Resilience, quality of life and symptoms of depression among elderlies receiving outpatient care

Objective: to analyze the relation between resilience and demographic variables, quality of life and symptoms of depression in elderlies attended at a Geriatric Outpatient Clinic. Method: analytical cross-sectional study, conducted with 148 elderlies, with a questionnaire of sociodemographic and health characterization, the Resilience Scale, the World Health Organization Quality of Life Bref, the World Health Organization Quality of Life Old, and the Center for Epidemiologic Survey - Depression Scale. Descriptive statistics, Student’s t-test and Pearson correlation were used for data analysis. Results: there was a positive correlation between resilience and schooling (r = 0.208; p = 0.010), income (r = 0.194; p = 0.017), the World Health Organization Quality of Life Bref (r = 0.242; p = 0.003), and the World Health Organization Quality of Life Old (r = 0.522; p <0.001), and negative correlation regarding symptoms of depression (r = -0.270; p = 0.001). Conclusion: Resilience presented relation to schooling, income, quality of life and symptoms of depression in the elderly. These results are expected to help the multidisciplinary team plan actions aimed at developing resilience towards the promotion of health and good quality of life in old age.


Introduction
In the face of world population aging, the complexity of the biopsychosocial aspects of the human aging process becomes evident, which are often associated with physical, psychological and social overload in old age.
The presence of noncommunicable chronic diseases (NCDs) in the elderly can compromise their functional, cognitive, psychological, emotional, social and economic aspects, leading to disabilities, loss of autonomy and limitations that commonly correspond to a phase of life with negative connotation (1) . Given this, resilience, in its psychological concept, has been considered a fundamental factor to be developed throughout life (2) .
In old age, resilience is understood as the ability to cope, adapt and respond positively to changes that occur with advancing age. Psychologically resilient elderly do not surrender to adverse situations and, when facing them, demonstrate a capacity for positive adaptation, dealing with them and recovering their levels of subjective well-being (3) .
The elderly's resilient characteristics and attitudes, associated with external resources, can provide good Quality of Life (QOL) in old age (1) . QOL With regard to depression, it affected more than 300 million people worldwide in 2015, in different age groups, and predominantly among women (8) . In the same year, in Brazil, more than 11 million (5.8%) people aged 18 years or older were diagnosed with depression, with the largest proportion (11.1%) in the 60-64 age group (9) . The literature points out that, although depression often affects the elderly, it is less severe and prolonged and may last for years, with serious consequences for the emotional, psychological, functional and cognitive aspects of this population (10) .
The proportion and complexity of depression in the elderly population, which is often vulnerable by the process of human aging itself due to living with loss and illness, require physical and mental health care (10) .
A review sought to assess the implications of resilience in the elderly population, and studies have suggested that resilient and coping profiles are relevant in the recovery from stressful events, also pointing out that low levels of depression and hopelessness are related to low levels of resilience (1) .
During old age, the elderly are susceptible to multiple risk factors for depression. It is believed that the elderly who have resilient reserves and characteristics, such as emotional control, optimism, maintenance of social relationships and autonomy, is able to achieve better outcomes in the management of situations that precede the symptoms of depression (11) .
Other study results also showed an association between worse QOL and the presence of symptoms of depression (12)(13) .
In addition to assessments and interventions directed to functional and cognitive changes and limitations imposed by the aging process, nursing care for the elderly is necessary when working with psychosocial aspects, which are susceptible to situations of vulnerability and changes in the state of health and disease (14) .
From a theoretical approach (15) , a reflective investigation of resilience in nursing praxis revealed that the resilience of people in chronic conditions presents itself as a knowledge gap to be explored by the science of care. In this this perspective, resilience is known as a promoter of human potentialities such as cognitive, behavioral, emotional, psychosocial and cultural skills, and it may be included in education and health promotion programs in relation to the age group most affected by NCDs. Likert-type response scale was used, with scores from 1 to 5 for each question, which were transformed into a linear scale ranging from 0 to 100, where zero corresponds to the worst QOL and 100 to the best (18) . This instrument has been translated and validated in Brazil (18) . The validation of the Brazilian version results in the overall QOL score in the elderly, and the higher the score, the better the QOL (19) . The Brazilian version was translated and validated (19) , and presented internal consistency represented by Cronbach's alpha coefficient of 0.71 for facets, and 0.88 for overall QOL (19) ; d) Center Epidemiologic Survey -Depression Scale (CES-D), originally designed for a North American epidemiological study (20) , with the purpose of detecting symptoms of depression in adult populations through self-reported depression-related symptoms. It investigates the frequency of symptoms of depression that have occurred in the week prior to the interview.
The internal, construct and criterion validities of CES-D was performed in the elderly Brazilian population (21) .
This scale has three domains, that is, negative affects, problems initiating behavior, and positive affects, distributed in 20 items, with a Likert-type response scale, with 0 (never or rarely); 1 (few times); 2 (most of the times), and 3 (always). The total score ranges from 0 to 60 points. The internal consistency by Cronbach's alpha coefficient was 0.80 for negative affects, 0.68 for problems initiating behavior, and 0.63 for positive affects (21) . A cutoff score greater than 11 points differentiates cases of symptoms of depression Rev. Latino-Am. Enfermagem 2019;27:e3212.
from non-cases of symptoms of depression (21) , also adopted in this study; e) Resilience Scale (RS) (22) , which was adapted and validated for the Brazilian context (23)  indicating high resilience (23) , internal consistency was measured by Cronbach's alpha coefficient of 0.80; intra-observer reliability for continuous variables was 0.74, and Kappa weighted for ordinal variables from mild to moderate (23) .
The data resulting from this study were tabulated using a Microsoft Office Excel ® spreadsheet, 2016 version, containing a codebook and two spreadsheets that were used for double-input validation (typing).
After typing and validation, data were exported to the Statistical Analysis System ® software, version 9.4, for statistical analysis. Regarding health aspects, the mean of medical diagnosis per elderly was 7.4 (SD=7.4), and the most prevalent was systemic arterial hypertension (83.1%). Table 1 shows the characterization of the elderly, according to age group, sex, marital status, schooling, and family arrangement. With regard to the RS, the elderly with higher mean scores had income higher than the minimum wage, without symptoms of depression, and lived alone. Regarding WHOQOL-BREF, the elderly who obtained higher means in the scale score were male, with income higher than the minimum wage, and without symptoms of depression. In relation to WHOQOL-OLD, the elderly who presented higher means lived alone, with income higher than the minimum wage, and without symptoms of depression.

Discussion
During old age, resilience has been expressed as a protective factor for the elderly, possibly being a potential resource for changing habits and behaviors that offer a greater sense of well-being and QOL, besides maintaining physical and mental health (3) .
In this study, the sociodemographic characteristics of the elderly are similar to those found in other studies with Brazilian elderly receiving outpatient care. The mean for age was of 77.7 years (25) , there was predominance of females (26) , low schooling (27) , and widowhood (28) .
It is worth mentioning that 39.2% of the participants in this study were 80 years or older. This can be explained by the fact that increased longevity may be reflected in different behavioral, sociocultural, spiritual, belief and health patterns. A theoretical study, which addresses a broad discussion of resilience at an advanced age (85 years or older), found that older people live in a frequently vulnerable context, with variability of physical and mental conditions. However, having more years of life accompanied by potential gains, greater wisdom, experience, opportunities, a family and social support system, among others, can contribute to the development of coping mechanisms and adaptation to challenges and adversities (29) .
In this respect, the aspects that comprise resilient behavior and age groups, according to the literature findings (30)(31) , are still inconclusive, as suggested by the results of this study, in which age was not associated with resilience.
This fact is corroborated by the dynamic perspective of resilience, which refers to resilient behavior that does not necessarily occur in a linear and progressive manner, and it is not a characteristic absolutely related to the life experience that is acquired with advancing age (32) . Regardless of a specific age group, resilient In this regard (2) , the perspective of active aging, physical (mobility, independence, functionality, among others) characteristics (1) .
With regard to symptoms of depression, the physical, social and psychological demands related to aging may compromise the mental health of the elderly.
Most of the elderly in this study (64.2%) presented symptoms of depression, assessed through CES-D.
In general, the elderly receiving outpatient care have chronic diseases, relative degree of dependence and symptoms of depression (31) .
In this study, the relationship between symptoms of depression and resilience was negative and significant, and the mean score on RS was higher for the elderly representative. In addition, the cross-sectional design did not allow long-term follow-up to assess resilience, QOL and symptoms of depression in the elderly.

Conclusion
The results of this study showed that the elderly seem to be adapting and using resources and behavioral coping, adaptation and overcoming mechanisms, and that the variables schooling, income, symptoms of depression and QOL were related to resilience.
The emotional state of the elderly can contribute to the development of better resilient characteristics, which possibly will result in better physical and mental health, well-being promotion, pleasure, safety, and better understanding and acceptance of changes during aging.
In this sense and with regard to research in the field of nursing, the results of this study offer elements that may result in information that help in the elaboration and improvement of its practice, specifically in the elderly population, in order to strengthen coping, adaptation and overcoming in situations of disabilities and limitations that may arise with advancing age.