FACTORS RELATED TO DEPRESSIVE SYMPTOMS IN OLDER ADULTS WITH DIABETES MELLITUS

ABSTRACT

Objective:

to identify the factors related to depressive symptoms in older adults with Diabetes Mellitus.

Method:

a cross-sectional study with a quantitative approach conducted with 144 older adults registered in 72 Family Health units from the municipality of João Pessoa, Paraíba, Brazil. The data were collected from September to December 2019, using an instrument to obtain information referring to the sociodemographic and clinical profile and the Geriatric Depression Scale by means of descriptive and inferential statistics.

Results:

it was observed that 75.7% of the diabetic older adults did not present depressive symptoms. There was a significant association between depressive symptoms and the following variables: personal income (p=0.044), type of income (p=0.020), dyslipidemia (p=0.038), diabetes complications (p=0.045) and retinopathy (p=0.033).

Conclusion:

the social and health factors, as well as those related to diabetes, can exert negative influences on older adults’ psychological state and favor the onset of depressive symptoms.

DESCRIPTORS:
Depressive Symptoms; Diabetes Mellitus; Older Adults; Primary Health Care; Patient-Centered Care.

RESUMO

Objetivo:

identificar os fatores relacionados aos sintomas depressivos em pessoas idosas com diabetes mellitus.

Método:

pesquisa transversal, com abordagem quantitativa e realizada com a participação de 144 pessoas idosas cadastradas em 72 Unidades Saúde da Família do município de João Pessoa, Paraíba, Brasil. Os dados foram coletados no período de setembro a dezembro de 2019, utilizando instrumento para a obtenção de dados referentes ao perfil sociodemográfico e clínico e a Escala de Depressão Geriátrica mediante estatística descritiva e inferencial.

Resultados:

observou-se que 75,7% dos idosos com diabetes não tinham sintomas depressivos. Foi evidenciada associação significativa entre a sintomatologia depressiva e as variáveis renda pessoal (p=0,044), tipo de renda (p=0,020), dislipidemia (p=0,038), complicações do diabetes (p=0,045) e a retinopatia (p=0,033).

Conclusão:

os fatores sociais, de saúde e relacionados ao diabetes podem influenciar negativamente a condição psíquica da pessoa idosa e favorecer o surgimento de sintomas depressivos.

DESCRITORES:
Sintomas depressivos; Diabetes Mellitus; Idoso; Atenção Primária a Saúde; Assistência centrada no paciente

RESUMEN

Objetivo:

identificar los factores relacionados con síntomas depresivos en ancianos con Diabetes Mellitus.

Método:

investigación transversal, de enfoque cuantitativo y realizada con la participación de 144 adultos mayores registrados en 72 unidades de Salud de la Familia del municipio de João Pessoa, Paraíba, Brasil. Los datos se recolectaron entre septiembre y diciembre de 2019, utilizando un instrumento para obtener datos sobre el perfil sociodemográfico y clínico y la Escala de Depresión Geriátrica mediante estadística descriptiva e inferencial.

Resultados:

se observó que el 75,7% de los ancianos que padecían diabetes no tenían síntomas depresivos. Se registró una asociación significativa entre los síntomas depresivos y las variables ingresos personales (p=0,044), tipo de ingresos (p=0,020), dislipidemia (p=0,038), complicaciones de la diabetes (p=0,045) y retinopatía (p=0,033).

Conclusión:

los factores sociales, de salud y relacionados con la diabetes pueden ejercer influencias negativas sobre el estado psicológico de los ancianos y favorece la aparición de síntomas depresivos.

DESCRIPTORES:
Síntomas Depresivos; Diabetes Mellitus; Anciano; Atención Primaria de la Salud; Asistencia Centrada en el Paciente.

INTRODUCTION

The 21^st century brought along with it great technological advances for the population, especially in the health area, which provided for an increase in life expectancy at the global level. In developing countries such as Brazil, the aged population is growing quite rapidly, which represents an important achievement, as well as a challenge¹-². The repercussions of the high numbers of older adults are accompanied by high rates of chronic non-communicable diseases in the country, with Diabetes Mellitus as one of the most prevalent in this population group³.

The global prevalence estimate of Diabetes Mellitus for 2019 was 463 million individuals aged between 20 and 79 years old and it is predicted that approximately 700 million people will have been diagnosed with the disease by 2045⁴. Diabetes Mellitus represents a public health problem, mainly due to the disability degree caused by its complications, of which, in the Brazilian population, the most prevalent are diabetic retinopathy and neuropathy⁵.

It is a disease that significantly alters older adults’ everyday life; with diagnostic confirmation, it becomes indispensable to carry out special care measures, which include adherence to healthy habits, medication use and regular monitoring by the health team, with the implementation of these measures emerging as a challenge, as there is a moment of adaptation of the normal healthy body to the changes in the current body with emotional repercussions⁶.

In view of this context, older adults often experience mental illness processes with presence of depressive symptoms, which, in addition to being associated with frailty, should be an alert for the emergence of depression⁷-⁸. Depression refers to a disabling mental disorder that alters a person’s everyday life and has its effects potentiated by the presence of another underlying disease, diabetes in this case⁷-⁸.

It can cause significant distress, affecting the person’s quality of life and independence, especially among older adults, due to a frequent unsatisfactory health perception and to the high risk of falls and frailty, which increases the hospitalizations and death risks⁷-⁹.

Depressive symptoms are frequent among older adults, especially in women, and may be mistaken by health professionals, as the patients can present somatic symptoms that tend to mask this disorder, such as lack of appetite, sleep and indisposition¹⁰. In this case, nurses must resort to a multidimensional assessment during the Nursing consultation with older adults, given that it serves to guide the care to be provided to aged people, value the patients’ emotional aspects and seek to identify and prevent changes, in addition to offering support to face the adversities arising from their clinical condition¹¹.

In this way, there is a need to investigate the factors associated with depressive symptoms in the aged population with diabetes, in order to provide scientific subsidies that contribute to safe, resolute and good quality care on the part of nurses with a focus on integrality of the subjects.

Thus, the objective of the current study was to identify the factors related to depressive symptoms in older adults with Type 2 Diabetes Mellitus.

METHOD

This is a cross-sectional study with a quantitative approach, which was guided by the STROBE tool and carried out between June and October 2019 in 72 Family Health Units (FHUs) from João Pessoa, Paraíba, Brazil. Sampling stratified by the city’s Health Districts was chosen for the sample planning stage.

The municipality is territorially delimited in the form of Health Districts, in an attempt to organize the system’s progressive care network and guarantee the population access to basic as well as specialized services, including hospital care, having Permanent Education in Health as its main policy currently adopted. The Health Districts are under supervision of the Municipal Health Department with the responsibility of executing full management of the Unified Health System (Sistema Único de Saúde, SUS) at the municipal level and of formulating and implementing policies, programs and projects aimed at promoting good quality health for SUS users¹².

The population consisted in all the aged users with Diabetes Mellitus treated in the FHUs, corresponding to 10,647 individuals distributed across all five Health Districts, as follows: I - 2,641; II - 1,919; III - 3,072; IV - 1,554; and V - 1,461. Sample selection was carried out according to the allocation method proportional to the number of aged people with Diabetes Mellitus treated by each District compared to the total number of older adults assisted (Table 1).

Table 1
Distribution of the older adults treated, by Health District and according to presence of diabetes. João Pessoa, PB, Brazil, 2019.

	Appointments
Health District	No. of older adults	No. of diabetic older adults	Percentage of diabetic older adults in relation to the total
I	12,571	2,641	P1 = 5.4
II	9,366	1,919	P2 = 3.9
III	13,122	3,072	P3 = 6.3
IV	7,391	1,554	P4 = 3.2
V	6,184	1,461	P5 = 3.0
Total	48,634	10,647	-

Source: The authors (2019).

Sample size was obtained by the stratification procedure, considering a simple random sampling plan in each district, corresponding to 144 participants, as follows: District I = 38; District II = 28; District III = 38; District IV = 22; and District V = 18. In order to operationalize data collection, a maximum number of two patients per unit was established, with the need to reach an even number for proportional division. Given the above, an interview was included in Health Districts I (n=38) and II (n=28), which resulted in a sample comprised by 144 participants.

The inclusion criteria defined were the following: being aged at least 60 years old and presenting a medical diagnosis of Type 2 Diabetes Mellitus. The older adults excluded were those that were not capable of verbal communication and who had cognitive conditions that precluded them from answering the questions as per the Mini-Mental State Examination¹³.

In order to obtain data referring to the sociodemographic and clinical profile, a semi-structured questionnaire was prepared, which was submitted to a previous assessment by evaluators, MScs and PhDs in the area. The Geriatric Depression Scale (GDS-15) - Short version was used to assess the presence of depressive symptoms, being the most used instrument to investigate depressive symptoms in the aged population. This scale was translated and validated in Brazil and consists of 16 items with dichotomous answers. Its score varies between zero and 15 points, obtaining the following results: less than or equal to five points means a normal individual or without depressive symptoms and more than five points represents an individual with depressive symptoms¹⁴.

Data collection was conducted from September to December 2019 by means of individual interviews in the waiting rooms of the FHUs, before or after the appointments. To preserve privacy and offer tranquility during collection, the older adults were invited to stay in place farther away from the other people.

The data collected were entered into a database in Microsoft Excel and were subsequently imported and processed in the Statistical Package for Social Science, version 22.0, where descriptive and inferential statistical analyses were performed. The significance level used for the statistical analyses was 5% (p<0.05). The Mann-Whitney and Kruskal-Wallis tests were used to associate the variables.

The project corresponding to this study was approved by the Research Ethics Committee of the Health Sciences Center at the Federal University of Paraíba, under opinion No. 3,411,237.

RESULTS

Of the 144 aged individuals, 96 (66.7%) were female, 49 (34%) were aged between 65 and 69 years old, 79 (54.9%) were married or in a stable relationship, 48 (33.3%) had from nine to 12 years of study, 127 (88.9%) had a personal income between one and three minimum wages, and 108 (75%) were retired.

Regarding their health conditions, it was evidenced that: 80 (55.6%) aged individuals did not practice physical activity; 129 (89.6%) did not consume alcoholic beverages; 121 (84%) had some comorbidity associated with Diabetes Mellitus, of which 110 (76.4%) had Systemic Arterial Hypertension; and 129 (89.6%) used oral hypoglycemic agents daily. Regarding the characteristics of Diabetes Mellitus, 42 (29.2%) and 44 (30.6%) participants had, respectively, a diagnosis and treatment time from six to 10 years, 81 (56.3%) had a family history of the disease and 80 (55.6%) reported presence of complications, with neuropathy in 54 (37.5%). It was identified that 109 (75.7%) older adults did not present depressive symptoms, while 35 (24.3%) did have such symptoms.

Regarding the association between the depressive symptoms and the sociodemographic variables, Table 2 shows that there was statistical significance between depressive symptoms and the personal income (p=0.044) and source of income (p=0.020) variables.

Table 2
Association between depressive symptoms and sociodemographic variables of the older adults with Diabetes Mellitus. João Pessoa, PB, Brazil, 2019.

Variables	Depressive Symptoms
	Mean	Standard Deviation	p-value
Gender
Female	3.61	2.77	0.859
Male	3.50	2.80
Age group
60 - 64 years old	4.15	2.94	0.723
65 - 69 years old	3.10	2.85
70 - 74 years old	3.76	2.52
75 - 79 years old	3.22	2.46
80+ years old	4	3.12
Marital status
Divorced	4.11	2.74	0.680
Single	3.92	2.87
Widowed	3.51	2.75
Married or stable union	3.43	2.80
Schooling
Illiterate	4.06	2.70	0.138
1 - 4 years of study	3.37	2.56
5 - 8 years of study	3.44	2.73
9 - 12 years of study	3.77	3.08
13+ years of study	2.25	2
Personal income
< 1 minimum wage	4.83	1.32	0.020
1 - 3 minimum wages	3.45	2.75
4 - 5 minimum wages	1.50	1.07
6+ minimum wages	2	-
No income	6.08	2.77
Occupation
No	3.60	2.68	0.207
Yes	3.46	2.99
Type of income
None	6.17	4.11	0.044
Benefits	5.50	2.12
Own work	4.08	3.66
Pension	3.57	2.63
Rent	3.50	1.70
Retirement	3.44	2.60
Employee	2.80	1.48

Source: The authors (2019).

In relation to the association between depressive symptoms and the health conditions of the sample, it was possible to observe statistical significance between depressive symptoms and the dyslipidemia variable (p=0.038) (Table 3).

Table 3
Association between depressive symptoms and health conditions of aged people with Diabetes Mellitus. João Pessoa, PB, Brazil, 2019.

Variables	Depressive Symptoms
	Mean	Standard Deviation	p-value
Physical activity
No	3.64	2.78	0.679
Yes	3.50	2.77
Consumption of alcoholic beverages
Yes	4	3.27	0.707
No	3.53	2.72
Presence of comorbidities
No	3.91	2.71	0.052
Yes	3.51	2.79
Systemic arterial hypertension
No	4.26	2.92	0.092
Yes	3.36	2.70
Musculoskeletal
No	3.61	2.91	0.879
Yes	3.49	2.43
Dyslipidemia
Yes	3.84	2.88	0.038
No	2.57	2.04
Glaucoma
No	3.59	2.79	0.892
Yes	3.33	2.58
Heart disease
Yes	4.62	2.08	0.224
No	3.47	2.31

Source: Authors, (2019).

Table 4 shows statistical significance between depressive symptoms and complications of Diabetes Mellitus (p=0.045) and also retinopathy (p=0.033).

Table 4
Association between depressive symptoms and characteristics of Diabetes Mellitus. João Pessoa, PB, Brazil, 2019.

Variables	Depressive Symptoms
	Mean	Standard Deviation	p-value
Diagnosis time
1 - 2 years	3.52	3.21	0.632
3 - 5 years	3.21	2.95
6 - 10 years	3.36	2.20
11 - 20 years	4.06	2.83
21+ years	4.07	3.10
Treatment time
1 - 2 years	3.69	3.32	0.583
3 - 5 years	3.06	2.75
6 - 10 years	3.39	2.19
11 - 20 years	4.20	2.90
21+ years	3.77	3.21
Family history of diabetes
Yes	3.79	2.77	0.241
No	3.30	2.77
Diabetes complications
Yes	4	2.89	0.045
No	3.05	2.54
Neuropathy
Yes	3.85	2.81	0.302
No	3.41	2.75
Retinopathy
Yes	4.58	2.78	0.033
No	3.36	2.73
Stroke
Yes	4.56	3.24	0.281
No	3.51	2.74
Nephropathy
Yes	4	3.10	0.736
No	3.55	2.76
Infarction
No	3.64	2.78	0.192
Yes	2.17	2.31
Diabetic foot
Yes	5.33	5.03	0.498
No	3.54	2.72

Source: The authors (2019).

DISCUSSION

The results of this study indicate presence of depressive symptoms in a small percentage of the participants, which can be related to the excessive emotional burden of chronic diabetes, as it requires the patient to implement changes in lifestyle and adhere to a strict treatment regime for self-control of the pathology, with these symptoms being common in patients who are subjected to more expensive treatments, as in relation to those who use insulin therapy, when compared to those who only use oral hypoglycemic agents¹⁵.

Depression in people with Diabetes Mellitus has a synergistic effect, as presence of both diseases contributes to a decrease in self-care, increases the risk of complications of a micro- and macro-vascular nature, and imposes higher chances of mortality¹⁶. Therefore, it is necessary that health professionals pay attention regarding the existence of these pathologies in older adults.

In a study carried out with users with diabetes in the Primary Care services of Encarnación in Paraguay, presence of mild depression was identified in 32.9% of the participants, revealing the importance of care with psychosocial interventions to be developed by the team, pointing out that this depression level can be treated at the HU, whereas more severe levels should be referred to specialists¹⁷. Nurses play a key role in the identification of depressive symptoms in aged people with Diabetes Mellitus, and Nursing consultations are a propitious moment for these findings.

The association between depressive symptoms and the sociodemographic variables presented statistical significance, in which older adults with low personal incomes or who do not earn any income had a higher mean of depressive symptoms. It is known that restriction of financial resources tends to leave older adults in a condition of social vulnerability, thus generating moments of stress that can affect the physical and cognitive domains and favor discouragement, social isolation and sadness¹⁸.

The vulnerability experienced by a large part of the older adults is not an exclusive Brazilian reality, as it is also observed with significant frequency in underdeveloped or developing countries, which can cause serious harms to health and quality of life due to lack of financial, family and governmental support, contributing to the emergence of depressive symptoms¹⁹.

In the case of older adults with Diabetes Mellitus, the need for differentiated care, especially in relation to their diet, can trigger depressive symptoms, either due to family conflicts generated by high expenses for maintaining a healthy diet or to the impossibility of purchasing food due to low monthly incomes²⁰-²¹.

The presence of dyslipidemia was associated with higher means of depressive symptoms, corroborating the data of a study carried out in Recife - PE, which identified that changes in the lipid profile with increased levels of LDL-C, HDL-C and systolic blood pressure were related to a higher number of depressive symptoms in aged diabetics²².

Dyslipidemia is common in diabetic patients, especially in those with central obesity, which contributes to insulin resistance. This problem is characterized by high levels of triglycerides and the presence of small, low-density lipoproteins, which are highly atherogenic, increasing the risk of cardiovascular disease²³. The relationship between dyslipidemia and depressive symptoms could be due to the presence of comorbidities, especially arterial hypertension, as it causes greater harms to the individual’s health, increases the risk of complications and negatively interferes with their daily routine²⁴.

The association between the complications of diabetes and retinopathy variables presented statistical significance with depressive symptoms, showing that older adults with complications of the disease, mainly retinopathy, had higher means of depressive symptoms. Complications related to diabetes compromise older adults’ quality of life and potentiate the vulnerabilities related to the disease and to aging, which favors the emergence of psychological problems²².

A telephone survey carried out in Maringá - PR²⁵ identified that age over 80 years old, time since diagnosis of the disease, insulin use and altered Body Mass Index are risk factors for microvascular complications such as nephropathy, peripheral neuropathy and retinopathy. Of these factors, only the Body Mass Index can be modified by the individual, which requires a change in the aged person’s lifestyle and adaptation of their routine, contributing to the emergence of fear, anguish, uncertainty, anxiety, hopelessness and sadness²⁵.

Diabetic retinopathy is a complex pathology, being one of the main causes of blindness in people with diabetes. A research study carried out in the Republic of Croatia evidenced the prevalence of this complication in 44.5% of the participants²⁶, whereas in China, 40% of the diabetics have some type of retinopathy associated with aging and with presence of comorbidities such as arterial hypertension and metabolic syndrome²⁷.

In this context, it becomes indispensable to monitor the blood parameters and pay attention to eye diseases in older adults with Diabetes Mellitus. Self-care represents an important tool for the prevention of complications, especially retinopathy, which should be encouraged and supported by health professionals, as the impacts of this complication are intense in older adults, generating dependence and frailty, which can favor the emergence of depressive symptoms²⁸.

It is relevant that Nursing professionals working in Primary Health Care focus on health promotion and disease prevention actions with a stimulus for healthy and active aging, in addition to the development of activities that explore education, culture, leisure and self-care. Such actions can strengthen ties with the users and their family members, contribute to quality care and promote better quality of life²⁹.

The multidimensional assessment of an aged person represents a key instrument for acting in Primary Health Care, as it points out the main older adults’ demands as well as their frailty, identifies the need for referral to other specialized services, individualizes the care plan and organizes the health care network, promoting dignified, safe and good quality care that respects the health policy for older adults³⁰.

The study does have limitations, considering that the sample comprises the FHUs of a single Brazilian municipality. Finally, it is suggested that further research studies be carried out in other municipalities with different scenarios and varying health system complexity levels for the purpose of comparing results.

CONCLUSION

The focus of this study was to identify the factors related to depressive symptoms in older adults with Diabetes Mellitus; therefore, it was noticed that social factors and those related to the disease can exert a negative influence on older adults’ psychological state and favor the emergence of depressive symptoms.

Aged people with Diabetes Mellitus who present depressive symptoms are more susceptible to complications related to the disease, which favors an increase in frailty and deterioration of quality of life. In this way, this study can help Nursing undergraduates and professionals to know the older adults’ reality and the risks to which they are exposed and, based on that, promote actions at the waiting rooms in the Family Health units and in Nursing consultations to encourage adoption of healthy living habits and self-care, in order to preserve older adults’ autonomy and biopsychosocial well-being in the Primary Health Care context.

The results of this study are relevant for Nursing and other health areas, as they identify the profile of aged diabetics and the characteristics that favor the emergence of depressive symptoms, which allows for new reflections and discussions about public policies that can alleviate the problems related to this theme as well as preventive and care measures for this population group. Therefore, we recommend that further studies be carried out to better understand this phenomenon.

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Edited by

Associate editor: Dra. Luciana Nogueira

Publication Dates

• Publication in this collection
  16 Dec 2022
• Date of issue
  2022

History

• Received
  15 July 2021
• Accepted
  19 July 2022