PREVALENCE OF DEPRESSIVE AND ANXIETY SYMPTOMS IN VERY OLD POPULATION COMPARED TO OLD POPULATION

INTRODUCTION
The number of the old people is increasing fast in both developed and underdeveloped countries (1), and all the projecting suggests that in 2030 will live about one billion people over 65 years, representing 13 % from the total world population (2). There are different arbitrary criteria for the definition of the old and very old people (3, 4). Inour paper we will use ≥ 60 for old people and ≥80 for very old people. The data of an important meta-analysis (5) showed a high prevalence of depression and anxiety in the old age group (not separated in old age and very old age groups). Point prevalence for major depression was 3.29% and lifetime prevalence 16.52 %. For minor depression data (6) indicated 10.4 % of point prevalence. Both major and minor depression (7) are associated with an entire cohort of deleterious effects including increased risk for suicide, coronary disease, stroke and a poor outcome of somatic illnesses (8). Usually the diagnosis of depression in old people is obtained mainly in primary care. However, data (9) suggests that almost half of the cases go undetected in primary care. Unrecognised causes of depression represents a much too common cause of disability and reduced well-being (9). Some (10, 11) studies indicate, in both genders an increasing of the prevalence of depression with increasing age. Further studies (12) reported the decline of depression with increasing age, while others (13, 14) reported no significant trends of the prevalence of depression with increasing age.
Studies (15, 16) regarding the prevalence of anxiety in old age also indicates high values of 3.2% to 15.3% in community-based studies.
Yet there are between 15–52.3% of older adults manifesting subclinical levels of anxiety symptoms that are also distressing to everyday life (17).
Anxiety disorders in elderly are also associated with and important degree of disability and an increased risk of overall mortality (18).
There are some conflicting reports regarding the prevalence of anxiety disorders across separate older age groups. Some (19, 20) suggest a decrease of the prevalence of anxiety disorders with increasing age (in the first study a 4.3% prevalence estimated for current anxiety disorders in those aged 70–84 years old compared to a 2.3% prevalence for current anxiety disorders in those aged 85–103, and in the second study 8.0% of those 65–74 years old had an anxiety disorder in the past 12 months compared to 5.6% of those aged 75 years). Other authors (16) suggested that there may be important subgroups to consider within the category of the ”older adults” with different risk for different old age periods (65–74 years- 13.9%, 75–85 years-10.4% and 55–64years 6.9%).
It is difficult to say from the current data if very old people are at increased risk for depression and anxiety compared to their younger counterpart. On one hand the very old people represent a vulnerable group to depression and anxiety because they frequently have risk factors for depression and anxiety such as frailty, a plethora of somatic diseases, bereavement and loneliness (21, 22). On the other hand, the group of very old people may represent a cohort of “survivors” of both somatic and mental illnesses which, due to their long life experience may better cope with adverse situations which may led to depression or anxiety (23, 24). Moreover, both depression and anxiety might present lower values comparing to theirs’ younger groups as a consequence of selective survival (25, 26).
The data about the prevalence of depression and anxiety in the old age group compared to the very old age group is rather contradictory. The purpose of our paper is to compare the prevalence of depression and anxiety in the two above mentioned age groups in order to understand if increasing age in the old age people is associated with an increased prevalence of depression and anxiety. We compared the prevalence of depression and anxiety in two groups of old people, the first one aged 60-79 years and the second one aged ≥80 years.

MATERIALAND METHODS DESIGN
The data analysed refers to a population of elderly patients (age≥ 60; N=82) included in a prospective study with 100 patients who presented for laboratory evaluations between 1st February and 30th June 2016 in the outpatient clinic of the National Institute of Gerontology and Geriatrics “Ana Aslan” (NIGG “Ana Aslan”), Bucharest, Romania. For all the participants, were recorded socio- demographic (gender, age, marital status, environmental origin, level of education, socio-economic status), and clinical (medical conditions) data. This study was approved by the Ethical Committee of the University of Medicine and Pharmacy of Craiova, Romania, and had a collaboration protocol with the outpatient clinic NIGG “Ana Aslan”. Details of the study were explained to the patients and a written consent was obtained from all the participants.
PSYCHOMETRIC TESTS
In order to evaluate the levels of depression and anxiety we used the Hospital Anxiety and Depression Scale (HADS). HADS is a self-rating scale with 14 items, 7 attributed to depression and 7 to anxiety symptoms (27). On each item, the patient can score from 0 to 3, meaning that a person can score between 0 and 21 for either anxiety or depression; the cut-off point is ≥ 8 for anxiety or depression (27). For depression (HADS-D) has a specificity of 0.79 and a sensitivity of 0.83. For anxiety (HADS-A) has a specificity of 0.78 and a sensitivity of 0.9 (28).
STATISTICALANALYSIS
Descriptive measures have been employed. We looked first if there are any differences, except age that in the two age groups: sex, socioeconomic status (as evaluated by “employed” or “retired” status) and somatic illnesses comorbidities. We used chi-square to compare the two groups regarding the above putative biases. Afterwards we compared the two groups in terms of prevalence of anxiety symptoms and depressive symptoms by using chi- square test. All the analysis has been performed using Statistical Package for the Social Sciences (SPSS) 22. RESULTS
We identified a number of 70 patients in the old age group and a number of 12 patients in the group of very old age. The patients from the first group had a median age of 69.41 years (±5.92). This group was comprised of 46 females (65.7%), and most of the individuals lived in urban areas, N=65 (92.9%). Just 4 people still had a job, while the rest, N=66 (94.3%) were retired. From this group 69 (98.6%) had at least one somatic illness and 33 (47.1%) had at least two somatic conditions.
The patients from the second group had a median age of 84.25 years (±4.634), 6 were females (50%), most of them lived in urban areas, N=11 (91.7%) and all of them were retired.
All the patients from this group had at least one somatic illness and 8 (66.7%) had at least two medical conditions. There were no differences between the two groups regarding sex (OR=.904, CI=.737-1.109, p=.304), place of residence (OR=.974, CI=.637-1.410 p=.886), socio- economic status (OR=.846, CI=770-930, p=.254) and the presence of one (OR=1.174, CI=1.072-1.286) p=.572) or two somatic illnesses (OR=2.242, CI=.618-8.136 p=.208).
From the total number of the very old patients, 10 (83.33%) out of 12 experienced depression compared to 30 (42.85%) out 70 from their younger counterpart. A statistically significant higher percent from the very old group compared to the old group experienced depression: OR=1.309, CI=1.066-1.609, p=.005.
From the total number of the old patients, a number of 50 out of 70 (71.4%) presented anxiety compared to 7 out of 12 (58.3%) from the very old age group, without significant statistic differences between the two groups: OR=.686, CI=.319-1.474, p=.498.
DISCUSSION
One important result of our study is that we found huge values of prevalence of depression and anxiety in old people (as an entire group).
The people from the very old age group (≥ 80 years)
presented a prevalence of depression of 83.3% and anxiety 58.3%.
By comparison the people from the old age group (60-79 years) had 42.85% depression and 71.4. % anxiety.
That data showed very high levels of depression and anxiety in both groups which indicates the need for an aggressive screening for depression and anxiety in the old age and very old age groups.
However, in the very old age group the prevalence of depression is statistically significant larger than in the old age group. This fact stands true in the condition were there were no differences between the two groups regarding the putative risk factors for depression: socio economic status or somatic comorbidities. On the other hand, the proportion of people with anxiety is higher in the old age group compared to the very old age group, even though it didn’t reached statistical significance.
These facts may represent an argument for the theory that increasing age is indeed associated with increasing risk for depression, but not for anxiety, and that age may well operate differently in terms of risk for depression and anxiety in various subgroups of the old age people.
Even though there is data from genetics (29), clinical (30), therapeutic (30), and the very high comorbidity between depression and anxiety (31) that suggests an important degree of overlap between the two conditions, there is also significant data suggesting important differences between the two above conditions. Neuroimaging data suggests as Goodwin (30) stated: “supporting the existence of a common abnormality in anxiety and depression in the ventral cingulate and the amygdala, but with disorder specific compensation during implicit regulation of emotional processing apparently through engagement of cognitive control circuitry in the depressed group.”
It may be well that some of the neurobiological differences between the two conditions can explain the results we obtained, that increasing age is associated with increasing prevalence of depression but not anxiety. The design of the study precludes any definitive answers to this questions but raises some other possibilities: that increasing in age m a y b e a s s o c i a t e d w i t h d i f f e r e n t neurobiological/psychological changes that can increase the risk only for depression in the very old group, or maybe human brains are more prone, due to ageing process, to rather develop depression than anxiety. That implies that risk and protective factors (be it neurobiological, psychological, social and so on) for depression and anxiety may express themselves different at different ages subgroups in the old age population and more refined work should be done in order to try to disentangle various contributors to these two common diseases in the old age population. Also this implies that old age should not be considered one big unique group but instead probably various age intervals of old age groups should be separately analyzed.
LIMITATIONS:
The main limitation of our study is the low number of patients in the very old age group. Yet we can make two speculations about this issue: the number of people with depression and anxiety is so high in this age group that even a very small group like ours may generate solid data. The second speculation is that the trend observed in the bigger old age group continues in the very old age group, suggesting that the results we obtained are correct. CONCLUSIONS
Both depression and anxiety are present with very high prevalence rates in the old age patients. Still, there is an increase in risk for depression in the very old age group. More research for identifying risk and protective factors in different segments of the old age people is necessary for both depression and anxiety.

REFERENCES:

1.United Nations Development Programme (September 2005). „UN Human Development Report 2005, International Cooperation at a Crossroads-Aid, Trade and Security in an Unequal World”
2.National Institute on Aging, 2007. Why population aging matters – a global perspective
3.Forman DE, Berman AD, McCabe CH, Baim DS, Wei JY. PTCA in the
elderly: The „young-old” versus the „old-old”. Journal of the American Geriatrics Society. 1992; 40 (1): 19–22.
4.”Demographics of Aging”. Transgenerational.org.
5.Volkert J, Schulz H, Härter M, Wlodarczyk O, Andreas S. The prevalence of mental disorders in older people in Western countries – a meta-analysis. Ageing Research Reviews 12 2013; 339–353
6. Polyakova M, Sonnabend N, Sander C, et al. Prevalence of minor depression in elderly persons with and without mild cognitive impairment: a systematic review. J Affect Disord 2014; 152:28–38
7.Cuijpers P, Vogelzangs N, Twisk J, Kleiboer A, Li J, Penninx BW. Differential mortality rates in major and subthreshold depression: meta- analysis of studies that measured both. Br J Psychiatry 2013; 202:22–27
8. Meeks TW, Vahia IV, Lavretsky H, Kulkarni G, Jeste DV. A tune in “a minor” can “b major”: a review of epidemiology, illness course, and public health implications of subthreshold depression in older adults. J Affect Disord 2011; 129:126–142
9. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 2009; 374:609–619
10. Gostynski M, Ajdacic-Gross V, Gutzwiller F, Michel JP, Herrmann F. Depression bei Betagten in der Schweitz. Nervenartz 2002; 73:851–860.
11.Pahkala K, Kesti E, Köngäs-Saviaro P, Laippala P, Kivelä SL. Prevalence of depression in an aged population in Finland. Soc Psychiatry Psychiatr Epidemiol 1995; 30: 99–106.
12.Hybels CF, Blazer DG, Pieper CF. Toward a threshold for subthreshold depression: an analysis of correlates of depression by severity of symptoms using data from an elderly community sample. Gerontologist 2001; 41:357–365
13. Meller I, Fichter MM, Schroppel H. Risk factors and psychosocial consequences in depression of octo- and nonogenarians: results of an epidemiological study. Eur Arch Psychiatry Clin Neurosci 1997;
247:278–287. 

14.Steffens DC, Skoog I, Norton MC et al. Prevalence of depression and its treatment in an elderly population. The Cache County Study. Arch Gen Psychiatry 2000; 57:601– 607

15.Forsell Y, Winblad B. Anxiety disorders in non-demented and demented elderly patients: prevalence and correlates. Journal of Neurology, 1997; 62, 294–295.
16.Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 2005; 62, 593–602.
17.Bryant C, Jackson H, Ames D. The prevalence of anxiety in older adults: methodological issues and a review of the literature. Journal of Affective Disorders, 2008; 109, 233–250.
18.van Hout HP, Beekman AT, de Beurs E et al. Anxiety and the risk of death in older men and women. The British Journal of Psychiatry, 2004,
185, 399–404.
19.Schaub RT, Linden M. Anxiety and anxiety disorders in the old and very old—results from the Berlin Aging Study (BASE). Compr Psychiatry 2000; 41:48–54
20.Gum AM, King-Kallimanis B, Kohn R. Prevalence of mood, anxiety, and substance—abuse disorders for older Americans in the National Comorbidity Survey Replication. Am J Geriatr Psychiatry 2009;
17:769–781.
21.Bruce ML. Psychosocial risk factors for depressive disorders in late life. Biol Psychiatry 2002: 52: 175–184.
22.Blazer DG. Depression in Later Life. Springer: New York 2002.
23.Martin P, Poon LW, Clayton GM, Lee HS, Fulks JS, Johnson MA. Personality, life events and coping in the oldest-old. Int J Aging Hum Dev 1992; 34: 19–30.
24.Mirowsky J, Ross CE. Age and depression. J Health Soc Behav 1992: 33: 187–205.
25.Blazer DG, Koening HG. Mood disorders. In Textbook of Geriatric Psychiatry, Busse EW, Blazer DG (eds), 2nd edn. American Psychiatric Press: Washington, DC; 1996; 235–263.
26.Haynie DA, Berg S, Johansson B, Gatz M, Zarit SH. Symptoms of depression in the oldest-old: a longitudinal study. J Gerontol: Psychol Sci
2001: 56B: 111–118.

27.Zigmond AS, Snaith, RP. The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica. 1983; 67 (6): 361–370.
28.Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. Journal of Psychosomatic Research. 2002; 52 (2): 69–77.
29.Kendler KS, Prescott CA, Myers J, Neale MC. The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women. Arch Gen Psychiatry. 2003;60(9):929-937.
30.Goodwin GM. The overlap between anxiety, depression, and obsessive-compulsive disorder. Dialogues Clin Neurosci. 2015;17:249- 260.
31.Hofmeijer-Sevink MK, Batelaan NM, van Megen HJ, et al. Clinical relevance of comorbidity in anxiety disorders: a report from the Netherlands Study of Depression and Anxiety (NESDA). J Affect Disord. 2012;137(1- 3):106-112.)

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