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PREVALENCE OF DEPRESSION AND ITS

ASSOCIATED RISK FACTORS AMONG ELDERLY IN FELDA BUKIT GOH, KUANTAN, PAHANG

BY

NUR SURIATI BINTI SULAIMAN

A dissertation submitted in partial fulfilment of the requirement for the degree of Master of Medicine

(Family Medicine)

Kulliyyah of Medicine

International Islamic University Malaysia

MAY 2020

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ABSTRACT

The world’s population is aging rapidly. Older people are at risk of having a mental illness such as depression but it is often misdiagnosed and undertreated. As a consequence, it may affect their general wellbeing and daily function. This study aimed to measure the prevalence of depression and its associated risk factors among elderly living in FELDA Bukit Goh, Kuantan, Pahang. It was a cross-sectional study design and conducted from June to September 2018. The participants aged more than 60 years were recruited in this study. There were a total of 259 participants randomly selected to complete the interviewed-base questionnaires. The questionnaires consisted of four sections which included the sociodemographic profile, Geriatric Depression Scale (GDS), Elderly Cognitive Assessment Questionnaire (ECAQ), and Modified Barthel Index (MBI). In the data analysis, descriptive statistics were used to measure the prevalence of depression and logistic regression was used to explore the association of depression with the background variables. Out of 259 participants, the majority of them were female. This study showed the prevalence of depression among the participants was 19.3%. The risk factors that significantly associated in this study were elderly without formal education (adjusted odds ratio (aOR):2.38, 95% confidence interval (CI):1.07-5.31), cognitive impairment (aOR:3.68, 95% CI 1.29-10.5), and marked dependent (aOR:3.17 95% CI:1.47-6.86). In conclusion, this study has shown that the prevalence of depression among the elderly in FELDA Kuantan considerably alarming.

Thus, healthcare providers who are managing the elderly patients should take the initiative to screen depression at any given opportunity especially among those without formal education, have a cognitive impairment, and marked dependent.

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APPROVAL PAGE

I certify that I have supervised and read this study and that in my opinion, it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Master of Medicine (Family Medicine).

………..

Mohd Aznan Mohd Aris

Supervisor

I certify that I have supervised and read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Master of Medicine (Family Medicine).

………..

Mohamad Che’ Man

Co-Supervisor

………..

Muhammad Zubir Yusof

Co-Supervisor

I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Master of Medicine (Family Medicine)

………..

Ramli Musa Examiner

This dissertation was submitted to the Department of Family Medicine and is accepted as partial fulfillment of the requirements for the degree of Master of Medicine (Family Medicine).

………..

Mohd Aznan Md Aris

Head, Department of Family Medicine

This dissertation was submitted to the Kulliyyah of Medicine and is accepted as partial fulfillment of the requirements for the degree of Master of Medicine (Family Medicine).

………..

Azmi Md Nor

Dean Kulliyyah of Medicine

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DECLARATION

I hereby declare that this dissertation is the result of my own investigation, except where otherwise stated. I also declare that it has not been previously or concurrently submitted as a whole for any other degrees at IIUM or other institutions.

Nur Suriati binti Sulaiman

Signature……….…….….…. Date ………..….………

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v

YRIGHT PAGE

INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA DECLARATION OF COPYRIGHT AND AFFIRMATION OF

FAIR USE OF UNPUBLISHED RESEARCH

PREVALENCE OF DEPRESSION AND ITS ASSOCIATED RISK FACTORS AMONG ELDERLY IN FELDA BUKIT

GOH, KUANTAN, PAHANG

I declare that the copyright holders of this dissertation are jointly owned by the student and IIUM.

Copyright © 2020 by Nur Suriati binti Sulaiman and International Islamic University Malaysia.

All rights reserved.

No part of this unpublished research may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without prior written permission of the copyright holder except as provided below.

1. Any material contained in or derived from this unpublished research may be used by others in their writing with due acknowledgement.

2. IIUM or its library will have the right to make and transmit copies (print or electronic) for institutional and academic purposes.

3. The IIUM library will have the right to make, store in a retrieval system and supply copies of this unpublished research if requested by other universities and research libraries.

By signing this form, I acknowledged that I have read and understand the IIUM Intellectual Property Right and Commercialization policy.

Affirmed by Nur Suriati binti Sulaiman

……..……..……… ………..

Signature Date

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ACKNOWLEDGMENT

In the name of Allah, The Most Gracious and The Most Merciful.

All praises and thanks due to Allah, peace, and blessings for His Messenger, Prophet Muhammad s.a.w.

I would like to dedicate this work to my dear husband, Mohd Ruzmi Khairi bin Rusli, who granted me the gift of the unwavering belief in my ability to accomplish this goal:

thank you for your support and patience. To my beloved kids, Muhammad Umar Abdul Aziz and Muhammad Al Fateh, this is for all of you. To my both parents, Sulaiman bin Mohd and Fatimah binti Chek, thank you for the endless love and support.

A special thanks to my supervisor Prof. Dr. Mohd Aznan bin Md Aris for his guidance, patience and continuous supervision throughout this study despite his busy schedule.

My deepest thanks to my co-supervisors Assist. Prof. Dr. Mohamad bin Che’ Man and Assist. Prof. Dr. Muhammad Zubir bin Yusof for their leadership, continuous support and encouragement. Their guidance helped me in all the time of research and writing of this thesis.

Finally, I would like to thank all of my friends and postgraduate students of Family Medicine Department IIUM for their time, effort and support for this study.

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TABLE OF CONTENTS

Abstract ... ii

Approval Page ... iii

Declaration ... iv

Copyright Page ... v

Acknowlegdement ... vi

Table of Contents ... viii

List of Tables ... x

List of Figures ... xi

List of Abbreviations ... xii

CHAPTER ONE INTRODUCTION ... 1

1.1 Background of The Study ... 1

1.2 Problem Statement ... 4

1.3 Purpose of The Study... 5

1.4 Research Objective ... 6

1.4.1 General Objective... 6

1.4.2 Specific Objectives... 6

1.5 Research Questions ... 7

1.6 Conceptual Framework ... 8

1.7 Research Hypothesis ... 9

1.8 Significance of The Study ... 9

1.9 Limitations of The Study ... 10

1.10 Definitions of Terms ... 11

CHAPTER TWO LITERATURE REVIEW ... 13

2.1 Prevalence of Depression ... 13

2.2 Factors Associated with Depression ... 15

2.2.1 Sociodemographic data ... 15

2.2.2 Disease variable ... 18

2.2.3 Activities of Daily Living (ADL) ... 19

2.2.4 Cognitive status ... 21

2.2.5 Other variables ... 22

2.2.6 Barriers ... 23

CHAPTER THREE METHODOLOGY ... 25

3.1 Study Design ... 25

3.2 Study Area ... 25

3.3 Target Population... 26

3.4 Study Population ... 26

3.4.1 The inclusion criterias: ... 26

3.4.2 The exclusion criteria: ... 27

3.5 Study Duration ... 27

3.6 Sample Size Calculation ... 27

3.7 Sampling Method ... 28

3.8 Data Collection Process ... 28

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3.9 Research Instruments ... 28

3.9.1 Sociodemographic data ... 28

3.9.2 Elderly Cognitive Assessment Questionnaire (ECAQ) ... 29

3.9.3 Geriatric Depression Scale-15 (GDS-15)... 29

3.9.4 Modified Barthel Index (MBI) ... 30

3.10 Statistical Analysis... 30

3.11 Ethical Consideration... 31

CHAPTER FOUR RESULTS AND FINDINGS ... 32

4.1 Baseline Profiles ... 32

4.1.1 Sociodemographic Profiles ... 32

4.1.2 Cognitive Impairment ... 34

4.1.3 Activities of Daily Living (ADL) ... 34

4.2 Prevalence of Depression in Elderly... 34

4.3 Factors Associated with Depression ... 35

4.3.1 Sociodemographic Profiles and Depression... 35

4.3.2 Cognitive Impairment and Depression ... 37

4.3.3 Activities of Daily Living (ADL) and Depression ... 37

4.4 Significant Predictor Variables for Depression ... 38

4.4.1 Sociodemographic Profiles and Depression... 38

4.4.2 Cognitive Impairment and Depression ... 39

4.4.3 Activities of Daily Living (ADL) and Depression ... 39

CHAPTER FIVE DISCUSSION AND CONCLUSION ... 40

5.1 Baseline Profiles ... 40

5.1.1 Sociodemographic Profile ... 40

5.1.2 Cognitive Impairment ... 41

5.1.3 Activities of Daily Living (ADL) ... 42

5.2 Prevalence of Depression ... 43

5.3 Sociodemographic Variables and Depression ... 44

5.4 Other Variables ... 49

5.4.1 Cognitive Impairment ... 49

5.4.2 Functional Impairment in Activities of Daily Living (ADL)... 52

5.4.3 Protective Factors ... 54

5.5 Conclusion ... 55

5.6 Conflict of Interest ... 56

5.7 Acknowledgement ... 56

REFERENCES ... 57

APPENDIX I: CASE RECORD FORM ... 67

APPENDIX II: IREC APPROVAL LETTER ... 76

APPENDIX III: FELDA OFFICE APPROVAL LETTER ... 77

APPENDIX IV: QUESTIONNAIRES FORM ... 78

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LIST OF TABLES

Table 1.1 Definition of Terms 11

Table 4.1 Sociodemographic Profile 33

Table 4.2 Cognitive Impairment 34

Table 4.3 Activities of Daily Living (ADL) 34

Table 4.4 Prevalence of Depression 35

Table 4.5 Association Between Sociodemographic Profiles and Depression Among Participants

36 Table 4.6 Association Between Cognitive Impairment and Depression

Among Participants

37 Table 4.7 Association Between Activities of Daily Living (ADL) and

Depression Among Participants

37 Table 4.8 Significant Predictors Variables Associated with Depression 38 Table 4.9 Association between Cognitive Impairment and Depression 39 Table 4.10 Association between Activities of Daily Living (ADL) and

Depression

39

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x

LIST OF FIGURES

Figure 1.1 Conceptual Framework 8

Figure 3.1 The map of the Kuantan District 26

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LIST OF ABBREVIATIONS

UN United Nation

WHO World Health Organization

DSM-5 Diagnostic and Statistical Manual of Mental Disorders-5

FELDA Federal Land Development Authority

CDC Centers for Disease Control and Prevention GDS-15 Geriatric Depression Scale-15

ADL Activities of Daily Living

MBI Modified Barthel Index

AD Alzheimer Disease

VD Vascular Dementia

DOSM Department of Statistics Malaysia

MCI Mild Cognitive Impairment

QoL Quality of Life

MDD Major Depressive Disorder

BADL Basic Activities of Daily Living IADL Instrumental Activities of Daily Living

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CHAPTER ONE INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Our world is aging rapidly. World Health Organization (WHO) estimated between 2015 and 2050, the world’s proportion of elderly people aged 60 years and above rising from 12% to 22% (WHO, 2017). According to the latest population estimates and projections from the United Nations Department of Economic and Social Affairs (UN DESA) Population Division, 1 in 6 people in the world is elderly by 2050, up from 1 in 11 in 2019 (UN DESA, 2020). Therefore, the demand for primary and long term care will be increased, thus require a larger and better workforce towards it. There is no standard numerical criterion, western countries often used aged 65 years and above as elderly but United Nations (UN) agreed cut off of 60 years and above to refer to the older population. WHO had developed ten priorities for global strategy and action plan on aging and health. There are:

a) Build a platform for innovation and change b) Support country planning and action c) Collect better global data on healthy aging

d) Promote research that addresses the needs of older people e) Align health systems to the needs of older people

f) Lay the foundations for a long term care system in every country g) Ensure the human resources necessary for integrated care

h) Undertake a global campaign to combat ageism

i) Make the economic case for investment in healthy aging

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j) Develop a global network for age-friendly cities and communities (WHO, 2017).

Globally, the most common mental and neurological disorders among the elderly are dementia and depression, which affect around 5% and 7% of the world’s older population respectively, however, it is often overlooked or misdiagnosed (WHO, 2017). Mental health problems are under-identified by health personnel and older people themselves, thus makes people reluctant to seek help (Mukhtar & P. S. Oei, 2011; Olver, 2012; Sözeri-Varma, 2012). It is a natural part of a human, being sad or blues sometimes. When it persists in a longer duration and affects daily activities, it may lead to depression (Ikeda, 2012; Olver, 2012; Unsar & Sut, 2010).

Based on the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM- 5), Major Depressive Disorder (MDD) is a syndrome that negatively affects a person’s life and consist of symptoms that affect the individual’s functionality (DSM-5, 2013).

The main symptoms are a depressed mood and loss of interest or pleasure. The individual presented with five or more following symptoms for the same two week period, it is sufficient to diagnose as Major Depressive Disorder (MDD). The symptoms are:

a) Depressed mood most of the day

b) Markedly diminished interest or pleasure

c) Significant weight loss or change 5% body weight in a month d) Insomnia or hypersomnia

e) Psychomotor agitation or retardation f) Fatigue or loss of energy

g) A feeling of worthlessness or inappropriate guilt h) Diminished ability to think or concentrate

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3 i) Recurrent thoughts of death

Those who do not fully meet the above criteria but still exhibit clinically significant symptoms may be diagnosed with various subsyndromal depressive disorders such as dysthymia and unspecified depressive disorder (DSM-5, 2013). The term of late-life depression is used for Major Depressive Disorder (MDD) which appears for the first time at the age of 60 or later (Sözeri-Varma, 2012).

Stigma towards mental illness among the elderly is still high as they prefer to focus on bodily complaints rather than psychological distress. Many of them presented with medical comorbid and rarely highlight about their psychological or mental issues (Puteh et al., 2015; Sinha Sati P, Shrivastava Saurabh R, 2013; Wan Mohd Azam et al., 2013; Yunming, Changsheng, Haibo, Wenjun, & Shanhong, 2012). As regard to depression, the elderly may see it as a consequence of losses in physical, functional, and social domains rather than an actual disorder that needs to be treated (Abdulraheem, Oladipo, & Amodu, 2011). Depression is not a normal part of growing elder and it is potentially treatable. Thus, proper identification and intervention will improve functional capacity and quality of life in the elderly (Da Silva, Scazufca, & Menezes, 2013; Mukhtar & P. S. Oei, 2011; Park & Unützer, 2011).

A countryside or rural area is a geographical area situated outside towns or cities.

It has a low population density compared to town. In Malaysia, the Federal Land Development Authority (FELDA) was established on 1st July 1956 under the Land Development Ordinance (Land Development Ordinance) 1956. It aimed for land development and relocate the settlers to eradicate poverty through the cultivation of oil palm and rubber, industrial and commercial social economy.

However, in 1990, FELDA was no longer recruiting new settlers. The government has entrusted FELDA to stand with their finances and become a statutory

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body that can generate their income to support various development through a variety of businesses through private corporate entities, such as Koperasi Permodalan FELDA Malaysia Bhd (KPF) and Felda Holdings Bhd (FHB). A FELDA settler is the main person that owns and manages a plot of agricultural land given by FELDA. They worked in palm oil or rubber plantations. Felda Bukit Goh, Kuantan Pahang was established in 1967 with 671 settlers and their main source of income through oil palm.

Older adults have important contributions to society and act as ‘pillar’ in their family. Good general health and social care are important for promoting older people's health, preventing disease, and managing chronic illnesses. Health care providers should be well trained in giving education, training, and support for the benefits to the elderly and the general public.

1.2 PROBLEM STATEMENT

The elderly population is increasing worldwide and presents both challenges and opportunities. As they grow older, they are susceptible to various comorbid illnesses as well as mental disorders. Globally, there were over 20% of people aged more than 60 years old suffered from a mental or neurological disorder (except headache disorders) and accounted for 6.6% of all disability (WHO, 2017). The productivity and quality of life might be reduced therefore affected society as a whole. As a consequence, it will increase the perception of poor health, the utilization of health care services and costs starting from preventive measures until the treatment of complications (Zhao, Huang, Xiao, Gao, & Liu, 2012).

Depression in the elderly can be prevented. Failure to act is costly. In 2016, the WHO reported the most common mental disorders in older people were dementia and depression (WHO, 2017). Unfortunately, it was still underrated due to the

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misconception that it is part of the aging process and not require any intervention (Azlini, Nurul, & Lukman, 2014; Barua & Kar, 2010; Sözeri-Varma, 2012). Park and Unutzer (2011), reported only one-fifth of the elderly with depression received adequate treatment (Park & Unützer, 2011).

In older age, mental health status is determined by biological, psychological, and social aspects in individuals (Sözeri-Varma, 2012). Early detection of depression enabled older people to get early intervention thus reduce morbidity and mortality (Ibrahim, Che, Ma, & Ahmad, 2013; Rashid & Tahir, 2014; Vanoh, Shahar, Yahya, &

Hamid, 2016). Optimum general health and social care are important for promoting older people's health, preventing disease, and managing chronic illnesses.

At the present moment, there is a lack of study done for elderly depression especially for those living in a rural area, particularly in Malaysia (Ibrahim, Che, et al., 2013; Mohd et al., 2013; Rashid, Manan, 2010). Furthermore, with the presence of cognitive impairment and denial of feelings among the elderly and their family members, it may cause difficulties in making a diagnosis and delay the treatment (Khaw, Teo, & Rashid, 2010; Ratcliff & Chang, 2015).

A study conducted in this population can give an overview and better understandings of elderly depression. Early detection and prompt intervention may decrease the health burden to the individuals and community, reduce the rate of morbidity and mortality, and improve quality of life (QoL).

1.3 PURPOSE OF THE STUDY

Depression among the elderly can cause a huge impact and affect daily living. The stigma surrounding mental illness makes them reluctant to seek help from the medical health personnel (Abe, Fujise, Fukunaga, Nakagawa, & Ikeda, 2012a; Wan Mohd Azam

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et al., 2013). Early detection of depression among the elderly may promote early and optimal management as well as provide long term care to the patient and family (WHO, 2017).

To date, there are limited studies conducted about depression in the elderly in the rural community such as in FELDA settlement (A Rashid & A Manan, 2010;

Ibrahim et al., 2013a; Wan Mohd Azam et al., 2013). Felda Bukit Goh is one of the highest populations of the elderly in the rural area in Kuantan, Pahang. Based on 2016 population data (unpublished) from the Felda authority of Felda Bukit Goh, there were 574 elderly aged 60 years and above in their community (FELDA, 2017).

The purpose of this study was to measure the prevalence of depression among the elderly in a rural area, particularly in FELDA settlement. Besides that, the associated factors that contribute to depression can be explored in this population. These are important keys to identify the vulnerability risk factors for depression among elderly living in this area.

1.4 RESEARCH OBJECTIVE 1.4.1 General objective

To determine the prevalence of depression and its associated factors among the elderly in Felda Bukit Goh, Kuantan.

1.4.2 Specific objectives

i. To describe the sociodemographic profile among the elderly in Felda Bukit Goh, Kuantan, Pahang.

ii. To measure the prevalence of depression and its associated risk factors among the elderly in Felda Bukit Goh, Kuantan.

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iii. To determine the association between sociodemographic profile with depression among the elderly in Felda Bukit Goh, Kuantan.

iv. To measure the association between activities of daily living (ADL) with depression among the elderly in Felda Bukit Goh Kuantan.

1.5 RESEARCH QUESTIONS

1. What is the prevalence of depression in the elderly in Felda Bukit Goh, Kuantan?

2. How do the socio-demographic factors of the participants related to depression at risk?

3. What are the predictors that contribute to depression among the elderly in this population?

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8 1.6 CONCEPTUAL FRAMEWORK

Figure 1.1 Conceptual framework

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9 1.7 RESEARCH HYPOTHESIS

Marked dependent in Activities of Daily Living (ADL) has a significant association with depression among the elderly.

NULL HYPOTHESIS:

There is no significant association between depression and marked dependent in Activities of Daily Living (ADL).

1.8 SIGNIFICANCE OF THE STUDY

In primary care level, elderly with depression often do not address their low mood but instead present with nonspecific symptoms such as insomnia, anorexia, and fatigue, thus making it underdiagnosed (Nair, Hiremath, & Nair, 2013; Stahl, Beach, Musa, &

Schulz, 2017; Yunming, Changsheng, Haibo, Wenjun, & Shanhong, 2012). They used to dismiss depression as an acceptable response to life stress events or a normal part of life.

Despite managing the physical illness, health care providers deliberately required to assess the psychological and social aspects of the patients. For example, they should look for depressive symptoms rather than rely on the patient to disclosure their mood changes. Furthermore, lack of connection between primary care providers and mental health providers has created a fragmented system of care particularly in managing these issues (Normala, Azlini, Nurul, & Lukman, 2014; Stahl et al., 2017).

The effects of mental disorders are not limited to the individual level, it may also give a burden to society (Nikmat, Hawthorne, & Al-Mashoor, 2011; Xie, Zhang, Peng, & Jiao, 2010). Therefore, there is a need for a better understanding of depression in the elderly to improve general health. The findings in this study are significant to

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measure the prevalence and its predictors for depression in the elderly in this population.

With that, individuals, communities, health care providers, and stakeholders could sit together and strategize a plan to create awareness about depression among the elderly and empower the general public.

1.9 LIMITATIONS OF THE STUDY

There were a few limitations encountered during this study. There are:

a) Previously, there were no available preliminary studies done before among this population. Therefore, the selected study type is a cross-sectional study to ensure the aims of the study to be achieved. However, the results are limited to identification of the variables only and unable to establish the causal relationships among the study variables.

b) The distribution of participants at the study site was not a true representation of our national population that is multicultural and diversed. FELDA settlement has a dense population of Malays making an overrepresentation of the majority in the study.

c) This study discussed mainly on contributing factors towards depression among elderly rather than focusing on the explanation of the pathophysiological process and biochemical changes that may be involved in determining depression.

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11 1.10 DEFINITIONS OF TERMS

Table 1.1 Definition of the terms

Variable Variable property Definition

Age (years) Continuous data Number of completed

years from the year of birth

Income (MYR) Continuous data Amount of money

received, especially regularly, for work or through investments.

Gender Categorical data

1) Male 2) Female

Gender according to identification card (IC)

Race Categorical data

1) Malay 2) Chinese 3) Indian

4) Other, specify

Race according to parents and birth certificate as claimed by participants.

Marital status Categorical data 1) Married 2) Single

3) Divorced/Widowed

A state of being married, single, divorced or widowed at the time of interview

Occupational status Categorical data 1) Working 2) Not working

A state of condition person's usual or principal work or business, especially as a means of earning a living

Living arrangement Categorical data 1) Staying alone 2) Staying with family

The way people

organizes how and where they live

Educational status Categorical data 1) Yes 2) No

Level of formal

curriculum/ learning process received by participants from primary education up to a higher level.

Chronic disease Categorical data 1) Yes 2) No

A disease that had been diagnosed by a medical doctor that last 1 year or

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more and require ongoing medical attention.

Smoking Categorical data

a) Yes b) No

A person who currently smokes at least one tobacco product every day, over one month or more.

Exercise Categorical data

a) Yes b) No

Physical activity that a person does to stay healthy or become stronger (Oxford)

History of fall Categorical data a) Yes b) No

A state of a move from a higher to a lower level, rapidly and without control over one year ago.

Depression Categorical data

a) Yes b) No

Based on the Geriatric Depression Scale (GDS) score

Activities of Daily Living (ADL)

Categorical data

a) Marked dependent b) Independent

Functional independence in daily activities. Based on the Modified Barthel Index (MBI) score.

Cognitive impairment Categorical data a) Yes a) No

A cognitive function that impaired in an individual where normal functioning

in society is

affected. Based on the Elderly Cognitive Assessment

Questionnaire (ECAQ) score.

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CHAPTER TWO LITERATURE REVIEW

2.1 PREVALENCE OF DEPRESSION

Older people play important contributions to the family and society. They act as ‘guru’

in society. The majority of them have good mental health, however, they are at risk of developing mental disorders, neurological disorders as well as physical illness such as diabetes mellitus, hypertension, heart problem, hearing loss, and others. Depression is commonly seen in elderly people, but it is often misdiagnosed and undertreated (James, Boyle, Buchman, & Bennett, 2011; Polyakova, Sonnabend, Sander, Mergl, &

Schroeter, 2014; Ratcliff & Chang, 2015).

In the community, the elderly are given higher status due to their age and life experiences. They valued as a knowledgeable person, source of reference for the younger generation, and even a problem solver (Normala, Azlini, Nurul, & Lukman, 2014). World Health Organization (WHO) reported the proportion of the global population with depression estimated at 4.4%. It was the leading cause of disability and the fourth leading contributor to the global burden of disease (WHO, 2017).

In previous studies in Malaysia, the prevalence of depression among elderly in the general population ranged from 10.6% to 30.1% (Aris, Halim, & Musa, 2014; Mohd et al., 2013; Rashid, Manan, 2010; Vanoh, Shahar, Yahya, & Hamid, 2016). Moreover, the results were higher in institutionalized care which ranged from 20.6% to 71.8%

(Khaw, Teo, & Rashid, 2010; Normala, Azlini, Nurul, & Lukman, 2014; Shahar et al., 2011). Elderly living in rural areas showed a high prevalence of depression compared to those living in urban areas (Ibrahim et al., 2013a; Tan & Hematram Yadav, 2012).

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