Emerging healthcare technologies have resulted in an overall reduction in mortality, because of which the ageing population has increased. However, from the perspective of older adults, ageing remains a challenging and distressing process. Generally, in the period after retirement, people experience loneliness, for example, due to loss of a spouse, isolation, health problems and financial troubles, all of which could lead to depression. The perceptions of and adaptations to these situations will determine the emotional outcomes for the person. Those who can better accept failure, frustration and adverse events live a happier life than those who are afraid and anxious in such circumstances (Beard et al, 2016).
Geriatric depression refers to a disorder in mental and emotional status in an older person. Since depression is among the leading causes of disability-adjusted life years (DALYs), it has become a major public health concern worldwide. Depression contributes to increased healthcare costs and mortality (Zivin et al, 2013). It is estimated that 25–45% of adults aged 65 years and above experience a certain level of depression (Mirkena et al, 2018).
In Malaysia, the prevalence of depression among older people has been found to be 2–35% (Maideen et al, 2014). Depression is estimated to be more prevalent among older individuals living in long-term care facilities than in those living at home. Lin et al (2007) reported that depression among older people residing in care homes was high, ranging from 22.2% to 81.8%. Similarly, a study of older Malay people in Peninsular Malaysia showed that the prevalence of depression in this group was 70.4% (Normala et al, 2014).
Traditionally, in Malaysia, people would care for their ageing parents or older family members themselves. However, the trend has now changed, where older adults are usually cared for by care workers or sent to daycare centres. The reliance of older adults on welfare institutions such as Residential Care Home for the Elderly (RCHfE) has increased in recent years (Nasser et al, 2011). Hence, it is expected that community- and home-based centres, such as Senior Citizen Activity Central (PAWE), will face greater demand in the future. PAWE is a daycare centre that provides daycare and health-related services to older adults. It is a publicly funded social centre, unlike English social care and daycare centres, which are operated by different types of providers (Orellana et al, 2020). Nonetheless, in both countries, these centres offer similar services, such as care- and/or health-related advice and guidance or activities specifically designed to engage older people who have health or social care needs. They can attend the centre for the whole day or for a few hours.
Evidence on depression among the older adults who use these daycare centres and research on psychological wellbeing in this setting are limited. Similar data for older people in the UK also seem to be rare (Orellana et al, 2020). A recent systematic review suggested that attending daycare centres could positively impact older adults' mental health, social interaction and physical function (Orellana et al, 2020). Furthermore, such interactions were also found to improve wellbeing, levels of happiness and life satisfaction, as well as reduce psychological problems such as loneliness and depression (Iecovich and Biderman, 2013). The present study aimed to determine the prevalence of depression among older adults attending daycare centres in Malaysia and to examine the relationship between depression and demographic factors.
Methods
Study design and setting
In Malaysia, a person aged 60 years and above is categorised as a senior citizen. PAWE was established by the government of Malaysia with the aim of helping senior citizens to become more independent and encourage them to interact among themselves and their communities. There are 52 PAWEs throughout Malaysia, of which five are located in Terengganu, serving a total of 1079 older people. At the centres, older people are involved in recreational activities that will improve their social skills, help them be more productive during the day and have a better quality of life. Such community-based programmes can meet the social needs of older people. The activities include religious classes, recreational and rehabilitation therapies, medical screening, health talks, and some other activities. This descriptive and cross-sectional study was conducted at the five PAWE centres in Terengganu.
Sample and procedure
Prior to the meeting with the participants, all of the officers in charge of the five PAWEs registered under the Department of Social Welfare in Terengganu were approached. The purpose of the meeting was to explain the study and to arrange the attendance of all older adults who were actively involved in PAWE activities three times a week for the past 3 months. A total of 350 older people were identified from the five PAWEs, and their demographic data were gathered from their individual records.
All of the participants who met the following criteria were recruited: (i) older than 60 years; (ii) able to provide consent; (iii) understood the Malay language; (iv) having a Montreal Cognitive Assessment (MoCA) score greater than 22/30; and (v) were alert and orientated. Those who were diagnosed with severe hearing impairment, communication problems or any psychiatric problem or those who had severe physical or psychological symptoms were excluded due to their inability to understand and respond to the questionnaire. Their ability to participate in the study was determined by the respective officers in charge via their health records. A total of 159 individuals were found to be eligible for recruitment into the study after MoCA screening. Lastly, the Malay Geriatric Depression Scale (M-GDS-15) was distributed among these 159 people to obtain descriptive data on their depression symptoms.
Measures
Three different measures were employed in this study.
Socio-demographic variables
Socio-demographic characteristics including age, sex, marital status, employment status, level of education, household income, place of residence, living arrangement and health status. Other parameters included were weight and height.
Depression variables
Symptoms of depression were measured using a Malay short-form of the Geriatric Depression Scale (M-GDS), a self-rated scale consisting of 15 items with dichotomous responses of ‘yes’ or ‘no’. The original GDS developed by Yesavage and Sheikh (1986) has been proven to have high sensitivity and specificity. It is a valid and reliable instrument with Cronbach's alpha values ranging from 0.88 to 0.91. Teh and Hasanah (2004) translated the GDS into Malay (M-GDS-15), validated it and showed it to have good internal consistency (Cronbach's alpha, 0.84), test-retest reliability (Spearman's correlation coefficient, 0.843), 100% sensitivity and 92% specificity with a cut-off point of 7/8. Those who scored 0–4 on the M-GDS-15 were considered to have no depression. A score of 5–8 indicated mild depression, 9–11 indicated moderate depression and 12–14 indicated severe depression (Teh and Hasanah, 2004).
Cognitive assessment
The MoCA has been used by physicians in a wide range of settings to identify mild cognitive impairment at an early stage, thereby allowing improved access to the appropriate support and interventions for dementia prevention (Julayanont et al, 2014). It has been translated into various languages and has been reported to have high sensitivity and specificity, as well as high test-retest reliability and internal consistency in detecting mild cognitive impairment (MCI) despite some cultural and country-specific modifications (Sahathevan et al, 2014). It is a one-page, 30-point test that can be completed in 10 minutes, testing eight cognitive domains: attention and concentration, executive function, memory, language, visual constructional skills, conceptual thinking, calculations and orientation. The scores range from 0 to 30, and higher scores indicated better cognition. In this study, the Malay version MoCA-BM was used with a lower cut-off of 22 or 23 after considering the education levels of most older adults in Malaysia (Din et al, 2016). The MoCA-BM has been found to have a sensitivity of 0.824 and specificity of 0.818 in detecting cognitive impairment among older Malay adults (Cheah et al, 2014). A total of 350 older people were identified from the five PAWEs, all of whom underwent the MoCA assessment. Of these, 159 were recruited because they met all the inclusion criteria and had an MoCA score greater than 22.
Ethics consideration
Ethics approval was obtained from UniSZA Human Research Ethics Committee (UHREC) and from the Department of Social Welfare, Malaysia, which has set up PAWEs. Each participant was assured of data confidentiality and anonymity, and they were informed that they could withdraw at any time for any reason. Permission to use the instruments was obtained from the developers of the MoCA and M-GDS.
Data analysis
All data from the completed questionnaires were entered and cleaned. Data analyses were performed using Statistical Package for Social Science (SPSS) V.22. Descriptive analysis (frequency, percentage, mean and standard deviation) was used to describe the demographic background of and the prevalence of depression among the participants. The chi-square test and multivariate logistic regression were applied to assess the associations between demographic characteristics and depression. The significance level was set at 0.05.
Results
Demographic characteristics
A total of 154 completed questionnaires were returned, yielding a 96.9 % response rate. The results of the demographic analysis showed that more than half the participants (n=95, 61.7%) were aged 60–70 years. Some 99 participants (64.3%) were women, 126 (81.8%) were non-smokers, 65 (42.2%) had completed primary school, and 148 (96.1%) lived in their own homes. Almost two-thirds (n=99, 64.3%) of the participants were married and were not working (n=100, 64.9%). Some 80.5% (n=124) had been able to perform activities of daily living (ADLs) for the past 30 days. Table 1 provides the details of the participants' demographic characteristics.
| Characteristics | n (%) |
|---|---|
| Age (mean=68.57±7.837) | |
| 60–70 years | 95 (61.7) |
| >70 years | 59 (38.3) |
| Gender | |
| Male | 55 (35.7) |
| Female | 99 (64.3) |
| Smoking status | |
| Smoker | 28 (18.2) |
| Non-smoker | 126 (81.8) |
| Body mass index | |
| Underweight | 8 (5.2) |
| Normal | 83 (53.9) |
| Overweight | 41 (26.6) |
| Obese | 22 (14.3) |
| Marital status | |
| Never married | 7 (4.5) |
| Married | 99 (64.3) |
| Widowed | 18 (11.7) |
| Divorced | 30 (19.5) |
| Education level | |
| No formal education | 40 (26.0) |
| Primary school | 65 (42.2) |
| Secondary school | 36 (23.4) |
| Higher education | 13 (8.4) |
| Employment status | |
| Not working | 100 (64.9) |
| Pensioner | 29 (18.8) |
| Working | 25 (16.2) |
| Source of income | |
| Pension (own/spouse's) | 34 (22.1) |
| Social welfare | 81 (52.6) |
| Children | 39 (25.3) |
| Monthly income | |
| <1000 RM | 116 (75.3) |
| >1000 RM | 38 (24.7) |
| Accommodation | |
| Own home | 148 (96.1) |
| Rented home | 2 (1.3) |
| Children's home | 1 (0.6) |
| Other | 3 (1.9) |
| Access to family (spouse/child/sibling) | |
| Yes | 66 (42.9) |
| No | 88 (57.1) |
| Duration of participation in PAWE | |
| 1–5 years | 113 (73.4) |
| >5 years | 41 (26.6) |
| Health problems | |
| Yes | 83 (53.9) |
| No | 71 (46.1) |
| Ongoing medication | |
| Yes | 86 (55.8) |
| No | 68 (44.2) |
| Able to perform ADLs in the past 30 days | |
| Yes | 30 (19.5) |
| No | 124 (80.5) |
| Problems with performing ADLs | |
| Yes | 20 (13.0) |
| No | 134 (87.0) |
| Family member with depression | |
| Yes | 28 (18.2) |
| No | 126 (81.8) |
Note: ‘Pensioner’ refers to a person who receives a government pension.
ADL: activities of daily living
Prevalence of depression
The mean score from the M-GDS-15 was 5.03±3.11, and more than half the participants were found to have some level of depression (n=91; 59.1%). The proportion of individuals with mild, moderate and severe depression was 46.8% (n=72), 9.7% (n=15) and 2.6% (n=4).
Table 2 shows the association between levels of depression and the participants' demographic characteristics. Depression was significantly associated with marital status, level of education, employment status, source of income, monthly income, access to family, ongoing medication and ability to perform ADLs.
| Characteristics | No depression n (%) | Depression n (%) | χ 2 (degrees of freedom) | p value |
|---|---|---|---|---|
| Age (mean=68.57±7.837) | 1.95 | 0.163 | ||
| 60–70 years | 43 (45.3) | 52 (54.7) | ||
| >70 years | 20 (33.9) | 39 (66.1) | ||
| Gender | 0.73 | 0.392 | ||
| Male | 25 (45.5) | 30 (54.5) | ||
| Female | 38 (38.4) | 61 (61.6) | ||
| Smoking status | 3.58 | 0.058 | ||
| Smoker | 7 (25.0) | 21 (75.0) | ||
| Non-smoker | 56 (44.4) | 70 (55.6) | ||
| Body mass index | 4.22 | 0.239 | ||
| Underweight | 2 (25.0) | 6 (75.0) | ||
| Normal (ref) | 31 (37.3) | 52 (62.7) | ||
| Overweight | 22 (53.7) | 19 (46.3) | ||
| Obese | 8 (36.4) | 14 (63.6) | ||
| Marital status | 13.60 (3) | 0.004* | ||
| Never married (ref) | 5 (71.4) | 2 (28.6) | ||
| Married | 45 (45.5) | 54 (54.5) | ||
| Widowed | 9 (50.0) | 9 (50.0) | ||
| Divorced | 4 (13.3) | 26 (86.7) | ||
| Education level | 28.98 (3) | <0.001* | ||
| No formal education (ref) | 11 (27.5) | 29 (72.5) | ||
| Primary school | 17 (26.2) | 48 (73.8) | ||
| Secondary school | 24 (66.7) | 12 (33.3) | ||
| Higher education | 11 (84.6) | 2 (15.4) | ||
| Employment status | 15.20 (2) | 0.001* | ||
| Not working | 32 (32.0) | 68 (68.0) | ||
| Pensioner | 21 (72.4) | 8 (27.6) | ||
| Working (ref) | 10 (40.0) | 15 (60.0) | ||
| Source of income | 31.17 (3) | <0.001* | ||
| Pension (own/spouse's) (ref) | 27 (79.4) | 7 (20.6) | ||
| Social welfare | 19 (23.5) | 62 (76.5) | ||
| Children | 17 (43.6) | 22 (56.4) | ||
| Monthly income | 34.52 (1) | <0.001* | ||
| <1000 RM | 32 (27.6) | 84 (72.4) | ||
| >1000 RM | 31 (81.6) | 7 (18.4) | ||
| Accommodation | 1.90 | 0.788 | ||
| Own home (ref) | 60 (40.5) | 88 (59.5) | ||
| Rented home | 1 (50) | 1 (50) | ||
| Children's home | 0 (0.0) | 1 (100.0) | ||
| Other | 2 (66.7) | 1 (33.3) | ||
| Access to family (spouse/child/sibling) | 7.02 (1) | 0.008* | ||
| Yes | 19 (28.8) | 47 (71.2) | ||
| No | 44 (50) | 44 (50) | ||
| Duration of participation in PAWE | 0.007 | 0.933 | ||
| 1–5 years | 46 (40.7) | 67 (59.3) | ||
| >5 years | 17 (41.5) | 24 (58.5) | ||
| Health problems | 1.00 | 0.317 | ||
| Yes | 37 (44.6) | 46 (54.4) | ||
| No | 26 (36.6) | 43 (63.4) | ||
| Ongoing medication | 3.67 (1) | 0.055 | ||
| Yes | 41 (47.7) | 45 (52.3) | ||
| No | 22 (32.4) | 46 (67.6) | ||
| Able to perform ADLs in the past 30 days | 0.89 (2) | 0.347 | ||
| Yes | 10 (33.3) | 20 (66.7) | ||
| No | 53 (42.7) | 71 (57.3) | ||
| Problems with performing ADLs | 1.13 | 0.287 | ||
| Yes | 6 (30.0) | 14 (70.0) | ||
| No | 57 (42.5) | 77 (57.5) | ||
| Family member with depression | 3.58 | 0.058 | ||
| Yes | 7 (25.0) | 21 (75.0) | ||
| No | 56 (44.4) | 70 (55.6) |
Note: ‘Pensioner’ refers to a person who receives a government pension.
indicates statistically significant differences compared with the reference group.
Ref: reference group for comparison; ADL: activities of daily living.
Factors that showed significant association with depression (p<0.20) were included in multivariate logistic regression, which showed that being divorced (odds ratio (OR)=18.20, confidence interval (CI)=2.00–165.26; p=0.010); having completed only primary school (OR=11.232, CI=1.14–110.69; p=0.038); and having monthly income less than RM 1000 (OR=5.065, CI=1.47–17.42; p=0.010) were the only factors associated with depression among the older participants (Table 3).
| Characteristics | χ2 | p value | Odds ratio (95% confidence interval) | p value |
|---|---|---|---|---|
| Marital status | 13.60 | 0.004* | ||
| Never married | ref | — | ||
| Married | 7.98 (1.12–56.60) | 0.038* | ||
| Widowed | 7.21 (0.75–69.19) | 0.087 | ||
| Divorced | 18.20 (2.00–165.26)* | 0.010* | ||
| Education level | 28.98 | <0.001* | ||
| No formal education | 6.158 (0.60–63.65) | 0.127 | ||
| Primary school | 11.232 (1.14–110.69) | 0.038* | ||
| Secondary school | 2.068 (0.25–17.22) | 0.502 | ||
| Higher education | ref | — | ||
| Employment status | 15.20 | 0.001* | ||
| Not working | 0.774 (0.26–2.30) | 0.645 | ||
| Pensioner | 2.106 (0.38–11.55) | 0.391 | ||
| Working | ref | — | ||
| Source of income | 31.17 | <0.001* | ||
| Pension (own/spouse's) | ref | — | ||
| Social welfare | 2.048 (0.43–9.72) | 0.367 | ||
| Children | 1.458 (0.35–6.04) | 0.603 | ||
| Monthly income | 34.52 | <0.001* | ||
| <1000 RM | 5.065 (1.47–17.42) | 0.010* | ||
| >1000 RM | ref | — | ||
| Access to family (spouse/child/sibling) | 7.02 | 0.008* | ||
| Yes | 77 (0.73–4.31) | 0.203 | ||
| No | ref | — |
Note: ‘Pensioner’ refers to a person who receives a government pension.
Ref: reference group for comparison.
indicates statistically significant differences compared with the reference group
Discussion
The results of the present study showed that more than half (59.1%) of the older participants recruited from PAWE centres were depressed, and 4.4% of these individuals were severely depressed. Although this proportion seems low, the findings of this study are alarming, as those with mild and moderate depression might progress to having severe depression if their condition is not detected and consequently treated. The findings indicated a considerably higher proportion of depression among the older participants compared with that reported in other nationwide studies, which ranged between 3.9 % and 13.9% (Mukhtar and Oei, 2011; Rashid and Tahir, 2015). However, the prevalence of severe depression in the present study was low, at 2.6%, compared with the 13.2% among older adults living in care homes (Al-Jawad et al, 2007), 9% among those living in rural Malaysia (Rashid and Tahir, 2015) and 6.3% among those living in urban settings (Sherina et al, 2004).
The findings of the present study showed that depression was associated with being divorced. This could be explained by the fact that spousal support is important for ensuring good mental health. A study conducted by Lawrence et al (2006) among white British and black Caribbean participants in the UK found that marital problems such abandonment by the spouse or lack of harmony in the marriage were causes of depression. Disruption in the social network or loss of a spouse may affect older adults' ability to maintain relationships and put them at risk of loneliness and isolation (Alpass and Neville, 2003). Emotional support from family members and the community is crucial to help older adults overcome these issues.
The proportion of older adults with depression was higher among those with no formal education or who had only attended primary school, compared with that among those with higher education levels. As is commonly acknowledged, many older adults prefer to spend their time reading (Adams et al, 2011). Therefore, the inability to read and write, together with limited ability to perform physical activities, might trigger the development of depression. These findings were consistent with those of previous studies that reported that older adults with higher levels of education were at lower risk of experiencing depression (Dao et al, 2018; Liu et al, 2018).
Older adults who were not working were found to be at risk of experiencing depression. This might be explained by these individuals not being able to afford a more comfortable retirement or the lack of opportunity to work leading to feelings of being unproductive or too dependent on others. This finding was supported by those of Pfeil et al (2017) and Yeunhee and Yoonjung (2017), who reported that unemployed older adults tended to be depressed. The Malaysian government has been working on a national policy for older persons, including a plan of action, focusing on three important areas: (i) older persons and development; (ii) advancing health and wellbeing into old age; and (iii) ensuring enabling and supportive environments. This planned action needs coordination among agencies, such as the ministries, non-government organisations and local communities. These organisations might find the results of the present study useful while devising the above-mentioned strategies, as the mental health of older adults is naturally an important factor to consider here.
Another important finding of the present study was that older adults with low monthly incomes (<RM 1000) are more likely to experience depression than those with incomes exceeding RM 1000 a month. Nearly three-quarters of the older participants in the present study had monthly incomes of less than RM 1000, and for most, the source of the income was social welfare (amounting to around RM 300 per month). Ng et al (2011) reported that more than half of the older people in Malaysia had a household income of less than RM 1600 per month, and 22% had incomes below the poverty line (RM 691 per month). Income is an important factor for wellbeing, and this includes older adults. Most participants in the present study were older women, who are often financially dependent on others; their income was just enough for them to fulfil their basic needs and did not cover medical or healthcare costs.
It is not surprising that financial worries would predispose older adults to depression (Rashid and Tahir, 2015; Liu et al, 2018). However, an unexpected finding of the present study was that even participants who had a family member as a guardian tended to have depression. This finding contradicted those of previous studies, which reported that older adults who lived with family members were at a low risk of having depression (Rashid and Tahir, 2015). One reason for this could be that the older participants in the present study felt entirely dependent on their families, believing themselves to be a burden. Additionally, caregivers have varying emotional responses and attitudes to caregiving, which can affect the emotional responses of the person receiving care (Longacre et al, 2017). Further exploration of informal guardians' experiences and emotional responses (e.g. stress) is warranted. Further, policy approaches and organisational and/or societal responsibilities in supporting informal guardians, which indirectly might influence older adults, must also be considered.
It has been reported that those with lower levels of education experience depressive symptoms more often than those with higher levels of education (Bauldry, 2015). Bjelland et al (2008) found a significant association between lower education levels and anxiety and depression, and Thurston et al (2006) found that receiving less than high-school level education was significantly associated with higher levels of these conditions. Thus, level of education plays a significant role in mental health (Bjelland et al, 2008; Bracke et al, 2013) and is a factor underlying mental health inequalities (Pampel, 2009). It is important for PAWEs to emphasise educational activities to level up members' knowledge and confidence and provide continuous social support to those who are less educated.
Study implications
On the basis of the findings of this study, the management of PAWEs in Terengganu, Malaysia, should perform a mandatory routine screening for depression among older attendees, perhaps by using a simple questionnaire and clinical psychological assessment.
The idea behind a standard assessment to routinely screen older people for depression germinated from a recommendation made by the Royal College of Physicians of London and the British Geriatrics Society (Dickinson, 1992). The assessments should specifically evaluate ADLs (Barthel ADL index), memory status (Abbreviated Mental Test), mood (GDS), morale (Philadelphia Geriatric Center Moral Scale) and social status (Social Status Checklist) (Dickinson, 1992). The GDS is a well-validated instrument that best fits the general purpose of screening the cognitive status of older adults (Yesavage et al, 1982). Arthur et al (1999) used this instrument routinely in primary care settings for early detection of depression among geriatric patients. Such early detection could contribute to healthcare cost savings and reduce the burden of depression on families and society (Vasiliadis et al, 2013).
Study limitations
This study has some limitations. First, the data were collected at a single point in time and using a non-probability convenience sampling, which may restrict the generalisability of the findings. Second, this study used a cross-sectional approach with no psychological assessment, which could have significantly limited the quality of the information gathered. The addition of qualitative approaches and clinical assessments, which could promote openness and simulate individual experiences, would have helped to explain the various traditional practices and would have substantially enhanced the value of the study.
Conclusion
A high proportion of older adults who attend PAWE daycare centres in Malaysia have depression. Depression is a particular risk for those who are divorced, less educated and unemployed or those with low incomes. Surprisingly, the findings also showed that having family caregivers at home was associated with depressive symptoms. This study highlighted the need for PAWE centres to re-evaluate and revise the activities and programmes they hold to effectively cater to the physical and emotional needs of older adults and thus reduce depressive symptoms.