ELDERLY INPATIENTS

. .

nERPUSTAKAAN KAMPUS KESIAAl~

qt..~fVERSITI SAINS IAM.AYS\A

VALIDATION OF MA'LA Y VERSION SHORT- FORM GERIATRIC DEPRESSION SCALE AND STUDY OF

PREVALENCE OF MA.JOR DEPRESSION AND ITS ASS()CIATED PSYCHC>SOCIAL FACTORS AMONG

ELDERLY INPATIENTS

AT LINIVERSITI SAINS MALAYSIA H()SPITAL

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DR. TEH EWE E()W

Dissertation Submitted In Partial Fulfillment Of The Requirement For The Degree Of

Master Of Medicine (Psychiatry)

LINIVERSITI SA INS MALAYSIA

MAY 2004

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VALIDATION OF MALAY VERSION SHORT-FORM GERIATRIC DEPRESSION SCALE AND STUDY OF

PREVALENCE OF MA.JOR DEPRESSION AND ITS ASS()CIATED PSYCHOSOCIAL FACTORS AMONG

ELDERLY INPATIENTS

AT UNIVERSITI SAINS MALAYSIA H()SPITAL .

B y

DR. TEH EWE EOW

Dissertation Su brnitted In Partial Fulfillment Of The Requirement For The Degree Of

Master Of Medicine (Psychiatry)

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ACKN<>WLEDGEMENTS

i I \vnuld like to express my deepest gratitude to n1y supervisor. Associate Professor Dr

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or llasanah Chc Is1nait llead of Depar·tn1ent of Psychiatry. Universiti Sains Malaysia i

! llospital. for her invaluahle guidance and encouragement throughout the preparation of this

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,~

dissertation.

1 \VOtlld also like to express n1y sincl:rc appreciation and gratitude to Dr Mohd /\yuh llaji Sadiq and Dr Sycd I latin1 Noor (Departn1cnt of C'01nnumity Medicine) lor their guidance

'

f and help in statistics.

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t 1 would also like to thank the I leads of Oepar1n1ent of Medical.. Surgery and Orthopaedic.

""'ll

l lniversiti Sains Malaysia llospital for allowing 1nc to conduct this study at the respective

I

wards. I am also thankful to the lJnivcrsiti Sains Malaysia for supporting this study with the Short-tenn Intensification of Research in Priority Areas Grant (104 I PPSP I 6111261 ).

1 an1 also indehted and grateful to Ycsavage .JA. who originally developed the Geriatric Depression Scale. fron1 Dcpartn1ent of Psychiatry and Rchavioral Sciences. Stanford University Medical Center. USA. for his kind pern1ission to translate. validate and use the scale in 1ny study.

Finally thanks to n1y helovcd wife Dr Pon Kah Min. for her support and encouragcn1cnt

d : through out n1y entire postgraduate study.

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1\ ;

TABLE OF C<lNTENTS

TITLE

ACKN<lWLED<; EMENTS TABLE <lF C<lNTENTS

LIST ()F TABLES LIST <>F FJ<;tiRI~S ABBI~I~VIATH>NS ABSTRACT

En~lish

BHhasa Malaysia

CHAPTER 1 INTR<lDUCTI<>N

1.1 Population Aging in Malaysia

1.2 Syn1pton1atology of Depression in The Elderly l.l Spectnun ol' Depression in The I ·:ldcrly

1.3.1 Non-Clinically Significant Depressive Syn1pton1s 1.3.2 Minor Depression

1.3.3 Major l)cpression

1.4 Clinical ln1plication of Depression in The Elderly 1.5 Prevalence of Depression atnong Elderly Inpatients 1.6 The Under-Recognition of The Condition

1 . 7 Geriatric Depression Scale

Ill

11

Ill

IX

XI

XII

XIII

XV

2 .1 3

4 4

4 5 6 7

'ti

1.7.1 CIDS-lO 1.7.2 CiDS-15

l.R Risk Factors or Geriatric Depression 1.8.1 Psychosocial Factors 1.8.2 Physical Illness

1.9 Interrelations orCicriatric Depression and Its Risk Factors 1.10 Scope or The Study

CIIAPTEH. 2 OB.JECTIYES 2.1

') ')

( icncral < )h.icct i ve Specific Objectives

CIIAPTER 3 METHODOLO(;Y(I): VALIDATION STUDY OF GDS

] .1 Introduction

.1.2 Translation

o r

^GDS

J.J Pretest and Revision or Scales 1.4 Instruments

1.4.1 Mini-Mental State Examination

1.4.2 M<Hltgnmery-Ashcrg Depression Rating Scale 1.4.3 M-(iDS-1 5 and M-CiDS-lO

].5 Study sample

1.6 Procedure J. 7 Data analysis

].7.1 Reliability 1.7.2 Validity

I\"

7 8 9 9 II 12 14

1)

15 15 IR 1 X I R 19 19 19 20 21

22 22 21

24

24

0

•

... ,.

'·

(

CHAPTER 4 METH<>D<>L<>GY (II): PREY A LENCE STUDY <>F MA.J<>R llEPRF:SSION

4.1 Background of Study Centre 4.2 Study Design

4.3 Study Satnple

4.3.1 Smnplc Size 4.3.2 Inclusion Criteria 4.3.3 Exclusion Criteria 4.4 Measures

4.4.1 Depression 4.4.2 Quality of I ,ifc

4.4.3 Psychosocial Variables 4.5 Procedure

4.6 Statistical Analysis

(:IIAPTEI~ 5 RF.SlJLTS (I): VALIDATION STlJDY ^()F GOS 5.1 Validation of M-GDS-15

5 .1.1 Subject Characteristics 5.1.2 M-CiDS-15 Scores

5.1.3 Reliability Analysis of M-GDS-15 5.1.4 Validity Analysis of M-CIDS-15

5.1.5 Response by Different (fender on M-CJDS-15 5.2 Validation of M-(iDS-14

5.2.1 Suggestion of 1\ New Scale. M-GDS-14

v

26

26

27 27

27 27

2R

28 28 29

29 29

31 31 31

32 33 35 43

44

44

•

n

5.2.2 M-CiDS-14 Scores

5.2.3 Reliability Analysis of M-GDS-14 5.2.4 Validity Analysis of M-GDS-14

5 .2.5 Response by Di fTercnt Gender on M-G DS-14 CHAPTER 6 RESULTS (II): PREVALENCE STlJOY <>F MA.JOR

llEPRESSI<>N

6.1 M-CiDS-14 As Measure Of Depression 6.2 Subject Characteristics

6.3 M -G DS-14 Scores

6.4 Prevalence of Major Depression

6.5 llnivariale Analysis uf Psychosocial Risk Factors 6.5.1 Dcn1ographic Characteristics

6.5.2 Socioecon01nic Status 6.5.3 ~ocial Support

6.5.4 Fmnily Role Played

6.5.5 Enviromncntal Social Needs

6.6 Correlation of W110QOL-BREF and M-GDS-14 Scores 6. 7 Prediction Model of Major Depression

(~IIAPTER 7 DISCUSSION

7.1 Validation of GDS

7.2 Prevalence

or

Ma_ior Depression

7.3 Psychosocial Risk Factors of Major Depression 7.4 Quality Of Life and Depressive Syn1pton1s

VI

45 46 48 53 55

55 55 57 58 59 59 65 67 72 74 76 77 80 80 82

•

"

CHAPTER 8 LIMITATI<>NS

8.1 Validation Study of Malay Version GDS 8.2 Prevalence of Major Depression

R.3 Risk Factors for Major Depression CI-IAJlTF.R 9 C<>NCLlJSI<>N

CHAJ>TERl 0 REC<>MMENI>ATI<>NS

1 0.1 Pritnary Prevention -- Pron1otion of Mental 11ealth

10.2 Early Detection- Screening of Elderly Major Depression 1 0.1 Treatn1cnt for Elderly Major Depression

REFERENCES

APPENiliCES

Appendix I (A) Clcncral Questionnaire Appendix I (B) Soalsel id i k l J nuun

Appendix ^II('\) lO-itcn1 Geriatric Depression Scale (GDS-]0) Appendix II (B) Skala Kenntrungan Cicriatrik-)0

Appendix Ill (A) 15-itcn1 Geriatric Depression Scale (GDS-15) Appendix Ill (B) Skala Ken1urungan Geriatrik-15

Appendix IV (A) WI·IOQOL-BRI~I:

Appendix IV (B) Malay Version WII()QOL-BREF

Appendix

v (/\)

Mini-Mental State Fxatnination (MMSE) Appendix V (B) lljian Ringkas Keadaan Mental ( l lhah Suai) Appendix VI rv1ontgon1ery· Asherg Dcprssion Rating Scale

Vtt

90 90 91 92

94 96 96 97 98

101

110 11 ~

t.lo 11 R

120 121 122

125 128 129 1)0

Appendix VII

Appendix VIII

•

DSM-IV Diagnostic Criteria of Major Depressive Episode

DSM-IV Research Criteria of Minor Depressive Disorder

VIII

134

135

IX

LISTS ()F TABLES

-:

'· Table Page

Table 5.1: Den1ographic characteristics of the different clinical depression groups 31 Table 5.2: Internal Consistency & Test-retest Rcliahility for M-GDS-15 34 Table 5.3: Cotnparison of M-GDS-15 individual iten1 positive responses \Vith 36

clinical diagnosis

or

tnajor depression

Table 5.4: Con1parison of M-GDS-15 individual iten1 positive responses with 37 c1 inical diagnosis of significant depression

Table 5.5: The optin1un1 cut-ofT points of M-GDS-15 for nu~jor depression and all ⁴² clinically significant depression

Table 5.6: The optin1ttn1 cut-ofT point for M-GDS-15 for tnajor depression by 43 gender

Table 5.7: The nptimun1 cut-ofT point for M-GDS-15 for al1 clinical1y significant 44

~ depression hy gender

-

^~ : Table 5.8: Internal Consistency & Test-retest Reliability for M-GDS-14 47

~-; Table 5.9: The optinuun cut-oiT points of M-<IDS-14 for tnajor depression and all 52 clinically significant depression

Table 5.10: The optin1un1 cut-oiT point for M-GDS-14 for rnajor depression hy 53 gender

Tahlc 5.11: The optin1un1 cut-oiT point for M-<IDS-14 for all clinically significant 54 depression hy gender

Table 6.1: Statistical analysis - (fender 59

Table (,.2: Statistical analysis ^-Age group 60

Table (,.3: Statistical analysis Fthnic group ⁶¹

Table 6.4: Statistical analysis · Marital status ⁽⁾²

Tnhlc 6.5: Statistical analysis ·- J·:ducational level 63

IJ Tahir 6.6: Statistical analysis- working status 64

"-

t.' X

Tahlc 6.7: Statistical analysis-- Adtnission ward 64

Tahle 6.8: Statistical analysis·· Personal Incon1c 66

Tahle 6.9: Statistical Analysis·· Subject response on financial adequacy 67

•

Ta hie 6.10: Statistical analysis - l.iving accon1pany condition 68

"'

Tahle 6.11: Statistical analysis·- Confiding relationship 69

• Table 6.12: Statistical analysis-- Pritnat)' care giver to ^su~jects when they were sick 70 Table 6.13: Statistical analysis-- Satisl~tction with personal relationship in general 70 Table 6.14: Statistical analysis - Satisn1ction with friends' support 71 T11blc 6.15: Stat.istical analysis- Satisfaction with spouse's support

72

Table 6.16: Statistical analysis- Involvcn1ent in farnily decision

73

Table 6.17: Statistical analysis-· lnvolven1cnt in caring for grandchildren

73

,.

Table 6.1 R: Statistical analysis-- Satisfaction with conditions of living place 74

-

Table 6.19: Statistical analysis- Satisfaction with transport 75

i

Table 6.20: Statistical analysis-- Accessibility to inforn1ation needed 75 Table 6.21: Statistical analysis - Opportunity for leisure activities 76 Table 6.22: Wlf()QOL-BREF scores hy each don1ain and in total 76 Table 6.23: Correlation between Wll()Q()L-BREF scores and M-GDS-14 scores

77

Table 6.24: l,ogistic regression n1odcl of predictors of 111~jor depression an1ong

78

elderly hospitalized patient for physical illness

Xl

LISTS OF Fl(;tJI{F..S

Page Figure

Figure 1.1: lntcrrclntions of a!,!ing. physical illness and depression in elderly 13 Figure 5.1: Distrihution of M-CiDS-15 scores hy gender 32 Figure 5.2: D i stri hut ion of M -Ci DS-1 5 scores hy age group 3 3 Figure 5.3: ROC curve of M-GDS-1 5 for major depression 40 Figure 5.4: ROC curve of M-GDS-1 5 for all clinically significant depression 41

Figure 5.5: Distrihution of M-GDS-14 scores hy gender 45

Figure 5.6: Distrihution of M-GDS-14 scores hy age group 46 Fi~urc 5. 7: R()C curve of M-GDS-14 for n1ajor depression 50

Figure 5.8: ROC curve of M-GDS-14 for all clinically significant depression S 1

Figure 6.1: Suhjccts participated in the study 56

Figure 6.2: Di stri hut ion of M -G DS-14 scores hy the suhj ccts 57 Figure 6.3: Numher of subjects with or without major depression hy gender 58

Figure 6.4: Suhjects ethnic group 60

Figure 6.5: Suhjects maritnl status 61

Figure 6.6: Numher of subjects with or without

rm~jor

depression by educational 62 level

Figur·e (,.7: Working stntus hy gender 6l

Figure (,.8: Numher of suhjccts with or without nwjor depression hy monthh 6:i

personal income ·

Figure 6.9: Number of people live \vith subjects 6R

I

,.

DSM CIDS

11/\M-D lit ISM

l'vt-CIDS MMSE ROC

SD SSRI

Wlf()QC)I,-BREF

'

,.

Diagnostic and Statistical Manual of Mental Disorders

< icriatric Depression Scale

llan1ilton Rating Scale for Depression t lnivcrsiti Sa ins Mcrlaysia llospital

Montgnn1ery-/\sherg Deprssion Rating Scale Malay version Geriatric Depression Scale Mini-Mental State Exmnination

Receiver operating characteristic Standard deviation

Selective serotonin rcuptakc inhihitor

World llealth Organii'.ation Quality of Li fc /\ssessn1ent- Brier Version

XII

X Ill

ABSTRACT

y ALl DATION OF MALAY VERSION SHORT-FORM GERIATRIC DEPRESSION SCALE AND STUDY OF PJU:VALENCE OF MA.JOR DEPRESSION AND ITS ASSOCIATED PSYCHOSOCIAL FACTORS AMONG ELDERLY INPATIENTS AT llNIVERSITI SAINS MALAYSIA IIOSPITAL

Back~round: Depression is prevalent among the elckrly physically ill inpatients and has important clinical implications. but ol'ten under recognized and under treated. There is no previous Malaysian data on the prevalence of major depression among the elderly inpatients.

Ohjcctivrs: This study aimed to validate the Ma1ay version of the short form Geriatric Depression Scale (GDS) in order to determine the prevalence of major depression and its associated psychosocial risk factors among the elderly inpatients hospitalized lor general medical condition.

Methods: The stucly consisted of 2 stages. First, the validation of the Malay versinn- (!f)S: follmvecl by a cross sectional prevalence study. participated hy 271 elderly inpatients. Data were collected using a self-administered questionnaire, the validatecl M:d;₁y vcrsion-CIDS and Wl IOQOI .-13REF. Ma_ior depression was de lined as score above the optimum cut-oiTpninl on Mal;1y version-( iDS determined at the \"<llidation study.

XI\'

Results: The validation study showed the itcn1-9 from Malay vcrsion-GDS-15 had no discrin1inatory value in diJTen.~ntiating cases and non-cases and poorly correlated with the total corrected itcn1 score. By on1itting the iten1-<>. the newly fortned scale, M-GDS-14. has satisf~tctory reliability and validity as a screening scale for depression an1ong physic~lly i1J elderly inpatients. At the cut ofT point of 7/R, the M-GDS-14 had 1 00°/o sensitivity and 92.0'% sp~cilicity in detecting major depression.

The overall prevalence ^f(w n1a.inr d~prcssion was l7.lo/o. 25.9°/o for n1ale and 45.R⁰/o for fcn1alc. Under 1ntlltivariahle analysis. the len1ale to n1alc odds ratio for n1ajor depression was 2.2 (p ⁼⁼ 0.03 ). Those depended on working as the primary source of personal incon1e, were at significant higher risk than pension group for m~jor depression (OR = 7.8). The sci f-rating of relatively having enough rnoncy to n1eet needs, satisfactory personal

"· ^I

relationship. adequate accessibility to inforn1ation needed and opportunity for leisure activities were all significant protective factors against ^nu~jor depression.

Conclusion: The prevalence yielded in this study was relatively high. Clinician should he aware of this highly con1orbid condition along with patients' physical illness. Good social resources play in1portant role in preventing 1najor depression in the elderly inpatients.

Key Words: Geriatric Depression Scale. prcvalc.1ce. n1ajor depression, elderly, inpatient.

physi~al illness.

XV

ABSTRAK

PENGESAIIAN SKALA KEMlll{liN(;AN <;EI~IATRIK SIN<;KAT VEI~SI

MELA YlJ DAN KA.JIAN PREV ALF.NS KF.MlJI~lJNf;AN MA.JOR SERTA

FAKTOR-FAKT<>I~ J>SIKOS<>SIAL VAN(; UF:RKAITAN Ill KALANGAN PESAKIT DALAM YANG TlJA 01 HOSPITAL lJNIVERSITI SAINS MALAYSIA

Lntar Bclakan~: Kcnntrungan adalah lazitn di kalangan pcsakit dalan1 yang tua dan mcn1punyai in1plikasi klinikal yang pcnting. nan1un scring tidak dikcsan dan dinl\vat dengan sc\v,~jarnya. I )ata Malaysia lcrdahulu tcntang prcvalcns kctnurungan n1ajor di kalangan pcsakit dalmn wad yang tua tidak kcdapatan.

Ohjcktif: Kaj ian ini hcrtujuan untuk n1cngcsahkan Skala Kcn1urungan Gcriatrik (GDS) agar diguna dalam pencntuan prcvalens kcn1urungan major scrta faktor-faktor risiko psikososial yang herkaitan dcngannya di kalangan pesakit tua yang masuk hospital kcrana pcnyakit fizikal.

Mctodolo~i: Kajian ini tcrdiri daripada dua pcringkat. Pcrtan1a. pcngcsahan GDS singkat vcrsi Mclayu. diikuti olch kajian prevalcns kcratan lintang yang disertai seramai 271 pcsakit dalam yang tua. Data dikun1pul n1clalui pcngisian scndiri horang soal sclidik~

GDS dan WI-IOQOL-BREr vcrsi Mclayu yang sudah dikesahkan. Ketnurungan m~jor

didcfinisi schagai pcncatatan n1ata yang n1elchihi titik potong optimum pada ODS vcrsi Mclayu yang ditcntukan scn1asa kajian pcngcsahan skala.

XVI

Kcputusnn: K,~jian pcngcsahan n1cnunjukkan soalan kc-9 pada GDS-15 vcrsi Mclayu tidak ada kuusa dalmn mcn1hczakan kcs-kcs kcn1urugan daripada hukan kcs. scrta bcrkordasi lcn1ah dcngan sknr total skala selcpas pcn1hctulan. Dcngan mcninggalkan soalan kc-9. skala haru yang lcrhcntuk. iaitu M-0 DS-14. tncn1punyai rcliahiliti dan kcsahan yang n1cn1uaskan schagai skala untuk mcnyaring kcnn1rungan di kalangan pcsakit tua dalan1 wad yang hcrpcnyakit fizikal. Pada titik potong 7/8. M-GDS-14 mcn1punyai kcpckaan 1 OOo/o dan kckhususan 92.0°/o dalan1 n1cngcsan kcn1urungan n1ajor.

Prcvnlcns kumurungan n1ajor kcscluruhan adalah J7.]o/o. 25.9¹Yo untuk lclaki dan 45.8o/o untuk pcrc1npunn. Dcngan analisa tnultivariahcl. ni~.hah ganjil pcrcn1puan kcpada lclaki untuk kcn1urungan 1najor adalah 2.2 (p :::: 0.03 ). Go Iongan yang bcrgantung kcpada

pckc~jaan untuk sun1hcr utmna pcndapalan diri n1cn1punyai risiko yang lchih tinggi yang signi fikan daripada yang n1cncrin1a pcnccn (OR = 7 .R). Mcn1punyai wang yang cukup untuk 111CI11Cnuhi kcpcrluan. hcrpuas hati dcngan pcrhuhungan pcrihadi. tncndapat pcluang untuk aktiviti riadah scrta hcrpuas hati dcngan pcngangkutan sccm·a rclati f mcngikut pcngkadaran diri. scnnmnya tnerupakan faktor-faktor pclindung tcrhadap kcnntrungan 1najor.

~ ' J<csimpulan: Prcvalcns yang diclapati dalan1 k~jian ini adalah tinggi bcrbanding dengan yang lain. Pakar pcrubatan pcrlu scdar akan kadar pcnyakit kcmurungan yang tinggi di kalangan pcsakit di san1ping n1cnghidapi pcnyakit fizika1. Sun1hcr sosial yang haik mcn1ainkan pcranan renting dalmn lncnccgah kcnlurungan ln~jor di kalangan pcsakit dalan1 wad yang tua.

~:

·..!

CIIAPTER 1 INTR()DtJCTION

1.1 Population Aging in Malaysia

;\s a developing cc untry. the process of dcvclopn1cnt in Malaysia has hrought ahout socioeconotnic as well as detnographic transforn1ation. The elderly population aged 60 years and above is projected to increase by 21 I ⁰/o fron1 1990 to 2020. that is rron1 1.05 111illio11 tO J.26 Jnillion. With I he proportion aged increase fr0111 5. 7°/o tO <)J~⁰/o: While the population aged 70 is projected to increase fron1 0.4 n1illion to 1.2 n1illion across 1990 to 2020 (Karin1 1997). In year 2000. the elderly population (aged 60 years and above) had reached 1.45 tnillion or 6.2°/o of the total population (Kc1ncnterian Kesihatan Malaysia 2000).

The population aging has great implication on the health. The elderly arc. on the whole less healthy than the non-elderly. With the increasing age. the elderly have greater exposure to health risk factors and lessening adaptability (Ehrahin1 1995). They arc at higher risk of n1orbidity and disabilities. particularly frotn the non-communicable, chronic 111edical problcn1 (e.g. cardiova~cular diseases. diabetes n1ellitus, cancer). They are also vulnerable to injuries fron1 the environn1ental hazard. Amon~ the elderly, increasing age is also associated with higher usc of health services and greater demand for specialized services (Davis 1985).

..

a

Apart from or along with physical illness. depression is highly prevalent among elderly people (Beckman et al 1999). There is also an increase on depressive symptoms with age among the elderly (Newman & Engel 1991 ).

1-:lderly hnve rich experiences and skills. have made their contributions in many ,,·ays and that still possess the poll:nti<ll to continlle to do so to t¹1eir l~tmily. society and nation. Acknowledging this. The National Policy For The l·:lderly was launched to enhance their well-being for the rest of their lives. The policy also encourages research studies to obtain information for systemic planning towards the well being of the elderly (Ministry of National lJnity and Social Development).

1.2 Symptomatology of Depression in The E.lderly

Controversy rcma1ns \>v·hether depression in late life differ symptomatically from those at younger age. J·:arlier studies suggested agitation (Winokur et al I 973). somatic symptoms (Nielson & Williams I 9XO. Katon 19X2) and hypochondriacal worries (Ciurland 1976. Pichot & Pull 1981) were common in elderly than younger depressed patients, thus often masked the depression. The believe that depression in late life presents differently from depression at other stages of the life cycle. lead to the view that criteria for diagnosing depression designed for usc in a younger adult population may he inappropriate for elderly subjects.

II

J The studies later~ however. did not confonn to these earlier findings (Blazer ct al 19R7. Bcrkn1at1 et al 1980. Ross & Mirowsky 19S4). Mesetti et al ( 1989) found no excess of agitation. son1atization and hypochondriasis in old age onset depression than the younger depressed patient. Stage et al (200 ^1} also did not find any clinical significant di fTcrences in syn1pton1atology hchveen younger and elderly depressed patients and concluded that the Diagnostic and Statistical Manual of Mental Disorders. Fourth l:dition ( DSM-IV: Atnerican Psychiatric Association 19<>4) concept of Major Depression and The lCD-I 0 Classi lication of Mental and Behavioural Disorders (ICD-1 0: World llcalth Organization 1992) criteria for depression can he used without tnodification for age.

1.3 Spectrum of Depression in The Elderly

The tern1 ·~depression~~ used in different context or literatures n1ay indicate different level of severity across the spcctrun1 of depression.

1.3.1 Non-Clinical Si~nificant Depressive Symptoms

Depressive sytnpton1s arc not uncon1n1on mnong the elderly. hut not all reach the clinical significant level. /\I though the depressed elderly often complain of somatic syn1ptorns such as sleep disturbance. anorexia and weight ^loss~ these symptoms arc less specific tor depression an1ong the elderly.

4

1.3.2 Min or Depression

In epiden1iological studies. n1inor depression is often defined as all depressive syndron1es decn1cd clinically significant. but not fulfilling criteria for major depression (Blazer 1994 ). It is son1ctimcs known as clinically significant non-n1ajor depression

"' (I ,uvretsky 2002). and includes a variety of often ill-defined depressive syndron1e. hut docs not lin1ited to the DSM-IV (1\P/\ 1'.>97) research criteria for minor depressive disorder only.

I.].J Majof llc(lrcssion

Major depression denotes the clinical depressive syndromes that ful fi II rigorous diagnostic criteria. such as DSM-IV diagnostic criteria for n1ajor depressive episode.

1.4 Clinicnllm(llications of Depression in The Elderly

Depression an1ong the elderly is associated with higher prevalence and risk of disability (Alexopoulos et al 1 <>96. Penninx et al 1998). There is also increase evidence that depression is associated with poorer outcon1e in several specific diseases. such as cardiovascular diseases (I ,esperance ct al 2000. F·ush et at 2001) and stroke (Paolucci ct al 2001 ).

•

..

5 The utility of health services and thus the health care cost is also increased with presence of depression an1ong the physically ill elderly (Koenig ct al 1989. Unutzcr et al 1 997~ Bulla et al 2001. Fischer et al 2002. Finkelstein et al 2003) .

Finally. depression in elderly patients increase the mortality. even after adjustn1cnt for sociodcn1ographic characteristics. health status. health behaviours. functional and cognitive in1pairn1cnt (C'ovinsky 1 999. Pcnninx c: al 1999).

1.5 Prevalence of Major Depression among Elderly Inpatients

The prevalence of depression is higher in n1cdically ill h0spitalizcd patients than cotntnunity population. The prevalence rates were usually 2-3 folds higher in studies included all forn1 of clinically significant depression than those limited only to n1ajor depression.

The studies elsewhere f()lmd the prevalence of tn~jor depression in elderly medical inpatients ranged fron1 5.9- 45% (Kok et al 1995. Kitchell et al 1982). This wide variation of prevalence rate narrows down to 5.9 -- 25°/o. when only studies with a structured and validated diagnostic interview arc included (Kok et al 1995~ .Jackson & Baldwin 1993).

Although the reported prevalence of mqjor depression in elderly n1edical inpatients varied.

several studies have reached a consensus of 15'Yo (Katona 1994 ).

6

There is no prevtous study on the prevalence of n1ajor depression an1ong the physically ill elderly inpatients in Malaysia.

1.6 ^{The lJ} ndcr-l~ccognition of The Condition

Despite the high prevalence and serious clinical in1plications. anajor depression an1ong the geriatric inpatients anostly goes on unrecognized and untreated. even though it is a potentially trcatahlc condition. There was only R. 7% of depressed patient identi tied by house staff in one study {Rapp et al I 988).

In another study. the docun1entation rate of depressive syn1pton1s by house staff was only 20°/o. which increased to only 27% after they had hcen informed of the possibility of anajor depn:ssion (Koenig 19R8a).

The usc

or

screening scale such as Oeriatric Depression Scale (C1DS) has been dctnonstrated a hcttcr detection rate of depression than n1edical and nursing staffs in soanc studies ( Rapp cl al 1988. Jackson & Baldwin 1991).

7 1. 7 {;eriatric Depression Scale

1.7.1 GDS-30

GDS is one of the n1ost widely used scales for depression screening an1ong the elderly population. The scale is designed for self-adn1inistration and the original version (GDS-JO) consisted of 30 questions in the fonn of yes I no (Ycsavagc et al 1983). The yes /no question forn1at has the advantage of less confusing to the elderly and ease to adn1inistcr.

The scale was developed with the recognition that depressive sympton1s in elderly patients require an instrUtnent designed to discrilllinate the pattern of depressive syn1pton1s J'rotn the general characteristics

or

the elderly population. During the developtnent

or

^the

scale. it \Vas f(nmd that the son1atic sympt01ns such as sleep disturnance. anorexia. weight loss. cardiac or gastrointestinal sytnptoms. failed to differentiate depressed and non- depressed elderly: thus these syn1ptoms arc not assessed hy the GDS.

During the original validation study. GDS-30 was found to have better internal consistency than two other pre-existing depression rating scales. namely Hamilton Rating Scale for Depression (JIAM-D) and Zung Self-rating Depression Scale (SDS). The test- retest reliability involved 20 suhjects. at nne week apart. \Vith a correlation of O.R5 ( y csavagc ct al 19R3 ). At the cut ofT of II. ( ⁱ DS-30 had R4o/o sensitivity and 95o;₀ SJ'll'Ci licity whereas a cut-ofT

or

¹⁴ decreased the sensitivity rate to R0°/o hut increased the

,.

specificity rate to 100% (Brink ct al 1982). The GDS-30 has been widely validated across different clinical setting. culture and language. (Koenig et al 1988b. Norris ct al 1987.

Cianguli ct al 1999)

1. 7.2 (; DS-15

The GDS-30 had hecn corn1nented to be too lengthy for the elderly especially in acute n1edically ill condition. The sho11er 15 questions version (GDS-15) was later developed for easier used and better acceptability. It takes an average of 5-7 minutes to con1plete and is composed of the 15 items fron1 the original GDS that had the highest correlation with depressive sympto1ns (Sheikh & Ycsavage 1986). The GDS-15 was shown to have high correlation (r = O.R9. p < 0.001) with the original 30 itcn1s version (Lesher & Berry hi II 1994 ).

The GDS-15 has also heen validated across different clinical setting. culture and language (Lesher & Bcrryhdl 1994. IY /\th ct al 1994. A has et al 1998. Liu ct al 1998.

Fountoulakis ct al 1999. de Cracn 2003 ).

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9

I.H l~isk Factors of (;crhttric l>cprcssion

1.8.1 l,sychosocial Factors

(a) Demographic Factors

Epiden1iological studies consistently reported a fen1ale preponderance in depression rates (Weissn1an & Klern1an 1977_ Weissn1an ct al 1993~ Wilhelm et al 1997_

Cole & Dendukuri 2003). However. tht~ gender difference in depression rate tends to narrow down towards older age (Jorn1 1987). The greater social adversity faced by female and age effect has been suggested as possible confounding for this di fferencc.

Sonnenberg et al (2000) exan1ined the gender di fTerences in late-life (aged 55 year and above) depression using stratified san1pling for age and gender~ the finding was the prevalence of depression in fctnale was aln1ost twice as high as in n1ale. Controlling for age and cotnpeting risk f~tctors. the relative risk for fen1ale reduced frotn 1.8 to 1.3~ thus the confounding effects of age and exposure risk only partially explained the effect of sex on depression.

In Sonnenberg et al (2000)_ they included subjects aged fi·on1 55 years and above.

The relative risk of fen1alc to tnalc for depression within the age group of 55-59 years in this study \Vas surprisingly lo\v (0. 71 ). When only considering those age 60 years and ahovc. the relative risk for fcn1ale hecan1c 2.07.

10

The association hetween age and depression has heen controversial. There arc studies found depressive syanptoms increases \Vith age (Newman & Engel J 99 J. Schocvers

ct al 2000). hut others found nodi llcrence (Green 1902. Turvey et al I ⁹⁹⁹⁾ or fewer (Eaton

& Kessler J 9R I. I .ivingston et al 2000). /\I though within the older population. there docs scen1 to he an increase in depressive syn1ptoms with age~ this should he attributed to age- related changes in risk factors. and not to aging it sci f (Beckman 1 999).

Findings regarding n1a.1or depression appe·u to he n1orc consistent that the prevalence decreases with age (Beckman 1999. Blazer 1997). despite one would expect the associated physical frailty and social adversity often encounter at the older old age predispose thcn1 to the greater vulnerahility of n1ajor depression. Koenig et al ( ^J 991 ). in a study of older (age > 70) and younger men admitted to the medical wards of a veterans·

hospital. found a sitnilar overall prevalence of depression. using DSM-IIIR criteria. in the

l\VO groups. Me:1jor depression. \vas however. con1moner in younger patients and minor

depression in the older group.

Most studies did not find being unmarried as risk ntctor for depression in the elderly. hut hercavemcnt wa~ found to he signHicant risk for depression in the old age (Cole & Dendukuri 200] ).

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11

The lower education had hccn in1plicatcd as risk f~1ctor for depression an1ong the old age in son1c studies (I larlow l't nl 1991. Roberts et al 2000). hut others reported no signi licant association (Schoevers ct al 2000. Livingston et al 2000).

(h) Socioeconomic Status and Social Support

Lower incon1e or borderline living expenses were also associated with higher risk of depression in the elderly (Mel forney & Mor 1988. Woo et at 1994).

Poor social support is a recognized associated risk of depression. Living alone. lack

or

confiding relationship and care provider when ill have all heen found to he significant risk of depression for the elderly (Kennedy et al 1989. Woo et at 1994. Beckn1an et at

1995).

Suhjccts with lower socio-cconon1ic status arc exposed to more life-events and have less social support in general. A ftcr controlling for life events and social support.

Murphy ( 191!2) found the association between socio-economic status was no longer

significant.

J.H.2 Physicallllncss

Several specific n1edical conditions have hecn associated with higher risk of depression. The review hy Koenig and Studenski ( 191!1!) found that 30-65% of individuals

12 were depressed in the year following a stroke. Patients with heart attacks were· also at particular high risk of depression (Giassrnan 2002) that prophylactic antidepressant trcatrncnt had been advocated. The association of depression with many other medical conditions such as cancer. Parkinson·s disease. CIH.lncrine and metabolic disorders were also described (Katona 1994 ).

Nevertheless. studies on the relationship of physical i1lness with depression were consistently shown that that the general aspects of physical health have stronger associations with depression than speci fie disease categories (Kinzie et a) 1986, Kennedy ct al 1989. Bcek1nan ct al 1997).

On contro11ing other risk factors. Beekn1an ct a) ( 1997) found that physical health was related to only n1inor depression. but not major depression among the aged population.

Katona ( 1994) in his review also concluded that risk factors for depression within the physically i11 elderly appear sin1ilar to those for depression in old age as a whole.

1.9 Interrelations of Geriatric l)epression and Its Risk Factors

The interrelations hetwecn geriatric depression with aging. physical illness and its psychosocial risk f~tctnrs arc sl1111tnarizcd in the Figure I.

Aging

Physical Illness

I I I T

Geriatric Depression

Psychosocial Mediators:

• Demographic Factors

• Social Adversities

• Disabilities

• Life Events

Figure 1.1: Interrelations of aging, physical illness and depression in elderly 13

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1.10 Scope of The Study

The scope of this dissertation would focus on:

I. Major depression·- the n1ost severe ronn across the spectrun1 of depression~

2. The elderly-- aged 60 years and a hove (follow the definition of The National Policy of The Elderly):

J. Inpatients- during the state or having acute or serious physical illness .

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15

CIIAPTEI~ 2 <>B.JECTIVES

2.1 c;cncral Objective

Validation of the Malay version of the ~hort fonn GDS. the GDS-15 in order to dctern1ine the prevalence of rnajor depression and its associated psychosocial risk factors among the elderly inpatients hospitalized for general n1edical condition at lJniversiti Sains Malaysia llospital (lllJSM} between February to .June 2003.

2.2 Specific ()hjcctivcs

t. To validate the ODS-15 rn elderly inpatients hospitalized for general 1nedical condition.

2. To dctcrn1ine the optimun1 cut off point of the GDS in detecting n1ajor depression.

J. To cxatnine whether rnale and fetnale patients respond differently to the GDS.

4. To detern1inc the prevalence of n1a.1or depression an1ong the elderly inpatients hospitalized for general medical condition at I HJSM.

5. To dctern1ine possihle associations if any. hetwccn psychosocial factors and ¹¹¹ajor depression among the elderly inpatients hospitalized for general n1cdical condition.

"

a) ^{l k mngraphic} ( 'haractcristics

•

^{( icmkr}

•

^Age

•

^{Ethnic group}

•

^{Marital status}

•

^{Educational level}

•

^{Working status}

•

^Admission 'Nard

h) Socioeconomic Status

• Personal income

/\mount

o r

^{monthly personal income}

Primary source

o r

^{personal income}

• Financial adequacy

c) Soci<tl Support

• I ,iving accompany condition Whether living nlone

Number

o r

^{people lived with}

• C onliding relationship

• Care giver i

r

sick

• Personal relationship

Personal relationship in general

!()

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"

Friends· support Spouse support

d) Family Role Played

• Involvement in 1:1mily decision

• Involvement in caring ror grandchiluren

c) I ~n,·ironmcntal Social Needs

• Satisl~tction with cnndit ions of 1 iving place

• Satisl~1ction with transport

• /\cccssihilily to inf<1nn;1tion needed

• Opportunity ror leisure activities

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6. To determine the association between depressive symptoms and quality of life in the clucrly inpatients hnspitali;.cu l'or gcncrnl medical condition.

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CHAPTEI~ J METHODOLOGY (I): VALIDATION STUDY OF GOS

J.l Intr-oduction

The lc1ck or suitable psychometric instruments is a ma_jor problem faced by local researchers in their researches as well as clinicians in their clinical practices. Most or the instruments developed in the West may not he suitable !'or local usc because of' language harriers and cultural dif'lerenccs. These instruments needed to he validated before they could be used locally as proper measures.

The shorter f'orm or CiDS with 15 items was chosen f'or validation because it is relatively simple. short and takes only 5-7 minutes to be self-completed hy respondents.

making it acceptable anu rmctical for usc in the medically ill geriatric patients. Furthermore. many studies had consistently reported CIDS-15 possessed good correlations

\\·ith the original longer version. (iDS-.10. It was also validated cross culturally in studies elsewhere.

12 Translation of GDS

The ODS-30 and GDS-15 was translated into Malay language (denoted as M-GDS- JO. M-GDS-15 hclm·v respectively) using trnnslation and hack translation method. Two schoolteachers who arc bilingual in both Lnglish and Malay translated the CiDS-15 and (i[)S-JO from r·:nglish into Malay. Two medical doctors who arc also bilingual translated

"

..

]C)

the Malay verston hack into English. Both scales. the original and the hack-translated English versions. were compared to determine the accuracy of the translation. with advice from The Centre for Languages and Translation of Universiti Sains Malaysia ("Pusat f3ahasa dan Tct:jcmahan tJnivcrsiti Sains Malaysia"").

.U Pretest and Rt.'\'ision of Scales

The M-C}DS-15 and M-CiDS<IO were tested on 20 elderly patients in the medical mu·ds in lllJSM. l:ach patient was assessed for possible misunderstanding or confusion of items in the scales.

J.4 Instruments

JA.l Mini-Mental Stat<.· F:xamination

The Mini-Mental Stale Lxamination (MMSE) is probably the most widely used measure of cognitive function. It was developed to differentiate organic from functional disorders. and could he used as a quantitative measure of cognitive impairment in an attempt to measure change, but was not for diagnosis sense (Folstein et al I 975). It takes 5-

I 0 minutes to he completed hy a trained rater.

..

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20

The MMSE has a maximum score of 30 points. with di flcrcnt domains assessed:

•

Orientation to time and place (I 0 points)

•

Registration ol three words (3 points)

•

Attention and calculntion () points)

•

^Rccallol'thrcc vvords (l points)

•

^{l.anguagc (R points)}

•

^Visual construction (I point)

/\II the questions must he asked and usually done in sequence. The cut-off point to indicate cognitive impairment is generally between 2.1-25 (Tombaugh & Mcintyre 1992).

3.4.2 MontJ_?;omcr1'-Asherg Depression Rating Scale

Montgnmcry-/\sbcrg Depression Rating Scale (M/\DRS: Montgomery & /\sberg 1 979) is a rating scale

r or

^the assessment or depression. which was drawn lrom a larger scale. the Comprehensive Psychopathological Rating Scale (CPRS). The MADRS consists of I 0 items that arc all core symptoms of depression:

•

^{Apparent sadness}

•

^{Reported sadness}

•

^{Inner tension}

•

^{Reduced sleep}

..

..

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21

•

^Reduced appetite

•

^{C onc.:cntration d i nicul tics}

•

^Lassitude

•

lnahility to lccl

•

^{Pessimistic.: thoughts}

•

^{Suicidal thoughts}

The rating is based on <1 clinical interview <1nd it takes around 20 minutes to he completed hy tr<Jincd raters. The lirst item is the rater's observation nr the patients, the rest arc based upon patient report. Items or the M/\DRS arc rated on a 0 to 6 scale (0 = no abnormality. (J = severe).

The M/\DRS has the advantage over the more commonly utili:t.ed 11/\M-D that it docs not rocus predominantly nn the somatic symptoms ol· depression. thus could he suitahly used in the elderly patients.

JA .. ' M-<;DS-15 and M-GDS-30

Description oi"CJDS-JO and CiDS-15 as in section 1.7.1 and 1.7.2

..

..

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3.5 Study sample

Subjects were 60 inpatients aged 60 years and above from medical. surgical and orthopedic department at lllJSM .

L:xclusion criteria were:

I. Significant cognitive impair111ent (MMSE score< 24/JO).

2. llistnry or presence or severe mental illness. including bipolar mood disorder.

schi/.nphrenia and other psychotic disorder . . ~. l1whility to unders1<1nd Malay language.

4. Patients who arc too ill to participate. 5. Refusal to participate.

Written informed consent was nhtained rrom eligihlc subjects after explained the nature or the study.

16 Procedure

Single researcher. who is trained in psychiatric interview and examination. inter\'ievved all the suh_jects individually. Subjects· cognitive runctinn was assessed using MMSL and only subjects with scnres 241.10 and above were recruited. Subjects \Yere assigned clinical diagnosis as ma_1or depression, mmor depression or no depression.

..

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23

Diagnosis of major depression was made if subjects' clinical features mel for DSM-IV

criteria of major depressive episode. Diagnosis of minor depression was given if subjects were clinically signilicanl depressed hut did not mel the DSM-JV criteria of major depressive episode: this incluued conditions met for J)SM-IV diagnostic criteria of' dysthymic disorder. research criteria lor minor depressive disorder. recurrent brier depressive disorder. Major depression and minor depression were grouped together as all clinically signilicant depression. T11e researcher also rated the subjects depressive symptoms by using M/\DRS. based on the findings <.luring the same interview.

/\11 the 60 subjects were g1ven self-administered translated M-GDS-15 after the clinical interview. Thus. the interviewer was blind to the score of GDS when the clinical di<Jgnosis w<Js nwdc. For those suh.iects who were unable to complete the sci f-rating scale

\\·i1houl assist;1nce. the rese1rcher re;Jd 1he questions orally. clic1ted answers l'rnm the suh.iect <lnd recorded his nr her response. Thirty or the subjects also completed the M- CiDS-10. Fi rty subjects were given M-GDS-15 fnr second administration 2 to 3 days after 1hc li rsl test.

3.7 nata analysis

1);1^1;1 entry and <lJWiysis v,:;1s done using SPSS software version <).0 (Norusis 1999) .

24

3.7.1 Reliability

The internal consistency of the M-GDS-15 was assc~scd using corrected itcnHotal correlation and Cronbach ·s alpha cocrficicnt. Correlation between the total scores of first Clnd second administration of M-CiDS-1) was computed lor test-retest reliability .

. .

3.7.2 Validity

The clinical diagnosis made was the gold standard in classifying subjects into no depression. minor depression or major depression. Individual item validity was tested ag<Jinst the clinical diagnoses using Chi square test (or Fisher's exact Test). To test the hypothesis that the total score of the scale ns n valid indices of depression. Kruskai-Wallis test \\·as used in which the classification vari:1hlc served as a between-subjects 1~1ctor v.·hiil' the subjects' total scores on the M-C i I1S-15 served as the dependent measure.

The corrcllltion between the score on the M-CIDS-15 and M/\DRS was used to indicate concurrent validity. The correlation between total scores on the M-GDS-15 and M-GDS-JO was determined to check M-GDS-15 adequacy to substitute the full scale of 30 i tcms.

The optimum M-CiDS-1 S cut-niT score !'or ma_1or depression (versus ₁wn-major depression) and clinically signilic<Jnt depression (versus no depression) v.:oulcl he (letel·₁₁₁₁^·1,,,tl _... h)' the l~eceivcr Operuting Charw;teristic (ROC) c _{urves separate} 1 _{y. The}