Late-life depression in Peru, Mexico and Venezuela: the 10/66 population-based study

Pilot trial protocol: community intervention to improve depressive symptoms among Peruvian older adults

BACKGROUND

Non-pharmacological interventions have proven effective at alleviating depression and anxiety symptoms in older adults. Methodological refinement and testing of these interventions in new contexts are needed on a small scale before their effectiveness and implementation can be evaluated. The purpose of this pilot study is to assess the feasibility of a future large-scale trial comparing an adapted mental health multi-component evidence-based intervention (VIDACTIVA) versus standard care for older adults experiencing depression symptoms in urban, resource-limited settings in Lima, Peru. Furthermore, this study will explore the acceptability, feasibility, and fidelity of implementing the intervention.

METHODS

We will conduct an open-label, mixed methods pilot feasibility study with two parallel groups. A total of 64 older adults, stratified by sex, will be randomized at a 1:1 ratio to either the "intervention" or "control." Participants will be followed for 22 weeks after enrollment. Those in the intervention group will receive eight VIDACTIVA sessions administered by community health workers (CHWs) over 14 weeks, with an additional eight weeks of follow-up. Participants in the control group will receive two psychoeducation sessions from a study fieldworker and will be directed to health care centers. Standard care does not involve CHWs. We will evaluate screening rates, recruitment strategies, retention rates, the acceptability of randomization, and assessments. Additionally, we will assess preliminary implementation outcomes-acceptability, feasibility, and fidelity-from the perspectives of CHWs (interventionists), older adults (main participants), older adults' relatives, and healthcare professionals.

DISCUSSION

If the findings from this feasibility trial are favorable, a fully powered randomized controlled trial will be conducted to evaluate `both the effectiveness and implementation of the intervention. This research will make a substantial contribution to the field of mental health in older adults, particularly by emphasizing a meticulous examination and documentation of the implementation process. By doing so, this study will offer valuable methodologies and metrics for adapting and assessing mental health interventions tailored to the unique needs of older adults in resource-constrained contexts and diverse cultural settings.

TRIAL REGISTRATION

The current trial registration number is NCT06065020, which was registered on 26th September 2023.

Demographic, socioeconomic and health determinants of depressive symptoms in adults 50 years and older from Mexico: a secondary data longitudinal analysis from the Mexican Health and Aging Study

BACKGROUND

Depression in ageing adults is a public health problem. Worldwide studies have identified social and health risk factors for depressive symptoms. However, little is known about their longitudinal determinants in Mexico.

OBJECTIVES AND SETTING

To find the prevalence of depressive symptoms and their longitudinal individual and contextual risk factors in Mexican adults aged 50 and older.

DESIGN

Secondary data of 6460 persons aged 50 years and older from the Mexican Health and Aging Study were analysed using a 'between-within' panel data analysis approach.

RESULTS

The prevalence of depressive symptoms increased from 35% in 2003 to 38% in 2015. The significantly longitudinal factors associated with these symptoms were getting older (OR 1.02, 95% CI 1.01 to 1.03), being a woman (OR 2.39, 95% CI 2.16 to 2.64), less time spent in formal education (0 years and less than 6 years OR 1.52, 95% CI 1.32 to 1.75 and OR 1.33, 95% CI 1.19 to 1.50, respectively), lower net worth (OR 1.13, 95% CI 1.08 to 1.17), being recently unemployed (OR 1.25, 95% CI 1.10 to 1.25), increased (OR 1.17, 95% CI 1.10 to 1.25) or increasing number (OR 1.23, 95% CI 1.15 to 1.31) of chronic conditions, poor (OR 4.68, 95% CI 4.26 to 5.15) or worsened (OR 1.71, 95% CI 1.61 to 1.81) self-rated health and having impairments on instrumental activities of daily living (IADLs) (OR 2.94 95% CI 2.35 to 3.67) or a new IADL impairment (OR 1.67, 95% CI 1.48 to 1.89), as well as having impairments on ADLs (OR 1.51, 95% CI 1.23 to 1.86) or a new ADL impairment (OR 1.34, 95% CI 1.21 to 1.48).

CONCLUSIONS

The prevalence of depressive symptoms in Mexican adults aged 50 and older is high. Our findings show that they are longitudinally associated with the individual's demographic, socioeconomic, health and disability characteristics. Efforts in public policy should focus on preventing chronic conditions and disability, as well as fighting inequalities to reduce the prevalence of depressive symptoms.

A Novel Indicator to Correct for Individual Reported Heterogeneity. An Application to Self-Evaluation of Later-Life Depression

Program evaluations often investigate complex or multi-dimensional constructs, such as individual opinions or attitudes, by means of ratings. A different interpretation of the same question may affect cross-country comparability, leading to the Differential Item Functioning problem. Anchoring vignettes were introduced in the literature as a way to adjust self-evaluations from this interpersonal incomparability. In this paper, we first introduce a new nonparametric solution to analyse anchoring vignette data, recoding a variable based on a rating scale to a new corrected-variable that guarantees comparability in any cross-country analysis. Then, we exploit the flexibility of a mixture model introduced to account for uncertainty in the response process (the CUP model) to test if the proposed solution is effectively able to remove this reported heterogeneity. This solution is easy to construct and has important advantages compared with the original nonparametric solution adopted with anchoring vignette data. The novel indicator is applied to investigate self-reported depression in an old population. Data that will be analysed come from the second wave of the Survey of Health, Ageing and Retirement in Europe, collected in 2006/2007. Results highlight the need of correcting for reported heterogeneity comparing individual self-evaluations. Once interpersonal incomparability resulting from the different uses of response scales is removed from the self-assessments, some estimates are reversed in magnitude and signs with respect to the analysis of the collected data.

Urbanicity and depression: A global meta-analysis

BACKGROUND

Previous meta-analyses have revealed that in adult and older adult populations of developed countries, depression is more prevalent in urban than rural areas. No meta-analyses have identified the effects of urbanicity on the general age demographic for developing countries. We conducted a meta-analysis of urban-rural differences in depression across all age demographics for developed and developing countries.

METHODS

PubMed and PsycINFO databases were searched for studies published between 1980 and 2020. Studies were included if they reported prevalences of urban and rural depression, or odds ratios comparing urban-rural depression prevalence. Studies were excluded for: nonrepresentative samples, non-standard measures of depression, and reporting continuous outcomes only. Meta-analytic models of urban-rural differences in the odds of depression were conducted across country development levels and age demographics.

RESULTS

From 1597 records screened and 302 full texts assessed for eligibility, 80 studies (N = 539,557) were included for meta-analysis. Urban residence was significantly associated with a higher prevalence of depression in developed countries (OR = 1.30, 95 % CI [1.17, 1.46], z = 4.75, p < .001), which was primarily driven by urban-rural differences in the general population age demographic (OR = 1.37, 95 % CI [1.22, 1.54], z = 5.38, p < .001).

LIMITATIONS

Studies reporting urban-rural differences in depression in terms of continuous symptom severity scores were not included.

CONCLUSIONS

Urbanicity appears to uniquely be associated with a higher prevalence of depression in developed countries, but not in developing countries.

Prevalence of depressive disorder in the adult population of Latin America: a systematic review and meta-analysis

Background

Depressive disorder is one of the leading causes of disability worldwide; however its prevalence and association with inequality and crime is poorly characterised in Latin America. This study aimed to: i. systematically review population-based studies of prevalence of ICD/DSM depressive disorder in Latin America, ii. report pooled regional, country, and sex-specific prevalence estimates, and iii. test its association with four country-level development indicators: human development (HDI), income (Gini) and gender inequality (GII), and intentional homicide rate (IHR).

Methods

We conducted a systematic review and meta-analysis of population-based studies reporting primary data on the prevalence of ICD/DSM depressive disorder in Latin America from 1990 to 2023, irrespective of language. We searched PubMed, PsycINFO, Cochrane Library, SciELO (regional database), LILAC (regional database), and available grey literature. Study quality was assessed using JBI's critical appraisal tools. We generated pooled estimates using random-effects meta-analysis; heterogeneity was assessed using the I2 statistic. Meta-regression analyses were used to test associations of depression prevalence with indicators of inequality and human development. The study was registered with PROSPERO (CRD42019143054).

Findings

Using data from 40 studies in Latin America, lifetime, 12-month, and current prevalence of ICD/DSM depressive disorder were calculated at 12.58% (95% CI 11.00%-14.16%); 5.30% (4.55-6.06%), and 3.12% (2.22-4.03), respectively. Heterogeneity was high across lifetime, 12-month, and current prevalence, sex, and countries. 12-month and current prevalence was associated with higher Gini and GII, 12-month prevalence with lower HDI, and current prevalence with higher IHR.

Interpretation

We found a high prevalence of ICD/DSM depressive disorders in Latin America, and a statistically significant association with inequality and development indicators. The high heterogeneity found across prevalence periods and the major gaps in country representation underscore the need to escalate efforts to improve mental health access and research capabilities in Latin America. Systematic, comparable prevalence estimates would inform more effective decision-making in the region.

Funding

Pfizer Independent Medical Education Grant.

Exploring the natural history of intrinsic capacity impairments: longitudinal patterns in the 10/66 study

BACKGROUND

intrinsic capacity (IC) is a construct encompassing people's physical and mental abilities. There is an implicit link amongst IC domains: cognition, locomotion, nutrition, sensory and psychological. However, little is known about the integration of the domains.

OBJECTIVES

to investigate patterns in the presentation and evolution of IC domain impairments in low-and-middle-income countries and if such patterns were associated with adverse outcomes.

METHODS

secondary analyses of the first two waves of the 10/66 study (population-based surveys conducted in eight urban and four rural catchment areas in Cuba, Dominican Republic, Puerto Rico, Venezuela, Peru, Mexico and China). We applied latent transition analysis on IC to find latent statuses (latent clusters) of IC domain impairments. We evaluated the longitudinal association of the latent statuses with the risk of frailty, disability and mortality, and tested concurrent and predictive validity.

RESULTS

amongst 14,923 participants included, the four latent statuses were: high IC (43%), low deterioration with impaired locomotion (17%), high deterioration without cognitive impairment (22%), and high deterioration with cognitive impairment (18%). A total of 61% of the participants worsened over time, 35% were stable, and 3% improved to a healthier status.Participants with deteriorated IC had a significantly higher risk of frailty, disability and dementia than people with high IC. There was strong concurrent and predictive validity. (Mortality Hazard Ratio = 4.60, 95%CI 4.16; 5.09; Harrel's C = 0.73 (95%CI 0.72;0.74)).

CONCLUSIONS

half of the study population had high IC at baseline, and most participants followed a worsening trend. Four qualitatively different IC statuses or statuses were characterised by low and high levels of deterioration associated with their risk of disability and frailty. Locomotion and cognition impairments showed other trends than psychological and nutrition domains across the latent statuses.

Prevalence of depression and anxiety in older people in low- and middle- income countries in Africa, Asia and South America: A systematic review and meta-analysis

BACKGROUND

There is rapid growth of older people in Low- and Middle- Income Countries (LMICs). The aim of this review was to assess the literature on prevalence of anxiety and depression in this demographic, which to our knowledge, has not yet been conducted.

METHODS

Databases including Medline, PsychInfo, Embase, Scielo and African Journals Online were searched for terms including "mental disorders", "neurotic disorders", "mood disorders" and "anxiety disorders". Studies published between 1990 and 2020 providing data on older people (≥50 years) in LMICs (defined by World Bank Criteria) were included and quality-assessed. Meta-analysis was conducted on a subset of higher-quality studies to derive pooled prevalence estimates of depression.

RESULTS

One hundred and forty relevant studies were identified, of which thirty-two were included in meta-analysis. One hundred and fifteen studies reported depression prevalence only, 19 reported both depression and anxiety, and six reported anxiety only. In all studies identified, depression prevalence ranged from 0.5 % to 62.7 %, and Generalised Anxiety Disorder prevalence ranged from 0.2 % to 32.2 %. The pooled prevalence of depression on meta-analysis was 10.5 % (95 % CI, 8.9 % - 11.2 %). Reported prevalence rates of depression were significantly different in studies using ICD-10 compared with DSM criteria, and between community and clinical settings.

LIMITATIONS

The search strategy contained bias towards English language papers and high income country (HIC) publications. There is significant heterogeneity within the meta-analysis.

DISCUSSION

A wide range of methodologies and clinical criteria are used in prevalence studies of depression and anxiety in older people. Studies using screening tools found higher prevalence rates; clinicians and researchers should ensure diagnosis is made with gold-standard clinical criteria. Meta-analysis data suggest that rates of depression are similar in older people in LMICs compared to HICs but mental healthcare resources are limited, suggesting a large potential treatment gap.

Arrhythmia and other modifiable risk factors in incident dementia and MCI among elderly individuals with low educational levels in Taiwan

Introduction

There is increasing evidence that arrhythmia is a risk factor for dementia; however, it appears that arrhythmia affects the cognitive function of individuals differentially across age groups, races, and educational levels. Demographic differences including educational level have also been found to moderate the effects of modifiable risk factors for cognitive decline.

Methods

This study recruited 1,361 individuals including a group of cognitively unimpaired (CU) individuals, a group of patients with mild cognitive impairment (MCI), and a group of patients with dementia with low education levels. The participants were evaluated in terms of modifiable risk factors for dementia, including arrhythmia and neuropsychiatric symptoms.

Results

Cox proportional hazard regression models revealed that among older MCI patients (>75 years), those with arrhythmia faced an elevated risk of dementia. Among younger MCI patients, those taking anti-hypertensive drugs faced a relatively low risk of dementia. Among younger MCI patients, male sex and higher educational level were associated with an elevated risk of dementia. Among CU individuals, those with coronary heart disease and taking anti-lipid compounds faced an elevated risk of MCI and those with symptoms of depression faced an elevated risk of dementia.

Discussion

The risk and protective factors mentioned above could potentially be used as markers in predicting the onset of dementia in clinical settings, especially for individuals with low educational levels.

Association between food insecurity and perceived stress among older adults (50+) in six low- and middle-income countries

OBJECTIVES

In this study, we assess the relationship between food insecurity andperceived stress among older adults (50+) in six low- and middle-income countries of China, Ghana, India, Mexico, Russia and, South Africa.

METHODS

Cross-sectional comparative analysis was conducted using nationally representative data from the WHO's Study on global AGEing and adult health survey. Bivariate and multivariate regression analyses examine if food insecurity was associated with perceived stress. We also examined the mediating role of health conditions on the association between food insecurity and perceived stress.

RESULTS

Across countries, the mean perceived stress score was higher among the older population with food insecurity. Regression analysis showed significant and positive association between food insecurity and perceived stress. Findings from the pooled data of six countries showed, older adults who experienced severe food insecurity (β = 4.05, p < .001) had higher perceived stress scores. The association was statistically significant in India, Russia, South Africa, and Ghana.

CONCLUSION

Food insecurity showed significant adverse impact on perceived stress among the older population in low- and middle-income countries. Policy measures to reduce household food insecurity are important for improving both mental and physical health conditions of the growing older population in low- and middle-income countries.

The pain and depressive symptoms cascade: A bidirectional analysis of the Mexican Health and Aging Study 2012-2015

OBJECTIVES

The association of pain and depression has not been evaluated in low- and middle-income countries, which have a disproportionate burden of pain compared to high-income countries.

METHODS

Using data from the Mexican Health and Aging Study (baseline, 2012; follow-up, 2015), we examined the bidirectional relationship between pain and depressive symptoms and identified shared predictors among community-dwelling participants ≥60 years (n = 7237). Multivariable logistic regressions models evaluated the association between (1) baseline pain and incident elevated depressive symptoms and (2) baseline depressive symptoms and incident pain, adjusting for demographic, socioeconomic, and health-related factors. Models included inverse probability weights and evaluated interactions by gender.

RESULTS

Participants (55.0% women) were on average 69.1 years old. Over half reported no pain (60.7%) and low/no depressive symptoms (67.9%) in 2012, of which, 20.2% reported elevated depressive symptoms and 25.3% self-reported pain in 2015. Baseline pain was associated with higher odds of incident elevated depressive symptoms (aOR 1.65; 95% CI, 1.41-1.93). Baseline elevated depressive symptoms were associated with higher odds of developing pain (aOR 1.57; 95% CI, 1.32-1.87). Age, gender, self-rated health, and activity of daily living limitations were shared risk factors for pain and elevated depressive symptomatology onset. Although the incidence of elevated depressive symptoms and pain was higher in women, there were no statistically significant interactions.

CONCLUSIONS

Older adults with pain or depression may be at risk for developing the other. These shared predictors could help identify patients in clinical settings, where pain and depression are often overlooked, reducing the cascading risk of this comorbidity.

Sub-national patterns and correlates of depression among adults aged 45 years and older: findings from wave 1 of the Longitudinal Ageing Study in India

BACKGROUND

Depression is a major public health challenge linked with several poor health outcomes and disabilities among adults aged 45 years and older in India. We aimed to describe the prevalence of depression and its association with a variety of sociodemographic correlates and co-existing health conditions for this age group in India and its states.

METHODS

In this prospective cohort study, data from wave 1 (baseline) of the Longitudinal Ageing Study in India were used to estimate the national and subnational state level age-standardised prevalence of depression-major depressive episodes-using the internationally validated Composite International Diagnostic Interview-Short Form (CIDI-SF) scale. Hierarchical mixed effect multivariate logistic regression models were used to study the sociodemographic correlates and co-existing health conditions of major depressive episodes among the nationally representative sample of 72 250 adults aged 45 years and older from 35 states or union territories (except the state of Sikkim). Associations between depression and self-rated health, co-morbid conditions, functional health, and life satisfaction measures were also examined.

FINDINGS

A total of 40 335 (58·3%) females and 29 407 (41·7%) males aged 45 to 116 years (median age 58 years) participated. The overall age-standardised prevalence of depression based on CIDI-SF scale was 5·7% (95% CI 5·5-5·8) compared with 0·5% (0·5-0·6) self-reported prevalence of depression among adults aged 45 years and older in India. Wide sub-national variations were seen in depression prevalence, ranging from 0·8% (95% CI 0·3-1·3) in Mizoram state to 12·9% (11·6-14·2) in Madhya Pradesh. Prevalence was higher in females (6·3% [95% CI 6·1-6·6] vs 4·3% [4·1-4·6]) for India, and this higher prevalence was more pronounced in some of the northern states. The risk of depression was higher in those residing in rural areas, widowed, with no or low education, and in the poorest quintile. Depression showed a strong positive association with poor self-rated health (OR 2·39 [95% CI 2·21-2·59]; p<0·0001), with one or more limitations in the activities of daily living (ADL; OR 1·60 [1·46-1·75]; p<0·0001), instrumental ADL limitations (OR 1·51 [1·40-1·64]; p<0·0001), and low cognitive judgment of life satisfaction (OR 1·94 [95% CI 1·78-2·10]; p<0·0001).

INTERPRETATION

Despite the substantial burden, depression remains undiagnosed and strongly linked with poor health and wellbeing outcomes in adults aged 45 years and older in India. The ageing population of India and the subnational variations amplify the implications of this new evidence to address the substantial gaps in prevention and treatment of depression.

FUNDING

LASI was funded by the Ministry of Health and Family Welfare, Government of India, the National Institute of Ageing, USA and the United Nations Population Fund, India.

Time and gender measurement invariance in the modified Calderon depression scale

Background

Assessing change and comparing groups requires high quality and invariant scales. However, there is limited evidence of simultaneous longitudinal and gender measurement invariance for depression scales. This evidence is even more scant with long-established panel studies from low and middle-income countries.

Methods

In this paper, we used three waves (years 2002, 2005, and 2009) of a nationally representative panel study to examine the psychometric properties of the modified Calderon Depression Scale (CAL-DM)—a one-item exclusion of a depression scale designed for a population residing in a middle-income country (i.e., Mexico). Our analytical sample included 16,868 participants: 7,696 men and 9,172 women. Using Confirmatory Factor Analysis (CFA), we first examined overall fit in each wave, and then we tested time, gender, and time-gender measurement invariance across three waves. We also estimated and compared depression score means by gender and time. Finally, we examined the association between depression scores and self-rated health.

Results

Our analyses indicated the CAL-DM is a robust scale, suitable for time, gender, and time by gender comparisons. Mean comparisons exemplified how the scale can be used as a latent variable or a summative score. Women have higher depression scores than men and the gap is narrowing from 3.4 in 2002 to 2.5 in 2009.

Conclusions

The CAL-DM is a reliable instrument to measure depression in the Mexican general population that can be used for epidemiological research. Our results will contribute to a burgeoning line of research that examines the social determinants of depression, and the risk factors associated with different individuals’ depression trajectories over the life course.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-02007-8.

The depressed frail phenotype as a risk factor for mortality in older adults: A prospective cohort in Peru

INTRODUCTION

Frailty and depression can coexist as depressed frail phenotype, useful for the comprehensive evaluation of older adults and prevention of adverse outcomes. The objective of this study was to evaluate the role of the depressed frail phenotype and its components as risk factors for mortality in older adults of the Centro Médico Naval (CEMENA) of Peru during 2010-2015.

MATERIAL AND METHODS

We carried out a secondary data analysis of a prospective cohort that included older adults (60 years and older) treated in the Geriatrics service of CEMENA between the years 2010-2015. Frailty was defined as the presence of three or more Fried phenotype criteria and depression was determined using a Yesavage ultrashort scale score of three or more. The presence of both conditions was defined as depressed frail phenotype. In addition, sociodemographic characteristics, medical and personal history, and performance-based measures were included. We employed crude and adjusted Cox regression models to evaluate the association of interest and estimate Hazard Ratios (HR) with their respective 95% confidence intervals (95% CI).

RESULTS

946 older adults were included in the analysis, with a mean age of 78.0 ± 8.5 years. 559 (59.1%) were male, 148 (15.6%) were found to be frail, 231 (24.4%) had depressive symptoms, 105 (11.1%) had depressed frail phenotype, and 79 (8.3%) participants died during follow-up. The adjusted Cox regression analysis revealed that depressed frail phenotype (HR = 3.53; 95%CI: 2.07-6.00; p < 0.001) was a risk factor for mortality in older adults.

CONCLUSIONS

The depressed frail phenotype was associated with a higher risk of mortality in older adults. It is necessary to develop longitudinal studies that allow estimating this phenotype's impact on mortality and evaluate interventions to improve quality of life and reduce the risk of adverse outcomes.

A cross-sectional study of potentially modifiable risk factors for dementia and cognitive function in India: A secondary analysis of 10/66, LASI, and SAGE data

OBJECTIVES

Dementia is rising globally, particularly in low-and-middle-income countries. India has almost four million people living with dementia, set to double by 2050. Targeting nine potentially modifiable risk factors (less education, hearing impairment, depression, physical inactivity, hypertension, obesity, smoking, diabetes, and social isolation) could possibly prevent or delay many dementias. We aimed for the first time to examine risk factors for dementia in India and their link with cognitive status and dementia, to inform prioritisation of public health interventions that could prevent or delay dementia.

METHODS

We conducted a cross-sectional analysis using three studies: 10/66 Dementia Study (n = 2004), Longitudinal Aging Study of India (n = 386), and Study of Global Ageing (n = 2441). Our exposures were the nine risk factors above. We calculated a cognitive z-score within each study and used dementia diagnosis in 10/66. We adjusted for socioeconomic factors, age, and sex using multivariable linear for cognition and logistic regression for dementia.

RESULTS

Less education, hearing impairment, depression, and physical inactivity were associated with lower z-scores and increased odds of dementia. Obesity was associated with higher z-score and lower odds of dementia. Social isolation was associated with lower z-scores and decreased odds of dementia. Results for smoking, diabetes, and hypertension were inconsistent.

CONCLUSION

Our risk estimates were larger for less education, hearing impairment and physical inactivity compared to global estimates and should be intervention priorities. This study highlights the need for longitudinal studies to clarify the relationship between these potentially modifiable risk factors and dementia in India.

Intrinsic capacity and its associations with incident dependence and mortality in 10/66 Dementia Research Group studies in Latin America, India, and China: A population-based cohort study

BACKGROUND

The World Health Organization (WHO) has reframed health and healthcare for older people around achieving the goal of healthy ageing. The recent WHO Integrated Care for Older People (ICOPE) guidelines focus on maintaining intrinsic capacity, i.e., addressing declines in neuromusculoskeletal, vitality, sensory, cognitive, psychological, and continence domains, aiming to prevent or delay the onset of dependence. The target group with 1 or more declines in intrinsic capacity (DICs) is broad, and implementation may be challenging in less-resourced settings. We aimed to inform planning by assessing intrinsic capacity prevalence, by characterising the target group, and by validating the general approach-testing hypotheses that DIC was consistently associated with higher risks of incident dependence and death.

METHODS AND FINDINGS

We conducted population-based cohort studies (baseline, 2003-2007) in urban sites in Cuba, Dominican Republic, Puerto Rico, and Venezuela, and rural and urban sites in Peru, Mexico, India, and China. Door-knocking identified eligible participants, aged 65 years and over and normally resident in each geographically defined catchment area. Sociodemographic, behaviour and lifestyle, health, and healthcare utilisation and cost questionnaires, and physical assessments were administered to all participants, with incident dependence and mortality ascertained 3 to 5 years later (2008-2010). In 12 sites in 8 countries, 17,031 participants were surveyed at baseline. Overall mean age was 74.2 years, range of means by site 71.3-76.3 years; 62.4% were female, range 53.4%-67.3%. At baseline, only 30% retained full capacity across all domains. The proportion retaining capacity fell sharply with increasing age, and declines affecting multiple domains were more common. Poverty, morbidity (particularly dementia, depression, and stroke), and disability were concentrated among those with DIC, although only 10% were frail, and a further 9% had needs for care. Hypertension and lifestyle risk factors for chronic disease, and healthcare utilisation and costs, were more evenly distributed in the population. In total, 15,901 participants were included in the mortality cohort (2,602 deaths/53,911 person-years of follow-up), and 12,939 participants in the dependence cohort (1,896 incident cases/38,320 person-years). One or more DICs strongly and independently predicted incident dependence (pooled adjusted subhazard ratio 1.91, 95% CI 1.69-2.17) and death (pooled adjusted hazard ratio 1.66, 95% CI 1.49-1.85). Relative risks were higher for those who were frail, but were also substantially elevated for the much larger sub-groups yet to become frail. Mortality was mainly concentrated in the frail and dependent sub-groups. The main limitations were potential for DIC exposure misclassification and attrition bias.

CONCLUSIONS

In this study we observed a high prevalence of DICs, particularly in older age groups. Those affected had substantially increased risks of dependence and death. Most needs for care arose in those with DIC yet to become frail. Our findings provide some support for the strategy of optimising intrinsic capacity in pursuit of healthy ageing. Implementation at scale requires community-based screening and assessment, and a stepped-care intervention approach, with redefined roles for community healthcare workers and efforts to engage, train, and support them in these tasks. ICOPE might be usefully integrated into community programmes for detecting and case managing chronic diseases including hypertension and diabetes.

Primary care-based screening and management of depression amongst heavy drinking patients: Interim secondary outcomes of a three-country quasi-experimental study in Latin America

INTRODUCTION

Implementation of evidence-based care for heavy drinking and depression remains low in global health systems. We tested the impact of providing community support, training, and clinical packages of varied intensity on depression screening and management for heavy drinking patients in Latin American primary healthcare.

MATERIALS AND METHODS

Quasi-experimental study involving 58 primary healthcare units in Colombia, Mexico and Peru randomized to receive: (1) usual care (control); (2) training using a brief clinical package; (3) community support plus training using a brief clinical package; (4) community support plus training using a standard clinical package. Outcomes were proportion of: (1) heavy drinking patients screened for depression; (2) screen-positive patients receiving appropriate support; (3) all consulting patients screened for depression, irrespective of drinking status.

RESULTS

550/615 identified heavy drinkers were screened for depression (89.4%). 147/230 patients screening positive for depression received appropriate support (64%). Amongst identified heavy drinkers, adjusting for country, sex, age and provider profession, provision of community support and training had no impact on depression activity rates. Intensity of clinical package also did not affect delivery rates, with comparable performance for brief and standard versions. However, amongst all consulting patients, training providers resulted in significantly higher rates of alcohol measurement and in turn higher depression screening rates; 2.7 times higher compared to those not trained.

CONCLUSIONS

Training using a brief clinical package increased depression screening rates in Latin American primary healthcare. It is not possible to determine the effectiveness of community support on depression activity rates due to the impact of COVID-19.

Elevated Depressive Symptoms and the Risk of Stroke among the Mexican Older Population

BACKGROUND/OBJECTIVES

Several longitudinal studies in high-income countries suggest that depression increases stroke risk. However, few prior studies have evaluated this association in low- and middle-income countries (LMICs), where rapidly aging populations may have markedly different vascular risk profiles.

DESIGN

Prospective cohort study.

SETTING

The Mexican Health and Aging Study is a national population-based study of older adults in Mexico.

PARTICIPANTS

A total of 10,693 Mexican adults aged 50 and older enrolled in 2001 with no history of prior stroke.

MEASUREMENTS

Depressive symptoms were assessed with a modified 9-item Centers for Epidemiologic Studies Depression Scale (elevated depressive symptom cutoff ≥5) in 2001 and 2003. We evaluated associations between baseline and short-term (2-year) changes in elevated depressive symptoms (categorized as stable low, recently remitted, recent-onset, or stable high symptoms) with incident self-reported or next-of-kin reported doctor-diagnosed stroke through 2015 using Cox proportional hazards models and sensitivity analyses applying inverse probability weights.

RESULTS

Over an average follow-up of 11.4 years (standard deviation = 4.2), 10,693 respondents reported 546 incident strokes. Individuals with elevated baseline depressive symptoms experienced a moderately higher hazard of incident stroke (hazard ratio [HR] = 1.13; 95% confidence interval [CI] = .95-1.36) compared with those without elevated baseline depressive symptoms. In analyses of short-term changes in elevated depressive symptoms (n = 8,808; 414 incident stokes), participants with recent-onset (HR = 1.38; 95% CI = 1.06-1.81) or stable high (HR = 1.42; 95% CI = 1.10-1.84) elevated depressive symptoms had a greater hazard of incident stroke compared to those with stable low/no depressive symptoms, whereas recently remitted (HR = 1.01; 95% CI = .74-1.37) symptoms was not associated with stroke hazard.

CONCLUSION

Strategies to reduce depressive symptoms merit evaluation as approaches to prevent stroke in middle-income countries. Findings are similar to those in high-income countries but should be replicated in other LMICs.

Longitudinal relationship of diabetes and depressive symptoms in older adults from Mexico: a secondary data analysis

INTRODUCTION

Several studies have argued a causal relationship between diabetes and depression, while others have highlighted that their association is a result of common risk factors. Because Mexico is a country with a high prevalence of diabetes, and diabetes and depression are a frequent comorbidity, we chose this country to investigate the longitudinal relationship of these two conditions, focusing on the influence of demographic, health, and socioeconomic factors which could act as common risk factors for both conditions.

RESEARCH DESIGN AND METHODS

Using the harmonized Mexican Health and Aging Study, a nationally representative sample of adults older than 50 with a response rate of 93%, we analyzed the longitudinal relationship of diabetes and depressive symptoms using 'between-within' random-effects models, focusing on the effect of demographic, socioeconomic and health factors.

RESULTS

While older adults with diabetes reported a higher prevalence of depressive symptoms in the four waves of the study, there was no causal longitudinal association between them once controlling for demographic, socioeconomic and health factors (between-effect OR=0.88, 95% CI 0.77 to 1.01; within-effect OR=0.87, 95% CI 0.69 to 1.11).

CONCLUSIONS

There is no causal longitudinal association between diabetes and depression; the higher prevalence of depression among older adults with diabetes seems a result of socioeconomic and health factors that are not exclusive to respondents with diabetes but are more frequent in this group. Our results highlight the importance of prevention and control of chronic conditions as well as the role of socioeconomic inequalities in mental health.

Is "Busy" Always Better? Time-Use Activities and Depressive Symptoms Among Older Mexican Adults

Background and Objectives

Depression among older Mexican adults is underrecognized and of increasing concern due to its association with comorbidities including cognitive and functional impairments. Prior studies have found an association between low involvement levels in social activities and depression. We aimed to examine the association of time-use activities and depressive symptomatology by sex.

Research Design and Methods

We used data from the 2012 and 2015 waves of the Mexican Health and Aging Study. Participants aged 60 and older who had low or no depressive symptoms in 2012 were included in these analyses (N = 4,309). Factor analysis was used to group activities and logistic regression models were used to assess the association of baseline time use with depressive symptomatology in 2015.

Results

Among those with low or no depressive symptomatology in 2012, 21.0% reported elevated symptoms (5+) in 2015. Those with elevated depressive symptoms were more likely to be women, older, lower educated, and with at least one activity of daily living limitation. Four time-use domains emerged from the factor analysis including hobbies and indoor activities, volunteering, caregiving, and working. The hobbies and indoor activities domain was associated with lower odds of elevated symptoms for men and women (odds ratio [OR]: 0.76, 95% confidence interval [CI]: 0.61–0.96; and OR: 0.75, 95% CI: 0.61–0.91, respectively). Additionally, the volunteer and community activities domain was associated with lower odds of depressive symptoms for women (OR: 0.72, 95% CI: 0.58–0.89) and men (OR: 0.77, 95% CI: 0.60–0.99).

Discussion and Implications

Understanding how older Mexicans distribute their time among different activities and its associations with depressive symptoms can help guide policy and sex-specific interventions for psychological well-being. Certain domains had lower odds for elevated depressive symptomatology; future work should examine this association in other countries as well as the context of the built environment.

Associations between Depression, Depressive Symptoms, and Incidence of Dementia in Latin America: A 10/66 Dementia Research Group Study

BACKGROUND

A growing body of evidence suggests that depression is related to dementia in older adults. Previous research has been done in high-income countries and there is a lack of studies in low- and middle income countries (LMICs).

OBJECTIVE

To examine the relationship between depressive symptoms and incidence of dementia in a population-based study of older adults in Latin America.

METHODS

The study is a part of the 10/66 Dementia Research Group's population survey and includes 11,472 older adults (baseline mean age 74 years) from Cuba, Dominican Republic, Mexico, Peru, Puerto Rico, and Venezuela. The baseline examinations were done in 2003-2007 and the follow-up examinations 4 years later. Semi-structured psychiatric interviews gave information about ICD-10 depression and sub-syndromal depression (i.e., ≥4 depressive symptoms) at baseline. Information on dementia were collected at the follow-up examination. Competing risk models analyzed the associations between depression and incidence of dementia and the final model were adjusted for age, sex, education, stroke, and diabetes. Separate analyses were conducted for each site and then meta-analyzed by means of fixed effect models.

RESULTS

At baseline, the prevalence of depression was 26.0% (n = 2,980): 5.4% had ICD-10 depression and 20.6% sub-syndromal depression. During the follow-up period, 9.3% (n = 862) developed dementia and 14.3% (n = 1,329) deceased. In the pooled analyses, both ICD-10 depression (adjusted sub-hazard ratio (sHR) 1.63, 95% confidence interval (CI) 1.26-2.11) and sub-syndromal depression (adjusted sHR 1.28, 95% CI: 1.09-1.51) were associated with increased incidence of dementia. The Higging I2 tests showed a moderate heterogeneity across the study sites.

CONCLUSION

Our findings suggest that late-life depression is associated with the incidence of dementia in LMICs in Latin America, which support results from earlier studies conducted in high-income countries.

Disability and severe depression among Peruvian older adults: analysis of the Peru Demographic and Family Health Survey, ENDES 2017

BACKGROUND

Depression is considered a mental health-related disability that affects approximately 350 million people worldwide. On the other hand, it is estimated that 15% of the world's population lives with some form of disability, and this scenario is currently riddled with the global burden of mental disorders, non-communicable diseases and other age-related comorbidities.

AIM

To assess the association between disability and depression among Peruvian older adults.

METHODS

We used data from the 2017 Peru Demographic and Familiar Health Survey, with a focus on adults aged 50 years and older. Whereas the presence of disability was assessed using different questions of the survey, depression was measured with the Patient Health Questionnaire-9 (PHQ-9). We calculated the adjusted prevalence ratios (aPR) using Poisson regression models with log link function, with their respective 95% confidence intervals (95% CI).

RESULTS

From the study population, 5% had a disability. In addition, 43.3% were screened positive for depression (13.2% for moderately severe/severe). After adjusting for confounding variables, disability was associated with moderate and severe depression (aPR: 1.06; 95% CI: 1.01-1.11, aPR: 1.10; 95% CI: 1.05-1.15).

CONCLUSION

Disability was positively associated with moderate and severe depression. Public health policies should address the early diagnosis and rehabilitation of patients with any of these problems. Likewise, coping strategies should be promoted among families of persons with disabilities.

Late life depressive symptoms and cognitive function among older Mexican adults: the past and the present

Objective: To evaluate associations between depression and individual cognitive domains and how changes in depressive symptoms relate to cognition three years later in the context of Mexico, a developing country experiencing rapid aging.Method: Data comes from the 2012 and 2015 waves of the Mexican Health and Aging Study (n = 12,898, age 50+). Depression is ascertained using a modified Center for Epidemiologic Studies - Depression Scale. Cognition is assessed using verbal learning, verbal memory, visual scanning, verbal fluency, visuospatial ability, visual memory, and orientation tasks. Depressive symptoms and cognitive functioning were both measured in 2012 and 2015. Scores across cognitive domains are modeled using ordinary least squares regression, adjusting for demographic, health, and economic covariates.Results: When depression and cognition were measured concurrently in 2015, depression exhibited associations with all cognitive domains. When considering a respondent's history of depression, individuals who had elevated depressive symptoms in 2012 and recovered by 2015 continued to exhibit poorer cognitive function in 2015 in verbal learning, verbal memory, visual scanning, and verbal fluency tasks compared to individuals who were neither depressed in 2012 nor 2015.Conclusions: Depression was associated with cognition across cognitive domains among older Mexican adults. Despite improvements in depressive symptomatology, formerly depressed respondents continued to perform worse than their counterparts without a history of depression on several cognitive tasks. In addition to current mental health status, researchers should consider an individual's history of depression when assessing the cognitive functioning of older adults.

Validation of the World Health Organization Disability Assessment Schedule 2.0 among older adults in an Asian country

INTRODUCTION

As populations age globally and the burden of chronic illnesses increases, valid measures of disability are needed for assessment in the older adult population. The aim of the current analysis was to explore the psychometric properties and validity of the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) in an epidemiological survey of older adults in Singapore.

METHODS

The study comprised secondary data analysis of the Well-being of the Singapore Elderly study. Inclusion criteria for the study were Singapore residents (Singapore citizens and permanent residents) aged 60 years and above. The 12-item interviewer-administered version of the WHODAS 2.0 was used to assess disability in the study. Data on cognition, health status and sociodemographic information were collected. Depression was assessed using the Automated Geriatric Examination for Computer Assisted Taxonomy.

RESULTS

The study found a one-factor model solution for WHODAS 2.0 with a high internal consistency of all items. The internal consistency for the overall scale was 0.92. The WHODAS 2.0 score positively correlated with multimorbidity, perceived overall health status, depression and subsyndromal depression. There was a significant inverse association between the WHODAS 2.0 score and the cognitive status. After adjustment for all sociodemographic variables in the multiple linear regression analysis, these measures remained significantly associated with the WHODAS 2.0 score.

CONCLUSION

WHODAS 2.0 was found to be a valid measure of disability among older adults. However, further research is required to determine its usefulness as a responsive instrument that can detect change following interventions.

Population attributable fractions for risk factors for dementia in low-income and middle-income countries: an analysis using cross-sectional survey data

BACKGROUND

Nine potentially modifiable risk factors (less childhood education, midlife hearing loss, hypertension, and obesity, and later-life smoking, depression, physical inactivity, social isolation, and diabetes) account for 35% of worldwide dementia, but most data to calculate these risk factors come from high-income countries only. We aimed to calculate population attributable fractions (PAFs) for dementia in selected low-income and middle-income countries (LMICs) to identify potential dementia prevention targets in these countries.

METHODS

The study was an analysis of cross-sectional data obtained from the 10/66 Dementia Research surveys of representative populations in India, China, and six Latin America countries (Cuba, Dominican Republic, Mexico, Peru, Puerto Rico, and Venezuela), which used identical risk factor ascertainment methods in each country. Between 2004 and 2006 (and between 2007 and 2010 for Puerto Rico), all residents aged 65 years and older in predefined catchment areas were invited to participate in the survey. We used risk factor prevalence estimates from this 10/66 survey data, and relative risk estimates from previous meta-analyses, to calculate PAFs for each risk factor. To account for individuals having overlapping risk factors, we adjusted PAF for communality between risk factors, and used these values to calculate overall weighted PAFs for India, China, and the Latin American sample.

FINDINGS

The overall weighted PAF for potentially modifiable risk factors for dementia was 39·5% (95% CI 37·5-41·6) in China (n=2162 participants), 41·2% (39·1-43·4) in India (n=2004), and 55·8% (54·9-56·7) in our Latin American sample (n=12 865). Five dementia risk factors were more prevalent in these LMICs than worldwide estimates, leading to higher PAFs for dementia: less childhood education (weighted PAF of 10·8% in China, 13·6% in India, and 10·9% in Latin America vs 7·5% worldwide), smoking (14·7%, 6·4%, and 5·7%, respectively, vs 5·5% worldwide), hypertension (6·4%, 4·0%, and 9·3%, vs 2·0%), obesity (5·6%, 2·9%, and 7·9%, vs 0·8%), and diabetes (1·6%, 1·7%, and 3·2%, vs 1·2%).

INTERPRETATION

The dementia prevention potential in India, China, and this sample of Latin American countries is large, and greater than in high-income countries. Less education in early life, hypertension, hearing loss, obesity, and physical inactivity have particularly high PAFs and could be initial targets for dementia prevention strategies.

FUNDING

No funding.

Urban-Rural Differences in Older Adult Depression: A Systematic Review and Meta-analysis of Comparative Studies

CONTEXT

Depression among older adults (aged 60 years or older) is a problem that could be exacerbated by global trends in urbanization and population aging. The study purpose was to assess whether urban, relative to rural, residence is associated with depression among older adults and whether associations differ in countries with developed versus developing economies.

EVIDENCE ACQUISITION

In 2017, the authors identified and extracted information from comparative studies of urban-rural depression prevalence among older adults. Studies were identified in PubMed, PsychINFO, and Web of Science and limited to English language articles published after 1985. Eighteen studies met inclusion criteria. Random effects meta-analysis was conducted to produce weighted pooled ORs estimating the association between urban-rural residence and depression for all study participants (N=31,598) and sub-analyses were conducted for developed (n=12,728) and developing (n=18,870) countries.

EVIDENCE SYNTHESIS

Depression prevalence was significantly higher among urban residents in ten studies and significantly higher among rural residents in three studies (all three conducted in China). Associations between urban-rural residence and depression generally remained significant after adjusting for covariates. In developed countries, the odds of depression were significantly higher among urban than rural residents (pooled OR=1.44, 95% CI=1.10, 1.88). However, in developing countries, this association was not observed (pooled OR=0.91, 95% CI=0.46, 1.77).

CONCLUSIONS

Converging trends of urbanization and population aging could increase the global burden of depression among older adults. The pathways through which urban-rural residence influences depression risk among older adults might differ by country context. Future research should focus on measuring variation in these contexts.

The prevalence of late-life depression in a Portuguese community sample: A 10/66 Dementia Research Group study

BACKGROUND

Late life depression is associated with a significant burden of disease. Estimating depression in older adults can be difficult and requires different methodological approaches from those fitting younger adults. As community prevalence data is scarce in Portugal, we estimated the prevalence of depression in a sample of older Portuguese adults. Moreover, we investigated the association between depression and disability.

METHODS

A cross-sectional comprehensive one-phase survey was conducted of all residents aged 65 and over of one urban and one rural catchment area in Southern Portugal. Standardized 10/66 assessments include a comprehensive cognitive module and the Geriatric Mental State (GMS)-AGECAT. Information on demographics, non-communicable disease risk factors and disability/functioning (WHODAS 2.0) was also recorded. Depression was assessed using both ICD-10 and EURO-D criteria.

RESULTS

We interviewed 1405 older people (mean age 74.9, SD = 6.7 years; 55.5% women) after 313 (18.2%) refusals to participate. The prevalence rate for ICD-10 depression was 4.4 (95% CI 3.5-5.6) and 18.0 (95% CI 16.0-20.1) using the EURO-D case definition. As compared with having no depression, ICD-10 depression was associated with a higher level of disability, even after adjusting for confounders (4.8, 95% CI 2.8-8.1). The same happened with subsyndromal depression ('EURO-D only') cases (2.2, 95% CI 1.4-3.5).

LIMITATIONS

Non-generalisability of findings outside of catchment areas.

CONCLUSIONS

In this sample of older Portuguese people, the prevalence of depression was high and so were the associated levels of disability. EURO-D diagnoses may provide a better picture of clinically significant old age depression as a basis for health and social service planning.

Dependence- and Disability-Free Life Expectancy Across Eight Low- and Middle-Income Countries: A 10/66 Study

Objective: The objective of this study was to estimate healthy life expectancies in eight low- and middle-income countries (LMICs), using two indicators: disability-free life expectancy (DFLE) and dependence-free life expectancy (DepFLE). Method: Using the Sullivan method, healthy life expectancy was calculated based on the prevalence of dependence and disability from the 10/66 cohort study, which included 16,990 people aged 65 or above in China, Cuba, Dominican Republic, India, Mexico, Peru, Puerto Rico, and Venezuela, and country-specific life tables from the World Population Prospects 2017. Results: DFLE and DepFLE declined with older age across all sites and were higher in women than men. Mexico reported the highest DFLE at age 65 for men (15.4, SE = 0.5) and women (16.5, SE = 0.4), whereas India had the lowest with (11.5, SE = 0.3) in men and women (11.7, SE = 0.4). Discussion: Healthy life expectancy based on disability and dependency can be a critical indicator for aging research and policy planning in LMICs.

Poverty, deprivation, and depressive symptoms among older adults in Hong Kong

OBJECTIVES

Examine the association of income poverty and material deprivation with depression in old age.

METHODS

Our data contains a survey of 1,959 older Chinese adults in Hong Kong. We used the Geriatric Depression Scale - Short Form to assess their depressive symptoms. Income poverty was defined as having household income below half the median household income (adjusted by household size); material deprivation was measured by a validated 28-item material deprivation. In addition to income poverty and material deprivation, we also assessed the effect of socio-demographic variables, financial strain, health indicators, and social and community resources on depressive symptoms.

RESULTS

Those who experienced material deprivation reported a significantly more severe depressive symptoms, even after income poverty and all other covariates were controlled for; the bivariate association between income poverty and depressive symptoms disappeared once material deprivation was controlled for. Further, we found a significant interaction effect between income poverty and material deprivation on depressive symptoms; and both engagement in cultural activities and neighborhood collective efficacy moderated the impact of being materially deprived on depressive symptoms.

CONCLUSION

Our results have important policy implications for the measurement of poverty and for the development of anti-poverty measures for materially deprived older adults.

A review of the 10/66 dementia research group

BACKGROUND

In this review we discuss how the study of dementia epidemiology in Low- and Middle-Income Countries (LMICs) has changed in the last 20 years, and specifically to review the evidence created by the 10/66 Dementia Research Group (DRG) and discuss future directions for research.

METHODS

We identified and collated all the papers related to the 10/66 Dementia Research Group, including papers from groups who adopted the 10/66 methodology, that have been published in peer-reviewed journals.

RESULTS

Over 200 papers including data from Africa, Asia, Europe and Latin America and the Caribbean were identified by this review. Many of the findings revolved around the epidemiology of dementia, mental health and non-communicable diseases, including the cross-cultural development and validation of measurement tools of cognition and functioning, need for care, care arrangements and mental health. Social ageing, care dependence and caregiver interventions were also topics that the group had published on.

DISCUSSION

A body of evidence has been generated that has challenged the view, prevalent when the group started, that dementia is comparatively rare in LMICs. The experience of the 10/66 DRG has shown that descriptive epidemiological research can be important and impactful, where few data exist. Monitoring population trends in the prevalence and incidence of dementia may be our best chance to confirm hypotheses regarding modifiable risk factors of dementia.

Family status and later-life depression among older adults in urban Latin America and the Caribbean

Rapid fertility declines in Latin American and Caribbean countries since the 1960s have contributed to smaller family sizes among the current cohorts of older adults. This may have mental health implications in these societies as the family unit is highly valued as a source of social support. Utilising data from the 2000 Survey of Health, Well-being and Aging in Latin America and the Caribbean (SABE), this study examines the association between parental status, marital status and the likelihood of experiencing depressive symptoms among adults 60 years and older in seven cities within Latin America and the Caribbean (N = 9,756): Buenos Aires, Bridgetown, São Paulo, Santiago, Havana, Mexico City and Montevideo. Results from multivariate logistic regressions indicate that parental status is not significantly associated with depressive symptoms. Nonetheless, unmarried older adults, both those living alone and those living with others, are more vulnerable to experiencing depressive symptoms than their married counterparts. Marriage is especially protective for older adults in Havana and Montevideo. Older adults’ perceived income adequacy significantly moderates the relationship between marital status and depressive symptoms. Other significant covariates, such as experiencing disability and comorbidity, showed positive associations with depressive symptoms. While families may still represent a critical component for the mental health of older adults, broader investments in health across the lifespan are needed to improve individual psychological wellbeing.

Depressive spectrum states in a population-based cohort of 70-year olds followed over 9 years

OBJECTIVE

Depression may be understood as a spectrum of more or less symptomatic states. Little is known about the long-term course of these states in older populations. We examined the prevalence and course of depressive states of different severity in a Swedish population sample of older people followed over 9 years.

METHODS

A population-based sample of 70-year olds without dementia (N = 563, response rate 71.1%) underwent a psychiatric examination; 450 survivors without dementia were reexamined at ages 75 and/or 79 years. Three depressive spectrum states were defined: major depression (MD), minor depression (MIND), and subsyndromal depression (SSD).

RESULTS

The cumulative 9-year prevalence of any depressive spectrum state was 55.3% (MD 9.3%, MIND 27.6%, SSD 30.9%). The cross-sectional prevalence increased with age, especially for MIND and SSD. Among those with baseline MD and MIND, 75.0% and 66.7%, respectively, had MD or MIND during follow-up. Among those with SSD, 47.2% had SSD also during follow-up and 36.1% had MD or MIND. Among those with MD during follow-up, 63.1% were in a depressive spectrum state at baseline. The corresponding proportion was 30% for those with MIND (but no MD) during follow-up.

CONCLUSION

In this population-based sample, over half experienced some degree of depression during their eighth decade of life. The findings give some support for the validity of a depressive spectrum in older adults. Most new episodes of major depression occurred in people who were in a depressive spectrum state already at baseline, which may have implications for late-life depression prevention strategies.

Role of mHealth in overcoming the occurrence of post-stroke depression

Depression associated with stroke affects roughly one-third of stroke survivors. Post-stroke depression (PSD) is thought to adversely influence functional outcome by limiting participation in rehabilitation, decreasing physical, social, and cognitive function, and affecting neuroplasticity thereby placing stroke survivors at high risk for future vascular events. PSD has also been associated with higher mortality rates after stroke. In Peru, a country where there is no national stroke program and mental health disorders are largely underdiagnosed and untreated, people with PSD are likely to be further challenged by dependency and impoverished conditions that will limit their use of ambulatory services, leading to inadequate clinical follow-up. In this scenario, mobile health (mHealth) technology offers a promising approach to extend access to high-quality and culturally tailored evidence-based psychological care to address PSD given that cell phone use, Internet connectivity, and digital health technology have met a rapid growth in the last years and thus contribute to the attainment of broader Sustainable Development Goals (SDGs). The limited evidence of the effectiveness of mHealth for PSD calls for researchers to fill a knowledge gap where Peru poses as an ideal setting because rapid expansion of digital technology and current mental healthcare reform could be leveraged to enhance post-stroke outcomes. This article proposes the rationale for a suitable evidence-driven, mHealth-based, PSD self-management intervention called iMOODS-Investigating the role of mHealth in overcoming occurrence of depression after stroke-that could be tested among recent stroke patients with PSD in resource constrained settings.

Poverty and disability in low- and middle-income countries: A systematic review

INTRODUCTION

Disability and poverty are believed to operate in a cycle, with each reinforcing the other. While agreement on the existence of a link is strong, robust empirical evidence substantiating and describing this potential association is lacking. Consequently, a systematic review was undertaken to explore the relationship between disability and economic poverty, with a focus on the situation in low and middle income countries (LMICs).

METHODS

Ten electronic databases were searched to retrieve studies of any epidemiological design, published between 1990-March 2016 with data comparing the level of poverty between people with and without disabilities in LMICs (World Bank classifications). Poverty was defined using economic measures (e.g. assets, income), while disability included both broad assessments (e.g. self-reported functional or activity limitations) and specific impairments/disorders. Data extracted included: measures of association between disability and poverty, population characteristics and study characteristics. Proportions of studies finding positive, negative, null or mixed associations between poverty and disability were then disaggregated by population and study characteristics.

RESULTS

From the 15,500 records retrieved and screened, 150 studies were included in the final sample. Almost half of included studies were conducted in China, India or Brazil (n = 70, 47%). Most studies were cross-sectional in design (n = 124, 83%), focussed on specific impairment types (n = 115, 77%) and used income as the measure for economic poverty (n = 82, 55%). 122 studies (81%) found evidence of a positive association between disability and a poverty marker. This relationship persisted when results were disaggregated by gender, measure of poverty used and impairment types. By country income group at the time of data collection, the proportion of country-level analyses with a positive association increased with the rising income level, with 59% of low-income, 67% of lower-middle and 72% of upper-middle income countries finding a positive relationship. By age group, the proportion of studies reporting a positive association between disability and poverty was lowest for older adults and highest for working-age adults (69% vs. 86%).

CONCLUSIONS

There is strong evidence for a link between disability and poverty in LMICs and an urgent need for further research and programmatic/policy action to break the cycle.

Confounding and Statistical Significance of Indirect Effects: Childhood Adversity, Education, Smoking, and Anxious and Depressive Symptomatology

The life course perspective, the risky families model, and stress-and-coping models provide the rationale for assessing the role of smoking as a mediator in the association between childhood adversity and anxious and depressive symptomatology (ADS) in adulthood. However, no previous study has assessed the independent mediating role of smoking in the association between childhood adversity and ADS in adulthood. Moreover, the importance of mediator-response confounding variables has rarely been demonstrated empirically in social and psychiatric epidemiology. The aim of this paper was to (i) assess the mediating role of smoking in adulthood in the association between childhood adversity and ADS in adulthood, and (ii) assess the change in estimates due to different mediator-response confounding factors (education, alcohol intake, and social support). The present analysis used data collected from 1994 to 2008 within the framework of the Tromsø Study (N = 4,530), a representative prospective cohort study of men and women. Seven childhood adversities (low mother's education, low father's education, low financial conditions, exposure to passive smoke, psychological abuse, physical abuse, and substance abuse distress) were used to create a childhood adversity score. Smoking status was measured at a mean age of 54.7 years (Tromsø IV), and ADS in adulthood was measured at a mean age of 61.7 years (Tromsø V). Mediation analysis was used to assess the indirect effect and the proportion of mediated effect (%) of childhood adversity on ADS in adulthood via smoking in adulthood. The test-retest reliability of smoking was good (Kappa: 0.67, 95% CI: 0.63; 0.71) in this sample. Childhood adversity was associated with a 10% increased risk of smoking in adulthood (Relative risk: 1.10, 95% CI: 1.03; 1.18), and both childhood adversity and smoking in adulthood were associated with greater levels of ADS in adulthood (p < 0.001). Smoking in adulthood did not significantly mediate the association between childhood adversity and ADS in adulthood. However, when education was excluded as a mediator-response confounding variable, the indirect effect of childhood adversity on ADS in adulthood was statistically significant (p < 0.05). This study shows that a careful inclusion of potential confounding variables is important when assessing mediation.

Risk factors for late-life depression and correlates of antidepressant use in Costa Rica: Results from a nationally-representative longitudinal survey of older adults

BACKGROUND

Risk factors for late-life depression have been studied in high-income countries, but there have been no longitudinal studies from middle-income countries. This study reports risk factors for late-life depression and correlates of antidepressant using the Costa Rican Longevity and Healthy Aging Study (CRELES), a nationally representative cohort of adults age 60 and over.

METHODS

CRELES contains baseline interviews in 2005 (n=2827) with follow-up interviews in 2007 and 2009. CRELES used the Geriatric Depression Scale Short Form to identify depression using cut-offs for mild and severe depression and contained a 14-question assessment to determine physical disability. Participants self-reported antidepressant use and chronic health conditions. We examined correlates of newly screened depression and new antidepressant use among participants not depressed or not using antidepressants in the previous study wave. We used generalized estimating equations to estimate the association among variables.

RESULTS

Increases in disability were associated with newly screening for mild and severe depression. New medical conditions and recent widowhood were associated with newly screening for severe depression. Recent widowhood was also associated with new use of antidepressant medication.

LIMITATIONS

Limitations of this study include absence of persons living in institutions, inconsistency of screening tools with clinical diagnoses, and possible effects of stigma and recall bias on screening.

CONCLUSIONS

Risk factors for late-life depression in Costa Rica are similar to risk factors in high-income countries. Patterns of antidepressant use suggest providers may recognize the role of bereavement as a risk factor for late-life depression but not of disability or chronic conditions.

Type 2 diabetes mellitus as a risk factor for dementia in a Mexican population

INTRODUCTION

Type 2 diabetes mellitus (T2DM) and dementia increase with age. Different studies have explored their association, but the possible relationship between them is still unclear.

METHODS

This is an analysis of the 10/66 Dementia Research Group (DRG) Mexico database; the sample comprised 1193 subjects ≥65 years old followed-up for three years. We calculated the incidence of dementia in subjects with diabetes using three models of analysis.

RESULTS

T2DM patients have nearly twice the risk of developing dementia (RR 1.9; 95% CI 1.3-2.6) after three years of follow-up. The incidence of dementia is higher in subjects with undiagnosed diabetes. Higher serum glucose levels have a stronger association with dementia.

CONCLUSIONS

It is important to implement early evaluation and monitoring cognitive performance in elders with diabetes to identify minor cognitive impairment and undertake timely interventions to prevent or delay the onset of dementia.

Development of a brief assessment and algorithm for ascertaining dementia in low-income and middle-income countries: the 10/66 short dementia diagnostic schedule

OBJECTIVES

To develop and evaluate a short version of the 10/66 dementia diagnostic schedule for use in low-income and middle-income countries.

DESIGN

Split-half analysis for algorithm development and testing; cross-evaluation of short-schedule and standard-schedule algorithms in 12 community surveys.

SETTINGS

(1) The 10/66 pilot sample data set of people aged 60 years and over in 25 international centres each recruiting the following samples: (a) dementia; (b) depression, no dementia; (c) no dementia, high education and (d) no dementia, low education. (2) Cross-sectional surveys of people aged 65 years or more from 12 urban and rural sites in 8 countries (Cuba, Dominican Republic, Peru, Mexico, Venezuela, India, China and Puerto Rico).

PARTICIPANTS

In the 10/66 pilot samples, the algorithm for the short schedule was developed in 1218 participants and tested in 1211 randomly selected participants; it was evaluated against the algorithm for the standard 10/66 schedule in 16 536 survey participants.

OUTCOME MEASURES

The short diagnostic schedule was derived from the Community Screening Instrument for Dementia, the CERAD 10-word list recall task and the Euro-D depression screen; it was evaluated against clinically assigned groups in the pilot data and against the standard schedule (using the Geriatric Mental State (GMS) rather than Euro-D) in the surveys.

RESULTS

In the pilot test sample, the short-schedule algorithm ascertained dementia with 94.2% sensitivity. Specificities were 80.2% in depression, 96.6% in the high-education group and 92.7% in the low-education group. In survey samples, it coincided with standard algorithm dementia classifications with over 95% accuracy in most sites. Estimated dementia prevalences in the survey samples were not consistently higher or lower using the short compared to standard schedule.

CONCLUSIONS

For epidemiological studies of dementia in low-income and middle-income settings where the GMS interview (and/or interviewer training required) is not feasible, the short 10/66 schedule and algorithm provide an alternative with acceptable levels of performance.

Prevalence of Depression among Older Adults—Results from the Well-being of the Singapore Elderly Study

Introduction: Depression is a significant public health issue across all sociodemographic groups and is identified as a common and serious mental health problem particularly among the older adult population. The aims of the current study were to determine the prevalence of depression and subsyndromal depression among older adults in Singapore. Materials and Methods: The Well-being of the Singapore Elderly (WiSE) study was a comprehensive single phase, cross-sectional survey. Stage 1 Geriatric Mental State-Automated Geriatric Examination for Computer Assisted Taxonomy (GMS-AGECAT) depression syndrome was used for this analysis. Association of depression and subsyndromal depression with sociodemographic characteristics, social support as well as comorbidity with chronic physical illnesses and quality of life was assessed. Results: The prevalence of GMS-AGECAT depression and subsyndromal depression was 3.7% and 13.4%, respectively. The odds of depression were significantly higher among those aged 75 to 84 (2.1) as compared to those aged 60 to 74 years and in those who had a history of depression diagnosis by a doctor (4.1). The odds of depression were higher among those of Indian and Malay ethnicities (5.2 and 3.2 times, respectively) as compared to those of Chinese ethnicity. Those with depression and subsyndromal depression were associated with more disability, poorer life satisfaction, and medical comorbidities. Conclusion: Our study suggests that the prevalence of depression seems to have decreased as compared to a decade ago wherein the prevalence of depression was estimated to be 5.5%. This positive trend can be ascribed to concerted efforts across various disciplines and sectors, which need to be continually strengthened, monitored and evaluated. Key words: Comorbidity, GMS-AGECAT, Social support, Subsyndromal depression

A comparative cross-cultural study of the prevalence of late life depression in low and middle income countries

BACKGROUND

Current estimates of the prevalence of depression in later life mostly arise from studies carried out in Europe, North America and Asia. In this study we aimed to measure the prevalence of depression using a standardised method in a number of low and middle income countries (LMIC).

METHODS

A one-phase cross-sectional survey involving over 17,000 participants aged 65 years and over living in urban and rural catchment areas in 13 sites from 9 countries (Cuba, Dominican Republic, Puerto Rico, Mexico, Venezuela, Peru, China, India and Nigeria). Depression was assessed and compared using ICD-10 and EURO-D criteria.

RESULTS

Depression prevalence varied across sites according to diagnostic criteria. The lowest prevalence was observed for ICD-10 depressive episode (0.3 to 13.8%). When using the EURO-D depression scale, the prevalence was higher and ranged from 1.0% to 38.6%. The crude prevalence was particularly high in the Dominican Republic and in rural India. ICD-10 depression was also associated with increased age and being female.

LIMITATIONS

Generalisability of findings outside of catchment areas is difficult to assess.

CONCLUSIONS

Late life depression is burdensome, and common in LMIC. However its prevalence varies from culture to culture; its diagnosis poses a significant challenge and requires proper recognition of its expression.

Depressive Symptoms Affect Working Memory in Healthy Older Adult Hispanics

OBJECTIVES

Low and middle income nations will experience an unprecedented growth of the elderly population and subsequent increase in age-related neurological disorders. Worldwide prevalence and incidence of all-types of neurological disorders with serious mental health complications will increase with life expectancy across the globe. One-in- ten individuals over 75 has at least moderate cognitive impairment. Prevalence of cognitive impairment doubles every 5 years thereafter. Latin America's population of older adult's 65 years and older is growing rapidly, yet little is known about cognitive aging among healthy older Latinos. Clinically significant depressive symptomatology is common among community-dwelling older adults and is associated with deficits across multiple cognitive domains, however much of the literature has not modeled the unique effects of depression distinct from negative and low positive affect. Our objective was to understand how mental health affects cognitive health in healthy aging Latinos.

METHODS

The present study used confirmatory factor analysis (CFA) and structural equation modeling (SEM) to examine the relative effects of Negative Affect, Positive Affect and Geriatric Depression on Verbal Memory, Verbal Reasoning, Processing Speed, and Working Memory in healthy aging Latinos. Data was collected from a sample of healthy community dwelling older adults living in San Jose, Costa Rica. Modeling of latent variables attenuated error and improved measurement reliability of cognition, affect, and depression variables.

RESULTS

Costa Ricans enjoy a notoriety for being much happier than US citizens and are renowned as one of the happiest nations in the world in global surveys. This was born out in these data. Costa Rican affective profiles differed substantively from US profiles. Levels of negative affect and depression were similar to US samples, but their levels of positive affect were much higher. Cognitive performance of these Costa Rican older adults was similar to US-age and education matched peers. CFA and SEM found that increased depressive symptomatology had deleterious effects on Working Memory made up of subtest scores sampling simple attention and vigilance for numbers. Verbal Memory, Verbal Reasoning, and Processing Speed were not affected by self-reported Positive Affect, Negative Affect or Depressive symptoms.

CONCLUSION

Costa Rican older adults were happy, as evidenced by the high ratio of positive affect to relatively low negative affect. Thus, we were somewhat surprised to find that depressive symptoms were selectively correlated to decrements in working memory and that negative and positive affect contributed negligible amounts of variance to any of the cognitive factors. Because of the methodological rigor of latent variable analysis, these results are very specific. The Working Memory factor is not contaminated with Speed of Processing or other measured cognitive factors. Likewise, the measured Geriatric Depression represents symptoms that are richly cognitive, not overtly affective.

Participation in Physical, Social, and Religious Activity and Risk of Depression in the Elderly: A Community-Based Three-Year Longitudinal Study in Korea

BACKGROUND

We examined the longitudinal association between participation in individual or combinations of physical, social, and religious activity and risk of depression in the elderly.

METHODS

Elderly subjects aged ≥ 60 years who completed the Living Profiles of Older People Survey in Korea (n = 6,647) were included. The baseline assessment, Wave 1, was conducted in 2008, and a follow-up assessment, Wave 2, was conducted in 2011. We defined participation in frequent physical activity as ≥ 3 times weekly (at least 30 minutes per activity). Frequent participation in social and religious activity was defined as ≥ 1 activity weekly. The primary outcome was depression at 3-year follow up.

RESULTS

Multivariable logistic regression analysis showed that subjects who participated in frequent physical, social, and religious activity had an adjusted odds ratio of 0.81 (95% confidence interval [CI], 0.69-0.96), 0.87 (95% CI, 0.75-1.00), and 0.78 (95% CI, 0.67-0.90), respectively, compared with participants who did not participate in each activity. Participants who participated in only one type of activity frequently and participants who participated in two or three types of activities frequently had an adjusted odds ratio of 0.86 (95% CI, 0.75-0.98) and 0.64 (95% CI, 0.52-0.79), respectively, compared with participants who did not participate in any type of physical, social, and religious activity frequently.

CONCLUSION

Participation in physical, social, and religious activity was associated with decreased risk of depression in the elderly. In addition, risk of depression was much lower in the elderly people who participated in two or three of the above-mentioned types of activity than that in the elderly who did not.

Prevalence and risk factors for depression among community resident older people in Kerala

BACKGROUND

Depression is the most common mental health problem in late-life. We need more information about the incidence and prevalence of major and minor syndromes of depression in older people. This will help in service development.

AIMS

To estimate the prevalence of depressive disorders among community resident older people in Kerala, India and to identify factors associated with late-life depression.

MATERIALS AND METHODS

Two hundred and twenty community resident older subjects were assessed for depression by clinicians trained in psychiatry. They used a symptom checklist based on International Classification of Diseases Tenth Revision (ICD-10) Diagnostic criteria for research for Depression and Montgomery Asberg Depression Rating Scale for assessment of symptoms. A structured proforma was used to assess sociodemographic characteristics and medical history. The point prevalence of depression was estimated. Univariate analysis and subsequent binary logistic regression were carried out to identify factors associated with depression.

RESULTS

Prevalence of any ICD-10 (World Health Organization, 1992) depressive episode was 39.1% (95% confidence interval [CI] 32.6-45.9). There was significant correlation between depression and female gender (odds ratio [OR] 2.33; 95% CI 1.07-5.06) and history of a significant life event in the previous year (OR 2.39; 95% CI 1.27-4.49).

CONCLUSION

High prevalence rate of late-life depression is indicative of high burden due to depression among older people in the community. Better awareness among primary care clinicians can result in better detection and management of late-life depression.

Cross-sectional associations of depressive symptom severity and functioning with health service use by older people in low-and-middle income countries

Background: Comprehensive understanding of the determinants of health service use (HSU) by older people with depression is essential for health service planning for an ageing global population. This study aimed to determine the extent to which depressive symptom severity and functioning are associated with HSU by older people with depression in low and middle income countries (LMICs). Methods: A cross-sectional analysis of the 10/66 Dementia Research Group population-based surveys dataset. Participants (n = 4590) were those aged 65 or older, in the clinical range for depressive symptoms (defined as scoring four or more on the EURO-D), living in 13 urban and/or rural catchment areas in nine LMICs. Associations were calculated using Poisson regression and random-effects meta-analysis. Results: After adjustment for confounding variables, (EURO-D) depressive symptom severity was significantly associated with “any community HSU” (Pooled Prevalence Ratios = 1.02; 95% CI = 1.01–1.03) but not hospital admission. Conversely, after adjustment, (WHODAS-II) functioning was significantly associated with hospital admission (Pooled PR = 1.14; 95% CI = 1.02–1.26) but not “any community HSU”. Conclusions: Depressive symptom severity does not explain a large proportion of the variance in HSU by older people with depression in LMICs. The association of functioning with this HSU is worthy of further investigation. In LMICs, variables related to accessibility may be more important correlates of HSU than variables directly related to health problems.

Suicide ideation, dementia and mental disorders among a community sample of older people in Mexico

Data on the prevalence of and risk factors for suicide ideation among older people in developing countries is lacking.

OBJECTIVE

This study aimed to estimate if dementia and other mental disorders are associated with suicide ideation among the older people controlling for demographic and other suspected risk factors.

METHODS

We report on the Mexican study of dementia, part of the 10/66 international dementia research group, a series of cross-sectional population-based surveys in low and middle income countries. A survey was conducted to all residents aged 65 years and older from urban and rural catchment areas in Mexico City and Morelos (January 2006 to June 2007).

RESULTS

After 18 months of field work, a total of 2003 completed interviews were obtained, with a response rate of 85.1%. We found a lifetime prevalence of suicide ideation of 13.5% and a 2-week prevalence of 4.2%. The common factors associated with both lifetime and 2-week prevalence were having a large number of physical disorders (lifetime prevalence ratio = PR and 95% confidence interval = CI; PR = 2.23, CI = 1.63-3.06), depression (PR = 1.92, CI = 1.36-2.70) and anxiety (PR = 2.23, CI = 1.68-2.97) and screening positive for psychosis (PR = 1.64, CI = 1.15-2.34).

CONCLUSION

Dementia plays a minor role on suicide ideation after the other aforementioned variables were taken into account and its effect, if any, could be concentrated among those elders with lower severity scores of dementia. These results show the great challenges that Mexico faces in providing services for the older people with suicidality. As the population in the country ages, suicidality will constitute an additional challenge to the healthcare system.

Income inequality, socioeconomic deprivation and depressive symptoms among older adults in Mexico

Objective

Depression is the second most common mental disorder in older adults (OA) worldwide. The ways in which depression is influenced by the social determinants of health – specifically, by socioeconomic deprivation, income inequality and social capital - have been analyzed with only partially conclusive results thus far. The objective of our study was to estimate the association of income inequality and socioeconomic deprivation at the locality, municipal and state levels with the prevalence of depressive symptoms among OA in Mexico.

Methods

Cross-sectional study based on a nationally representative sample of 8,874 OA aged 60 and over. We applied the brief seven-item version of the Center for Epidemiologic Studies Depression Scale (CES-D) to determine the presence of depressive symptoms. Additionally, to select the principal context variables, we used the Deprivation Index of the National Population Council of Mexico at the locality, municipal and state levels, and the Gini Index at the municipal and state levels. Finally, we estimated the association of income inequality and socioeconomic deprivation with the presence of depressive symptoms using a multilevel logistic regression model.

Results

Socioeconomic deprivation at the locality (OR = 1.28; p<0.10) and municipal levels (OR = 1.16; p<0.01) correlated significantly with the presence of depressive symptoms, while income inequality did not.

Conclusions

The results of our study confirm that the social determinants of health are relevant to the mental health of OA. Further research is required, however, to identify which are the specific socioeconomic deprivation components at the locality and municipal levels that correlate with depression in this population group.