Family Practice Vol. 18, No. 1, 87-91
© Oxford University Press 2001
Psychological Problems |
Dementia and depression: two frequent disorders of the aged in primary health care in Greece
a Health Centre of Chrisoupolis (HCC), Macedonia,
b Laboratory of Biostatistics and
c Clinic of Social and Family, School of Medicine, University of Crete, Crete, Greece and
d Department of Medicine and Care, Faculty of Health Sciences, University of Linköping, Linköping, Sweden.
Correspondence to Stella Argyriadou, 7th Mariou Street, Chrisoupolis 64200, Macedonia, Greece.
Argyriadou S, Melissopoulou H, Krania E, Karagiannidou A, Vlachonicolis I and Lionis C. Dementia and depression: two frequent disorders of the aged in primary health care in Greece. Family Practice 2001; 18: 87–91.
Received 13 January 2000; Revised 30 June 2000; Accepted 5 September 2000.
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Abstract |
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Background. Dementia and depression are very common disorders among elderly people and their presence decreases the well-being of the aged.
Objectives. The purpose of this study was to assess the magnitude of dementia and depression among elderly people living in different settings in the catchment area of the Chrisoupolis health centre (HCCh) in northern Greece.
Methods. A total of 536 patients aged 65 years and over, including 48 subjects living in an old people's home, 75 subjects who were taking part in the activities of the open centre for the elderly and 413 subjects randomly selected from those visiting the HCCh, were interviewed by the primary health care team of the HCCh. Medical and family history data were recorded, while cognitive and mood disorders were assessed by using the Mini Mental State Examination and Geriatric Depression Screening Scale.
Results. At the time of the examination, 37.6% of the men and 41.6% of the women showed various degrees of cognitive impairment, while 29.9% of the women and 19.6% of the men showed mild to moderate depression. Diabetes mellitus and hypertension frequently were found to co-exist with depression and dementia.
Conclusion. The results reaffirm that there is a high prevalence of the studied mental disorders in older patients in the out-patient setting in Greece. A set of recommendations to Greek GPs has now been formulated, with specific emphasis on the use of different screening tools and the appropriate treatment of the most frequently co-existing chronic diseases.
Keywords. Dementia, depression, elderly people, general practice, Greece.
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Introduction |
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Dementia and depression are very common disorders in later life,1,2 and their presence decreases the quality of life of elderly people. GPs fail to recognize these conditions until they are advanced,3,4 but they are capable, after training, of developing skills to prevent or delay their progression.5–7
Primary health care (PHC) in Greece has evolved rapidly during the last decade, with ~180 health centres now functioning in rural areas. These PHC units are responsible for out-patient care including the provision of social care, nursing home services and terminal care, but there is little knowledge about the prevalence of dementia and depression in the Greek PHC setting. Therefore, it was interesting to investigate dementia and depression among the elderly living in different settings in the catchment area of the Chrisoupolis health centre (HCCh) and to compare these data with those of other countries across Europe and the world.
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Subjects and methods |
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Setting
The study was carried out in the catchment area of the HCCh in northern Greece, which comprises 22 000 inhabitants (2900 over 65 years).
Subjects
Eligible participants were those of 65 years or over who were: (i) living in an old people's home (48 subjects all included); (ii) visiting the open centre for the elderly during a 20-working day period (75 subjects); and (iii) visiting the HCCh for their routine medical care. The latter group comprised 497 subjects, who were selected randomly from among the elderly visiting one of the two out-patient clinics of the health centre during the same time period. Of the 497 original subjects, 84 failed to complete the examination so therefore were excluded. All participants were informed about the importance of and risk of developing cognitive and mental disorders, and were then invited to participate in this study. Thus the final number of subjects participating in and completing this study was 536 (Table 1
). A PHC team consisting of three GPs, four community nurses, a neurologist and a psychiatrist interviewed all subjects.
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The study was approved by the Scientific and Ethical Committee of the General Hospital of Kavala, Greece.
Instruments
The validated Greek version of the Mini Mental State Examination (MMSE) test and the short version of the Geriatric Depression Screening Scale (GDSS) for mood disorders were used.8–10 For the diagnostic classification of cognitive and mood disorders, the criteria of ICD-10 were applied.11 Possible cognitive impairment was defined when an MMSE score was in the range of 19–24 and cognitive impairment was in the range 0–18. Respondents who scored 
5 on the GDSS were classified as being depressed. The subjects were assessed further by the Hachinski scale test12 in order to obtain a more complete understanding of the cause of dementia.
Further information concerning demographic and background characteristics (age, gender, level of education, marital status) was also obtained. Social class was coded according to previous occupation and, for widows, according to their husband's former occupation.13 The educational level of subjects was also registered. Finally, a detailed clinical investigation was carried out by a GP, focusing on the possible appearance of co-existing diseases that could be correlated with the onset of dementia and depression. The medical records of the participants kept at the HCCh were also reviewed and the diagnosis of the following diseases and conditions was recorded: (i) diabetes mellitus; (ii) hypertension; (iii) head injury; (iv) stroke; (v) Parkinson's disease; and (vi) depression.
Data analysis
All statistical analyses were carried out using SPSS for Windows (Release 9.0). The associations between categorical variables, such as different subject groups and prevalence of disorders, were tested by means of Pearson's chi-squared test or Fisher's test where appropriate.14 Comparisons of mean values between groups were made by Student's t-test or analysis of variance. The independent influence of all potential factors in identifying the presence of dementia or depression was studied by means of unconditional logistic regression analysis.15
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Results |
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Prevalence of cognitive disorders
A total of 176 (36.1%) of the 488 elderly subjects from the HCCh and open centre for the elderly had an MMSE score
24, and 57 (11.7%) had a score <19. The corresponding scores among the 48 people from the old people's home were 37 (77.1%) and 25 (52.1%) (Fig. 1). With respect to gender, 92 of the 245 males (37.6%) had an MMSE score 24, and 34 (13.9%) a score <19; 121 females of the 291 (41.6%) had an MMSE score 24, and 48 (16.5%) a score <19. A total of 41 (19.2%) of the 213 elderly subjests who were examined further using the Hachinski's scale test were deemed abnormal, i.e. their dementia had a multi-infarct or mixed aetiology.
Prevalence of mood disorders
When assessed by the GDSS scale, a total of 102 (20.9%) people from the HCCh and the open centre for the elderly had an abnormal score; the corresponding number among the subjects from the old people's home was 33 (68.8%); 11 men (33.3%) and 22 women (66.7%) (Fig. 1).
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Prevalence of co-existing diseases and conditions
Table 2
shows the most common co-existing diseases and their prevalence among the participants of our study. The prevalence of hypertension and diabetes mellitus was statistically significantly higher in male subjects who were identified as low MMSE scorers in comparison with those with an MMSE score >24.
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Logistic regression analysis
The results of the logistic regression analysis are illustrated in Tables 3 and 4
. Age, education and family status have a basic significant independent influence on dementia as measured by the MMSE with a cut-off point of 24. Hypertension and diabetes mellitus had a similar marked influence on dementia, which just fails to reach statistical significance (P = 0.009 and P = 0.007, respectively). The results were not significantly changed when the same model with a cut-off point of 19 was used, with the exception of hypertension, which was not found to be significantly associated with low MMSE score (P = 0.009). Gender, place of residence, family status and hypertension have a statistically significant association with high GDSS scores.
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Discussion |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionReferences |
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Dementia and depression have not been included among common diagnoses which GPs made in previous studies from PHC centres in rural Greece. This can be explained partially by the lack of specific exposure of GPs to Geriatrics and Gerontology during their vocational training in Greece, as well as the lack of specific institutions in which additional knowledge could be obtained.
The main findings of this study were that both disorders seem to affect elderly people, and their prevalence varies among different community settings. Several methodological considerations should be discussed carefully before any interpretation of the study results. Sampling methods and screening tools, which were used in such prevalence studies, have already been broadly discussed. Our sample seems to be quite representative of residents needing care in the HCCh and of people living in specific institutions. Although the specificity and sensitivity of the MMSE can be affected by factors such as sex, level of education and age,16 this tool remains a simple screening tool at GPs' disposal for cognitive impairment only, and cannot be used to make even tentative psychiatric diagnoses.17,18 We used the MMSE with two cut-off points, and the majority of the elderly living in the old people's home presented cognitive impairment even when the cut-off was reduced.
As maintained by Gurland,19 elderly people from impoverished backgrounds perform less well on cognitive testing because of subtle, subclinical brain damage induced by childhood illness, inadequate nutrition and a greater propensity to hypertension and strokes. This is in accordance with the findings of our study in which the highest prevalence rate (52.1%) was found in those living in the old people's home. This is also in accordance with the findings of other studies. In the USA, 50–84% of those in residential homes for the elderly were reported to be demented,20,21 and in the UK 65–77% of the residents were reported to be moderately or severely demented.22 Hachinsky's scale results show that 19.2% of the subjects were found to be suffering from multi-infarct or mixed dementia, and this prevalence proved to be ~20% of that found post-mortem.23
Our results may overestimate the true prevalence of cognitive impairment, since research has shown that there is a clear reliance on verbal abilities in the MMSE, and people of lower educational status tend to perform badly, independently of their brain function.24 Our finding, which showed that well educated people had less probability of having a low MMSE score, could support this. Depression can also lead to false positives in the rating of dementia.25,26
Our study results also indicate that depression is prevalent in elderly people and mainly affects those living in an old people's home. However, depression both in Greece and elsewhere does not appear to be dealt with appropriately by GPs, who may be the first contact a patient has.27 Somatic symptoms due to chronic illness, cognitive impairment or behavioural problems may mask depressive symptomatology.28
Diabetes and hypertension were found to be more frequent in those people with a low score on the MMSE and a high score on the GDSS in comparison with those whose scores were within the normal range. It is uncertain, from the results of this study, if these illnesses are associated aetiologically with cognitive or mood disorders, although hypertension predicts a high GDSS score to a statistically significant degree, and a low MMSE to a statistically significant degree when a cut-off of <19 was defined. The GPs should have a higher index of suspicion of depression and/or dementia among elderly patients with physical illnesses, such as hypertension, diabetes and Parkinson's disease, and in those with a history of head injuries.
In conclusion, dementia and depression are common in elderly subjects who are assessed in different community settings. GPs and PHC personnel seem to be capable of assessing the health status of people.
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References |
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TopAbstractIntroductionSubjects and methodsResultsDiscussionReferences |
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1 Wells KB. Caring for depression in primary care: defining and illustrating the policy context. J Clin Psychol 1997; 58: 24–27.
2 Glasser M, Stearns AJ, de Kemp E, van Hout J, Hott D. Dementia and depression symptomatology as assessed through screening tests of older patients in an outpatients clinic. Fam Pract Res J 1994; 14: 261–272.[Medline]
3 Henndryx MS, Doebbeling BN, Kearns DL. Mental health treatment in primary care: physician treatment choices and psychiatric admission rates. Fam Pract Res J 1994; 14: 127–137.[Medline]
4 Stoppe G, Sandholzer H, Staedt J. Cerebral cognitive deficits in the aged. Diagnostic and therapeutic standards: organization of strategies for problem detection and solution. Z Arztl Fertbild (Jena) 1996; 90: 449–453.
5 De Courval PL, Saroyan A, Joseph L, Gauthier S. The competence of family physicians in caring for dementia patients. A survey of general practitioners in Quebec. Can Fam Physician 1996; 42: 1496–1502.[Web of Science][Medline]
6
Pont CD, Mant A, Kehoe L, Hewitt H, Brodaty H. General practitioner diagnosis of depression and dementia in the elderly: can academic detailing make a difference? Fam Pract 1994; 11: 141–147.
7 Eefsting JA, Boersma F, Van Den Brink W, Van Tilburg W. Differences in prevalence of dementia based on community survey and general practitioner recognition. Psychol Med 1996; 26: 1223–1230.[Web of Science][Medline]
8 Fountoulakis C, Tsolaki M, Chazi H, Kazis. Mini Mental State Examination (MMSE): a validation study in demented patients from the elderly Greek population. Encephalos 1994; 31:93–102 (in Greek, abstract in English).
9 Folstein MF, Folstein SE, McHugh PR. Mini Mental State. A practical method for grading the cognitive state of the patient for the clinician. J Psychiatr Res 1975; 12: 189–196.[Web of Science][Medline]
10 Sheikh JA, Yesavage JA. Geriatric Depression Scale (GDS) recent evidence and development of a shorter version. Clinical Gerontology 1986; 5: 165–172.
11 World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnosing Guidelines. 1992; translated into Greek by Stefanis K, Soldatos K, Mavreas B. Athens: BETA, 1993.
12
Hachinski VC, Illife LD, Du Boulay GH. Cerebral blood flow in dementia. Arch Neurol 1975; 32: 632–637.
13 Office of Population Censuses and Surveys. Classification of Occupations. HMS: London, 1980.
14 Armitage P, Berry G. Statistical Methods in Medical Research. 2nd edn. Oxford: Blackwell Scientific Publications, 1987.
15 Collett D. Modeling Binary Data. London: Chapman and Hall, 1991.
16 O'Connor DW, Pollit PA, Treasure FP, Brook CPB, Reiss BB. The influence of education, social class and sex on Mini-Mental State scores. Psychol Med 1989; 19: 771–776.[Web of Science][Medline]
17 Wind AW, Schellevis FG, Van Staveren G et al. Limitations of the Mini-Mental State Examination in diagnosing dementia in general practice. Int J Geriatr Psychiatry 1997; 12: 101–108.[Web of Science][Medline]
18 O'Connor DW, Pollitt PA, Hyde JB et al. The reliability and validity of the Mini-Mental State in a British community survey. J Psychiatr Res 1989; 23: 87–96.[Web of Science][Medline]
19 Gurland BJ. The borderlands of dementia: the influence of sociocultural characteristics on rates of dementia occurring in senium. In Miller NE, Cohen GD (eds). Clinical Aspects of Alzheimer's Disease and Senile Dementia. New York: Raven Press, 1981; 61–84.
20 Patee JJ, Gustafson JM. Global brain failure in a nursing home resident population. J Am Geriatr Soc 1984; 32: 308–315.[Web of Science][Medline]
21 Joseph A, Boult C. Managed primary care of nursing home residents. J Am Geriatr Soc 1998; 46: 1152–1156.[Web of Science][Medline]
22 Weyerer S, Mann AH, Ames D. Prevalence of depression and dementia in residents of old age homes in Mannheim and Camden. Z Gerontol Geriatr 1995; 28: 169–178.[Web of Science][Medline]
23
Mann AH, Graham N, Ashby D. Psychiatric illness in the residential homes for the elderly: a survey in one London borough. Age and Ageing 1984; 13: 257–265.
24 Fillenbaum G, Heyman A, Williams K, Prosnitz B, Burchett B. Sensitivity and specificity of standardized screens of cognitive impairment and dementia among elderly black and white community residents. J Clin Epidemiol 1990; 43: 651–660.[Web of Science][Medline]
25 Orrell M, Howard R, Payne A et al. Differentiation between organic and functional psychiatric illness in the elderly: an evaluation of four cognitive tests. Int J Geriatr Psychiatry 1992; 7: 263–275.
26 Mendenopoulos G. The multiinfarct dementia. In Mendenopoulos G (ed.). Non Alzheimer Dementia. Thessaloniki: University Studio Press, 1996; 26–35.
27 Bowers J, Jorm AF, Henderson S, Harris P. General practitioners' reported knowledge about depression and dementia in elderly patients. Aust NZ J Psychiatry 1992; 26: 168–174.[Web of Science][Medline]
28 Bowers J, Jorm AF, Henderson S, Harris P. General practitioners' detection of depression and dementia in elderly patients. Med J Aust 1990; 20: 192–196.
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