Journal of http://jag.sagepub.com/ Applied Gerontology
Fatigue and Depressive Symptoms in Older People Minna Mänty, Taina Rantanen, Pertti Era and Kirsten Avlund Journal of Applied Gerontology 2014 33: 505 originally published online 1 August 2012 DOI: 10.1177/0733464812454011 The online version of this article can be found at: http://jag.sagepub.com/content/33/4/505
Published by: http://www.sagepublications.com
On behalf of:
Southern Gerontological Society
Additional services and information for Journal of Applied Gerontology can be found at: Email Alerts: http://jag.sagepub.com/cgi/alerts Subscriptions: http://jag.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Apr 28, 2014 OnlineFirst Version of Record - Aug 1, 2012 Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014 What is This?
54011
lied GerontologyMänty et al.
JAG33410.1177/0733464812454011
Brief Reports
Fatigue and Depressive Symptoms in Older People
Journal of Applied Gerontology 2014,Vol. 33(4) 505–514 © The Author(s) 2012 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464812454011 jag.sagepub.com
Minna Mänty1,2, Taina Rantanen3, Pertti Era3,4,5, and Kirsten Avlund1,2,6
Abstract Fatigue is considered an important indicator of aging-related declines in health and functional abilities. Previous studies have indicated strong associations between fatigue and depressive symptoms among younger populations and in patient groups with specific diseases. However, it is not known how different measures of fatigue are associated with depressive symptoms among general older populations. The purpose of this study is to describe the prevalence of depressive symptoms among community-dwelling older adults reporting mobility-related or general feelings fatigue. The study population consisted of 75-year-old community-living individuals (n = 561). Both, mobility-related and general fatigue, were associated in a stepwise relationship with depressive symptoms: a higher level of fatigue was related to higher level of depressive symptoms. Especially major general fatigue was strongly associated with high level of depressive symptoms. It is important
Manuscript received: February 3, 2012; final revision received: April 24, 2012; accepted: June 6, 2012. 1
Section of Social Medicine, Department of Public Health Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark 3 Gerontology Research Centre, Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland 4 GeroCenter Foundation for Research and Development, Kinkomaa, Finland 5 Department of Rehabilitation, Central Finland Health Care District, Jyväskylä, Finland 6 Danish Aging Research Center, Universities of Odense, Aarhus and Copenhagen, Denmark
2
Corresponding Author: Minna Mänty, Section of Social Medicine, Department of Public Health, Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark. Email: [email protected]
Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014
506
Journal of Applied Gerontology 33(4)
for professionals of the field to be aware of the associations between different measures of fatigue and depressive symptoms. Keywords fatigue, depressive symptoms, aging
Introduction There has been a growing interest in fatigue as an early marker of aging-related declines in health and functional abilities (Avlund, 2010). Fatigue is a commonly reported symptom in older people, which has been associated with sedentary lifestyle, poor functional performance, and higher levels of disability (Avlund, Rantanen, & Schroll, 2006; Hardy & Studenski, 2008; Mänty et al., 2012, Vestergaard et al., 2009). Previous studies have also indicated strong associations between fatigue and depressive symptoms among younger general populations (Addington, Gallo, Ford, & Eaton, 2001; Lin et al., 2009; Watt et al., 2000), primary care patients (Skapinakis, Lewis, & Mavreas, 2003, 2004), and in patients with a specific condition, such as, cancer (Brown & Kroenke, 2009), multiple sclerosis (Bakshi et al., 2000; Pittion-Vouyovitch et al., 2006), or chronic pulmonary disease (Breslin et al., 1998). However, the association between unexplained fatigue and depressive symptoms has rarely been reported among general community-dwelling older adults. Furthermore, during recent decades fatigue has been conceptualized using various definitions, and several measures of fatigue have been developed, ranging from simple global questions on general fatigue to more complex and specified measures of physical or mental fatigue (Avlund, 2010; Watt et al., 2000). It has been suggested that general or mental fatigue might be more strongly associated with depressive symptoms as compared to feelings of fatigue relating to physical function (Watt et al., 2000). However, only a few studies have been carried out to investigate this issue (Breslin et al., 1998; Watt et al., 2000) and none of these among older populations. The objective of this study was to describe the prevalence of depressive symptoms among older communitydwelling adults reporting mobility-related or general feelings fatigue.
Method Participants This descriptive cross-sectional study is based on baseline data of the Nordic Research on Aging Study (NORA; Kauppinen, Davidsen, & Sundh, 2002). The original study population (n = 835) consisted of a random sample of 75-year-old
Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014
507
Mänty et al.
persons living in Glostrup, Denmark (n = 480) and of all 75-year-old citizens living in Jyväskylä, Finland (n = 355). Of the original study population, 20% did not have independent mobility and 11% to 13% lacked information on depressive symptoms, diseases, or general fatigue, leaving 561 participants (55% women) for the analyses. The selected participants tended to have slightly better health and physical function as compared to nonparticipants (data not shown).
Materials and Procedure At both sites, all assessments were carried out using identical standard protocols. Face-to-face interviews were conducted at participants’ homes and included structured questions on depressive symptoms, fatigue and other covariates. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D, score range 0-60) with a cutoff score of ≥ 16 to identify subjects with depressed mood (Radloff, 1977). Mobility-related fatigue was measured using a structured and previously validated instrument, the Mobility-Tiredness Scale (MOB-T: Avlund, Kreiner, & Schultz-Larsen, 1996). Participants were asked whether they felt fatigued after performing six mobility tasks: rising from a chair or bed, walking indoors, getting outdoors, walking outdoors in a nice weather, walking outdoors in a bad weather, and climbing stairs. Answers were summed for a total fatigue score (range 0-6), with higher scores indicating higher levels of fatigue. For the purpose of this study, we computed a categorical fatigue variable to explore the possible gradient association between fatigue and depressive symptoms: (1) No fatigue, (2) fatigue in 1 to 3 tasks and (3) fatigue in 4 to 6 tasks. The level of general fatigue was evaluated with a structured question on experienced feelings of general fatigue during the past 14 days using the following categorization; (1) No fatigue, (2) minor fatigue (a little) and (3) major fatigue (a lot). Information on the number of chronic diseases was checked during the medical examination by a physician. Income was defined as low (only compulsory old age pension) versus high (compulsory old age pension plus other sources of income).
Statistical Analyses The associations between mobility-related and general fatigue with depressive symptoms were examined using Kruskal-Wallis test, chi-square test and logistic regression. Regression models were adjusted for gender, geographic location, number of chronic diseases, and income. Gender-by-fatigue interactions
Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014
508
Journal of Applied Gerontology 33(4)
on depression were found to be nonsignificant (all p values >.05), and therefore the primary analyses were performed in men and women combined. However, we performed secondary analyses stratified by gender due to previously observed significant gender differences in fatigue and depression. All analyses were performed using SAS software version 9.2 (SAS Institute Inc., Cary, NC).
Results Fatigue was common in this study population. 56% of the participants reported mobility related fatigue; 30% in 1 to 3 tasks and 26% in 4 to 6 tasks. Respectively, 38% of the participants reported general fatigue: 31% minor and 7% major general fatigue. Depressive symptoms according to level of fatigue are presented in Table 1. Overall, the mean CES-D score was 10.5 (SD 8.5) and the proportion of participants having depressive mood 24%. Mean CES-D score as well as the proportion of those reporting depressed mood (CES-D ≥ 16) were significantly higher among participants reporting higher levels of both types of fatigue (Table 1). Participants reporting mobility-related fatigue in 1 to 3 tasks were around two times more likely (OR 2.3, 95% CI [1.4, 3.8]) and those reporting fatigue in 4 to 6 tasks around 4 times more likely (OR 4.3, 95% CI [2.5, 7.3]) to have depressed mood as compared to those reporting no mobility-related fatigue (Table 2). Respectively, participants reporting minor general fatigue were around 3 times (OR 2.9, 95% CI [1.8, 4.7]) and those with major general fatigue over 9 times more likely (OR 9.4, 95% CI [4.3, 20.5]) to have depressed mood as compared to those reporting no general fatigue (Table 2). However, although fatigue was strongly associated with depressive symptoms, over two thirds (62%-71%) of participants reporting mobility-related fatigue and over one third (34%-65%) of those reporting general fatigue did not have depressed mood (Table 1). Our gender-stratified secondary analyses showed that women reported more fatigue as well as depressive symptoms as compared to men (Table 1). However, the association between fatigue and depression was similar for men and women (Table 2).
Discussion The findings of this descriptive study indicate that in older adults mobilityrelated and general fatigue are both associated in a stepwise relationship with depressive symptoms: a higher level of fatigue appeared to be related to a higher level of depressive symptoms. To our knowledge, this is the first study to report
Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014
Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014
509
8.1 (7.3) 33 (13) 9.7 (8.1) 18 (16) 6.7 (6.2) 15 (12)
10.5 (8.5) 136 (24)
12.2 (8.7) 88 (28)
8.4 (7.9) 48 (19)
No fatigue
9.8 (9.2) 15 (25)
13.1 (7.8) 34 (31)
12.4 (8.2) 49 (29)
Fatigue in 1-3 tasks
10.9 (8.8) 18 (30)
14.3 (9.9) 36 (43)
12.5 (9.8) 54 (38)
Fatigue in 4-6 tasks
Fatigue and Depressive Symptoms in Older People Minna Mänty, Taina Rantanen, Pertti Era and Kirsten Avlund Journal of Applied Gerontology 2014 33: 505 originally published online 1 August 2012 DOI: 10.1177/0733464812454011 The online version of this article can be found at: http://jag.sagepub.com/content/33/4/505
Published by: http://www.sagepublications.com
On behalf of:
Southern Gerontological Society
Additional services and information for Journal of Applied Gerontology can be found at: Email Alerts: http://jag.sagepub.com/cgi/alerts Subscriptions: http://jag.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Apr 28, 2014 OnlineFirst Version of Record - Aug 1, 2012 Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014 What is This?
54011
lied GerontologyMänty et al.
JAG33410.1177/0733464812454011
Brief Reports
Fatigue and Depressive Symptoms in Older People
Journal of Applied Gerontology 2014,Vol. 33(4) 505–514 © The Author(s) 2012 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464812454011 jag.sagepub.com
Minna Mänty1,2, Taina Rantanen3, Pertti Era3,4,5, and Kirsten Avlund1,2,6
Abstract Fatigue is considered an important indicator of aging-related declines in health and functional abilities. Previous studies have indicated strong associations between fatigue and depressive symptoms among younger populations and in patient groups with specific diseases. However, it is not known how different measures of fatigue are associated with depressive symptoms among general older populations. The purpose of this study is to describe the prevalence of depressive symptoms among community-dwelling older adults reporting mobility-related or general feelings fatigue. The study population consisted of 75-year-old community-living individuals (n = 561). Both, mobility-related and general fatigue, were associated in a stepwise relationship with depressive symptoms: a higher level of fatigue was related to higher level of depressive symptoms. Especially major general fatigue was strongly associated with high level of depressive symptoms. It is important
Manuscript received: February 3, 2012; final revision received: April 24, 2012; accepted: June 6, 2012. 1
Section of Social Medicine, Department of Public Health Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark 3 Gerontology Research Centre, Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland 4 GeroCenter Foundation for Research and Development, Kinkomaa, Finland 5 Department of Rehabilitation, Central Finland Health Care District, Jyväskylä, Finland 6 Danish Aging Research Center, Universities of Odense, Aarhus and Copenhagen, Denmark
2
Corresponding Author: Minna Mänty, Section of Social Medicine, Department of Public Health, Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark. Email: [email protected]
Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014
506
Journal of Applied Gerontology 33(4)
for professionals of the field to be aware of the associations between different measures of fatigue and depressive symptoms. Keywords fatigue, depressive symptoms, aging
Introduction There has been a growing interest in fatigue as an early marker of aging-related declines in health and functional abilities (Avlund, 2010). Fatigue is a commonly reported symptom in older people, which has been associated with sedentary lifestyle, poor functional performance, and higher levels of disability (Avlund, Rantanen, & Schroll, 2006; Hardy & Studenski, 2008; Mänty et al., 2012, Vestergaard et al., 2009). Previous studies have also indicated strong associations between fatigue and depressive symptoms among younger general populations (Addington, Gallo, Ford, & Eaton, 2001; Lin et al., 2009; Watt et al., 2000), primary care patients (Skapinakis, Lewis, & Mavreas, 2003, 2004), and in patients with a specific condition, such as, cancer (Brown & Kroenke, 2009), multiple sclerosis (Bakshi et al., 2000; Pittion-Vouyovitch et al., 2006), or chronic pulmonary disease (Breslin et al., 1998). However, the association between unexplained fatigue and depressive symptoms has rarely been reported among general community-dwelling older adults. Furthermore, during recent decades fatigue has been conceptualized using various definitions, and several measures of fatigue have been developed, ranging from simple global questions on general fatigue to more complex and specified measures of physical or mental fatigue (Avlund, 2010; Watt et al., 2000). It has been suggested that general or mental fatigue might be more strongly associated with depressive symptoms as compared to feelings of fatigue relating to physical function (Watt et al., 2000). However, only a few studies have been carried out to investigate this issue (Breslin et al., 1998; Watt et al., 2000) and none of these among older populations. The objective of this study was to describe the prevalence of depressive symptoms among older communitydwelling adults reporting mobility-related or general feelings fatigue.
Method Participants This descriptive cross-sectional study is based on baseline data of the Nordic Research on Aging Study (NORA; Kauppinen, Davidsen, & Sundh, 2002). The original study population (n = 835) consisted of a random sample of 75-year-old
Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014
507
Mänty et al.
persons living in Glostrup, Denmark (n = 480) and of all 75-year-old citizens living in Jyväskylä, Finland (n = 355). Of the original study population, 20% did not have independent mobility and 11% to 13% lacked information on depressive symptoms, diseases, or general fatigue, leaving 561 participants (55% women) for the analyses. The selected participants tended to have slightly better health and physical function as compared to nonparticipants (data not shown).
Materials and Procedure At both sites, all assessments were carried out using identical standard protocols. Face-to-face interviews were conducted at participants’ homes and included structured questions on depressive symptoms, fatigue and other covariates. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D, score range 0-60) with a cutoff score of ≥ 16 to identify subjects with depressed mood (Radloff, 1977). Mobility-related fatigue was measured using a structured and previously validated instrument, the Mobility-Tiredness Scale (MOB-T: Avlund, Kreiner, & Schultz-Larsen, 1996). Participants were asked whether they felt fatigued after performing six mobility tasks: rising from a chair or bed, walking indoors, getting outdoors, walking outdoors in a nice weather, walking outdoors in a bad weather, and climbing stairs. Answers were summed for a total fatigue score (range 0-6), with higher scores indicating higher levels of fatigue. For the purpose of this study, we computed a categorical fatigue variable to explore the possible gradient association between fatigue and depressive symptoms: (1) No fatigue, (2) fatigue in 1 to 3 tasks and (3) fatigue in 4 to 6 tasks. The level of general fatigue was evaluated with a structured question on experienced feelings of general fatigue during the past 14 days using the following categorization; (1) No fatigue, (2) minor fatigue (a little) and (3) major fatigue (a lot). Information on the number of chronic diseases was checked during the medical examination by a physician. Income was defined as low (only compulsory old age pension) versus high (compulsory old age pension plus other sources of income).
Statistical Analyses The associations between mobility-related and general fatigue with depressive symptoms were examined using Kruskal-Wallis test, chi-square test and logistic regression. Regression models were adjusted for gender, geographic location, number of chronic diseases, and income. Gender-by-fatigue interactions
Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014
508
Journal of Applied Gerontology 33(4)
on depression were found to be nonsignificant (all p values >.05), and therefore the primary analyses were performed in men and women combined. However, we performed secondary analyses stratified by gender due to previously observed significant gender differences in fatigue and depression. All analyses were performed using SAS software version 9.2 (SAS Institute Inc., Cary, NC).
Results Fatigue was common in this study population. 56% of the participants reported mobility related fatigue; 30% in 1 to 3 tasks and 26% in 4 to 6 tasks. Respectively, 38% of the participants reported general fatigue: 31% minor and 7% major general fatigue. Depressive symptoms according to level of fatigue are presented in Table 1. Overall, the mean CES-D score was 10.5 (SD 8.5) and the proportion of participants having depressive mood 24%. Mean CES-D score as well as the proportion of those reporting depressed mood (CES-D ≥ 16) were significantly higher among participants reporting higher levels of both types of fatigue (Table 1). Participants reporting mobility-related fatigue in 1 to 3 tasks were around two times more likely (OR 2.3, 95% CI [1.4, 3.8]) and those reporting fatigue in 4 to 6 tasks around 4 times more likely (OR 4.3, 95% CI [2.5, 7.3]) to have depressed mood as compared to those reporting no mobility-related fatigue (Table 2). Respectively, participants reporting minor general fatigue were around 3 times (OR 2.9, 95% CI [1.8, 4.7]) and those with major general fatigue over 9 times more likely (OR 9.4, 95% CI [4.3, 20.5]) to have depressed mood as compared to those reporting no general fatigue (Table 2). However, although fatigue was strongly associated with depressive symptoms, over two thirds (62%-71%) of participants reporting mobility-related fatigue and over one third (34%-65%) of those reporting general fatigue did not have depressed mood (Table 1). Our gender-stratified secondary analyses showed that women reported more fatigue as well as depressive symptoms as compared to men (Table 1). However, the association between fatigue and depression was similar for men and women (Table 2).
Discussion The findings of this descriptive study indicate that in older adults mobilityrelated and general fatigue are both associated in a stepwise relationship with depressive symptoms: a higher level of fatigue appeared to be related to a higher level of depressive symptoms. To our knowledge, this is the first study to report
Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014
Downloaded from jag.sagepub.com at ANADOLU UNIV on May 10, 2014
509
8.1 (7.3) 33 (13) 9.7 (8.1) 18 (16) 6.7 (6.2) 15 (12)
10.5 (8.5) 136 (24)
12.2 (8.7) 88 (28)
8.4 (7.9) 48 (19)
No fatigue
9.8 (9.2) 15 (25)
13.1 (7.8) 34 (31)
12.4 (8.2) 49 (29)
Fatigue in 1-3 tasks
10.9 (8.8) 18 (30)
14.3 (9.9) 36 (43)
12.5 (9.8) 54 (38)
Fatigue in 4-6 tasks
