married/couple, not married) and diabetes (yes vs. gestational, prediabetes, no) were considered as potential confounders in the associations between depression, and SCD and SCD-related outcomes by age. For analyses by gender, age, race/ethnicity, income, education, employment, marital status and diabetes were considered as confounders. The “Other” racial category included participants who identified as Asian, non-Hispanic; American Indian/Alaskan Native, non-Hispanic; Native Hawaiian or Other Pacific Islander, non-Hispanic; and Other, non-Hispanic.
Analytic Approach
Descriptive statistics were used to describe the sociodemographic characteristics of the study population, their depression status, SCD status and SCD-related outcomes. Crude and multivariable logistic regression models were used to determine the associations between depression and SCD (aged 45–59, 60–69, 70–79, and ≥80; and by gender), and between depression and SCD-related outcomes (aged 45–69, and ≥70; and by gender). SCD-related outcomes examined included: 1) Have you experienced confusion or memory loss that is happening more often or is getting worse?; 2) Given up day-to-day chores due to confusion or memory loss; 3) Need assistance with day-to-day activities due to confusion or memory loss?; 4) When you need help with day-to-day activities are you able to get it?; 5) Does confusion or memory loss interfere with work or social activities?; 6) Have you discussed your confusion or memory loss with a health care professional? Interaction terms defined by depression*age group (45–59, 60–69, 70–79, ≥80) and depression*gender were included in partially adjusted (controlling for age and gender) and fully adjusted models (additionally controlling for race/ethnicity, income education, employment, marital status and diabetes). Age groups were collapsed due to small numbers for SCD-related outcomes (45 to 69; and 70 and older). All analyses considered the multi-stage complex sampling strategy and were conducted in SAS version 9.4 (SAS Institute Inc., Cary, NC).
Results
Table 1 shows the sociodemographic characteristics and depression status of the study sample. There were statistically significant differences in self report of depression by gender, age, income, education, employment, marital status, and diabetes status. Respondents who reported depression tended to be women, aged 45–59, earned less than $50,000, attained less than a high school degree or had some college educational attainment, unemployed, not married and had diabetes. There were also statistically significant differences in SCD by age, education, income, employment, marital status and diabetes status. Respondents who reported SCD tended to be older (80 and older), earn less than $50,000, attained less than a high school education, unemployed or retired, not married and had diabetes.
Table 1.
Sociodemographic Characteristics of 2018 Behavioral Risk Factor Surveillance System Respondents in Oregon by Depression and Subjective Cognitive Decline Status
| N (%) | Depression | No Depression | P-value | SCD | No SCD | P-value | |
|---|---|---|---|---|---|---|---|
| Gender | <0.001 | 0.368 | |||||
| Men | 3,762 (46.0) | 559 (31.8) | 3,203 (49.1) | 399 (48.3) | 3,363 (45.8) | ||
| Women | 4,635 (54.0) | 1,195 (68.2) | 3,440 (41.8) | 478 (51.7) | 4,157 (54.2) | ||
| Age | <0.001 | 0.001 | |||||
| 45–59 | 3,134 (41.8) | 766 (46.9) | 2,368 (40.7) | 311 (38.1) | 2,823 (42.2) | ||
| 60–69 | 2,648 (28.9) | 607 (32.1) | 2,041 (28.2) | 264 (26.9) | 2,384 (29.1) | ||
| 70–79 | 1,748 (17.6) | 287 (13.8) | 1,461 (18.4) | 185 (16.6) | 1,563 (17.7) | ||
| 80+ | 883 (11.7) | 97 (7.2) | 786 (12.6) | 119 (18.4) | 764 (10.9) | ||
| Race/ Ethnicity | 0.053 | 0.554 | |||||
| White, NH | 7,070 (80.6) | 1,500 (82.1) | 5,570 (80.3) | 715 (78.0) | 6,355 (80.9) | ||
| Black, NH | 560 (7.6) | 99 (9.0) | 461 (7.3) | 64 (9.6) | 496 (7.4) | ||
| Other, NH* | 400 (5.6) | 80 (3.9) | 320 (6.0) | 54 (5.9) | 346 (5.6) | ||
| Hispanic | 383 (6.1) | 78 (5.0) | 305 (6.4) | 46 (6.5) | 337 (6.1) | ||
| Income | <0.001 | <0.001 | |||||
| <$15,000 | 578 (7.2) | 240 (13.8) | 338 (5.7) | 139 (15.9) | 439 (6.2) | ||
| $15,000–<$50,000 | 2,752 (37.5) | 735 (49.4) | 2,017 (34.8) | 384 (50.5) | 2,368 (36.0) | ||
| ≥$50,000 | 3,837 (55.3) | 568 (36.7) | 3,269 (59.4) | 245 (33.6) | 3,592 (57.8) | ||
| Education | <0.001 | <0.001 | |||||
| <HS Graduate | 478 (10.2) | 138 (15.1) | 340 (9.2) | 84 (17.8) | 394 (9.4) | ||
| HS Graduate | 2,234 (32.5) | 472 (31.1) | 1,762 (32.8) | 253 (33.4) | 1,981 (32.4) | ||
| Some College | 2,262 (26.9) | 584 (30.6) | 1,678 (26.1) | 264 (26.8) | 1,998 (26.9) | ||
| College Graduate | 3,427 (30.4) | 563 (23.2) | 2,864 (32.0) | 277 (22.0) | 3,150 (31.3) | ||
| Employment | <0.001 | <0.001 | |||||
| Employed | 3,778 (47.7) | 613 (34.0) | 3,165 (50.7) | 220 (25.8) | 3,558 (50.1) | ||
| Unemployed | 1,303 (17.8) | 564 (37.8) | 739 (13.4) | 285 (36.3) | 1,018 (15.7) | ||
| Retired | 3,276 (34.5) | 570 (28.2) | 2,706 (35.9) | 371 (37.9) | 2,905 (34.2) | ||
| Marital Status | <0.001 | <0.001 | |||||
| Married/Couple | 4,818 (61.8) | 777 (48.1) | 4,041 (64.8) | 391 (46.0) | 4,427 (63.5) | ||
| Not married | 3,542 (38.2) | 972 (51.9) | 2,570 (35.2) | 482 (54.0) | 3,060 (36.5) | ||
| Diabetes | <0.001 | <0.001 | |||||
| Yes | 1,409 (16.4) | 384 (24.0) | 1,025 (14.8) | 230 (25.5) | 1,179 (15.4) | ||
| No | 6,994 (83.6) | 1,370 (76.0) | 5,624 (85.2) | 647 (74.5) | 6,347 (84.6) |
Other, NH includes participants who identified as Asian, non-Hispanic; American Indian/Alaskan Native, non-Hispanic; Native Hawaiian or Other Pacific Islander, non-Hispanic; and Other Race, non-Hispanic
Table 2 shows SCD-related outcomes by age group and gender. Among age groups, adults aged 60–69 had the highest mean of giving up day-to-day chores and needing assistance with day-to-day activities due to confusion or memory loss. However, adults aged 70–79 reported getting help with day-to-day activities when needed less frequently and reported confusion or memory loss interfering with work or social activities more frequently than other age groups. Majority of respondents aged 45–59 and 60–69 had discussed their confusion or memory loss with a health care professional while only 35% of respondents aged ≥80 had done so. Men reported giving up day-to-day chores and needing assistance with day-to-day activities due to confusion or memory loss; and confusion or memory loss interfering with work or social activities more frequently than women. However, women reported getting help with day-to-day activities when needed less frequently than men. Majority of women (59%) had discussed their confusion or memory loss with a health care professional while approximately 39% of men had done so.
Table 2.
Subjective Cognitive Decline-Related Outcomes by Age Group and Gender
| Given up day-to-day chores due to confusion or memory loss Mean (SE) |
Need assistance with day-to-day activities due to confusion or memory loss? Mean (SE) |
When you need help with day-to-day activities are you able to get it? Mean (SE) |
Does confusion or memory loss interfere with work or social activities? Mean (SD) |
Have you discussed your confusion or memory loss with a health care professional? N (%) |
|
|---|---|---|---|---|---|
| Overall | 3.93 (0.07) | 4.03 (0.06) | 2.22 (0.09) | 3.86 (0.09) | 424 (49.1) |
| 45–59 | 3.64 (0.10) | 3.83 (0.10) | 2.35 (0.12) | 3.54 (0.10) | 175 (54.1) |
| 60–69 | 4.29 (0.07) | 4.26 (0.07) | 2.53 (0.14) | 4.11 (0.09) | 135 (54.3) |
| 70–79 | 4.09 (0.15) | 4.11 (0.14) | 1.61 (0.14) | 4.21 (0.15) | 71 (44.6) |
| 80+ | 3.88 (0.13) | 4.02 (0.10) | 2.06 (0.07) | 3.83 (0.34) | 43 (35.1) |
| Men | 4.02 (0.09) | 4.13 (0.09) | 2.49 (0.14) | 4.02 (0.09) | 170 (39.4) |
| Women | 3.84 (0.10) | 3.94 (0.08) | 1.99 (0.10) | 3.71 (0.14) | 254 (58.6) |
Note: SCD-related outcomes on a five-point scale (Always, usually, sometimes, rarely, never) were dichotomized to determine if these outcomes were a challenge (assigned as 1) vs. if they rarely or never happened (assigned as 0).
The interaction terms between depression*age and depression*gender were not statistically significant in the partially adjusted (OR: 0.86; 95% CI: 0.64 – 1.15 for depression*age; and OR:1.05; 95% CI:0.66 – 1.67 for depression*gender) or fully adjusted (aOR:0.80; 95% CI: 0.57 – 1.12 for depression*age; and aOR: 1.40; 95% CI: 0.84 – 2.33 for depression*gender) models with SCD.
Table 3 shows the association between depression and SCD by age group and gender. After adjusting for gender, race/ethnicity, income, education, employment, marital status and diabetes, respondents aged 45–59 who reported depression were more than four times as likely (adjusted odds ratio (aOR): 4.46; 95% CI: 3.05 – 6.52) to report SCD in the past year compared to respondents in the same age group who did not report depression. Among respondents who were aged 60–69, those who reported depression were almost four times as likely (aOR): 3.69; 95% CI: 2.33 – 5.83) to report SCD in the past year compared to peers who did not report depression. Among respondents who were aged 70–79, those who reported depression were about three and a half times as likely (aOR): 3.53 95% CI: 2.15 – 5.80) to report SCD in the past year compared to those respondents who did not report depression. Finally, among respondents aged ≥80, those who reported depression were more than four times as likely (aOR): 4.35; 95% CI: 1.38 – 13.7) to report SCD in the past year compared to respondents who did not report depression. Men with depression were almost four times as likely (aOR): 3.68; 95% CI: 2.52 – 5.38) while women with depression were almost five times as likely (aOR): 4.76; 95% CI: 3.29 – 6.87) to report SCD compared to men and women without depression, respectively.
Table 3.
Association between Depression and Subjective Cognitive Decline by Age Group and Gender
| Crude OR (95% CI) | Adjusted OR (95% CI)a | |
|---|---|---|
| 45–59 | 6.55 (4.53 – 9.46) | 4.46 (3.05 – 6.52) |
| 60–69 | 4.56 (3.03– 6.85) | 3.69 (2.33 – 5.83) |
| 70–79 | 4.04 (5.48 – 6.57) | 3.53 (2.15 – 5.80) |
| 80+ | 5.91 (2.32 – 15.1) | 4.35 (1.38 – 13.7) |
| Men | 5.35 (3.81 – 7.51) | 3.68 (2.52 – 5.38) |
| Women | 5.29 (3.83 – 7.30) | 4.76 (3.29 – 6.87) |
Bolded estimates are statistically significant at p<0.05.
For models by age group: Adjusted models controlled for gender, race/ethnicity, income, education, employment, marital status, and diabetes status.
For models by gender: Adjusted models controlled for age, race/ethnicity, income, education, employment, marital status, and diabetes status.
Table 4 shows the association between depression and SCD-related outcomes in the overall population and by age (aged 45–69 and aged ≥70). Among the overall study population, those with depression were four times more likely to have SCD (aOR): 3.99; 95% CI: 3.12 – 5.09), almost twice as likely to give up day-to-day chores due to confusion or memory loss (aOR): 1.91; 95% CI: 1.13 – 3.23), were almost three times more likely to need assistance with day-to-day activities due to memory loss (aOR): 2.65; 95% CI: 1.51 – 4.63), were more than three times more likely to not get help with day-to-day activities when needed (aOR): 3.42; 95% CI: 1.24 – 9.41), were twice as likely to have confusion or memory loss interfere with work or social activities (aOR): 2.30; 95% CI: 1.30 – 4.06) and twice as likely to have discussed their confusion or memory loss with a health care professional (aOR): 2.27; 95% CI: 1.43 – 3.62).
Table 4.
Association between Depression and Subjective Cognitive Decline-Related Outcomes among Overall Population and by Collapsed Age Groups (45–69 and 70 and older)
| Overall | 45–69 | 70+ | ||||
|---|---|---|---|---|---|---|
| Crude OR (95% CI) | Adjusted OR (95% CI) | Crude OR (95% CI) | Adjusted OR (95% CI) | Crude OR (95% CI) | Adjusted OR (95% CI) | |
| Have you experienced confusion or memory loss that is happening more often or is getting worse? | 4.93 (3.90 – 6.22) | 3.99 (3.12 – 5.09) | 5.63 (4.29 – 7.40) | 4.36 (3.24 – 5.86) | 4.45 (2.68 – 7.39) | 3.52 (2.06 – 6.02) |
| Given up day-to-day chores due to confusion or memory loss | 2.88 (1.76 – 4.71) | 1.91 (1.13 – 3.23) | 2.34 (1.33 – 4.11) | 1.64 (0.93 – 2.91) | 4.84 (1.75 – 13.4) | 2.26 (0.77 – 6.66) |
| Need assistance with day-to-day activities due to confusion or memory loss? | 2.75 (1.70 – 4.46) | 2.65 (1.51 – 4.63) | 2.90 (1.60 – 5.25) | 2.38 (1.26 – 4.51) | 2.64 (1.12 – 6.23) | 2.98 (0.91 – 9.71) |
| When you need help with day-to-day activities are you able to get it? | 2.43 (1.20 – 4.91) | 3.42 (1.24 – 9.41) | 3.01 (1.26 – 7.21) | 4.46 (1.31 – 15.2) | 0.66 (0.12 – 3.58) | 0.09 (0.01 – 0.56) |
| Does confusion or memory loss interfere with work or social activities? | 3.09 (1.90 – 5.02) | 2.30 (1.30 – 4.06) | 2.48 (1.42 – 4.35) | 1.86 (0.94 – 3.68) | 4.32 1.62 – 11.5) | 2.44 (1.03 – 5.79) |
| Have you discussed your confusion or memory loss with a health care professional? | 2.54 (1.64 – 3.92) | 2.27 (1.43 – 3.62) | 2.89 (1.76 – 4.75) | 1.87 (1.09 – 3.23) | 1.57 (0.70 – 3.53) | 2.99 (1.20 – 7.40) |
Bolded estimates are statistically significant at p<0.05.
Adjusted models controlled for gender, race/ethnicity, income, education, employment, marital status, and diabetes status
Among respondents aged 45–69, depression was associated with SCD, needing assistance with day-to-day activities due to memory loss, not getting help with day-to-day activities when needed and having discussed their confusion or memory loss with a health care professional. For example, respondents aged 45–69 who reported depression were four times as likely to report SCD (aOR: 4.36; 95% CI: 3.24 – 5.86), twice as likely to need assistance with day-to-day activities due to memory loss (aOR: 2.38; 95% CI: 1.26 – 4.51), four times as likely to not get help with day-to-day activities when needed (aOR: 4.46; 95% CI: 1.31 – 15.2), and almost twice as likely to have discussed their confusion or memory loss with a health care professional (aOR: 1.87; 95% CI: 1.09 – 3.23). Among respondents aged ≥70, depression was associated with SCD, getting help with day-to-day activities when needed, confusion or memory loss interfering with work or social activities, and having discussed their confusion or memory loss with a health care professional. For example, respondents aged ≥70 who reported depression were almost four times as likely to have SCD in the past year (aOR: 3.52; 95% CI: 2.06 – 6.02); were 91% less likely to not get help with day-to-day activities when needed (aOR: 0.09; 95% CI: 0.01 – 0.56); but twice as likely to have confusion or memory loss interfering with work or social activities (aOR: 2.44; 95% CI: 1.03 – 5.79); and three times as likely to have discussed their confusion or memory loss with a health care professional (aOR: 2.99; 95%CI: 1.20 – 7.40).
Table 5 shows the relationship between depression and SCD-related outcomes by gender. Men with depression were almost four times more likely to report needing assistance with activities due to confusion or memory loss (aOR: 3.60; 95% CI: 1.28 – 10.1); over twelve times more likely to need help with activities and were not able to get it (aOR: 12.5; 95% CI: 2.58 – 60.7); and almost three times more likely to have discussed confusion or memory loss with a health care professional (aOR: 2.98; 95% CI: 1.40 – 6.31) compared to men without depression. On the other hand, women with depression were twice as likely to report to have given up day-to-day chores due to confusion or memory loss (aOR: 2.10; 95% CI: 1.09 – 4.06).
Table 5.
Association between Depression and Subjective Cognitive Decline-Related Outcomes by Gender
| Men | Women | |||
|---|---|---|---|---|
| Crude OR (95% CI) | Adjusted OR (95% CI) | Crude OR (95% CI) | Adjusted OR (95% CI) | |
| Given up day-to-day chores due to confusion or memory loss | 2.40 (1.21 – 4.79) | 1.03 (0.41 – 2.59) | 3.22 (1.73 – 6.00) | 2.10 (1.09 – 4.06) |
| Need assistance with day-to-day activities due to confusion or memory loss? | 3.54 (1.68 – 7.44) | 3.60 (1.28 – 10.1) | 2.23 (1.25 – 3.97) | 1.61 (0.79 – 3.28) |
| When you need help with day-to-day activities are you able to get it? | 3.32 (1.08 – 10.2) | 12.5 (2.58 – 60.7) | 1.91 (0.76 – 4.82) | 0.72 (0.21 – 2.46) |
| Does confusion or memory loss interfere with work or social activities? | 3.02 (1.60 – 5.70) | 1.84 (0.77– 4.40) | 3.07 (1.55 – 6.08) | 1.76 (0.78 – 3.97) |
| Have you discussed your confusion or memory loss with a health care professional? | 3.61 (1.97 – 6.64) | 2.98 (1.40 – 6.31) | 1.51 (0.85 – 2.69) | 1.42 (0..81 – 2.51) |
Bolded estimates are statistically significant at p<0.05.
Adjusted models controlled for age, race/ethnicity, income, education, employment, marital status, and diabetes status
Discussion
To the best of our knowledge, this is the first study to examine age and gender disparities in the association between depression, SCD, and SCD-related outcomes in a population-based sample. We identified age as an important factor to consider to improve our understanding of how depression relates to both SCD as well as SCD’s impact on daily life. Specifically, we found a U-shaped relationship between SCD and depression by age group such that those with depression in the 45–59 (midlife) and 80 or older (oldest-old) age groups were most likely to report SCD. In addition, age disparities were also found in the association between depression and certain SCD-related outcomes including giving up chores; needing assistance with daily activities; needing help with day-to-day activities and not being able to get it; and interference with work or social activities due to SCD. We also found gender disparities in the association between depression and all SCD-related outcomes examined, such that men with depression were more likely to report negative impacts of SCD in most cases. Consideration of how SCD influences the lives of middle- and older aged adults in the context of depression is particularly important to consider, as limitations in instrumental activities of daily living (such as chores) as well as participation in physical, social, and cognitive activities have profound implications for both cognitive and functional outcomes throughout the aging process (Brown, Peiffer, & Martins, 2013; Kelly et al., 2017). Beyond the recognition of cognitive symptoms as a potential feature of depression, SCD associated with depression may pose unique challenges to healthy aging. Reports of cognitive problems are often the first indicator of cognitive impairment, but are also common in depression (Conradi, Ormel, & de Jonge, 2011). This can reduce the specificity of SCD as a potential precursor to AD when it co-occurs with depressive symptoms. Our findings show that this overlap may be particularly salient in midlife and also among the oldest-old, although relevant in all age groups. Further, given the importance of functional limitations in the diagnosis of neurocognitive disorders, our findings suggest that gender differences may be important to consider since men were more likely to report the need for assistance with daily tasks and interference with normal activities due to SCD.
There are some considerations to keep in mind when examining depression across the life course. Depression can be challenging to diagnose at older ages due to factors such as comorbidities and cognitive impairment (Reynolds, Alexopoulos, Katz, & Lebowitz, 2001), as older adults tend to report different symptoms than younger adults, such as somatic (e.g., fatigue) and cognitive (e.g., trouble concentrating) problems rather than changes in mood (Schaakxs, Comijs, Lamers, Beekman, & Penninx, 2017). In the current study, we found that depression was reported more so by middle-aged respondents (45–59) compared to older respondents, and was not more common in late-life. The prevalence of depressive symptoms (as measured by the Patient Health Questionnaire-9) among older adults in the US was 6.1% (Cheruvu & Chiyaka, 2019). In the current study, 15% of adults aged 65 and older reported depression. Given that depression was assessed via self-report of the diagnosis of a “depressive disorder (including depression, major depression, dysthymia, or minor depression,” older respondents may have experienced depression but were never diagnosed. Further, endorsement by older respondents could have been influenced by failure to recognize depressive symptoms such as anhedonia or loss of interest, or attribution of symptoms to the aging process or cognitive changes. This under-recognition of depressive symptoms in older adults is an identified challenge of self-report measures (Balsamo, Cataldi, Carlucci, Padulo, & Fairfield, 2018).
We also found a U-shaped relationship between depression and SCD, with the highest effect estimates seen among middle-aged respondents, aged 45–59, and those aged 80 and older. This finding is crucial as it highlights that depression may play a major role in SCD not only for older adults but for middle-aged adults as well. Much of the previous research on SCD has been conducted with older adults and focused on risk for cognitive decline or dementia, with depression considered as a confounding factor in these relationships (Rabin, Smart, & Amariglio, 2017). Although depression may indeed influence reports of memory or other cognitive problems, our findings suggest that the role of SCD in depression at younger ages is an important area of future research. Both depression and SCD are known to be associated with increased cognitive decline risk (Ownby et al., 2006; Studart & Nitrini, 2016), and their syndemic co-occurrence seems to increase this risk in older adults more than either depression or SCD alone. In a longitudinal study by Liew, older adults with co-occurring depression and SCD had a higher risk of developing a neurocognitive disorder than individuals with either condition alone (Liew, 2019). Our findings suggest that examining these relationships across adulthood, not just at older ages, may be important for maximizing cognitive health.
Depression also played a major role in poorer SCD-related outcomes for respondents aged 45–69 compared to adults aged ≥70. For both age groups, depression was associated with reports of worsening confusion or memory loss and discussing these symptoms with a health care professional. However, a statistically significant association was seen between depression and needing assistance with day-to-day activities due to confusion or memory loss for respondents aged 45–69 but not among respondents aged ≥70. The variation seen in age could be influenced by a greater sensitivity to the loss of independence in daily tasks among middle-aged adults prior retirement, when limitations in family and work responsibilities may be more notable and troublesome. In addition, older adults may be more likely to attribute the need for assistance with daily activities to health conditions that directly impair functional ability and are more common at older ages, rather than confusion or memory loss.
Gender disparities were apparent in the association between depression and SCD-related outcomes. While women with depression were more likely to give up chores due to confusion or memory loss compared to women without depression, men with depression endorsed more negative SCD-related outcomes overall and in different categories. Men with depression were more likely to need assistance with activities, to not get that help when needed and to discuss memory changes with a healthcare professional compared to men without depression. This is in line with previous research that found men have a higher odds of reporting SCD compared to women (Brown et al., 2020b), and suggests that in addition to a higher SCD prevalence, men with depression may experience more extensive functional consequences due to confusion or memory loss. Gender differences in depressive symptoms have previously been identified, including more rumination and somatic concerns in women (Marcus et al., 2005), and higher instances of substance use disorder in men (Marcus et al., 2008). However, our findings suggest that the cognitive symptoms of depression may also differ by gender. This is important to consider in assessment and treatment of depression, but also when viewed in the context of SCD and potential cognitive decline risk. Some studies have found a stronger association between a history of depression and Alzheimer’s disease in men than in women (Fuhrer et al., 2003; Forno et al., 2005), although a recent systematic review concluded there is insufficient evidence at present to fully support this relationship. Future work should examine cognitive trajectories, ideally beginning in midlife, to determine SCD’s role in predicting cognitive decline in the context of depression and whether that differs based on gender. Furthermore, interventions geared towards improving SCD-related outcomes by attenuating depression should consider these disparities by gender since characterization of symptoms, and therefore tailoring of treatment strategies, may differ.
The findings of this study must be considered with limitations in mind. The study was cross-sectional; therefore, we are unable to infer causation from the study’s findings. The only states that asked the SCD module were New Jersey, Oregon and Pennsylvania. Therefore, results might not be generalizable to other populations. The SCD module was only asked of respondents aged ≥45 and may be relevant to even younger populations. Making the SCD a core module should be considered in future implementation of the BRFSS, as well as asking younger populations about their experience with SCD. Due to small numbers, we had to recategorize the age groups to have sufficient sample size for analyses including SCD-related outcomes. In addition, our measurement approach for SCD as well as depression may have influenced our findings. SCD was operationalized by one global question and mainly captured memory loss, not other domains of cognition such as language and executive functioning. The operationalization of depression in the BRFSS was also limited to one item regarding whether a healthcare provider has ever told the participant they have a depressive disorder. This does not distinguish between those with a history of depression and those currently experiencing depression or depressive symptoms, and also does not consider the use of antidepressants or access to other treatments. Individuals who have been successfully treated for depression likely experience different symptoms, including SCD and SCD-related outcomes. In addition, depression was self-reported and therefore, there may be under-reported as depression tends to be underdiagnosed among older populations (Allan et al., 2014). Nevertheless, the self-report of depression may also overestimate the age-related differences seen in the study.
Conclusions
Age disparities exist in the association between depression and SCD, and SCD-related outcomes. Intervention programs that are geared to improving SCD should not only aim to assess/diagnose and treat depression, but should also consider addressing SCD-related outcomes, and age group and gender differences in these outcomes. Future research should include longitudinal designs to determine the temporal sequence and pathways between depression and SCD-related outcomes, and extending these to include middle-age may be important for identifying differences in associations across adulthood.
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