Prevalence of Geriatric Depression and Alexithymia and their association with sociodemographic characteristics in a sample of elderly persons living in Buenos Aires, Argentina

Tartaglini, María Florencia; Dillon, Carol; Hermida, Paula Daniela; Feldberg, Carolina; Somale, Verónica; Stefani, Dorina Prevalencia de Depresión Geriátrica y Alexitimia. Su asociación con características sociodemográficas, en una muestra de adultos mayores residentes en Buenos Aires, Argentina Revista Brasileira de Geriatria e Gerontologia, vol. 20, núm. 4, julio-agosto, 2017, pp. 518527 Universidade do Estado do Rio de Janeiro Rio de Janeiro, Brasil


InTroDuCTIon
The aging of the world population is an intrinsic process of demographic transition.In Argentina, 14% of the population is made up of 60-year-old adults and the city of Buenos Aires is considered to have the oldest population in the country (17%) 1 .
Analyzing the process of aging involves considering how the socio-cultural system influences the lifestyle of the senescent.Psychosocial factors affect the etiology of diseases by determining the attitudes and behaviors of individuals in relation to the health-disease process 2 .Although the developments within successful aging show that aging is not synonymous with disease, an increase in the number specific pathologies that affect health are also observed in this stage of the life cycle 3 .
In this context, the study of depression in the elderly has become one of the most significant problems for public health 4 .Specifically, Geriatric Depression is one of the most frequent and incapacitating health conditions among this population.It is estimated that around 10% of the elderly living in the community and between 15% and 35% of those residing in geriatric institutions suffer from depressive disorders 5 .Balmón Cruz and Dorado Primo 6 describe how, from 70 years of age onwards, these symptoms become more common due to the increase of physical health problems and disabilities, as well as affective and economic losses.
In recent decades the association between Major Depressive Disorders and Alexithymia has also begun to be studied 7 .Rojas Ramírez y García Méndez 8 describe how Sifneos was the first to propose using the Greek term Alexithymia to describe the difficulties in identifying and communicating feelings, limited imaginary capacity, rigid and stereotyped interpersonal relations and predominance of operative thinking suffered by psychosomatic patients.Different positions can be observed when analyzing the relationship between Depression and Alexithymia: López-Ibor Aliño 9 argues that the characteristics of Alexithymia coincide with certain manifestations of Depression, whereas Taylor et al. 10 affirmed that Alexithymia is an independent construct and distinct from Depression.
Fisch 11 , meanwhile, suggests that Alexithymia is concomitant with Depression, causing it to be masked through somatic symptoms, and describes it as a multidimensional construct that responds to situational stressors.Despite the controversy that surrounds this link, studies that analyze the association of high levels of Alexithymia and Anxiety and Depression in elderly persons have begun to thrive 12 .
Regarding sociodemographic characteristics and their relation to the appearance of depressive symptoms, scientific literature emphasizes that the different types of losses that appear in old age, as well as the limitations of access to activities that promote well-being, could influence the increase of the prevalence of chronic diseases, which contribute to the emergence of depression.The interruption of work 13 leads to a number of deprivations (income, purchasing power, the social role of working, etc.) and produces a change in the social clock.It has also been observed that both psychic morbidity and coping behavior are different in males and females 14,15.In this regard, some studies have highlighted factors associated with the appearance of depressive symptoms, such as the female gender, advanced age and living alone 16 .Arancibia and Behar 7 , in a bibliographic review on the subject, point out the probable association between age, gender, educational level and Alexithymia and Depression 8,9 .
Based on the above, the objective of this study was to evaluate the prevalence of Geriatric Depression and Alexithymia and their association with the sociodemographic characteristics of independent elderly persons without known depression.

MeTHoDS
A cross-sectional study was performed 17 .The subjects of the sample were selected from the target population (elderly persons, middle socioeconomic level and residents of the city of Buenos Aires and its areas of influence, Argentina) through a non-probabilistic, intentional type sampling strategy, in the clinical care area of the Instituto de Neurociencias Buenos Aires (the Buenos Aires Neurosciences Institute) (INEBA), the Instituto de Investigaciones Cardiológicas Profesor Dr. Alberto C. Taquini (the Professor Dr. Alberto C. Taquini Cardiological Investigation Institute) and the Hospital Dr. César Milstein.
The research protocol and informed consent form were approved by the respective Ethics and Research committees of the institutions described.
The inclusion criteria were male and female independent subjects who were older than 60 years.Likewise, those with a previously known diagnosis of major depression, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 18 (DSM V), (Alzheimer's Disease, Frontotemporal Dementia, Parkinson's Disease, and other neurodegenerative diseases), or who were diagnosed with Schizophrenia, Substance and/or Alcohol Abuse or Dependence, according to the DSM V 18 , were excluded.This information was provided by general practitioners from medical records.Following the pilot study the evaluation protocol selected was administered to the elderly through an individual interview conducted by the lead researcher of the project, and lasted approximately 40 minutes.The instruments used were: a) a sociodemographic data questionnaire: in order to obtain the socio-demographic and cultural profile of the elderly, a questionnaire was used, elaborated on an ad hoc basis, consisting of 22 questions, open and closed with fixed options, information about the variables of age, gender, nationality, marital status, education, level of employment and current employment status; b) an adapted version of the Yesavage Geriatric Depression Questionnaire 5 : this is one of the most used instruments among the elderly population and is recommended by the Spanish Society of Family and Community Medicine.It is a self-administered scale that was designed by Yesavage et al. 19 specifically for the elderly population.For the present study, the version adapted and validated into Spanish by Martínez de la Iglesia et al. 5 .This is composed of 15 items, and has an internal consistency was 0.99, using the Kuder-Richarson test (a variation of Cronbach's Alpha for dichotomous variables).The sensitivity was 81.1% and the specificity was 76.7%.The cutoff scores of the scale are: 0 to 4 normal, 5 to 8 mild depression, 8 to 11 moderate depression and 12 to 15 severe depression; C) the Latin American Consensual Toronto Alexithymia Scale LAC TAS-2020: through a Likert scale, this evaluates Alexithymia by means of three factors or subscales: I) difficulty identifying feelings and distinguishing between feelings and the bodily sensations of emotional arousal, (II) difficulty in describing feelings to others, and (iii) externally oriented thinking.The overall reliability was calculated by Varela et al. 20 through Cronbach's Alpha, yielding values between 0.77 and 0.78, considered adequate for this type of study.It is composed of 20 items with five possible response options.According to their answers, the subjects are placed in a continuum of between 20 and 100 points, with the cut-off scores: <40 non-Alexithymic, between 41 and 55 indefinite Alexithymia, >56 defined Alexithymia.
A population prevalence of 10% of depression, a confidence limit of +5% of absolute precision and a 95% confidence interval were used to calculate the sample size to estimate frequencies, and a sample of 139 subjects was calculated.R e g a rd i n g st at i st ic a l a n a ly ze s , t he sociodemographic variables and the prevalence of Geriatric Depression and Alexithymia were described in the total sample according to the distribution of the data.Likewise, the χ 2 (Chi-squared) test of statistical independence was used to evaluate the probable association between the variables Geriatric Depression and Alexithymia.Finally, the χ 2 test and Student's t-test were used to evaluate the association of sociodemographic variables with Geriatric Depression and Alexithymia, respectively.
To assess the strength of the statistically significant associations, Odds Ratio and 95% confidence intervals were calculated.For these statistical analyzes, a probability of error value of less than or equal to 0.05 was used.

reSuLTS
During the period from January 2013 to March 2015, 237 possible candidates were registered for participation in the study.Of these, 22 did not meet the inclusion criteria, 39 met one of the exclusion criterion (12 had moderate cognitive impairment, four had Parkinson's disease, 16 had already experienced depression and seven were excluded for other reasons).Therefore 176 subjects were analyzed.The mean age was 73 years (+7.1 years) and 72.7% of the participants were women.The rest of the demographic characteristics are shown in Table 1.
The prevalence of Geriatric Depression in the sample was 35.8% (95%CI 29.1-43.1),taking into account all levels of severity.The prevalence of Alexithymia at all levels of severity, meanwhile, was 50.6% (95%CI: 43.2-57.9)among the participants interviewed.
The means and deviations of the factors that make up Alexithymia are described in Table 2.When Alexithymia is present, Geriatric Depression is almost three times more likely, OR 2.79 (95%CI 1.47-5.39),p 0.0014.
Wit h reference to t he comparison of sociodemographic variables and levels of Alexithymia, it was observed that those with a primary educational level and a low occupational level had higher levels of Alexithymia, with a p value <0.001 for both cases.

DISCuSSIon
The present study assesses the prevalence of Geriatric Depression and Alexithymia and their association with the sociodemographic characteristics of elderly persons without known depression.
A prevalence of Depression of 35.8% was found, considering the total score of the different levels (mild, moderate and severe).This finding coincides with other prevalence studies carried out in recent years, where the increase of these symptoms based on age was identified 6,21,22 .The World Health Organization (WHO) 23 , states that the greatest occurrence of Depression occurs in adults over 65 years old, and highlights the complexity of performing a correct differential diagnosis.This difficulty is due to the presentation of the condition (somatizations), the misattribution of coexisting diseases, as well as polypharmacy, which is common among older adults.Geriatric Depression may be a new episode in an individual who has previously experienced depression, or may represent the late appearance of depression in someone who has never suffered from the condition.Also, some authors consider that the late presentation of Depression is more frequent among the elderly, and is more influenced by environmental factors than by genetic load 7 .Alexopoulos 24 points out that in the last years of life different types of losses occur (physical, economic and psychosocial), which, together with the changes associated with the aging process (vascular and degenerative), 25 may predispose the individual to the emergence of Depression.A prevalence of 50.6% of Alexithymia was found in the present study.The relative newness of the concept, and the fact that analysis has mainly been carried out among the psychosomatic population (chronic asthma, hypertension, chronic urticaria, rheumatoid arthritis, psoriasis, hyperthyroidism, obesity and others) limits comparison with prevalence studies in the general population.In this sense, the results of the present study provide empirical evidence for the study of Alexithymia at a local level, and coincide with the prevalence indicated by Urrutia et al. 26 in a validation and adaptation of the TAS-20 instrument for Latin America.In this study, a sample of 670 subjects belonging to a general population (non-patients) found a prevalence of Alexithymia of 43.5% in the subgroup of elderly adults (n=42; mean age of 63.4% years).
Similarly, and considering the type of design of the present study, it is noteworthy that only an association between Alexithymia and Geriatric Depression was identified.In this sense, the results are partially coincident with other studies that link Alexithymia with a greater severity of anxious, depressive symptoms, and a worse response to pharmacological treatment.Other researchers point to Alexithymia as a trigger and/or perpetuator of psychophysiological disorders, and as an index of prognosis in chronic diseases 3,7,27 .Also, studies 28 have emphasized that the perceptive decline of emotions during old age produces a reduction in spontaneous expression, as well as the accentuation of an anchoring in immediate reality.Therefore, Alexithymia can be considered to be a factor associated with the deterioration of the health of the elderly.
When analyzing Geriatric Depression and sociodemographic variables, significant associations were found with gender and work.Thus, women presented higher levels of Geriatric Depression than men (29.6% and 6.2%, respectively).These results coincide with those of Lopes et al. 22 , who highlighted a higher frequency of Depression among older adult women.Similarly, Matud et al. 29 , observed that levels of depression remained stable throughout the life cycle of women, until they became senior citizens, when there was a notable increase.Although gender differences have traditionally been analyzed as a consequence of constitutional, genetic and/or endocrine factors, in recent decades the predominance of socio-cultural variables, such as those that condition the way in which men and women manifest and cope with psychological suffering, have been highlighted 22 .
Regarding labor activity, the present study found an association between the absence of work and high levels of Geriatric Depression.These results were in agreement with other studies that described the link between the interruption of work (due to retirement, unemployment, voluntary retirement, or withdrawal from work due to a sick family member, among other reasons) and the presence of depressive symptomatology 30 .As the activity of work is an axis that organizes daily life, it can become both a source of family conflicts and a buffer against such conflicts.Therefore, the absence of work will modify the social relations of the individual and especially the bond between couples.Thus, this new situation may ease or accentuate binding conflicts, and depending on how the subject deals with these changes, the psychic health of the elderly may be affected 13.In this regard, Vélez Álvarez et al. 31 found that elderly persons who perform some type of informal work have a good perception of their quality of life and value their health positively.The authors concluded that work gives older adults a sense of meaning in their lives, favoring an active and healthy aging.
Finally, when analyzing Alexithymia and sociodemographic variables significant differences were found, indicating that elderly persons with primary and low occupational levels have high levels of Alexithymia.Similar findings were published by Honkalampi et al. 32 and Shibata et al. 33 and, in Argentina, by Urrutia et al. 26 , who found that people with a low educational level had higher Alexithymia scores.Although the study by Urrutia et al. was performed among the general population, as mentioned above, Alexithymia was found to be associated with different psychosomatic diseases.Therefore, educational level and subsequent occupational level could also condition the state of health of a person.In this regard, the WHO 34 describes the Social Determinants of Health as those circumstances and contexts that determine the life cycle of a person, from birth to old age.The structural determinants of health are represented by socioeconomic and political context and by the position that individuals occupy in society, according to social class, gender, age, ethnicity and territory.They act through intermediary determinants, which are shaped by conditions of employment and work, income and economic situation, lifestyle, psychosocial, behavioral and biological factors, and the health system 35 .
Regarding the limitations of the present study, the selection of the sample was intentional, rather than representative, and therefore the data cannot be generalized to the entire population.Furthermore, with regard to the association between Alexithymia and Geriatric Depression, the future undertaking of a cohort design study is required to verify if this association is causal, and it is important to carry out more evaluation interviews for the purpose of analyzing the factors that make up the Alexithymia scale.

ConCLuSIon
From the results obtained, it is recommended that the evaluation of Geriatric Depression and Alexithymia is included in the clinical care of the elderly, as well as the consideration of the social determinants of health, not only for diagnosis and treatment, but also for the promotion of healthy behavior.
*DIF: difficulty identifying feelings and distinguishing between feelings and the bodily sensations of emotional arousal; * DDF: difficulty describing feelings to other people; * EOT: a stimulus-bound, externally oriented thinking.