Depressive symptoms and physical function among the elderly in nursing homes during the COVID-19 pandemic in China: A cross-sectional study

1. Introduction

Depression remains a great challenge to clinicians and imposes the risk of mortality and morbidity among the elderly.[1–3] It is reported that depression was also one of the most common problems in the elderly in nursing homes besides chronic illness, and should be diagnosed and differentiated from other psychological illnesses.[4] Nevertheless, geriatric depression is largely unexplored in nursing homes, partly due to their relatively occult and lack of specific performance.[2,5] The prevalence of depression varies enormously depending on a lot of factors, especially where the elderly come from, for example, in homes, communities, or nursing homes.[6] It was noteworthy that the severity of depression among the elderly in the nursing homes was more significant as compared to that of the community and homes.[7–9] A meta-analysis indicated that the detection rate of depressive symptoms in nursing homes was 37.5%.[10] Recent studies identified the prevalence of depression in homes, community, and nursing homes elderly people was 46.4%, 17.5%, and 57.1%, respectively in China.[11–13] Currently, no consensus exists regarding the prevalence and risk factors for the elderly with depression. According to the reports above, there is a higher depression rate in nursing homes than compared in homes and communities, but there are few relevant reports, and more studies are needed to investigate the depression rate in nursing homes in China. In the present article, we assessed the prevalence and related factors of depression among elderly people in nursing homes in China.

Depression is generally associated with both internal and external factors including age, gender, and impaired cognitive and physical function.[14–16] Previous studies found that elderly women are more at risk of depression,[17,18] but in Patra’s and Tsai’s[19,20] studies, gender was not a risk factor for depression among elderly people. It is necessary to further explore the risk factors of depression in the elderly in nursing homes, especially in the Chinese population where there is a lack of related reports. Dementia residents with high depression scores were more possible suffering behavioral dysfunctions and poorer physical health than the normal elderly,[21] but most studies focused on the cognitive function of dementia patients to identify the correlation between depression and poor health symptoms not explore the specific cognitive disease, for instance, Alzheimer’s disease (AD) or Parkinson’s disease (PD). Other studies have reported the correlation between depression and poor health symptoms, including pain, sleep disturbances, and dyspnea.[22–25] However, other chronic somatic diseases correlated with depression has been poorly researched in nursing homes, and more related researches are needed to better understand them.

The incubation period of the novel coronavirus disease 2019 (COVID-19) is 1 to 14 days, and people are generally susceptible. The outbreak occurred during the period of the Spring Festival (the Spring Festival is one of the most important festivals in China), with high personnel mobility, which has brought challenges to the prevention and control work. The elderly appeared strong susceptibility, most of them were serious, and symptoms not typical, so the elderly were regarded as the focus group by China State Council[26] during the COVID-19 outbreak. The aging of the population poses a challenge that has never been faced before in China. According to the epidemiological study of 99 COVID-19 patients at an average age of 55.5 years, and patients aged 60 and above accounted for 37%.[27]The elderly was under great psychological burden and mental and psychological pressure, and it was easy to have depression. As a protective measures, the Chinese government advocates home quarantine in the whole society, and anyone should wear masks when they leave homes and should not gathered together, in order to interrupt the transmission chain. According to previous studies reported that these measures lead to sadness and loneliness among older adults.[28] However, the prevalence of depression and how it distributes among the elderly in nursing homes are not know. Specially, this study analyzed the complex relationships among depression, physical function, and chronic diseases in nursing homes based on Shandong province. Shandong is different from some of the other regions – such as Beijing and Shanghai – because the province has a higher proportion of aging population. Shandong is a major agricultural province, as the hometown of Confucius and Mencius, the birthplace of Confucian culture, has the largest total aged population and the second in terms of deep aging in China.[29] With the influence of Chinese traditional filial piety culture and Confucian culture, most of the elderly are keen to live in the community or their own homes. Nursing homes are always the final choice of professional care for the elderly with severe functional or other physical limitations. The overwhelming evidence showed that there was a high rate of depression among the elderly in Chinese studies,[9,14] and compared with other European countries, the number and severity of emotional diseases of the elderly in Chinese nursing homes had increased significantly.[1,2]

Therefore, this study investigated the psychological and physiological status of the elderly during the COVID-19 epidemic, in order to provide a basis for the formulation of psychological crisis intervention program for the elderly in emergencies.

2. Material and methods 2.1. Participants

Convenience cluster sampling was used. According to the standard put forward by Kendall (1975),[30] the sample size was at least 5 to 10 times the number of items. Combined with the number of items in the questionnaire and the specific situation of the elderly in the nursing home, a total of 400 questionnaires were distributed. Questionnaires were distributed and collected on the spot in nursing homes. Three well-trained postgraduate nursing students then distributed questionnaires to the elderly who fulfilled the inclusion criteria. During the COVID-19 pandemic – the specified period of research, we invited to 400 eligible old adults, to fill out a survey questionnaire. Although illustrated exhaustively, nineteen of them refused to join the research because they were tired or uninterested, and only 381 old adults completed our questionnaire. This study was conducted among the elderly residents aged 60 years and above with 3 months or more living residence, who consent to participate in the study and came from 4 nursing homes in Weifang City, Shandong province from August to October 2021. The elderly who had serious diseases or cannot communicate clearly, such as deafness were excluded from this study. This study was conducted after Medical Ethics Committee of Weifang Medical University approval (approval number: 2019SL076). All participants were informed of the study content, and oral informed consent was obtained from themselves or their guardians.

2.2. Questionnaire 2.2.1. Resident-level factors.

The data of resident-level factors were collected using the self-design assessment questionnaire, including age, gender, marital status, educational level, residence status, main income source, the number of children, the number of chronic diseases and medicines, and so on.

Chronic diseases were classified as nervous system including AD, PD, and stroke, circulatory system (hypertensive, myocardial infarction or interventional surgery history, heart failure, and pulmonary heart disease), respiratory system (asthma and chronic bronchitis), digestive system (liver cirrhosis and peptic ulcer), locomotor system-bone and joint, urinary system (cervical spondylitis, history of the lumbar spine, and rheumatoid arthritis), endocrine system (diabetes mellitus and thyroid disease), and other past and present medical history (cancer, cataract, infectious history, and history of intubation), including other common diseases.

2.2.2. Patient health questionnaire.

The Patient Health Questionnaire (PHQ-9) was employed to measure depression.[31] Cronbach’s alpha value was 0.886 in this study. The critical score was 5, 10, 15, and 20. No depression has a depression severity score between 0-4, mild depression between 5 and 9, moderate depression between 10 and 14, and moderately and severe depression is 15–19 and 20–27 respectively. A score of 5 or higher was regarded as depression.

2.2.3. Barthel Index.

The activities of daily living (ADL) was administered to assess the elderly activity of daily living function by modified Barthel Index (BI).[32] The modified BI is a 7-item scale except for unsuitable 3 items: bowels, bladder, stairs. Elderly people are advised to use the elevator instead of the stairs in nursing homes in China, we deleted item 10 walk up and down stairs in the original scale. The higher the score is, the worse the activity of daily living function is. Cronbach’s α coefficient of the scale in this study was 0.966.

2.3. Statistical analysis

Excel 2019 was used to establish the database and Statistical Package for Social Science version 21.0 for Windows (IBM Corp, Armonk, NY, USA) software was used for the elderly data analysis. Descriptive statistics were used to identify the characteristics of the elderly. Categorical variables were described by frequencies (percentages) and continuous variables were described by means (standard deviations). The differences among categorical variables were analyzed by chi-square tests. Pearson correlation coefficient was used to express the correlation between depression and ADL. Multiple logistic regression was employed to validate the correlation between geriatric depression and related factors in nursing homes. Odds ratio (OR) was used to present risk factors, with 95% confidence interval (95% CI). All tests were 2-tailed and statistically significant with P < .05.

3. Results 3.1. Baseline characteristics of the elderly

Of the 400 eligible elderly people who joined the investigation, a total of 19 questionnaires were excluded from the analysis because of incompleteness. The response rate was 95.3%, of which 381 were valid questionnaires. The average age of all the elderly was 82.25 ± 7.92 with a minimum of 60 and a maximum of 100 years. There were 312 (81.9%) old people who had chronic diseases, about 54.1% had 1 to 2 chronic diseases, and 20.1% had 3 to 4 diseases, 5.3% had 5 to 6 diseases. Table 1 shows the demographic characteristics of the elderly.

Table 1 - General information of the elderly in nursing homes [n (%)]. Variables No depression Depression χ 2 P Age (yr)  60–69 36 (87.8) 5 (12.2) 4.775 .189  70–79 70 (89.7) 8 (10.3)  80–89 177 (89.8) 20 (10.2)  90–100 52 (80.0) 13 (20.0) Gender  Male 142 (84.0) 27 (16.0) 4.358 .037*  Female 193 (91.0) 19 (9.0) Marriage  Single† 230 (71.9) 90 (28.1) 0.585 .444  Married 105 (86.1) 17 (13.9) Education background  Undergraduate 31 (83.8) 6 (16.2) 6.696 .153  College 36 (100.0) 0 (0.0)  High school 51 (86.4) 8 (13.6)  Junior high school 64 (84.2) 12 (15.8)  Primary school/no normal schooling 153 (88.4) 20 (11.6) Religious beliefs  No 303 (88.3) 40 (11.7) 0.549 .459  Yes 32 (84.2) 6 (15.8) Previous employer  Civil servants 153 (88.4) 20 (11.6) 1.304 .935  Soldier 15 (88.2) 2 (13.3)  Professional and technical personnel 66 (88.0) 9 (12.0)  Self-run, private enterprise 22 (88.0) 3 (12.0)  Farming 73 (88.0) 10 (12.0)  Other 6 (75.0) 2 (25.0) The main source of income  Pension 252 (88.7) 32 (11.3) 2.629 .296  Children subsidies 74 (84.1) 14 (15.9)  Other 9 (100.0) 0 (0.0) The way of payment for treatment cost  Basic medical insurance system for urban workers and residents 270 (87.7) 38 (12.3) 2.424 .298  New rural cooperative medical care 16 (100.0) 0 (0.0)  Other 49 (86.0) 8 (14.0) The number of children  0–1 39 (79.6) 10 (20.4) 11.302 .004*  2–4 269 (90.9) 27 (9.1)  ≥5 27 (75.0) 9 (25.0) Residence before admission to nursing home  Living alone 181 (92.3) 15 (7.6) 8.096 .017*  Living with spouse 95 (84.8) 17 (15.2)  Living with children 59 (80.8) 14 (19.2) Reasons for entering pension institutions  No children or children unable to take care of due to family or work 249 (89.2) 30 (10.8) 3.455 .178  Ask for professional care 79 (83.2) 16 (16.8)  Other 7 (100.0) 0 (0.0) Check-in nursing homes time (yr)  0–1 74 (89.2) 9 (10.8) 0.184 .912  2–3 124 (87.9) 17 (12.1)  ≥4 137 (87.3) 20 (12.7) Chronic diseases  0 64 (91.4) 6 (8.6) 19.431 <.001*  1–2 191 (92.7) 15 (7.3)  3–4 62 (77.5) 18 (22.5)  ≥5 18 (72.0) 7 (28.0) Medicines  0 165 (92.2) 14 (7.8) 14.141 .003*  1–2 79 (91.9) 7 (10.5)  3–4 63 (78.8) 17 (21.3)  ≥5 28 (77.8) 8 (22.2)

*P < .05.

†Single including unmarried, divorce or widowed.


3.2. Prevalence of depression

The mean score of PHQ-9 in the elderly was 3.56 ± 3.76. About 73.0% of the elderly in nursing homes had no depression, and 27.0% had depression. Among them, there were 57 (15.0%) elderly with mild depression (PHQ-9 score 5–9), 28 (7.3%) elderly with moderate depression (PHQ-9 score 10–14), and 9 (2.4%) with moderately severe (PHQ-9 score 15–19) and severe depression (PHQ-9 score 20–27), respectively.

3.3. Prevalence of ADL impairment

The mean score of ADL in the elderly was 5.76 ± 7.05, and the number of nursing home residents with mild self-care ability disorder accounted for 42.5% with 26.8% maximum strength and independence, and 16.5% were maximum disability and dependency. The incidence of ADL impairment was highest in eating (70.9%) while it was least in locomotion, further information is presented in Table 2.

Table 2 - Impairment of activities of daily living for the elderly in nursing homes. Items Completely self-care Moderately self-care Mostly independence Completely independence Number (%) Number (%) Number (%) Number (%) Hygiene 255 66.9 28 7.3 39 10.2 59 15.5 Toilet 247 64.8 42 11.0 29 7.6 63 16.5 Eating 270 70.9 29 7.6 35 9.2 47 12.3 Transfer 230 60.4 74 19.4 37 9.7 40 10.5 Locomotion 139 36.5 142 37.3 31 8.1 69 18.1 Dressing 233 61.2 57 15.0 37 9.7 40 10.5 Shower 161 42.3 92 24.1 68 17.8 60 15.7
3.4. The correlation between depression and ADL

Table 3 shows the results of correlation analysis showed that the total PHQ-9 score of the elderly in nursing homes was positively correlated with the total ADL score (R = 0.503, P < .01), indicating that the more severely damaged the ADL, the higher the depression level of the elderly in nursing homes.

Table 3 - Correlation analysis of The Patient Health Questionnaire and Activities of Daily Living among the elderly in nursing homes. Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 PHQ-9 Item 1 0.413* 0.386* 0.312* 0.270* 0.389* 0.262* 0.426* 0.260* 0.248* 0.457* Item 2 0.393* 0.369* 0.263* 0.240* 0.318* 0.226* 0.395* 0.255* 0.203* 0.411* Item 3 0.437* 0.405* 0.308* 0.264* 0.373* 0.271* 0.410* 0.316* 0.251* 0.465* Item 4 0.442* 0.445* 0.319* 0.298* 0.392* 0.242* 0.431* 0.271* 0.226* 0.476* Item 5 0.426* 0.413* 0.286* 0.317* 0.351* 0.242* 0.428* 0.269* 0.218* 0.458* Item 6 0.476* 0.444* 0.345* 0.350* 0.354* 0.225* 0.463* 0.334* 0.209* 0.498* Item 7 0.414* 0.407* 0.260* 0.271* 0.339* 0.247* 0.382* 0.265* 0.241* 0.435* ADL 0.476* 0.456* 0.331* 0.311* 0.395* 0.264* 0.467* 0.302* 0.246* 0.503*

ADL = activities of daily living, PHQ-9 = The Patient Health Questionnaire.

**P <.01.


3.5. Factors associated with depression

The chi-square test showed that the difference in demographic variables, including gender, the number of children, residence before admission nursing home, chronic diseases and medicines were regarded as statistically significant (P < .05) between depression and non-depression elderly (Table 2). Table 4 shows the correlation between chronic diseases and depression in the elderly in nursing homes, including AD, BHP, and cataract. The above 7 variables (gender, the number of children, residence before admission to nursing home, medicines, AD, BHP, and cataract) were incorporated in the logistic test model. In multiple logistic regression, the ADL level (OR = 4.942, 95% CI [3.049, 8.008]), AD (OR = 2.479, 95% CI [1.119, 5.572]), male (OR = 3.234, 95% CI [1.096, 9.541]), cataract (OR = 14.739, 95% CI [3.006, 72.263]) were the risk factors for depression among the elderly living in nursing homes (Table 5).

Table 4 - Correlation between chronic diseases and depression of the elderly in nursing homes. System No depression (%) Depression (%) χ 2 P Nervous system  AD 28 (75.7) 9 (24.3) 4.586 .032*  PD 55 (88.7) 7 (11.3) 1.428 .232  Sequelae of stroke 55 (88.7) 7 (11.3) 0.043 .836 Circulatory system  Hypertension 187 (88.6) 24 (11.4) 0.218 .641  Myocardial infarction 56 (91.8) 5 (8.2) 1.028 .311  Cardiac failure 12 (85.7) 2 (14.3) 0.000 1.000  Pulmonary heart disease 2 (66.7) 1 (33.3) 0.257 .321 Respiratory system  Asthma 15 (88.2) 2 (11.8) 0.000 1.000  Chronic bronchitis 20 (83.3) 4 (16.7) 0.152 .697 Digestive system  Peptic ulcer 21 (84.0) 4 (16.0) 0.094 .760  Cirrhosis 4 (80.0) 1 (20.0) 1.000 .476 Motor system  Cervical spondylosis 10 (90.9) 1 (9.1) 0.000 1.000  Lumbar spondylosis 27 (84.4) 5 (15.6) 0.130 .718  Rheumatoid arthritis 14 (93.3) 1 (6.7) 0.063 .801 Urinary system  Urinary tract infections 12 (85.7) 2 (14.3) 0.000 1.000  Urinary calculi 1 (100.0) 0 (0) 1.000 .879  BPH 5 (55.6) 4 (44.4) 6.244

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