Thesis Nurs. 1997 T469e c. 2 Thompson, Deborah L. The Effect of Depressio The effect of depression on perceived quality of 1997. on Perceived Quality of Life in the Elderly by Deborah L. Thompson, RN, BSN Submitted in Partial Fulfillment of the Requirements for the Masters of Science in Nursing Degree Approved by: Chairperson, Thesis Committee' Edinboro University of Pennsylvania i. yfox ’/ Xp y I Date /'Xt Committee Member Date fi__ 2 Committee Member Date c Acknowledgements This author wishes to extend sincere appreciation to the following people for their contributions in assisting me to complete this research project. To Dr. Charlotte Paul, Mrs. Jan Giltinan, and Dr. Ken Milles for their support and expertise in research. To my parents, brothers, and sisters-in-law for their constant prodding and encouragement as I worked. And last but certainly not least, I need to thank Brian and Jacob for all their patience and love throughout the entire thesis process. I could not have done it without all of your support....THANK YOU!!! ii Table of Contents Page Acknowledgements. ii Table of Contents . ill Abstract iv Chapter I - Introduction . . Background of the Problem Purpose of the Study . . Statement of the Problem Definition of Terms . . . Assumptions Limitations . . . . Chapter II - Review of the Literature . . Elderly . Depression .... Quality of Life . . Conceptual Framework 1 1 4 4 4 5 5 6 6 9 12 15 19 19 19 24 25 Chapter III - Methodology Sample Population . . Instrumentation . . . Data Collection . . . Data Analysis . . . . Chapter IV - Data Analysis Chapter V - Discussion . . Recommendations . . • • Implications for Nursing Appendix A Appendix B Appendix C Appendix D References Bibliography iii 29 31 32 Abstract This thesis is a compilation of literature, research data, and conclusions looking at the relationship between depression and quality of life in the community based elderly. The literature provided a great deal of information discussing the prevalence of depression in the elderly, and the corresponding need for quality of life. The Geriatric Depression Scale was used to measure elderly depression, and the Life Satisfaction Index was used to measure quality of life. The two tools are less than 25 items in length promoting the participant's ease in completion. two tools are inverted. The scoring of the A low score on the Depression Scale would indicate a low level of depression, where a high score on the Satisfaction Index would indicate a positive view of quality of life. The research data will establish the existance of the relationship between depression and quality of life. Even though a statistically significant relationship was established, a low level of predictability was obtained. iv Chapter 1 Introduction Background of the Problem Throughout the life span, there are many periods of potential depression which may influence an individual's outlook on life. Approximately two decades ago, mortality rates began to decline and assumptions were made regarding the health of the elderly. It was assumed their health must be improving, when in fact their health status appears to be remaining the same while medical treatments are improving. The elderly of today face diseases, conditions, physical/mental impairments, functional losses, and disabilities (Crimmins, 1996). The medical model of health is usually defined as an absence of disease. The social definition of illness is seen as a decrease in a person's ability to function in the roles they expect to fulfill (Liang, 1986). In an aging population, many problems associated with mobility, nutrition, communication, physical stamina, and health maintenance will become more promiment through their interaction with the other physical and emotional problems they have already experienced (National Center for Health Statistics, 1987). Many times the elderly perceive these health changes as negatively impacting their 1 2 value as a person. With these varied declines, average levels of depression increase at an accelerated rate in older age groups (Mirowsky & Ross, 1992). Across the life span, average levels of depression decline from early adulthood to middle age and then rise with older age. The acquisitions and achievements of young adulthood form the base for the prosperity of middle age, which eventually erodes with the declines and loss happening with old age (Mirowsky & Ross, 1992). These subtle changes across the adult life span are what allow depression to be one of the most serious undiagnosed health problems in the older adult. When studying depression in community based elderly, Blazer and Williams (1981) found a 14.7% prevalence of significant depressive symptomology. Depression in the elderly is often accompanied by subjective, age~related experiences of memory loss and cognitive dysfunction (Yesavage, et.al, 1983). Research suggests there is a strong correlation between perceived health and quality of life in the elderly (Moore, Newsome, Payne, & Tianswad, 1993). The concept of quality of life goes beyond physical condition. Quality of life encompasses all aspects of an individual s life including material 3 and physical components, in addition to social, emotional, and spiritual well-being (Yesavage, 1992). The Institute of Medicine (1986) defined quality of life as a sense of well-being. constant satisfaction with life, feelings of worth, and positive self-esteem. Good quality of life is a goal of the elderly. Quality of life is evaluated according to factors such as an individual's autonomy and self-respect within their own environment (Fletcher, Dickinson, & Philp, 1992). The individual is the only proper judge of his or her well-being. When there is little variation from middle age abilities, there is a greater feeling of well-being stability (Neugarten & Havighurst, 1961). Individual perceptions appear to be the basis of whether or not an individual is depressed. When negative issues arise, depression begins to develop. As these feeling of depression continue, the individual's views related to their quality of life also begin to take a negative turn. In the literature, there is a four sector definition of the good life. Psychological well-being, behavioral competence, perceived quality of life, and an objective environment are all needed to feel positive 4 in relation to life (Steiner et al, 1996). This researcher believes, after reviewing the aforementioned data, there is a correlation between depression and perceived quality of life. Purpose of the Study The purpose of this research study is to assess the relationship between depression and perceived quality of life in an elderly, community based population. The subsequent correlation of the individual test scores will determine if there is a relationship between depression, and perceived quality of life. Statement of the Problem This study is focused on the following question: Does depression directly relate to perceived quality of life in an elderly, community based population? Definition of Terms The following terms are defined for this research study: Depression: A state of mind, or adaptive mechanism, in which the client experiences sadness, pathos, and withdraws physically, emotionally, mentally, and verbally from society and social activities (Forbes & Fitzsimmons , 1981). Elderly: An individual greater than 65 years of age 5 Quality of Life: The multidimensional, subjective evaluation by both interpersonal and social criteria of the person-environment system of an individual's life in a time past, current, and anticipated (Birren, Lubben, Rowe, & Deutchman, 1991). Assumptions In this study, it was assumed the elderly population selected for this study are community based without major depressive syndrome diagnoses. The focus of this study is to evaluate the level of depression in the individual, and determine the degree of relationship to perceived quality of life. Limitations There are two limitations of this study. First, there is the attendance at the senior center. If the number of attendees at the center is down, the potential number of participants for this study could also be compromised. Second, there is individual willingness to participate in the study. Even if there is a large number of elderly in attendance, if the individuals are not willing to participate, there would be an impact on this study. If these limitations materialize, there could be difficulty in obtaining a satisfactory sample population size. 6 Chapter II Review of the Literature The reviewed literature addressed four topics related to this researcher's theory: (a) the elderly, (b) depression, (c) quality of life, and (d) Betty Neuman’s System Model. In relation to the elderly, various issues were identified as relevant, such as health, historical trends, and changes in views. Depression was widely discussed throughout the literature. Definitions, parameters, patterns, and characteristics of elderly depression were examined for relevancy. Quality of life is a topic which is quite varied throughout the reference material. Betty Neuman's Systems Model states the individual is a multidimensional being. When one area of life is compromised by a stressor, the entire person feels the effects. Elderly Approximately two decades ago, mortality rates began to decline, and the assumption was made that the health in the elderly was improving. In reality, the improvements were being made in health care which aided in prolonging life. Many health problems such as disease, impairments, and functional losses were 7 able to be addressed (Cummins, 1996). Medicine looks at health as defined by an absence of disease while society views health as a relationship between the physical, social, cultural, psychological, and environmental aspects of life (Birren, Lubben, Rowe & Deutchman, 1991). Mirowsky and Ross (1992) developed three views of the aging process. historical trend. First, there is age as a This view states that depression and a diminished self-esteem increase as the individual gets older. These changes are due to the loss of control which many elderly face. Secondly, age as a stage sees the achievements and acquisitions of early adulthood build the foundation for prosperity of middle age. This prosperity can eventually disintegrate with the losses of old age. The life-style hypothesis sees the average level of depression declining from early adulthood to middle age, and then rising subsequently as aging occurs. Thirdly, age as decline explores physical and mental decline. This decline accumulates with increasing rates of disease and dysfunction, less activity, decreased peak performance, and increased problems with memory attention. This hypothesis also states 6 Chapter II Review of the Literature The reviewed literature addressed four topics related to this researcher's theory: (a) the elderly, (b) depression, (a) quality of life, and (d) Betty Neuman's System Model. In relation to the elderly, various issues were identified as relevant, such as health, historical trends, and changes in views. Depression was widely discussed throughout the literature. Definitions, parameters, patterns, and characteristics of elderly depression were examined for relevancy. Quality of life is a topic which is quite varied throughout the reference material. Betty Neuman's Systems Model states the individual is a multidimensional being. When one area of life is compromised by a stressor, the entire person feels the effects. Elderly Approximately two decades ago, mortality rates began to decline, and the assumption was made that the health in the elderly was improving. In reality, the improvements were being made in health care which aided in prolonging life. Many health problems such as disease, impairments, and functional losses were 7 able to be addressed (Cummins, 1996). Medicine looks at health as defined by an absence of disease while society views health as a relationship between the physical, social, cultural, psychological, and environmental aspects of life (Birren, Lubben, Rowe & Deutchman, 1991). Mirowsky and Ross (1992) developed three views of the aging process. historical trend. First, there is age as a This view states that depression and a diminished self-esteem increase as the individual gets older. These changes are due to the loss of control which many elderly face. Secondly, age as a stage sees the achievements and acquisitions of early adulthood build the foundation for prosperity of middle age. This prosperity can eventually disintegrate with the losses of old age. The life-style hypothesis sees the average level of depression declining from early adulthood to middle age, and then rising subsequently as aging occurs. Thirdly, age as decline explores physical and mental decline. This decline accumulates with increasing rates of disease and dysfunction, less activity, decreased peak performance, and increased problems with memory attention. This hypothesis also states 8 average levels of depression increase at an accelerated rate in older age groups proportional to the rate of decline (Mirowsky and Ross, 1992). Tressler and Mechanic (1988) researched health status in the elderly. They found a correlation between psychological stressors and low self-rated health. An increase in psychological stress led to a decrease in satisfaction with the client’s self-rated health. Psychological stressors may include bereavement, and diminished ability to perform activities of daily living (U. S. Congress, 1985). The elderly often experience a loss of self-esteem which is related to a loss of productivity, and a loss of control over their life. These losses seem to be central to depressive symptoms in elderly individuals (Dunn & Sacco, 1989). The elderly also experience elevated levels of stress associated with fair to poor levels of health, all due to life events and chronic strain. Krause (1987) identified a list of stressful events including such items as losing the ability to drive, being judged legally incompetent, retirement, or the death of a grandchild. Areas of chronic strain can include a change in ability to perform self-care, 9 constant or recurring pain, loneliness, diminished eyesight, hearing loss, and declining financial status (Steiner et al, 1996). With all the changes the elderly must face, some elderly develop a shaken sense of well-being. Steiner, et al (1996) identified dimensions which affect well-being in the elderly as physical health, social behavior, emotional/psychological stability, cognitive status, economic prosperity, role functioning, and overall quality of life. Depression Depression is one of the most serious undiagnosed health problems in elderly in the United States. Elderly depression is a major contributor to twenty percent of the suicides in this country (Yesavage, 1992) . In 1993, a research study was completed in Pennsylvania looking at primary care physicians’ perception, diagnosis, and treatment of depression in older people. According to the study, all the participants stated they had experienced varied degrees of depression throughout their lives ranging from days to months at a time. The clients were asked what specific experiences in their older life led to depressive episodes. The most frequently 10 mentioned experiences were death of a loved one or friend, illness, death of a spouse, and not being able to perform tasks they were once able to do in their daily routine. The study concludes there were 2 issues blocking resolution of elder depression. First, the elderly are not being effectively diagnosed with depression, and secondly, the elderly are often unwilling to discuss depression with others (Pennsylvania Department of Aging, 1993). Blazer and Williams (1981) found 14 percent prevalence of significant symptomology of the community based elderly population studied. Between 5 and 20 percent of the 20 million aged in America are estimated to be depressed (Gurland, 1976). Depression is clinically defined in terms of health status or functional ability (Birren, Lubben, Rowe, & Deutchman, 1991). The majority of researchers agree the definition of depression should include characteristics such as physical, emotional, behavioral, intellectual, and cognitive functioning (Birren, Lubbin, Rowe, & Deutchman, 1991). Some examples of physical dysfunction related to depression may include gastrointestional dysfunction, anorexia, recurrent headaches, and excessive fatigue (Forbes, & Fitzsimmons, 1981). 11 Depression can also be exhibited through emotions. Envy can arise when the individual compares himself with others he sees as more active than himself. They can also become more critical of others than they were in the past due to their perceived failures (Weiss, Nagel, & Aronson, 1986) . Elder depression is also often accompanied by subjective experiences of memory loss, and cognitive impairments (Yesavage et al, 1983). In research done with community based elderly, there was frequent documentation of an increase in various psychiatric symptoms when compared to younger age groups (Blazer, Hughes, & George, 1987). Blazer and Williams (1981) also researched elder depression. This study showed the majority of elderly subjects with depression had no previous history of psychiatric illness (Weiss, Nagel, & Aronson, 1986). The prevalence of symptoms increased with age but major depressive disorders do not. Psychiatric instability did not appear to be the primary cause of depression while physical illness was (Kennedy et al, 1989). Due to the increase in age, and the organic decline seen in the elderly, depression is more prevalent today than any other time in the last twenty years (Mirowsky, & Ross, 1992). 12 Average levels of depression increase after age sixty. Retirement, widowhood, and economic hardship account for the rise in depression, along with physical degeneration, and the loss of personal control. Depression often rises with major lifestyle changes, accumulating erosion of function, and control. Depression will also fall and rise correspondingly with the gains and losses experienced during the life cycle (Mirowsky, & Ross, 1992). Quality of Life Quality of life is an issue of much importance to older adults and to the individuals who work with them (Moore, Newsome, Payne & Tiansawad, 1993). Good quality of life is a goal of the elderly (Fletcher, Dickinson & Philp, 1992). The individual is the only proper judge of their well-being. When the elderly feel there is little variation from their pattern of activity found in middle age, there is a greater sense of well-being (Neugarten, Havighurst, & Tobin, 1961). Subjectively perceived quality of life is a combination of sense of well-being, level of satisfaction with life, feelings of value, and positive self-esteem (Institute of Medicine, 1986). 13 Perception is an active process where the individual reacts, links, and responds to their environment. The perceived meanings given to an individual’s physical, mental, and social health provides an integral part of the individual's perception of their quality of life (Lee, 1993). There is a strong correlation between perceived health and quality of life in elderly populations (Moore, Newsome, Payne, & Tiansawad, 1993). Health is commonly listed as a component of the quality of life definition, but research displayed a need to include other elements as well. Both objective and subjective elements need to be included. Objective elements could be described as items such as finances, health, mental functioning, and social contacts. Some examples of subjective elements are happiness, well-being, life satisfaction, and positive self-esteem (Birren, Lubben, Rowe & Deutchman, 1991). Quality of life becomes an even more pertinent issue as the older adult lives to an older age than many individuals in the past. The elderly often ask questions of themselves to aid in determining why they are alive, and what their life quality is (Bass, 1986). Assessment tools need to be based on 14 the individual’s own opinion of his or her physical, emotional, and social well-being. Hughes (1990) believed in the importance of multidimensional assessments to accurately reflect quality of life in the elderly. There have been several research studies looking at quality of life. Laborde and Powers (1985) postulated a positive view of life satisfaction was directly related to a good perception of health, strong internal locus of control, and a low level of pain. Magilvy (1985) stated the best predictors of quality of life are functional social support, and perceived functional health. Functional health has been defined as the personal opinion of the individual regarding their own feelings in relation to how they perceive their life to be (Magilvy, 1985). Finally, Ryden (1984) felt functional dependency, health, and socioeconomic status are significant variables directly affecting morale, and perceived quality of life- When the individuals feel they are dependent on others for their daily care, are in poor health, and have decreased socioeconomic status, often they feel they do not have a high quality of life. 15 There are two reasons for evaluating quality of life which directly relate to this study. Assessing the impact of environment on perceived quality of life is crucial when working with elderly clients, A major change in environment, whether objective or subjective, can produce elderly depression which possibly directly effects their quality of life. Also, understanding the causes and consequences of decreased perceptions of quality of life may be the most important reason for research (Birren, Lubben, Rowe, & Deutchman, 1991). Studies have shown that perceived health is significant as it relates to quality of life in older people. Outcomes of research related to quality of life and perceived health fall into two categories. First, there are the predictors for positive quality of life. Secondly, there is a need to determine if relationships between aspects of life and quality of life exist (Moore, Newsome, Payne, and Tianswad, 1993). Quality of life is of major importance to the elderly, and further research should be done. Conceptual Framework Betty Neuman’s Systems Model is a comprehensive, dynamic, and multidimensional view of individuals who 16 are in constant interaction with environmental stressors. The model focuses on the ability to adapt. Neuman states nurses can use this model to assist individuals to attain and maintain maximum levels of total wellness (Neuman, 1980). There are basic assumptions providing the foundation for Neuman's conceptual framework which relate to this study. Neuman believed each individual, over time, develops a normal range of response to their environment. This is referred to ' as a normal line of defense otherwise known as the usual wellness/stability state. The interrelationships of variables such as Physiological, sociocultural, developmental, and spiritual, determine the nature and degree of the system’s reaction to stressors. This reaction can affect the degree of protection an individual has from their flexible line of defense which acts as a buffer outside the normal line of defense (Neuman, 1980) . Stressors can be extrapersonal, interpersonal, and intrapersonal. Extrapersonal stressors occur outside the system, interpersonal stressors are between systems, and intrapersonal stressors occur within the system. More than one stressor can impact the individual system at one time (Venable, 1980). 17 In Neuman's model, the goal of primary prevention is to prevent the penetration of the normal line of defense by stressors. Once a reaction to a stressor has occurred, secondary prevention needs to take place in the form of early treatment of symptoms, and attempts to strengthen the lines of defense. Tertiary prevention is the intervention following active treatment to maintain adaptation by strengthening resistance to stressors (Neuman, 1982). Neuman's model emphasizes the whole person. She presents the approach to seeing the individual's perceptions of stressors affecting various parts of the individual, possibly skewing their perceptions of themselves. When one part is involved, the other parts are also affected to a degree. When multiple stressors impale varied areas of the individual, a systematic breakdown of defenses may occur. This breakdown may be manifested in a depression developing into a negative perception of the individual’s quality of life* Neuman's model is directly pertinent to this study considering her emphasis on the whole person. Her model also allows for the impact of stressors to develop into breakdowns in the system. This impact , emotional, intellectual, could affect the physical, emotio 18 and spiritual aspects of the individual. This complete view of the person gives creedance to the problem being researched in this study. Looking at the relationship between depression and perceived quality of life is the basis for this study, and Neuman's model states a breakdown in one area of the system can cause a breakdown in another. 19 Chapter III Methodology The purpose of this study is to determine: What is the relationship between depression and perceived quality of life in the elderly? The findings from this study will contribute to previous research done related to geriatric depression and perceived quality of life. Sample Population The sample size consisted of 42 elderly participants who attended 1 of 3 senior centers in Northwestern Pennsylvania. Instrumentation This study utilized the Geriatric Depression Scale and the Life Satisfaction Index. These scales were chosen due to their validity and reliability in prior research done with elderly, community based populations . Both scales are short in length allowing reliable and valid multidimensional assessment without participant burden (Steiner et al, 1996) . health problem Depression has long been a major associated with in the elderly, and is often Often depression increased morbidity and mortality. 20 in the elderly can be related to loss of control which is addressed in this tool (Weiss, Nagel, & Aronson, 1986). The Geriatric Depression Scale was developed especially to assess depression in the elderly (Dunn, & Sacco, 1989). The tool consists of 15 yes or no questions. Each answer which reveals depression is given 1 point. A score of 5 to 9 indicates the strong probability of depression with a score of 10 almost always being indicative of depression (Moore, Newsome, Payne, & Tiansawad, 1993). For this study the score of 10 will represent depression. A copy of the Geriatric Depression Scale can be found in Appendix A. Yesavage et al (1983) performed two studies to validate the Geriatric Depression Scale. The first study looked at a large pool of items which were compiled and then tested for the extent to which they measured depression in the elderly. The scale was administered to 47 individuals, all over 55 years of Data analysis was based on the rationale that the 100 item scale should have prima facia validity looking at those items which best correlated age. providing the best measure for depression. This a median correlation abbreviated tool demonstrated 21 of 0.675 (range 0.47-0.83). The 100 item tool showed a lesser correlation with a median correlation of 0.51 (range 0.07-0.83) (Yesavage, et al, 1983). In summary, the research done demonstrated the tool with lesser items was valid to be used in elderly populations. The second study provided a basis for comparing properties of the scale to other existing measures of depression. This study had 2 groups, one diagnosed with depression, and the second were clients from a community senior center. In this study, Cronbach's Alpha was done to look at internal reliability. A score of 0.87 was obtained using the fifteen item tool to be used in this study (Yesavage et al, 1983). The findings of both studies provided evidence for the validity and reliability of the scale as a measure of geriatric depression. These studies also found a high degree of internal consistency in the scale. In comparing the mean scores of those with the diagnosis of depression the research criteria in the scale was found to be consistent with the results of the study (Yesavage et al, 1983). 22 Dunn and Sacco (1989) also did a research study to evaluate the reliability and validity of the Geriatric Depression Scale in an elderly community based population. It was found, even though the scale was done in different geographical locations, a strong internal correlation remained in the results of the Geriatric Depression Scale administration. This study utilized Alpha values for the Geriatric Depression Scale. The score for the scale was 0.91 which indicated good internal consistency for this scale. To further determine validity, correlation was done between the Geriatric Depression Scale and the Depressive system checklist. This checklist provides a self-report score relating to the criteria necessary for a diagnosis of major depression. The correlation score was r=0.82, n-227, displaying a strong validity for the scale (Dunn, & Sacco, 1989). Quality of life assessments are based on a emotional, Person's own opinion of their physical, of life has become a and social well-being. Quality Major criterion for evaluating health and medical Both quality of life and health include indicators status measurement tools need to of Physical, social, emotional, and mental function interventions. along with perceived well-being (Kutner 23 In measuring quality of life there are reasons for doing research. Assessment needs to be done to determine the impact of the environment on quality of life (Birren, Lubben, Rowe, & Deutchman, 1991). Individuals with multiple medical problems may also have functional and support issues which can affect quality of life (Paist, & Jafri, 1996). The Life Satisfaction Index consists of 20 statements which the respondent can agree or disagree with. The index measured mood, zest for life, and achievement of personal goals. This tool also evaluates factors such as the degree to which residents maintain autonomy and self-respect within the individual's environment (Fletcher, Dickinson, & Philp, 1992). For each item chosen which corresponds to the answer key, 1 point is According to the research, a score of 12 of quality of life. indicated a positive perception A copy of the Index can be seen in Appendix B scored. (Neugarten, & Havighurst, 1961). In the initial validation study, this index in the evaluation of appeared to be satisfactory The index quality of life in elderly populations. interview Was correlated with clinical psychologist Coefficient score was 0.73 The Correlation scores. 24 indicating a moderately strong validity of this tool (Neugarten, & Havighurst, 1961). In later studies, the Life Satisfaction Index displayed high levels of agreement with independent rating of life satisfaction. This tool correlated with other life satisfaction scales with scores ranging from 0.5 0.8 displaying a moderate to strong internal validity. Also, there was strong correlation with other life satisfaction scales and the index agreed consistently with associations between measures of well-being. The internal measures of reliability scores in this study ranged from 0.5-0.8 displaying a moderate to strong level of reliability. (Fletcher, Dickinson, & Philp, 1992). Data Collection The researcher contacted three senior centers and scheduled educational sessions, unrelated to the research topics studied. Verbal and written consent was obtained from each center. A sample of the letters obtained is located in Appendix C. After the completion of the session, the participants were asked to volunteer to participate in a research study evaluating the and quality of life relationship between depression the participants were made in the elderly. All of research being done, and aware of the nature of the 25 the purpose of the research. Participation was strictly voluntary, and anonymity was preserved. Implied consent was obtained when the participants volunteered for the study after they had been made aware of the nature of research being done, and how their anonmyity would be preserved. Between the 3 centers, 42 participants completed the questionaires. Each client was also asked to write their age and gender on their questionaires. All of the questionaires were coded so correlation betweeen the 2 forms could be accomplished, and anonymity could be further preserved. Data Collection After the data was collected, it was analyzed to determine if there was a significant relationship between depression and perceived quality of life. The scores were added, and correlation between the scores of the 2 tools were done using the Pearson-R Product-Moment Correlation Coefficient. This test is to be used in research where there are two variables, where score data is being used, and there is one score for each variable for each subject (Linton, & Gallo, 1975). charted, the Pearson R, After the data was coefficient of degrees of freedom, and the 26 determination were calculated. The significance test for R was also done to determine the significance of the research findings. The Pearson R has limits of +1 to -1, and for a positive and perfect relationship, a value of +1 would be obtained. A -1 would indicate a negative relationship with a 0 score meaning there is no relationship between the variables. (Linton, & Gallo, 1975) . 27 Chapter IV Data Analysis This study was designed to determine if there is a relationship between depression and quality of life in a community based elderly population. The sample group consisted of 42 elderly clients in attendance at 3 senior centers located in Northwestern Pennsylvania. The Geriatric Depression Scale and the Life Satisfaction Index were distributed personally, and subsequently collected. All 42 sets of questionairres were used for the data collected in this study. The Geriatric Depression Scale was used to determine the level of depression for each participant . A scoring range of 0-15 is possible. The Life Satisfaction Index was used to determine the level of perceived quality of life with each participant. A scoring range of 0-20 is Possible. The sociodemographic characteristics of the The participants were sample group were reviewed. 57% (n=28) and 33% (n=13) Primarily female with were from 68 years to being male. The range of ages All of 82 years with the mean age being 75 years, involved in community the participants were obviously 28 social functions, and therefore there were no homebound individuals involved in this study. Using the Pearson product-moment correlation coefficient, the relationship between depression and quality of life in an elderly population was analyzed. The statistical analysis produced a Pearson R of -0.44 with 40 degrees of freedom, a coefficient of determination of -0.20, and a probability of <0.01 which is less then 0.05 thus determining a statistically significant result. The coefficient of determination obtained does indicate a low level of predictability (20%) when using the Geriatric Depression Scale and the Life Satisfaction Index. With the Geriatric Depression Scale yielding a low score to indicate lack of depression, and the Life Satisfaction Index yields a high score indicating high quality of life, a negative Pearson R would be expected since there is an inverse relationship between the scoring of the relationship two tools. This information indiates a between depression and quality of life in this sample of elderly population (Appendix D). statistically In conclusion, the data revealed a between depression significant inverse relationship sample population and quality of life exists in this of community based, elderly individuals. 29 Chapter 5 Discussion With the vast growth in the elderly populaiton, this research study was done to assist in understanding the specific needs of this age group. The nurse s role in the care of the elderly depends on research being done providing further information. Depression and quality of life are issues of concern for the elderly according to Gurland (1976). Depression becomes more prevalent in old age as many life changes occur. Loss of friends, loss of spouse, retirement, and decreased independance all contribute to elderly depression. Between 5 and 20% of the 20 million aged in America are estimated to be depressed In research conducted with community based elderly, documentation reveals an increase in psychiatric symptoms as compared to younger age groups (Blazer, Hughes, & George, 1987). Blazer and Williams (1981) researched elderly depression and learned the majority of elderly subjects with depression had no previous history of psychiatric illness. Mirowsky and Ross (1992) found depression more prevalent today in the elderly than any other time in the last 20 aforementioned researchers In summary, the indicate widespread depression in the elderly. years. However, the current research did not find a high number of clinically depressed individuals. 30 Quality of life in the elderly also has great importance. Good quality of life has become an important goal of the elderly (Fletcher, Dickinson, & Philp, 1992). Magilvy (1985) stated the best predictors of quality of life are functional social support, and perceived functional health. Ryden (1984) felt functional dependancy, health, and socioeconomic status are significant variables affecting morale and perceived quality of life in the elderly. The elderly need to feel pleased with the life they now have to promote both physical and emotional well-being. In summary, the aforementioned researchers indicated an importance of quality of life in the elderly participants in Northwestern Pennsylvania. Overall, this study found a correlation between depression and quality of life which supports the results of Moore, Newsome, Payne, and Tianaswad (1993) which found a correlation between health and quality of life for an elderly population. Neuman (1992) reinforces the connection between theory emphasizes mental and physical health. Her breakdown in one system the whole person, where a Stressors will cause a breakdown in another. in the mental/ causing depression, a breakdown 31 emotional system, could promote other breakdowns affecting quality of life in the elderly individual. Nurses will be able to utilize the knowledge gained of the relationship between quality of life in three ways. depression and First, it will alert them to the seriousness of elderly depression. Secondly, heightened awareness of quality of life issues enables for more efficient nursing education, and comprehension of the perceived quality of life in the elderly today. Thirdly, recognition of elderly depression should trigger an evaluation of quality of life issues promoting quick and accurate initiation of a nursing plan of care related to these issues. Recommendations Based on the results of this study, the resarcher recommends further research be done to evaluate the relationship between depression and quality of life in different geographic areas, This should be done to determine if this relationship is indicative of Northwestern Pennsylvania or is true accross the elderly population. It is also suggested this research be repeated in elderly not living in the community. Elderly based apartment complexes, or nursing homes would be possible locations to gather 32 participants for a repeat study. Also, this study could be done looking at specific components within the elderly population. For example, a comparision between men and women could be done. This study was not well balanced between male and female participants, and a relationship between depression and quality of life was established. Looking at a specific population within the broad population group would prove beneficial in the treatment of individuals within the test groups. Implications for Nursing This study provides more information for nurses providing care for the community based elderly. Being able to identify the relationship between depression and quality of life in the elderly will allow for more comprehensive care for the elderly. The trend in nursing care is moving towards community based care, and with more and more elderly living in the community today, it will continue to become more important for nurses to be able to identify issues causing concern for the elderly. 33 Appendix A Geriatric Depression Scale Choose the best J SUEJ SUEJ SUS-J SUSJ SUBJ SUSJ SUEJ SUE.J E-UB-J SUE J subj :••• :c- ’ w •-- - 3U5J 2 5 3 0 4 1 0 3 ■5 ^10 #11 #12 #13 #14 #15 #16 #17 #13 0 2 1 1 1 10 0 4 1 #r? -? #20 #21 #22 #23 #24 #25 #26 #27 #23 #29 #30 6 3 1 3 2 3 0 0 0 0 .•S PROBABILITY <.01 VAR. #2 14 17 9 16 12 17 14 10 11 15 13 13 17 15 8 15 11 14 6 11 17 29 16 18 8 16 17 13 15 11 S:J8.J SUS J SUEJ SUB J SUE J SUEJ SUE J SUS J S'JBJ 3.JSJ SUS J SUE J #31 #32 #33 #34 #35 #36 #37 #33 #39 #40 #41 #42 0 2 1 1 5 5 4 c 13 16 13 13 15 11 11 ‘ 7 6 3 3 LEGEND: : Depresssion Scale Scores VARIABLE #1- Geriatric Satisfaction Index Scores VARIABLE #2- Life !— 14 15 13 ■ 37 References Bass, D. (1986). Planning to meet lifecare needs. Silver Spring, Maryland: National Association of Social Workers. Birren, J. E., Lubben, J. E., Rowe, J. C. , & Deutchman, D. E. (1991). The concept and measurement of quality of life in the frail elderly. San Francisco, CA: Academic Press, Inc. Blazer, D. & Williams, C. D. (1981). Epidemiology of dysphoria and depression in an elderly population. American Journal of Psychiatry, 137, 439. Blazer, D., Hugher, D. C., & George, L. K. (1987). The epidemology of depression in elderly community population. The Gerontologist, 27(3), 281-287. Crimmins, E. M. (1996). Mixed trends on Population health among older adults. Journal of Gerontology, 518(5), 5223-5225. Dunn, V. K., & Sacco, W. P. (1989). Psychometric evaluation of the geriatric depression scale and the Zung self-rating depression scale using an elderly community samp1e. Psychology and Aging. ill, 125-126. 38 Fletcher, A. E., Dickinson, E. J., & Philp, I. (1992). Review: Audit measures: Quality of life instruments for everyday use with elderly patients. Age and Aging, 21, 142-150. Forbes, E. J., & Fitzsimmons, V. M. (1981). The older adult: A process for wellness. St. Louis: The C. V. Mosby Company. Gurland,B. J., Wilder, D. E., & Berkman, C. (1988). Depression and disability in the elderly: Reciprocal relations and changes with age. International Journal of Geriatric Psychiatry, 3, 163-179. Hughes, B. (1990). Quality of life. In S. M. Peace (Ed.), Researching Social Gerontology. London: Sage. Institute of Medicine. (1986). Improving guality of life in nursing homes. Washington D. C.: National Academy Press. Kennedy, G. J., Kelman, H. R., Thomas, C., Wisniewski, W., Metz, H., & Bijur, P. E. (1989). Hierarchy of characteristics associated with depressive symptoms in an urban elderly sample. American Journal of Psychiatry, 146(2), 220-225. Krause, N. (1987), Stress in racial differences in self-reported health among the elderly. Gerontologist, 27, 72-76. 39 Laborde, J. M., & Powers, M. J. (1985). Life satisfaction, Health control orientation, and Illness-related factors in persons with osteoarthritis, Research Nursing Health, 8(2), 183-190. Kutner, N. G., Ory, M. G., Baker, D. I. , Schechtman, K. B., Hornbrook, M. C. , & Mulrow, C. D. (1992). Measuring the quality of life of the elderly in health promotion intervention clinical trials. Public Health Reports, 107(5), 530-539. Lee, A. J. (1993). Health perceptions of middle, new middle and older rural adults. Family Community Health, 16(1), 19-27. Liang, J. (1986). Self-reported physical health among aged adults. Journal of Gerontology, 41(2), 248-260. Linton, M., & Gallo, P. S. (1975). The practical statistician: Simplified handbook of statistics. Monterey, CA: Brooks/Cole Publishing Company. Magilvy, J. K. (1985). Quality of life of hearing impaired older women. Nursing Research, 34(3 1, 140-144. Mirowsky, J.z & Ross, C. E. (1992). Age and depression. Journal of Health and Social Behavior, 33, 187-205. 40 Moore, B. S., Newsome, J- A., Payne, P. L. , & Tiansawad, S. (1993). Nursing research: Quality o of life and perceived health in the elderly. Journal of Gerontological Nursing, 19(11), 7-14. National Center for Health Statistics. (1987). Health statistics on older persons (DHHS, PHS publication No. 87-1409). Washington D.C.: U. S. Government Printing Office. Neugarten, B. L. , Havighurst, R. J., & Tobin, S. S. (1961). The measurement of life satisfaction. Journal of Gerontology, 16, 134-143. Neuman, B. (1980). The Betty Neuman health-care systems model: A total person approach to patient problems. In Riehl, J. P., & Roy. Sr., C. (Eds.), Conceptual Models for Nursing Practice, New York: Appleton-Century-Crofts. Neuman, B. (1982). The Neuman systems model_:_ Application to nursing education and, practice. Norwalk, CT : Appleton-Century-Crofts. Neuman, B. (1989). The Neuman systems mode_l. Norwalk, CT : Appleton-Century-Crofts. (1996). Functional Paist, S. S., & Jafri, A. assesment in older patients: Key to improving quality of life. Postgraduate 101-108. Medicine, 99(51, 41 Pennsylvania Department of Aging. (1993). Depression in older persons: A study of primary care physicians * perception, diagnosis, and treatment (Department of Aging Contract No. 9121). Pennsylvania: Thomas, E.A. Ryden, M B. (1984). Mora+le and perceived control in institutionalized elderly. Nursing Research, 33(3) , 130-136. Steiner, A., Raube, K., Stuck, A. E., Aronow, H. U., Draper, D. Rubenstein, L. Z., & Beck, J. C. (1996). Measuring psychosocial aspects of well-being in older community residents: Performance of four short scales. The Gerontologist, 36(1), 54-62. U. S. Congress. (1985). Technology and Aging in America (Office of Technology Assessment Publication OTA-BA-264). Washington D. C.: U. S. Government Printing Office. Venable, J. F. (1980). The Neuman health-care systems model: An analysis. In Riehl, J. P., & Roy, C . , (Eds . ) . Conceptual models for nursing practice (2nd ed.).New York: Appleton-Century-Crofts. K. Weiss, I. K., Nagel, C. L., & Aronson, M. (1986). Applicability of depression scales to the old 42 old person. Journal of American Geriatric Society, 34, 215-218. Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, 0., Huang, V., Adey, M. , & Leirer, V. 0. (1983). Development and validation of a geriatric screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37-49. Yesavage, J. A. (1992). Depression in the elderly: How to recognize masked symptoms and choose appropriate therapy. Postgraduate Medicine, 91:1, 255-261. 43 Bibliography Publication Manual of the American Psychological Association (Fourth ed.). (1994). Washington D.C.; American Psychological Association. Bass, D• (1986) ■ Planning to meet lifecare needs. Silver Spring, Maryland: National Association of Social Workers. Birren, J. E., Lubben, J. E., Rowe, J. C., & Deutchman, D. E. (1991). The concept and measurement of quality of life in the frail elderly. San Francisco, CA: Academic Press, Inc. Blazer, D. & Williams, C. D. (1981). Epidemiology of dysphoria and depression in an elderly population. American Journal of Psychiatry, 137 Blazer, D., Hugher, D. C., & George, L. K. (1987). The epidemology of depression in elderly community population. The Gerontologist, 27(3), 281-287. Crimmins, E. M. (1996). Mixed trends on Population health among older adults. Journal of Gerontology, 518(5), 5223-5225. Dunn, V. K., & Sacco, W. P. (1989). Psychometric scale and evaluation of the geriatric depression the Zung self-rating depression scale using an elderly community sample* 125-126. Psychology. and Aging, 44 Fletcher, A. E., Dickinson, E. J. , & Philp, I (1992). Review: Audit measures: Quality of life instruments for everyday use with elderly patients. Age and Aging, 21, 142-150. Forbes, E. J., & Fitzsimmons, V. M. (1981). older adult: A process for wellness. The St. Louis: The C. V. Mosby Company. Gurland, B. J., Wilder, D. E., & Berkman, C. (1988). Depression and disability in the elderly: Reciprocal relations and changes with age. International Journal of Geriatric Psychiatry, 3, 163-179. Hughes, B. (1990). Quality of life. In S. M. Peace (Ed.), Researching Social Gerontology, London; Sage. Institute of Medicine. (1986). of life in nursing homes. Improving guality Washington D. C.: National Academy Press. Kennedy, G. j., Kelman, H. R., Thomas, C., Wisinewski, W., Metz, H., & Bijur, P. E. (1989). Hierarchy of characteristics associated with depressive symtoms in an urban elderly sample American Journal of Psychiatry/ 146121, 220-225. Krause, N. (1987). Stress in racial differences self-reported health among the elderly. Gerontologist, 27, 72-76. 45 Laborde, J. M., & Powers, M. J. (1985). Life satisfaction, Health control orientation, and Illness-related factors in persons with osteoarthritis, Research Nursing Health, 8(2), 183-190. Kutner, N. G., Ory, M. G., Baker, D. I. , Schechtman, K. B., Hornbrook, M. C., & Mulrow, C. D. (1992). Measuring the quality of life of the elderly in health promotion intervention clinical trials. Public Health Reports, 107(5), 530-539. Lee, A. J. (1993). Health perceptions of middle, new middle and older rural adults. Family Community Health, 16(1), 19-27. Liang, J. (1986). Self-reported physical health among aged adults. Journal of Gerontology, 41(2), 248-260. Linton, M., & Gallo, P. S. (1975). The practical statistician: Simplified handbook of statistics. Monterey, CA: Brooks/Cole Publishing Company. Magilvy, J. K. (1985). Quality of life of hearing impaired older women. Nursing Research, 34(3), 140-144. Mirowsky, J., & Ross, C. E. (1992). Age and depress ion. Journal of Health and Social Behavior, 33, 187-205. 46 Moore, B. S., Newsome, J. A., Payne, P. L. , & Tiansawad, S. (1993). Nursing research: Quality o of life and perceived health in the elderly. Journal of Gerontological Nursing, 19(11), 7-14. National Center for Health Statistics. (1987). Health statistics on older persons (DHHS, PHS publication No. 87-1409). Washington D.C.: U. S. Government Printing Office. Neugarten, B. L., Havighurst, R. J., & Tobin, S. S. (1961). The measurement of life satisfaction. Journal of Gerontology, 16, 134-143. Neuman, B. (1980). The Betty Neuman health-care systems model: A total person approach to patient problems. In Riehl, J. P., & Roy. Sr., C. (Eds.), Conceptual Models for Nursing Practice, New York: Appleton-Century-Crofts . Neuman, B. (1982). The Neuman systems model: Application to nursing education and practice. Norwalk, CT: Appleton-Century-Crofts. Neuman, B. (1989). The Neuman systems model. Norwalk, CT: Appleton-Century-Crofts. Paist, S. S., & Jafri, A. (1996). Functional assesment in older patients: Key to improving quality of life. Postgraduate Medicine, 99(5) , 101-108. 47 Pennsylvania Department of Aging. (1993). Depression in older persons: A study of primary care physicians 1 perception, diagnosis/ and treatment (Department of Aging Contract No. 9121). Pennsylvania: Thomas, E.A. Ryden, M B. (1984). Mora+le and perceived control in institutionalized elderly. Nursing Research, 33(3) , 130-136. Steiner, A., Raube, K., Stuck, A. E.z Aronow, H. U., Draper, D. Rubenstein, L. Z., & Beck, J. C. (1996). Measuring psychosocial aspects of well-being in older community residents: Performance of four short scales. The Gerontologist, 36(1), 54-62. U. S. Congress. (1985). Technology and Aging in America (Office of Technology Assessment Publication OTA-BA-264). Washington D. C.: U. S. Government Printing Office. Venable, J. F. (1980). The Neuman health-care systems model: An analysis. In Riehl, J. P-/ & Roy' G. , (Eds . ) . Conceptual models for. nursing practice (2nd ed.).New York: Appleton-Century-Crofts. , & Aronson, M. K. Weiss, I. K. , Nagel, C. L. scales to the old (1986). Applicability of depression 48 old person. Journal of American Geriatric Society, 34, 215-218. Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, 0., Huang, V., Adey, M. , & Leirer, V. 0. (1983). Development and validation of a geriatric screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37-49. Yesavage, J. A. (1992). Depression in the elderly: How to recognize masked symptoms and choose appropriate therapy. Postgraduate Medicine, 91:1, 255-261.