Elsevier

Journal of Affective Disorders

Volume 272, 1 July 2020, Pages 305-317
Journal of Affective Disorders

Review article
Modifiable Protective and Risk Factors for Depressive Symptoms among Older Community-dwelling Adults: A Systematic Review

https://doi.org/10.1016/j.jad.2020.03.119Get rights and content

Highlights

  • Depressive symptoms appear to be more common among older adults

  • Social support/activity, self-rated health, and exercise were protective of depression

  • Sleep disturbance was a risk factor for depressive symptoms

  • These modifiable factors should be considered in prevention programs

Introduction

Depression is a leading cause of disability worldwide and constitutes a primary contributor to the overall global burden of disease (World Health Organization [WHO], 2018). Depression is more common in later life, with an estimated prevalence among those aged 60 years and older of 7% for females and 5% for males, compared to 4% for females and 3% for males in the broader adult population (WHO, 2017). Many more people (including older adults) experience depressive symptoms that are not severe or persistent enough to merit a diagnosis, but are still associated with significant distress or impairment in important domains of daily functioning (Hjarsbech et al., 2011; Rowe & Rapaport, 2006; Strine et al., 2009). Furthermore, depressive symptoms often go undetected (Fiske, Wetherell, & Gatz, 2009), and this is especially the case among older adults due to the uncertainty about what constitutes depression in this cohort (Alexopoulos, 2005; Chapman & Perry, 2008; Chew-Graham et al., 2012; Rodda et al., 2011; Thomas & Shute, 2006). As the proportion of people aged 60 years and older is projected to increase from 13% in 2017 to 21% in 2050 (United Nations, 2017), it is likely that the number of older adults experiencing depressive symptoms will also increase substantially unless appropriate prevention strategies are developed and implemented.

Depressive symptoms can be especially debilitating for older adults. Compared to younger cohorts, older adults tend to have more limited social networks and suboptimal coping strategies (Fiske et al., 2009; Vink, Aartsen, & Schoevers, 2008; von Faber et al., 2016). In addition, the impact of depressive symptoms on daily functioning and well-being is greater among older adults, and can often result in direct medical costs and indirect economic costs due to reduced mobility (Bock et al., 2016; Donohue & Pincus, 2007). Preventing depressive symptoms in later life therefore has the potential to reduce the impact of these symptoms on both individuals and society.

Community-based interventions that focus on enhancing protective factors and minimizing risk factors have been identified as an important element of comprehensive approaches to the prevention of depressive symptoms among older people (WHO, 2012, 2018). Identifying the factors associated with depressive symptoms among older adults can assist in informing effective community-based programs aimed at preventing these symptoms. Three systematic reviews examining potential factors could be located (Cole & Dendukuri, 2003; Djernes, 2006; Vink et al., 2008), of which only one focused specifically on community-dwelling older adults (Cole & Dendukuri, 2003). The reviews had a degree of overlap, with 15 studies included in at least two reviews and three studies included in all three reviews. The majority of studies included in the reviews had longitudinal study designs and were primarily focused on non-modifiable factors, of which gender, functional impairment, and history of depression were typically found to be the most important (Cole & Dendukuri, 2003; Djernes, 2006; Vink et al., 2008). The most relevant modifiable factors were found to be low levels of social support, poor self-rated health, and sleep disturbance (Cole & Dendukuri, 2003; Djernes, 2006; Vink et al., 2008).

With the existence of cohort effects between different groups of seniors across time (Fozard & Wahl, 2012), current research on relevant protective and risk factors for depressive symptoms is needed to ensure intervention developers have access to up-to-date evidence to inform their efforts. It is particularly important to include modifiable factors in analyses to provide the information inputs required to develop interventions that can effectively target those variables that have the greatest potential to produce favorable change (Singh & Okereke, 2015). The present systematic review addressed these needs by synthesizing recent research on factors associated with depressive symptoms among older community-dwelling adults, with a particular focus on modifiable factors. Sociodemographic variables were also examined to enable the identification of specific groups of individuals within the broader older community-dwelling population who are most in need of intervention.

Section snippets

Search strategy

This review was conducted in accordance with the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff & Altman, 2009). As the most recent systematic review that could be located included studies up to December 2005 (Vink et al., 2008), a comprehensive search of the following databases was conducted for articles published from January 2006, with an end date of June 2018: Google Scholar, EBSCO, Medline, PubMed, ProQuest, PsychInfo,

Study and participant characteristics

The characteristics of the 75 studies included in the review are described in Table 1. Across the studies there were 205,590 participants (baseline age ranged from 60 to 105 years), with sample sizes ranging from 108 to 37,193 (mean = 2,741; median = 1,253). The majority of studies included both females and males, with four studies comprising only males. The studies varied in terms of cultural setting: 23% (n = 17) were conducted in the United States, 16% (n = 12) in China, 15% (n = 11) in

Discussion

This systematic review assessed 75 studies examining various modifiable and non-modifiable factors associated with depressive symptoms among older community-dwelling adults. All but one of the studies were deemed to be of high quality, and the mean quality score was 0.94. Of the 21 factors identified in this review, good social/family support, better self-rated health, engagement in physical activity, and participation in social activities were identified as key protective factors, while sleep

Conclusion

Results of this and previous reviews highlight the complex nature of the etiology of depressive symptoms and the likely interrelationships between various psychosocial, behavioral, and sociodemographic factors. The important roles of social support and participation, better self-rated health, physical activity, and sleep quality in protecting against depressive symptoms among community-dwelling older adults were confirmed. This suggests that interventions that encourage social support, enhance

Author Declaration Statement

We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome.

We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us.

We confirm that we

Contributors

Author CW conceptualized the study and took primary responsibility for preparing the manuscript. Author SP assisted with the design of the study, reviewing potential studies to include, assessing the quality of studies included, and manuscript preparation. Author MJ provided conceptual input for the study design and contributed to the preparation of the manuscript. The funder played no role in the conducting of the research or the reporting of the results.

Role of Funding Source

This work was supported by an Australian Government Research Training Program (RTP) Scholarship awarded to Caitlin Worrall.

Declaration of Competing Interest

None.

Acknowledgement

None.

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