SOCIAL SUPPORT AND DEPRESSIVE SYMPTOMS IN OLDER ADULSTS TREATED IN AN OUTPATIENT SERVICE

APOYO SOCIAL Y SÍNTOMAS DEPRESIVOS EN ANCIANOS ATENDIDOS EN UN SERVICIO AMBULATORIO

ABSTRACT

Objective:

to assess social support, to screen the scores indicative of depression, and to identify if social support is associated in any way with the scores and with the sociodemographic variables.

Method:

a cross-sectional and analytical study conducted at a Specialty Outpatient Service for Older Adults in São Paulo. A total of 133 aged individuals were selected from February 2019 to July 2021. During data collection, a structured questionnaire with diverse sociodemographic and clinical information was used, as well as having a caregiver or not; in addition, the following instruments were applied: Mini-Mental State Examination, Geriatric Depression Scale, Katz, Lawton and Social Support Scale.

Results:

the study participants' mean age was 74.2 years old, they were mostly women (72.9%), married (35.3%), white-skinned (70.7%) and retired (74.5%), they had four years of study (31.6%) and incomes up to one minimum wage (30.8%), and they were hypertensive (73.6%), diabetic (38.3%) and dyslipidemic (31.5%). It was observed that, in all the Social Support Scale domains, most of the interviewees perceived high support. It was evidenced that the highest frequency of aged people with normal psychological state corresponded to those with the highest frequency of high support perception in the Emotional and Positive social interaction domains.

Conclusion:

the study was able to evidence that aged people with a low perception of social support were the ones that presented more depressive symptoms. Therefore, by evidencing and knowing the sociodemographic profile of the service, it is possible to favor planning of the care provided by the multiprofessional team and propose strategic actions for comprehensive care.

DESCRIPTORS:
Older adult; Depression; Social support; Outpatient care; Protection factors; Risk factors

RESUMEN

Objetivo:

evaluar el apoyo social, rastrear las puntuaciones que indican depresión e identificar si hay alguna asociación entre el apoyo social con las puntuaciones y las variables sociodemográficas.

Método:

estudio transversal y analítico realizado en el Servicio Ambulatorio de Especialidades para Ancianos de San Pablo. Se seleccionaron 133 adultos mayores entre febrero de 2019 y julio de 2021. En la recolección de datos se utilizó un cuestionario estructurado con diversa información sociodemográfica y clínica o tener cuidador o no, además de aplicarse los siguientes: Mini-Examen de Estado Mental, Escala de Depresión Geriátrica, Katz, Lawton y Escala de Apoyo Social.

Resultados:

la media de edad de los participantes del estudio fue de 74,2 años, la mayoría eran mujeres (72,9%), personas casadas (35,3%), de raza blanca (70,7%), jubilados (74,5%), con cuatro años de estudio (31,6%), ingresos de hasta un salario mínimo (30,8%), y con hipertensión (73,6%), diabetes (38,3%) y dislipidemia (31,5%). Se observó que en todos los dominios de la Escala de Apoyo Social, la mayoría de los entrevistados indicó una percepción de apoyo elevado. Se hizo evidente que la mayor frecuencia de personas mayores con estado psicológico normal correspondió con aquellas con mayor frecuencia de percepción de apoyo elevado en los dominios Emocional e Interacción social positiva.

Conclusión:

el estudio logró evidenciar que los ancianos que presentaron una percepción de apoyo social bajo fueron las que tuvieron más síntomas depresivos. En consecuencia, al poner de manifiesto y conocer el perfil sociodemográfico del servicio, fue posible favorecer la planificación de la asistencia prestada por el equipo multiprofesional y proponer acciones estratégicas para la integralidad de la atención.

DESCRIPTORES:
Anciano; Depresión; Apoyo social; Asistencia ambulatoria; Factores de protección; Factores de riesgo

RESUMO

Objetivo:

avaliar o apoio social, rastrear os escores indicativos de depressão e identificar se há associação do apoio social com os escores e as variáveis sociodemográficas.

Método:

estudo transversal e analítico, realizado no Ambulatório de Especialidades do Idoso em São Paulo. Foram selecionados 133 idosos no período de fevereiro de 2019 a julho de 2021. Na coleta de dados, utilizou-se um questionário estruturado, com informações sociodemográficas, clínicas, ter ou não cuidador e foram aplicados os instrumentos: Miniexame do estado mental, Escala de Depressão Geriátrica, Katz, Lawton, Escala de apoio Social.

Resultados:

a idade média dos participantes do estudo foi de 74,2 anos, mulher (72,9%), casada (35,3%), branca (70,7%), aposentadas (74,5%), quatro anos de estudos (31,6%), renda de até um salário-mínimo (30,8%) hipertensas (73,6%), diabéticas (38,3%) e dislipidêmicas (31,5%). Observou-se que em todos os domínios da escala de apoio social a maior parte dos entrevistados teve percepção de apoio alto. Evidenciou-se que a maior frequência de pessoas idosas com quadro psicológico normal eram aquelas com maior frequência de percepção de apoio alto nos domínios emocional e interação social positiva.

Conclusão:

o estudo pode evidenciar que pessoas idosas que apresentaram percepção de apoio social baixo foram as que apresentaram mais sintomas depressivos. Portanto, ao evidenciar e conhecer o perfil sociodemográfico do serviço pode-se favorecer o planejamento do cuidado prestado pela equipe multiprofissional e propor ações estratégicas para integralidade do cuidado.

DESCRITORES:
Idoso; Depressão; Apoio social; Assistência ambulatorial; Fatores de proteção; Fatores de risco

INTRODUCTION

Depression is a mental disorder that affects more than 264 million people of all ages at the global level. One out of five individuals has experienced or will experience an episode of depression at some point in their life1. According to data from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística, IBGE) in 2019, nearly 13.2% of the aged population in Brazil suffer from depression2.

The Health, Well-being and Aging (Saúde, Bem-Estar e Envelhecimento, SABE) study, carried out in 2019 with a sample of the aged population in the municipality of São Paulo, highlighted that depressive symptoms in older adults are more frequent among women, aged people with low schooling levels and older adults with incomes of less than their everyday needs and expenses. In addition to that, higher prevalence of depressive symptoms was observed in older adults with impaired visual and auditory functioning and compromised oral health. Participating in religious group emerged as a protective factor against depression3.

Depression symptoms are grouped into emotional, neurovegetative and cognitive, but they can usually occur in association with other psychiatric diseases and disorders, making it difficult to detect the depressive syndrome1. Depression compromises memory and functional capacity and is associated with chronic physical multimorbidities, use of more medications and dependence in the activities of daily living, limiting older adults' functions and leading them to mood swings and deterioration of their quality of life1.

Social support can mitigate depression and, in this study, it is defined as the extent to which an individual perceives that friends, family members and other people provide various types of psychological support and other forms of support, when necessary4. A social support network can often make a person more resilient to daily stressors, protecting them from depression5.

Older adults' social isolation, both from family and friends, is associated with higher levels of depression and psychological distress symptoms6. A number of studies show that the feeling of loneliness is associated with an increased risk of cardiovascular accidents, as this feeling, at a high level, is a risk factor for depression, which, in turn, is associated with an increased risk of experiencing a cardiovascular event7.

The lower the older adults' social support, the lower their psychological stress. Isolation exerts a strong negative impact on older adults' mental health and, thus, strengthening of the family and community ties, intergenerational coexistence and social participation are strong protective factors for their health6.

The hypothesis of this research lies in the fact that the low social support perceived by aged people is associated with depressive symptoms. The objectives were as follows: to assess social support; to screen the scores indicative of depression; and to identify if social support is associated in any way with the scores and with the sociodemographic variables.

METHOD

This is a cross-sectional and analytical study conducted in the Specialty Outpatient Service for Older Adults (Ambulatório Médico de Especialidades Idosos, AMEI) from the Southeast region of the municipality of São Paulo. The process used to select the individuals included in the sample was by convenience, from February 2019 to July 2021, with 133 aged individuals comprising the final sample. A total of 17 patients were excluded for not meeting the inclusion criteria.

The criteria to be included in the research were as follows: being aged at least 60 years old and having their cognitive state preserved. Aged people who were disoriented and confused according to what was spoken by the nurses of the service were not included, as well as those who had a record of dementia in their medical charts or who, at the time of the interview, did not reach the minimum score according to the Mini-Mental State Examination (MMSE)8^-9.

A structured questionnaire with information on age, gender, schooling, marital status, occupation, presence of a caregiver, family income, medical diagnosis and comorbidities was used for data collection. The interviews lasted a mean of 90 minutes.

MMSE was used to screen the cognitive changes. Its total score can vary between zero and 30 points. The cutoff points used in this study were 18 for illiterates, 21 for schooling between 1 and 3 years, 24 for individuals with 4 to 7 years of study, and 26 for people with more than 7 years of formal education8^-9^.

The brief version of the Geriatric Depression Scale (GDS) was used to screen the scores indicative of depression. When counting the score, one point is assigned to each affirmative answer, with the exception of items 1, 5, 7, 11 and 13, where one point is given to a negative answer; six or more answers indicate presence of depressive symptoms. The score varies from zero to 15 points, where a score of zero to five points indicates normal psychological state, from six to ten points means mild depression, and from 11 to 15 points indicates a severe depression condition10^-11.

Social support was assessed by means of the Medical Outcomes Study (MOS)12^-13, which consists in 19 questions based on an initial instruction: “If you need to, how often can you count on someone?” It is divided into four social support domains: material (four questions - provision of practical resources and material help); affective (three questions - demonstrations of love and affection); emotional/information (four questions - expressions of positive affect, understanding and feelings of trust; and four questions - availability of people to ask for advice or guidance) and positive social interaction (four questions - availability of people to have fun or relax). There are five answer options for each question, indicating how often the person considers each type of support available, namely: zero (never); one (rarely); two (sometimes); three (almost always) and four (always). The score varies between zero (minimum) and 76 (maximum); the higher the score, the higher the perceived frequency about the possibility of having someone's support.

Descriptive analysis was used for the sociodemographic and clinical characterizations, as well as for having a caregiver and a social support network or not. Mean, standard deviation, maximum and minimum were calculated for the continuous variables and frequency and percentage, for the categorical ones. In order to verify the association between the social support scale and the categorical sociodemographic variables, Fisher's exact or the chi-square tests were used. Both tests were employed for possible associations between depression levels and categorical sociodemographic variables. To relate the different perceptions of support to the quantitative variables, Analysis of Variance (ANOVA) was used when the metric followed normality in all perceptions and homoscedasticity of the variances. In the cases of non-normality, the Kruskal-Wallis test was used. In order to relate social support to age, ANOVA was used to verify if, on average, age differed across the varied perceptions of support. Fisher's test was used to verify a possible association of social support and marital status with having a caregiver. The significance level considered corresponded to p<0.05, and the program used for the analysis was R, version 4.1.1.

The study was approved by the Research Ethics Committee of Universidade Federal de São Paulo and is in accordance with Resolution No. 466 of December 12^th, 2012, which deals with research in human beings.

RESULTS

The mean age of the study participants was 74.2 years old (Standard Deviation of 8.0). Most of them were women (97; 72.9%), married (47; 35.3%), white-skinned (94; 70.7%), had a companion for the consultation (72; 54.1%), did not have a caregiver (105; 78.9%), used the bus or underground to get to the AMEI (77; 58.0%), were retired or pensioners (99;74.5%), had 4 years of study (42; 31.6%), and earned an income of one minimum wage (41; 30.8%). The most prevalent comorbidities were systemic arterial hypertension (98; 73.6%), diabetes mellitus (51; 38.3%) and dyslipidemia (42; 31.5%). The most frequently used medications were anti-hypertensives (97; 72.9%), oral hyperglycemic agents (51; 38,3%) and lipid-lowering drugs (45; 33.8%) (Table 1).

Table 1 -
Sociodemographic characteristics of the aged people treated at the AME for Older Adults. São Paulo, São Paulo, Brazil, 2021. (n=133)

Characteristics	Older adults (N=133) N (%)
Age (years old)	74.2* (60-97)†
Gender
Female	97 (72.9)
Male	36 (27.1)
Skin color
White	94 (70.7)
Non-white	39 (29.3)
Marital status
Married	47 (35.3)
Single	21 (15.8)
Widowed	40 (30.1)
Divorced/Separated	25 (18.8)
Occupation
Employee	2 (1.5)
Employee/Retired	7 (5.3)
Freelancer	3 (2.3)
Freelancer/Retired	12 (9)
Housewife	10 (7.4)
Retired/Pensioner	99 (74.5)
Companion for the appointment
Yes	72 (54.1)
No	61 (45.9)
Caregiver
Yes	28 (21.1)
No	105 (78.9)
Transportation means to reach the service
Bus	39 (29.3)
Underground	12 (9)
Bus and underground	22 (16.5)
Own vehicle	27 (20.3)
Others (taxi, third-party vehicle)	33 (24.9)
Schooling
Illiterate	17 (10.6)
1-3 years of study	24 (17.0)
4-6 years of study	44 (31.1)
7+years of study	48 (41.3)
Monthly income
0-0.5 minimum wages	2 (1.6)
1 minimum wage	41 (30.8)
1.5 minimum wages	11 (8.3)
2 minimum wages	39 (29.3)
2.5 minimum wages	2 (1.6)
3 minimum wages	16 (12)
3.5+ minimum wages	22 (16.4)
Comorbidities
Systemic Arterial Hypertension	98 (73.6%)
Diabetes Mellitus	51 (38.3%)
Dyslipidemia	42 (31.5%)
Medications
Antihypertensive drugs	97 (72.9%)
Oral hypoglycemic agents	51 (38.3%)
Lipid-lowering drugs	45 (33.8%)

• Values expressed as mean* and as minimum-maximum^†

Most of the interviewees presented normal psychological state (72; 54.1%), followed by mild (52; 39.1%) and severe (9; 6.7%) depression.In all the MOS domains, most of the interviewees had a high perception of support (Table 2).

Table 2 -
Scores of the Medical Outcomes Study domains obtained by the aged people treated at the AME for Older Adults. São Paulo, São Paulo, Brazil, 2021. (n=133)

Medical Outcomes Study domains
Material	n (%)	Affective	n (%)	Emotional	n (%)	Positive social interaction	n (%)
LSP*	14 (10.5%)	LSP*	8 (6.0%)	LSP*	15 (11.3%)	LSP*	30 (22.5%)
ASP†	34 (25.6%)	ASP†	30 (22.5%)	ASP†	50 (37.6%)	ASP†	31 (23.3%)
HSP‡	85 (63.9%)	HSP‡	95 (71.4%)	HSP‡	68 (51.1%)	HSP‡	72 (54.1%)

• *LSP = Low Social Support Perception; †ASP =Average Social Support Perception; ‡HSP = High Social Support Perception

In Table 3, it is verified that the aged people with a high support perception are older than those with a low support perception. It is noted that this was the only significant data. There was a higher percentage of aged people with a caregiver classified as having high support perception when compared to the groups with average and low perception in the Material domain of MOS. The groups with average and low support perception in relation to the caregiver were similar for the Material domain. In relation to marital status, there was a higher percentage of widowed individuals in the high support perception group, when compared to the other groups.

Table 3 -
Variables that were associated with the Medical Outcomes Study for the individuals researched at the AME for Older Adults. São Paulo, São Paulo, Brazil, 2021. (n=133)

Variables
Medical Outcomes Study domains	Age (Mean [SD])	Marital status				Caregiver
		Married	Single	Widowed	Divorced	Yes	No
Material
LSP*	74.2 (7.6%)	4 (28.60%)	4 (28.60%)	4 (28.60%)	2 (14.30%)	1 (7.1%)	13 (92.9%)
ASP†	72.4 (7.5%)	10 (29.4%)	8 (23.50%)	7 (20.60%)	9 (26.50%)	3 (8.80%)	31 (91.20%)
HSP‡	74.8 (8.3%)	33 (38.8%)	9 (10.6%)	29 (34.1%)	14 (16.5%)	24 (28.2%)	61 (71.8%)
p	0.349§	0.227||				0.028||
Affective
LSP*	74.3 (7.20%)	1 (12.5%)	3 (37.5%)	2 (25.0%)	2 (25.0%)	0 (0.0%)	8 (100.0%)
ASP†	73.3 (8.6%)	13 (43.3%)	6 (20.0%)	3 (10.0%)	8 (26.7%)	7 (23.3%)	23 (76.7%)
HSP‡	74.4 (8.03%)	33 (34.7%)	12 (12.6%)	35 (36.8%)	15 (15.8%)	21 (22.1%)	74 (77.9%)
p	0.759¶	0.026||				0.374||
Emotional
LSP*	71.6 (7.0%)	5 (33.3%)	5 (33.3%)	1 (6.7%)	4 (26.7%)	3 (20.0%)	12 (80.0%)
ASP†	74.2 (7.9%)	19 (38.0%)	8 (16.0%)	12 (24.0%)	11 (22.0%)	9 (18.0%)	41 (82.0%)
HSP‡	74.6 (8.30%)	23 (33.8%)	8 (11.8%)	27 (39.7%)	10 (14.7%)	16 (23.5%)	52 (76.5%)
p	0.428§	0.088||				0.792||
Positive social interaction
LSP*	69.9 (6.20%)	11 (36.7%)	8 (26.7%)	4 (13.3%)	7 (23.3%)	4 (13.3%)	26 (86.7%)
ASP†	74.4(7.3%)	9 (29.0%)	5 (16.1%)	11 (35.5%)	6 (19.4%)	9 (29.0%)	22 (71.0%)
HSP‡	75.8 (8.4%)	27 (37.5%)	8 (11.1%)	25 (34.7%)	12 (16.7%)	15 (20.8%)	57 (79.2%)
p	0.003§	0.219||				0.322**

• *LSP = Low Social Support Perception;†ASP = Average Social Support Perception; ‡HSP = High Social Support Perception; §ANOVA; ||Fisher's exact test; ¶Kruskal Wallis test; **Chi-square test.

The age, marital status and caregiver variables presented no association with GDS.

Table 4 shows that there was an association of the Emotional and Positive social interaction domains of MOS with GDS. The highest frequency of aged people with normal psychological state corresponded to those with the highest frequency of high support perception in the Emotional and Positive social interaction domains.

Table 4 -
Association between the Medical Outcomes Study and Geriatric Depression Scale for the individuals researched at the AME for Older Adults. São Paulo, São Paulo, Brazil, 2021. (n=133)

Medical Outcomes Study domains	Geriatric Depression Scale			p
	Normal psychological state	Mild depression	Severe depression
Material
LSP*	5 (6.9%)	7 (13.5%)	2 (22.2%)	0.387||
ASP†	17 (23.6%)	15 (28.8%)	2 (22.2%)
HSP‡	50 (69.4%)	30 (57.7%)	5 (55.6%)
Affective
LSP*	3 (4.2%)	3 (5.7%)	2 (22.2%)	0.159||
ASP†	14 (19.4%)	13 (25%)	3 (33.3%)
HSP‡	55 (76.4%)	36 (69.2%)	4 (44.4)
Emotional
LSP*	4 (5.6%)	7 (13.5%)	4 (44.4%)	0.022||
ASP†	28 (38.9%)	21 (40.4%)	1 (11.1%)
HSP‡	40 (55.6%)	24 (46.2%)	4 (44.4%)
Positive social interaction
LSP*	10 (13.9%)	15 (28.8%)	5 (55.6%)	0.023||
ASP†	18 (25.0%)	13 (25.0%)	0 (0.0%)
HSP‡	44 (61.1%)	24 (46.2%)	4 (44.4%)

• *LSP = Low Social Support Perception; †ASP =Average Social Support Perception; ‡HSP = High Social Support Perception; ||Fisher's test.

DISCUSSION

The findings of this research related to the older adults' sociodemographic data corroborate national and international studies that drew the sociodemographic profile of community-dwelling aged people and show a similar mean age, predominance of women, married and white-skinned individuals and with low schooling levels14^-17.

The most common morbidities in the study were systemic arterial hypertension, diabetes mellitus and dyslipidemia16. They are the most prevalent chronic diseases in the aged population due to inadequate nutrition, lifestyle, physiological changes and decreased autonomy to prepare their own food¹⁸. These morbidities are risk factors for cardiovascular diseases that can be induced and potentiated by depression19.

In this research, most of the older adults had a high of social support perception and normal psychological state. Social support has a strong relationship with the subjective well-being of an individual, especially in older adults, who suffer many social losses in their life cycle phase. As benefits of social support for older adults' health, we can mention the improvement in medical parameters such as mental health, depression and disabilities; in social parameters such as prevention of institutionalization; and in health parameters, such as well-being and quality of life20.

Older interviewees, with caregivers and widowed had a high social support perception. With advancing age, older adults may need care from other people. A good relationship between the caregiver and the person being cared for contributes to a sensation of security and acceptance that favors the social support perception21. Unlike this research, in which the older adults believed that they would have the support of a person if they needed it, another study showed that social support was perceived positively among the married participants22.

Depression results from a complex interaction between social, psychological and biological factors. There are several factors associated with depression in older adults. Some studies indicate that females, with advanced age and low schooling levels are more likely to develop depression23^-24. However, there was no association between the age, marital status and caregiver variables and GDS among those researched.

The highest frequency of aged people with normal psychological state also corresponded to those with the highest frequency of high support perception in the Emotional and Positive social interaction domains. The Positive social interaction domain is related to having someone to do pleasant things with, relax, have fun and distract the mind; in turn, the Emotional domain is related to sharing fears, advice, listening, being listened to and receiving information when needed. Social support fits as an important part of comprehensive health care for older adults and is one of the most relevant aspects when thinking about improvements in the living and health conditions of these people21; it has been pointed out in the literature as a mediating factor of depression25.

This research had as limitations the fact that it was carried out in a single locus specialized in the care of older adults, with assistance only provided to patients from the public health system, which may not represent other realities; therefore, the results cannot be generalized. In addition, collection of a larger sample of the population was hampered due to the COVID-19 pandemic period and the need to close the locus for a period of almost 12 months.

By evaluating social support and screening depression and the association of social support with depression and with the sociodemographic variables, the study was able to contribute to knowing the profile and health needs of the older adults cared for at the locus, providing information for planning the care provided by nurses and the multiprofessional team and potential changes in the services offered, in order to increase adherence to the treatment, as well as to provide comprehensive care to aged people in their biological, social and psychological dimensions.

CONCLUSION

The sociodemographic profile of the participants interviewed in an outpatient care unit specialized in older adults presented a mean age similar to that of national and international studies and predominance of women, married, white-skinned and retired individuals, with low schooling levels, dependent on public transportation, with a companion for the consultations, but without a caregiver at their homes. The most prevalent diseases were systemic arterial hypertension, diabetes mellitus and dyslipidemia. For the most part, the psychological state was normal, and the perception of support was high for all domains of the instrument that assesses social support.

The highest frequency of aged people with no depressive symptoms corresponded to those with the highest frequency of high support perception in the Emotional and Positive social interaction domains.

Therefore, with this evidence and knowing the sociodemographic profile of the older adults who attend the service specialized in caring for aged people, it is possible to propose a greater offer of activities and more spaces that favor coexistence between the older adults themselves and the health team, to strengthen bonds and provide fun, conversations and distractions, among other leisure activities, which can reduce loneliness and even depression in these aged people and favor planning of the care provided by nurses and the multiprofessional team in its entirety.

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NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the thesis - Social support, functional capacity and depression in older adults treated in a Specialty Outpatient Service for Older Adults, presented at the Graduate Program in Nursing of Escola Paulista de Enfermagem, Universidade Federal de São Paulo, in 2022.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research of the Universidade Federal de São Paulo under Opinion No. 3,227,127 and Certificate of Presentation for Ethical Appraisal No. 04341418.5.0000.5505.

Edited by

EDITORS

Associated Editors: Renata Cristina de Campos Pereira Silveira, Monica Motta Lino. Editor-in-chief: Elisiane Lorenzini.

Publication Dates

• Publication in this collection
  06 Jan 2023
• Date of issue
  2022

History

• Received
  30 June 2022
• Accepted
  27 Oct 2022