Influence of sociodemographic factors on dementia and depression onset in the elderly

Introduction: The most common mental disorders in the elderly are depression and dementia. Objective: Examine the impact of sociodemographic characteristics on the appearance of depression and dementia in elder patients treated in Primary Health Center (PHC), Banja Luka. Method: The study included 208 patients over 65 years of age, selected by random selection method, registered in 6 family medicine teams at the PHC Banja Luka in the period from March to May 2016. Respondents completed the Sociodemographic Questionnaire, Beck’s Depression Inventory, and Folstein Mini-Mental State Examination (MMSE) for dementia assessment. Different statistical procedures were used in the data processing: descriptive analysis in the form of frequencies and percentages, Chi-square test, T-test. The results of the research were statistically analyzed by SPSS 11.5 program. Results: The study included 208 patients older than 65, of whom 38.9% were male. Impaired cognition was found in 7.2% and moderate depression in 24.5% of patients. Dementia was statistically significantly (p = 0.000) more present in the eldest respondents ≥ 81 years, while depression was mostly present in patients aged 76-80. Physically active individuals were significantly less affected by depression (p = 0.001) and dementia (p = 0.000). Dementia and depression occurred more frequently in people living alone and people with a low level of education. Conclusion: A family physician plays an important role in the early detection of depression and dementia in the elderly, the identification of risk factors, prevention, and treatment of these patients.


Introduction
The number of old persons is increasing worldwide and is expected to grow from 841 million in 2013 to two billion in 2050 1,2 . The most common mental disorders in the elderly are depression and dementia. According to previous studies conducted worldwide, the prevalence of depression in the elderly varies significantly, with estimates found in the literature ranging from 3% to 35% 3,4 . Older age includes more frequent health problems: immobility, financial difficulties, stress, alienation, dissatisfaction, retirement, career loss, loss of a spouse, family members or friends, moving out of children, loss of hope, a decrease of needs and motivations for activities that used to be a normal part of life. These are additional "objective" reasons that create a suitable ground for the depressive reaction of elderly persons. 5,6 Recognized depression can be very successfully treated, and the elderly respond to treatment as well as younger ones 7 .
Dementia is characterized by progressive intellectual decline, which leads to an inability to meet the basic social, moral and work responsibilities of the affected person. The World Health Organization (WHO) defines dementia as a deterioration of memory with possible associated other cognitive deficits: dysphasia, apraxia, agnosia, and difficulty in orientation and/or making everyday decisions. Age is the most significant risk factor for dementia 1,2 . Numerous epidemiological studies have found that in addition to aging, there are a number of other risk factors for dementia, such as brain injury, depression, low mental capacity at an earlier age, or decreased psycho-physical activity in older age 8 . Other risk factors include hypercholesterolemia, hypertension, atherosclerosis, coronary disease, smoking, obesity, and diabetes 9 . According to the results of extensive population studies, the prevalence of dementia ranges from 9-14% in older persons over 65 and is as high as 30-35% in persons over 85 10 .
There is more and more evidence showing depression may be a risk factor for the development of dementia 11 . A previous history of depression increases the risk of developing Alzheimer's disease and vascular dementia. This association is important even if depression appeared more than ten years before the appearance of dementia. Depression almost doubles the risk of developing dementia. 12 Objective Examine the impact of sociodemographic characteristics on the appearance of depression and dementia in the elderly treated in family medicine outpatient facilities at the Banja Luka Primary Health Center.

Method
The study included patients 65 years of age and older who were treated in the Primary Health Center (PHC), Banja Luka. All patients were acquainted with the research objectives and signed their written consent. The Ethics Committee of the Banja Luka Primary Health Center gave its consent for the research. The study was conducted following the Helsinki declaration on medical research and the principles of good scientific practice.
There were 208 participants, selected by random selection method from a registry of patients in six family medicine teams in Primary Health Center (PHC), Banja Luka. Every second patient of 65 years and older was selected from the patient registry regardless of gender. For statistical purposes, all patients were divided into four groups according to age: the first group consisted of patients aged 65 to 70, the second group patients of 71 to 75, the third group patients of 76 to 80 and the fourth group 81 years of age and older.
The study was conducted as a prospective study from March 20th, 2016 to May 20th, 2016 using the method of patient surveys and data collection from electronic health records.
We used the following instruments for data collection: 1. A general questionnaire containing socio-demographic data (gender, age, marital and family status, educational degree, physical activity). We measured patients` body weight and height and a Body Mass Index (BMI) was calculated.
2. The presence of depression was determined using Beck's Depression Inventory 13,14 . The Beck Depression Inventory (BDI) is a 21-item, self-rated scale that evaluates key symptoms of depression including mood, pessimism, sense of failure, self-dissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying, irritability, social withdrawal, indecisiveness, body image change, work difficulty, insomnia, fatigability, loss of appetite, weight loss, somatic preoccupation, and loss of libido. Individual scale items are scored on a 4-point continuum (0=least, 3=most), with a total summed score range of 0-63. Higher scores indicate greater depressive severity. The patient`s task was to read each question carefully, and then select in each one of them a statement that describes in the best way how the patient felt that week and that day. Each statement was assigned to the appropriate number. By summing, we get a score from which we determine the presence of depression in patients. The standard cutoff scores were as follows: 0-9 points no depression; 10-18 points indicate mild depression; 19-29 points indicate moderate depression and score ≥ 30 indicates severe depression.
3. A short, Folstein Mini-Mental State Examination (MMSE) 15 is a brief, quantitative measure of cognitive status in adults. It can be used to screen for cognitive impairment, to estimate the severity of cognitive impairment at a given point
3. Kratka Folsteinova Mini-mental skala (MMSE) 15 je brz, kvantitativan test kognitivnog statusa kod odraslih. Može se koristiti za skrining kognitivnog oštećenja, za procenu ozbiljnosti kognitivnog oštećenja u datom trenutku, za praćenje kognitivnih promena kod pacijenata koji su već oboleli i da bi se dokumentovao pacijentov odgovor na lečenje. Ovim upitnikom testirali smo pacijentovu orijentaciju, sadašnju in time, to follow the course of cognitive changes in an individual over time, and to document an individual's response to treatment. With this questionnaire, we tested patient orientation, current memory, attention and calculation, memory and language. By summing all the individual scores, we got a final score which indicated the level of cognition in our patients. The MMSE has a maximum score of 30 points. The scores are generally grouped as follows: 24-30 points: normal cognition; 19-23 points: borderline cognition and < 19 points impaired cognition.

Statistical processing and data analysis
We have statistically analyzed the results of the research in SPSS 11.5 program on several levels. Different statistical procedures were used in the data processing: descriptive analysis in the form of frequencies and percentages for sample and response review of each question individually. Differences between individual categories of respondents (age, gender, number of household members, education level, etc.) were analyzed by the Chi-square test on the measuring scales (mental status, depression). A T-test was used to compare the average values of the two groups of respondents. In all applied analytical methods, the significance level was 0.05 and 0.01.

Results
The study included 208 patients older than 65 years. Out of this number, 81 were men (38.9%) and 127 women (61.1%). The average age of the respondents was 73.7 years. The majority of patients were 65 to 70 years of age -76 (36.5%), and 31 (14.9%) were 81 or older. The majority of the respondents are married -127 (61.1%), while 73 (35.1%) are widowed. A small number of them live alone 57 (27.4%), with spouses 87 (41.8%) and one third resides in more numerous families with three or more members.
More than half of the respondents are physically inactive, 110 (52.9%) i.e. being active for less than an hour daily, 65 (31.3%) are active for one to three hours a day, while 33 patients (

Statistička obrada i analiza podataka
Statistički smo analizirali rezultate istraživanja koristeći SPSS 11.5 program na nekoliko nivoa. Različite statističke procedure su korišćene u obradi podataka: deskriptivna analiza u obliku frekvencija i procenata za pregled uzorka i odgovora svakog individualnog pitanja. Razlike između individualnih kategorija učesnika (starost, pol, broj članova domaćinstva, nivo obrazovanja itd) analizirane su χ2 testom na mernim skalama (mentalni status, depresija). T-test je korišćen za upoređivanje srednjih vrednosti dve grupe učesnika studije. U svim primenjenim analitičkim metodama nivo značajnosti je bio 0.05 i 0.01. In our study, the highest number of patients had normal cognition -149 (71.6%), which was mostly observed in the group of the youngest respondents aged 65 to 70 years -64 (84.2%). Impaired cognition is mostly prevalent in patients of 81 years of age and older, and a statistically significant difference (p=0.000) between age and dementia is observed, in a way that the respondents of the oldest age have the highest percentage of impaired cognition and the youngest respondents of 65 to 70 years of age have the lowest percentage of impaired cognition ( Table 1). Out of all respondents, mild and moderate depression is present in 106 (51.0%) patients. Age was statistically significantly affected by depression (p=0.010). Moderate depression is mostly expreed in patients over 76 years of age, with the lowest number of patients -10 (13.2%) in the youngest age group 65 to 70 years. The majority of patients with no depression were found in the group of the youngest respondents -45 (59.2%) ( Table 1).
The results of our study have shown that the gender of the respondents did not significantly affect the occurrence of depression (p = 0.312  The results of the study have shown there was a statistically significant difference between physical activity and cognitive status of the patients (p = 0.000). In the group of 15 (7.2%) patients with impaired cognition, all 15 patients were physically inactive. As physical activity increases, so does the improvement of mental status ( Table 3).
Out of the total of 106 patients (51.0%) with depression, physical inactivity was reported in 27 (24.5%) patients with mild depression and 39 (35.5%) patients with moderate depression, which is a total of 66 patients with depression. In patients who are active for more than three hours a day, mild depression occurs in 12 (36.4%) and moderate in only one patient. With the increase of physical activity, the appearance of depression decreases (p = 0.001) ( Table 3).
The results of our study have shown that the nutrition status did not significantly affect cognitive status (p = 0.849) or the onset of depression (p=0.687).
Rezultati naše studije pokazali su da uhranjenost ne utiče značajno na kognitivni status (p = 0.849) i nastanak depresije (p = 0.687). A statistically significant difference (p=0.022) was observed between the number of household members and the cognitive status of patients. Cognitive status is better in patients living in a household with two or more members. Impaired cognition is more present in patients living alone (Table 4).
The results have shown a significant statistical difference (p=0.001) between the number of household members and the appearance of depression in patients. Moderate depression appeares in a larger percentage of patients living alone. Out of the total of 106 (51.0%) patients showingelements of depression, 41 (27.1%) with mild depression live in households with two or more family members, but 24 (42.1%) with moderate depression live alone (Table 4).
The study results have shown a statistically significant difference between the level of education and cognitive status (p = 0.000). As the level of education increases, the number of patients with impaired and borderline cognition decreases (Table 5).

Discussion
In our study, the largest number of patients (71.6%) has had normal and 7.2% impaired cognition. Mild depression was registered in 26.4% of the patients and moderate depression in 24.5%. Urošević et al. 16 in their study which included 100 patients aged 65 to 84, conducted at the Ćuprija Primary Health Center, in 2010 have shown that the elderly treated in primary health care had a high percentage (55.0%) of depression prevalence.
We have also noted statistically significant differences between age and cognitive status of the patients (p = 0.000). The oldest patients have had the most impaired cognition. Depression in our patients is also significantly influenced by age (p=0.010). Mild and moderate depression is present in 51.0% of our patients. Contrary to our results, in the study of Urošević et al. 16 , no correlation between depression and age was found.
A prospective, analytical study conducted in 2012 by Matović et al. 17 at the Foča Primary Health Center, on 300 patients older than 70 years, found that pre-obesity was registered in 42.3%, and obesity in 20.8% of patients. Likewise, in our study, more than half of the patients had nutritional problems (pre-obesity and obesity), which is certainly a health problem. However, overweight and obesity have not been found to be risk factors for depression and dementia.
No correlation was found between gender, cognitive status and depression onset in our study, while results from other studies showed that women were more likely to become ill. In their study, Matović et al. 17 found that cognitive functions were significantly better in men than in women, as well as those younger than 80 years of age compared to those over 80 years of age. In their study, Urošević et al. 16 pointed out that out of 100 patients aged 65 to 84 years, 66 were women, of which 40 (60.6%) belonged to the group of patients with depression. Ajduković et al. 20 conducted testing in two nursing homes for the elderly. Research results have shown that women, elderly and disabled had higher prevalence of depression.
We found a statistically significant correlation between the degree of physical activity and cognitive status of the patients (p = 0.000). As physical activity increases, the cognitive status improves. Patients who were physically active two or more hours per day were not in the category with impaired cognition. Depression decreases with increasing physical activity (p = 0.001). Ajduković et al. 20 found in their study significant differences between mobile and immobile patients in all the variables they have examined. Depression was more prevalent in immobile patients. The average results of mobile elderly persons did not indicate the presence of clinically significant depression.
The number of household members also significantly affected the cognitive status of the patients (p=0.022). Cognitive status is better in patients living in a household with two or more members, while impaired cognition is more prevalent in patients living alone.
There was a statistical significance (p = 0.001) between depression prevalence and the number of household members, as our results have shown. Moderate depression occurs more frequently in patients living alone. The same results, that persons living alone are at increased risk for depression, were shown in the study conducted by Matović et al. 17 The cognitive status of patients depends significantly on their educational background (p = 0.000). As the level of education increases, the number of patients with impaired and borderline cognition decreases. With an increasing educational level, depression in patients decreases (p = 0.018). In their research, Urošević et al. 16 found that a group of patients with depression had, on average, a lower level of education than a healthy group, which is consistent with our results.
Given the identified risk factors that accelerate the process of decay of mental functions with age (unhealthy lifestyles, cardiometabolic risk factors, psychosocial factors, chronic health conditions), the role of family physicians in the early detection of risk factors is being imposed. Modification of risk factors in developed countries has already led to savetuje se prestanak pušenja, umeren unos alkohola, kontrola telesne težine i umerena fizička aktivnost.
Promoting healthy lifestyles as early as young and middle age has got a protective effect on suffering from mental illness in older age. The family physician should educate his/ her patients about the need for constant physical activity from youth to very old age; a continuous psychic activity that involves lifelong learning and the acquisition of new knowledge; introduction of the Mediterranean diet; advise to avoid addiction to tobacco, drugs, alcohol, opiates, black coffee or other agents; advise to be active after retirement; to have an optimistic stand in life, to laugh, to be of a cheerful spirit; not to blame others for their own failures; avoid loneliness, develop good communication, get used to stressful situations; do not accept prejudice about aging and old age as illness, powerlessness, and dependence on others; it is necessary to follow the instructions of physicians in the treatment and use of medicines 27,28 .

Conclusion
The results of our study have indicated that 7.2% of the patients have had impaired cognition, 26.4% had mild and 24.5% moderate depression. Age, physical activity, number of household members, and educational background have had a statistically significant effect on the appearance of dementia and depression in the elderly, while gender and nutritional status were not statistically significant for their occurrence. A family physician plays an important role in the early detection of depression and dementia in older patients, the identification of risk factors for the diseases, prevention, and treatment of these patients.