Association between depression and sociodemographic characteristics, quality of sleep and living habits among the elderly of the north-east of Brazil: a cross-sectional population based study

Johnnatas Mikael Lopes Sabrina Gabrielle Gomes Fernandes Fábio Galvão Dantas Jovany Luís Alves de Medeiros About the authors

Abstracts

Introdução:

Os transtornos depressivos podem ser definidos como episódios de humor deprimido ou perda de interesse e prazer por quase todas as atividades. A depressão é considerada o principal transtorno mental em idosos, podendo relacionar-se com a qualidade do sono e hábitos de vida, além de ser influenciada por questões sociodemográficas.

Objetivo:

Verificar a prevalência de depressão em idosos no interior do Nordeste brasileiro e qual a sua relação com o perfil sociodemográfico, qualidade do sono e hábitos de vida.

Método:

Delineou-se um estudo epidemiológico do tipo transversal, tendo como base a população idosa da zona urbana de Campina Grande-PB. Foi investigada a presença de depressão como variável dependente, assim como aspectos sociodemográfios, qualidade do sono e hábitos de vida como variáveis independentes. Foram obtidas estimativas de prevalência das variáveis e medidas de associação por meio de regressão de Poisson. Adotou-se um nível de significância de 5% para as estimativas.

Resultados:

Participaram do estudo 168 idosos com idade média de 72,3 (±7,8) anos, sendo em sua maioria mulheres, 122 (72,6%). O quadro depressivo foi identificado em 72 idosos (42,9%). As idosas estavam duas vezes mais associadas ao quadro depressivo (RP=2,26) que os homens. A qualidade subjetiva do sono muito bom (RP=0,34), o médio/alto risco de distúrbio do sono (RP=4,08), tomar medicações para dormir uma ou duas vezes na semana (RP=5,21) e três vezes ou mais (RP=8,69), disfunção diurna uma ou duas vezes por semana (RP=14,40) e três vezes ou mais (RP=27,00) e má qualidade do sono no índice de Pittsburgh apresentaram associação com a depressão na análise bivariada, mas sem relação após ajustamento multivariável

Conclusion:

A prevalência de depressão mostrou-se elevada na população estudada, sendo claramente mais frequente nas idosas. Por outro lado, não foi possível detectar associação da depressão com os hábitos de vida e a qualidade do sono.

Idoso; Depressão; Sexo; Sono; Índice de Massa Corporal; Atividade Motora


Introduction:

Depressive disorders can be defined as episodes of depressed mood or loss of interest and pleasure in nearly all activities. Depression is considered a major mental disorder in the elderly, and may be related to quality of sleep and living habits as well as being influenced by sociodemographic factors.

Objective:

To determine the prevalence of depression among the elderly in the north-east of Brazil, and the relationship between the condition and socio-demographic profile, quality of sleep and living habits. Method: An epidemiological cross-sectional study was performed of the elderly population of the urban area of Campina Grande, Paraiba. The dependent variable presence of depression and the independent variables sociodemographic aspects, sleep quality, and living habits were investigated. Estimates of the prevalence of the variables were obtained and association measured using Poisson Regression. A 5% significance level was adopted for the estimates.

Results:

The study included 168 elderly patients with a mean age of 72.3 (±7.8) years, most of whom, 122 (72.6%), were women. Depression was identified in 72 elderly persons (42.9%). Elderly women were twice as associated with depression (PR=2.26) as men. A subjective quality of sleep of very good (PR=0.34), medium/high risk of sleep disturbance (PR = 4.08), taking sleeping medications once or twice (PR=5.21) and three times or more (PR=8.69) a week, daytime dysfunction once or twice (PR=14.40) and three times or more (PR=27) a week and poor quality of sleep on the Pittsburgh index were associated with depression in bivariate analysis, although there was no relationship following multivariable adjustment.

Conclusion:

The prevalence of depression was high in the studied population, being noticeably more frequent among elderly woman. However, it was not possible to detect an association between depression and living habits and sleep quality.

Elderly; Depression; Sex; Sleep; Body Mass Index; Motor Activity


INTRODUCTION

According to the diagnostic manual of the American Psychiatric Association, depressive disorders are defined as episodes of depressed mood or loss of interest and pleasure in almost all activities, and can also include changes in appetite or weight, sleep and psychomotor activities, a reduction in energy, and feelings of worthlessness or guilt, among other negative effects.11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington, DC : American Psychiatric Association; 1987.

The World Health Organization (WHO) estimates that 151 million people suffer impairment of their activities of daily living and general health as a result of depression.22. Prince M, Patel V, Saxena S, Maj M, Maselko J, Philips MT, et al. No health without mental health. Lancet 2007;370(9590):859-77. In several countries, including Brazil, depression is one of the mental disorders that most affect the health of individuals,33. World Health organization [Internet]. Geneva: WHO. 2007- . Mental Health, Suicide Prevention (SUPRE);[acesso em 12 jul 2010]; [aproximadamente 2 telas]. Disponível em: http://www.who.int/mental_health/prevention/suicide/suicideprevent/en
http://www.who.int/mental_health/prevent...
and is considered the most common psychiatric illness among the elderly.44. Oliveira DAAP, Gomes L, Oliveira RF. Prevalência de depressão em idosos que freqüentam centros de convivência. Rev Saúde Pública 2006;40(4):734-6. According to Kaplan et al.,55. Kaplan HI, Sadock BJ, Grebb JA. Compêndio de psiquiatria: ciências do comportamento e psiquiatria clínica. 7ª ed. Porto Alegre: Artmed; 2007. the prevalence of depression among the elderly is 15%, with the figure among those living in communities approximately 2-14%, rising to almost double (30%) among institutionalized elderly individuals.

Zimerman66. Zimerman GI. Velhice: aspectos biopsicossociais. Porto Alegre: Artmed; 2007. states that depression causes effects that impair the life of the elderly. In terms of intellectual capabilities, a sufferer may experience reduced mental capacity and memory disturbances, which hinder the learning process; in the social sphere, he or she may be excluded from groups and suffer abandonment and isolation; and from a somatic perspective, heart, lung and gastrointestinal problems may occur.66. Zimerman GI. Velhice: aspectos biopsicossociais. Porto Alegre: Artmed; 2007.

Several worldwide studies have observed that gender, age and marital status are associated with depression.77. Schulze B. Mental-health stigma: expanding the focus, joining forces. Lancet 2009;373(9661):362-3. A study by Minicuci et al.88. Minicuci N, Maggi S, Pavan M, Enzi G, Crepaldi G. Prevalence rate and correlates of depressive symptoms in older individuals: the Veneto study. J Gerontol Ser A Biol Sci Med Sci 2002;57(3):155-61. in which 58% of older people with depression were female found that depression was more common among women. In Brazil, Nogueira et al.99. Nogueira EL, Rubin LL, Giacobbo SS, Gomes I, Cataldo Neto A. Screening for depressive symptoms in older adults in the Family Health Strategy, Porto Alegre, Brazil. Rev Saúde Pública 2014;48(3):368-77. also identified a higher incidence of depression among elderly women (around 35.9%) in a study in Porto Alegre (RS).

It is evident also that a low level of physical activity, functional capacity, obesity and cardiovascular dysfunction generate a higher frequency of depressed elderly persons.99. Nogueira EL, Rubin LL, Giacobbo SS, Gomes I, Cataldo Neto A. Screening for depressive symptoms in older adults in the Family Health Strategy, Porto Alegre, Brazil. Rev Saúde Pública 2014;48(3):368-77. , 1010. Florindo S, Gobbi S, Corazza DI, Costa JLR. Depressão no idoso: diagnóstico, tratamento e benefícios da atividade física. Motriz 2002;8(3):91-8. The influence of factors such as the level of schooling and marital status of the elderly individual on the onset of senile depression still causes disagreement in literature,1111. Teixeira LMF. Solidão, depressão e qualidade de vida em idosos: um estudo avaliativo exploratório e implementação-piloto de um programa de intervenção [dissertação]. Lisboa: Universidade de Lisboa; 2010. with some studies finding that people without a steady partner are at greater risk of depression than those living with a partner.1212. Alonso J, Burob A, Bruffaerts R, He Y, Posadana-Villa J, Lepine JP, et al. Association of perceived stigma and mood and anxiety disorders: results from the world mental health surveys. Acta Psychiatr Scand 2008;118(4):305-14.

In addition to these factors, sleep disturbances such as Obstructive Sleep Apnea Syndrome (OSAS), Excessive Daytime Sleepiness (EDS) and insomnia seem to be related to depressive symptoms among the elderly.1313. Lucchesi LM, Pradella-Hallinan M, Lucchesi M, Moraes WAS. O sono em transtornos psiquiátricos. Rev Bras Psiquiatr 2005;27(Suppl 1):27-32. However, there is no evidence of how deep these connections are, or to what extent they are dependent factors.

In recent years depression has been considered the mental disorder most responsible for functional disability, and also the condition which leads to the worst general health conditions among populations in a number of different countries.1414. Singer AE, Meeker D, Teno JM, Lynn J, Lunney JR, Lorenz KA. Symptom trends in the last year of life from 1998 to 2010: a Cohort Study. Ann Intern Med 2015;162(3):175-83. However, information on the sleep patterns and mental characteristics of the elderly population of regions with very particular cultural and socio-economic characteristics, such as the north-east of Brazil, an area which also contains marked internal variations, are incipient. Therefore, the aim of the present study was to investigate the prevalence of depression among the elderly in the north-east of Brazil, and its relationship with socio-demographic profile, quality of sleep and living habits.

METHOD

Study design

A cross-sectional population-based study was conducted of elderly residents of the urban area of the city of Campina Grande (PB), between June and September of 2010. This city is one of the largest in the interior of north-east of Brazil and is considered one of Brazil's industrial and technological hubs. Elderly people were considered to be those aged over 60 years.

Population and sample

The target population of the study consisted of approximately 40,000 elderly individuals resident in the urban area in 2010. To represent this population, an ideal sample was estimated using the following equation: {[z22. Prince M, Patel V, Saxena S, Maj M, Maselko J, Philips MT, et al. No health without mental health. Lancet 2007;370(9590):859-77. x p (1-p)] x k}/ε22. Prince M, Patel V, Saxena S, Maj M, Maselko J, Philips MT, et al. No health without mental health. Lancet 2007;370(9590):859-77., where z is the confidence level for a probabilistic error of 5% (z=1.96), p is the estimated prevalence of outcome (p= 20%), k is the sample correction coefficient (k=1.2), given that sampling is by cluster, ε is the margin of error estimation for the estimated prevalence (ε=6%). Thus, the estimated sample had 205 participants. In addition, the elderly population of the city of Campina Grande (PB) was considered as infinite for the prevalence estimated.

A complex sample was developed in which the first stage consisted of the random selection of clusters of basic health units (BHU) in the four urban health districts of the city. The sample was proportional to the elderly population in each health district. Streets in each UBS were covered from one end to the other, on both sides, moving forward nine houses from the corner chosen as a starting point. This systematic sampling of households was determined by the proportion of old people and houses to be visited in the city, and is similar to the strategy of the National Household Sampling Survey (PNAD, acronym in Portuguese). If there were no elderly persons in the household selected the next, or, if necessary, the previous, house was selected. If there was more than one elderly person at a location, data collection was performed for all individuals.

Study variables and data collection instruments

The outcome variable of the study was the presence of depressive symptomatology, which was diagnosed by the long Brazilian version of the Geriatric Depression Scale, a psychometric instrument for tracking elderly people with depression. The instrument contains 30 items, allocating points to elderly persons who provide a negative response. Elderly individuals with scores of up to 10 points are considered normal while those above that are considered depressive. Elderly persons with average scores between 11 and 20 are considered to have moderate depression, while those who score between 21 and 30 are categorized as severely depressed.1515. Paradela EMP, Lourenço RA, Veras RP. Validação da escala de depressão geriátrica em um ambulatório geral. Rev Saúde Pública 2005;39(6):918-23.

The independent factors were socio-demographic data such as gender (male and female), age, marital status (with/without partner) and schooling, classified as illiterate or illiterate, low (primary education or equivalent) and high (high school/higher education) level of education.

The living habits of the elderly persons were also considered, with planned physical activity, nutritional status and cardiovascular risk taken as predictors. Planned physical activity was classified by asking whether the elderly person dedicated at least 30 minutes daily to exercise, with a positive or negative response. Body mass index (BMI) served as an indicator of nutritional status, with elderly individuals with BMI≤24.9 kg/m2 classified as underweight/normal and those with BMI>25 kg/m2considered overweight/obese.1616. Sichieri R. Índice de massa corporal e indicadores antropométricos de adiposidade em idosos. Rev Saúde Pública 2005;39(2):163-8. Height was measured through a Wiso(r) brand portable stadiometer and mass determined by means of a digital scale accurate to 100 g. The risk of cardiovascular dysfunction was determined by waist circumference, with 94 cm or more a risk factor for men and 80 cm or more a risk factor for women. An inelastic tape measure was used for this measurement.1717. Haun DR, Pitanga FJG, Lessa I. Razão cintura/estatura comparado a outross indicadores antropométicos de obesidade como preditor de risco coronariano elevado. Rev Assoc Med Bras 2009;55(6):705-11.

Sleep quality was assessed by the presence of insomnia and the application of the Pittsburgh Sleep Quality Index, which measures various features of sleep. Insomnia was identified as "present" or "absent" based on the findings of difficulty falling and staying asleep or waking up early for no apparent reason.1818. Yokoyama E, Kaneita Y, Saito Y, Uchiayama M, Matsuzaki Y, Tamaki T, et al. Association between depression and insomnia subtypes: a longitudinal study on the elderly in Japan. Sleep 2010;33(12):1693-702. A positive response for any of these conditions represented insomnia.

The Pittsburgh Sleep Quality Index obtains information about the subjective quality of sleep (very bad, fairly bad, good and very good), sleep latency (more than 60 minutes, between 31 and 60 minutes, between 16 and 30 minutes, less than 15 minutes), sleep duration (less than five hours, between five and six hours, between six and seven hours and more than seven hours), habitual sleep efficiency (less than 85%, between 75% and 85%, between 65% and 74%, less than 65%), sleep disturbance (no risk, low risk and high risk), use of sleep medications, and daytime dysfunction (not during the last month, less than once a week, once or twice a week, three or more times a week). The Pittsburgh Quality of Sleep Index also provides an objective measure of the quality of sleep.1919. Bertolazi AN, Fagondes SC, Hoff LS, Dartora EG, Miozzo IC, De Barba ME, et al. Validation of the Brazilian portuguese version oh the Pittsburgh Sleep Quality Index. Sleep Medicine 2011;12(1):70-5.

Statistical method

All variables were classified as categorical, including age, which was transformed into age range, an ordinal variable. To estimate the prevalence of depression, the number of cases of depression was divided by the total sample and a confidence interval of 95% was determined. Analysis of the relationship between a depressed state and sociodemographic variables, lifestyle and sleep quality was carried out by means of a Generalized Linear Model (GLM) and Poisson regression based on data distribution. A significance level of 5% was used in order to minimize type I error. The SPSS software package version 20.0 was used for analysis.

Ethical procedures

The present study was approved by the Ethics Research Committee of the Universidade Estadual da Paraíba, CAAE 0299.0.133.000-09, based on Resolution nº 196/96 of the National Health Council. The participants in the study signed a Free and Informed Consent Form.

RESULTS

A total of 168 elderly persons took part in the study, a number which represented more than 80% of the estimated sample. The average age of the group was 72.3 (±7.8) years, and the majority of its members, 122 (72.6%), were female. A total of 72 elderly persons were identified as depressive [42.9% (CI95%:39.1-46.7%)].

Table 1 shows that twice as many women had depressive symptoms (PR = 2.26) as men, a fact made clear after adjustment for the other sociodemographic variables. It was also noted that age group, marital status and educational level did not correlate with the outcome of depression. There was also no association between planned physical activity, BMI and cardiovascular risk and depression (table 2).

Table 1
Relationship between sociodemographic characteristics and depression among the elderly living in the community. Campina Grande, PB, 2010.

Table 2
Relationship between living habits and depression among the elderly living in the community. Campina Grande, PB, 2010.

In relation to sleep characteristics, there was a negative association between the subjective quality of sleep of "very good" and depression among the elderly (PR=0.34), where 66% of elderly persons described having very poor sleep. This relationship was confirmed in the adjusted model. Depression was four times more prevalent (PR=4.08) in elderly persons with a medium/high risk of disturbed sleep than in those with no or a low risk of disturbed sleep. However, this association was not confirmed following adjustment.

Older people who took one or two sleeping medications a week (PR=5.21) and those who took such drugs three or more times a week (PR=8.69), were more likely to display depressive symptoms. Similarly, elderly persons with more than one daytime dysfunction had a higher incidence of depression, along with those classified as having poor sleep quality by the Pittsburgh Index (PR=3.03). However, these associations were not confirmed in the adjusted model (Table 3).

Table 3
Relationship between sleep characteristics and depression in community-dwelling elderly. Campina Grande, PB, 2010.

DISCUSSION

A high prevalence of elderly patients with depression was identified in the present study, well above that of findings in literature. While depression was more associated with older women, there was no association with the other sociodemographic factors or living habits. Following adjustment for confounding factors, there was no association between depression and very good subjective quality of sleep, a medium/high risk of disturbed sleep, taking sleep medication once or more a week, daytime dysfunction once or more a week, and poor objective quality of sleep.

Depression, a disease with multiple causes, is one of the most common psychiatric disorders among elderly persons.2020. Ferreira PCS, Tavares DMS, Martins NPF, Rodrigues LR, Ferreira LA. Características sociodemográficas e hábitos de vida de idosos com e sem indicativo de depressão. Rev Eletrônica Enferm 2013;15(1):197-204. While common in all stages of life, it is more prevalent among the elderly than in younger people. Furthermore, approximately 40% of cases of depression in old age are not diagnosed.2121. Benedetti TRB, Borges LJ, Petroski EL, Gonçalves LHT. Atividade física e estado de saúde mental de idoso. Rev Saúde Pública 2008;42(2):302-7. According to Batistoni et al.,2222. Batistoni SST, Neri AL, Cupertino APFB. Medidas prospectivas de sintomas depressivos entre idosos residentes na comunidade. Rev Saúde Pública 2010;44(6):1137-43. studies that seek to identify which factors are related to the incidence of depressive symptoms.

Barcelos-Ferreira et al.2323. Barcelos-Ferreira R, Izbicki R, Steffens DC, Bottino CMC. Depressive morbidity and gender in community-dwelling Brazilian elderly: systematic reviewand meta-analysis. Int Psychogeriatr 2010;22(5):712-26. reviewed scientific literature about depression in community-dwelling elderly persons in Brazil and identified a prevalence of depression of 7%, and a rate of depressive symptoms of 26%. A study of community-dwelling elderly persons in Canada found a prevalence of depression of between 1.3% and 18.8% in women and between 0.9 and 7.9% in men.2424. Ostbye T, Kristjansson B, Hill G, Newman SC, Brouwer RN, McDowell L. Prevalence and predictors of depression in elderly Canadians: the canadian study of health and aging. Chronic Dis Can 2005;26(4):93-9. It remains difficult to say with exact precision why more women suffer from depression than men, although some psychosocial assumptions have been suggested.2424. Ostbye T, Kristjansson B, Hill G, Newman SC, Brouwer RN, McDowell L. Prevalence and predictors of depression in elderly Canadians: the canadian study of health and aging. Chronic Dis Can 2005;26(4):93-9. The prevalence of depression in the present study was much higher than in other Brazilian and international surveys, perhaps due to the peculiarity of the study population.

Baptista et al.,2525. Baptista NN, Baptista ASD, Oliveira MG. Depressão e gênero: por que as mulheres deprimem mais que os homens? Temas Psicol 1999;7(2):143-56. found that women have a greater tendency to internalize stressful events, have different rights and status than males, are victimized in a number of societies and suffer various types of violence, resulting in a higher risk of depression. Studies have indicated a number of reasons for the higher prevalence of depression among women, including: a) the frequent presence of factors such as low income and low level of schooling; b) the fact that they are more emotionally effected by events such as widowhood, abandonment and loneliness; and c) a connection with hormonal functioning caused by fluctuating estrogen levels during the childbearing phase of a woman's life.2525. Baptista NN, Baptista ASD, Oliveira MG. Depressão e gênero: por que as mulheres deprimem mais que os homens? Temas Psicol 1999;7(2):143-56.

26. Pickett Y, Greenberg RL, Bazelais KN, Bruce ML. Depression treatment disparities among older minority home healthcare patients. Am J Geriatr Psychiatry 2014;22(5):519-22.
- 2727. Alvarado BE, Zunzunegui MV, Béland F, Sicotte M, Tellechea L. Social and gender inequalities in depressive symptoms among urban older adults of latin American and the Caribbean. J. Gerontol Ser B Psychol Sci Soc Sci 2007;62(4):226-36. For Angold & Worthman,2828. Angold A, Worthman CW. Puberty onset of gender differences in rates of depression: a developmental, epidemiologic and neuroendrocrine perspective. J Affect Disord 1993;29(2-3):145-58. biological variables are considered important in the issue of gender and depression. Suicide attempts are more common in premenstrual periods than at other times, probably due to the hormonal fluctuations and mood changes that occur during a woman's life.

A study by Oliveira et al.2929. Oliveira MF, Bezerra VP, Silva AO, Alves MSCF, Moreira MASP, Caldas CP. Sintomatologia de depressão autorreferida por idosos que vivem em comunidade. Ciênc Saúde Coletiva 2012;17(8):2191-98. described a greater predominance of depression among women, with 29.9% of 167 women interviewed classified as having moderate or severe depression. It was found that the greatest trauma reported by elderly persons was the loss of a companion. Unmarried elderly individuals suffer more from loneliness than married elderly persons. Symptoms of depression were associated with widowhood not just because of the pain of loss, but also by the social isolation suffered by the individual,2929. Oliveira MF, Bezerra VP, Silva AO, Alves MSCF, Moreira MASP, Caldas CP. Sintomatologia de depressão autorreferida por idosos que vivem em comunidade. Ciênc Saúde Coletiva 2012;17(8):2191-98. a finding which contradicts with those of the present study, in which marital status was not related to the depressive state, casting doubt over the importance of cultural aspects related to dealing with loss.

Minicuci et al.3030. Minicuci N, Maggi S, Pavan M, Enzi G, Crepaldi G. Prevalence rate and correlates of depressive symptoms in older individuals: the Veneto Study. J Gerontol Ser A Biol Sci Med Sci 2002;57(3):155-61. studied elderly persons with five years or more of schooling and found an approximately 30% greater prevalence of depressive symptoms than among those with less than five years of education. According to Maciel & Guerra,3131. Maciel ACC, Guerra RO. Prevalência e fatores associados à sintomatologia depressiva em idosos residentes no Nordeste do Brasil. J Bras Psiquiatr 2010;55(1):26-33. unfavorable social conditions are reflected in low levels of schooling and income, making the individual more susceptible to mental health problems such as depression. These authors also commented on the high levels of illiteracy in Brazil and ratified the idea of an inefficient social services network, reflected in areas such as housing, culture, income and health. According to Oliveira et al.,2929. Oliveira MF, Bezerra VP, Silva AO, Alves MSCF, Moreira MASP, Caldas CP. Sintomatologia de depressão autorreferida por idosos que vivem em comunidade. Ciênc Saúde Coletiva 2012;17(8):2191-98. the close relationship between education and health is a concern, as it has been observed that educationally disadvantaged people are not particularly concerned with healthy living habits. In contrast, the present study found no association between educational level and geriatric depression.

One feature of depressive disorders is a loss of interest and/or motivation in participating in cultural, leisure and physical activities. A total of 71.4% of individuals interviewed in the present study did not take part in planned physical activity. However, no association between physical inactivity and depression was identified. There is evidence that planned physical activity among the elderly encourages social interaction and provides a greater sense of control over events and challenges.2929. Oliveira MF, Bezerra VP, Silva AO, Alves MSCF, Moreira MASP, Caldas CP. Sintomatologia de depressão autorreferida por idosos que vivem em comunidade. Ciênc Saúde Coletiva 2012;17(8):2191-98. A reduction of symptoms of anxiety and depression through physical exercise can be explained by an increase in the release of catecholamine hormones such as ACTH, vasopressin, β-endorphin, dopamine, serotonin, the activation of specific receptors, and decreased blood viscosity, providing a calming and analgesic effect, giving a relaxing feeling after exercise.3232. Ruukanen JM, Ruoppila I. Physical activity and psychological well- being among people aged 65 to 84 years. Age Ageing 1995;24(4):292-6.

Despite the lack of a connection between obesity/overweight in the present study, there is evidence of this association in a number of other works. Depression and obesity can increase the risk of disability, reduce quality of life, and increase mortality and morbidity.3333. Frazer C, Christensen H, Griffiths K. Effectiveness of treatments for depression in older peolple. Med J Aust 2005;182(12):627-32. An increased risk of cardiovascular events has also been described as being related to depression in literature.3434. Atlantis E, Baker M. Obesity effects on depression: systematic review of epidemiological studies. Int J Obes 2008;32(6):881-91. , 3535. Wit LM, Straten AV, Van Herten M, Penninx BWJH, Cuijpers P. Depression and body mass index, a u-shaped association. BCM Public Health 2009;9:14.

The consequences of insomnia for mental health have still not been fully investigated, but it has been found that the condition can increase the risk of depression.1818. Yokoyama E, Kaneita Y, Saito Y, Uchiayama M, Matsuzaki Y, Tamaki T, et al. Association between depression and insomnia subtypes: a longitudinal study on the elderly in Japan. Sleep 2010;33(12):1693-702. In a study of 196 subjects aged 62 to 65 Yokoyama et al.1818. Yokoyama E, Kaneita Y, Saito Y, Uchiayama M, Matsuzaki Y, Tamaki T, et al. Association between depression and insomnia subtypes: a longitudinal study on the elderly in Japan. Sleep 2010;33(12):1693-702. found an association between depression and sleep disturbance, and identified a bidirectional relationship between the two. Sleep disturbances are a hallmark of the depressive disorder, with approximately 80% of patients with depression complaining of a deterioration in the quantity and quality of sleep.1818. Yokoyama E, Kaneita Y, Saito Y, Uchiayama M, Matsuzaki Y, Tamaki T, et al. Association between depression and insomnia subtypes: a longitudinal study on the elderly in Japan. Sleep 2010;33(12):1693-702. Lopes et al.3636. Lopes JM, Dantas FG, Medeiros JLA. Excessive daytime sleepiness in elderly: association with cardiovascular risk, obesity and depression. Rev Bras Epidemiol 2013;16(4):872-9. also identified an association between depression and excessive daytime sleepiness, a manifestation of sleep dysfunction during wakefulness, and found that men with depression were more associated with this dysfunction.

The Diagnostic and Statistical Manual of Mental Disorders describes disturbed sleep as an important factor in the diagnosis of depression,11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington, DC : American Psychiatric Association; 1987. as well as the use of sleeping medications, such as anxiolytics, which are commonly used in Brazil.3737. Lima MTR, Silva RS, Ramos LR. Fatores associados à sintomatologia depressiva numa coorte de urbana de idosos. J Bras Psiquiatr 2008;58(1):1-7. The present study identified an association with some characteristics such as objectively and subjectively measured quality of sleep, the use of sleep medication and daytime dysfunction. However, this relationship was no longer found after adjustment of the predictive model, perhaps due to the limitations of the present study.

The first of these was the impossibility of developing a general predictive model including groups of sociodemographic, living habit and sleep characteristic variables. This was because the large number of variables prevented the construction of an explanatory model, in view of the sample size. This may explain the lack of association for some bivariate associations in the final model. It was also noted that the elderly persons experienced difficulty when answering simple questions during data collection. Low accuracy of understanding was possible when answering questions regarding insomnia, when it was asked whether the individual experienced difficulty when falling or remaining asleep or woke up early for no apparent reason. This situation may reflect the low educational level of the population studied. Another limitation identified was the highlighted contrasts with existing literature, which may be related to the cultural characteristics of the north-east of Brazil, which are notably different from other regions of the country.

There are a number of possible strategies that could be used to improve the evidence of the elderly population of the north-east, such as stratifying the sample by socioeconomic or educational level, factors that are closely linked to access to health and social support, identifying chronic morbidities that affect the elderly, such as hypertension, diabetes, and types of medication used, as well as the neurological and chronic musculoskeletal conditions that lead to disability. Sleep could also be objectively measured with an Actimeter, which is an easy to use and low cost instrument, or even polysomnography samples.

CONCLUSION

The present study found that there was a high prevalence of depression among the elderly population of the north-east of Brazil, and that the condition was more common among women. No relationship was found, however, between living habits, characteristics of sleep quality and the presence of depressive symptoms.

Investigations of the living habits and quality of sleep of the elderly in specific populations should be encouraged, as joint strategies to tackle modifiable and minimize non-modifiable risk factors could reduce levels of depression among the elderly, and have a major positive impact on public health. It should also be noted that the prevalence of cardiovascular and cerebrovascular and sleep disorders, and the indiscriminate use of medication, is growing among the elderly population, contributing to an increase in depressive symptoms.

References

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Publication Dates

  • Publication in this collection
    July-Sep 2015

History

  • Received
    25 Apr 2014
  • Accepted
    26 May 2015
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