Depressive symptoms among older adults with diabetes mellitus: a cross-sectional study

Abstract

BACKGROUND
Diabetes mellitus is a chronic disease with long-term consequences that is often associated with depressive symptoms. This relationship predicts increased morbidity and mortality rates, leading to serious health consequences.

OBJECTIVE
To identify the prevalence and health factors associated with depressive symptoms among older adults with diabetes mellitus.

DESIGN AND SETTING
An observational cross-sectional study was conducted among 236 older adults in the Basic Healthcare Units of Jequié, Brazil.

METHODS
A survey containing sociodemographic, behavioral, and health conditions was used as a data collection instrument, in addition to the Geriatric Depression Scale. The main inclusion criterion was older adults diagnosed with diabetes mellitus. To identify the risk factors associated with depressive symptoms among older adults with diabetes mellitus, logistic regression analysis was conducted for calculating the odds ratio (OR), and a 95% confidence interval (CI) was considered statistically significant.

RESULTS
The prevalence of depressive symptoms was 24.2% among older adults with diabetes, corroborating the Brazilian average of 30%. The final multivariate analysis model for the risk of depressive symptoms showed a significant association with diabetes complications [OR = 2.50, 95% CI 1.318–4.74)] and osteoporosis [OR = 2.75, 95% CI 1.285–5.891)].

CONCLUSION
A high prevalence of depressive symptoms was observed among older adults with diabetes. Critically examining older adults with diabetes mellitus is necessary, and screening for depressive symptoms is highly recommended, especially for those with complications resulting from diabetes mellitus and musculoskeletal comorbidities, such as osteoporosis, as it seems to be associated with depressive symptoms.
KEYWORDS (MeSH terms):
Depression; Primary health care; Osteoporosis; Diabetes mellitus; Diabetes complications
AUTHORS’ KEYWORDS:
Depressive symptoms; Diabetic complications; Geriatric depression

Full text

Sao Paulo Med J. 20XX; XXX(X):xxx-xxx 1
ORIGINAL ARTICLE
https://doi.org/10.1590/1516-3180.2021.0771.R5.09082022
Depressive symptoms among older adults with diabetes
mellitus: a cross-sectional study
Diego Micael Barreto AndradeI, Roseanne Montargil RochaII, Ícaro José Santos RibeiroIII
Department of Health II, Universidade Estadual do Sudoeste da Bahia (UESB), Bahia (BA), Brazil
INTRODUCTION
Diabetes mellitus (DM) is a chronic disease that primarily aects older adults. Owing to long-
term consequences, such as complications of the kidneys, eyes, nerves, heart, and blood vessels,
DM constitutes a major public health problem.1,2 e prevalence of diabetes is increasing world-
wide. According to the International Diabetes Federation’s 2021 Diabetes Atlas, 537 million
adults aged between 20 and 79 years are living with diabetes. In Brazil, estimates show that up to
16.8 million people have DM, which is approximately 7% of the population.1
Moreover, the presence of depressive symptoms deserves equal attention because of its increas-
ing prevalence among community-dwelling older adults, ranging from 13% to 39%.
3
e prevalence
of depressive symptoms in Jequié, Bahia, Brazil, exceeded 88% of older adults, and was mostly
correlated with chronic diseases.4 Conversely, there are high rates of depression underdiagnosis
in older adults, which can increase the development of other risk factors in this population.5-7
Several studies have suggested an association between diabetes and depression. ere are var-
ious predictors of depression among older adults with DM, such as socioeconomic, individual,
behavioral, and clinical factors.8 Depression has been reported as a risk factor for type 2 diabe-
tes.9,10 Meanwhile, depression is reportedly two times more prevalent in people with DM than in
people who do not have diabetes.11-13 Depression has also been linked to family dysfunction and
poor health outcomes in patients with type 2 diabetes.12,14-16
Nonetheless, depression and diabetes represent the fourth and eighth most important causes
of disability-adjusted life years, respectively.
17
Moreover, this relationship predicts increased
morbidity and mortality rates, non-adherence to treatment, low quality of life, and an immense
public health impact.11,12,18-20
IPhD. Nurse and Professor, Faculty of Health
Sciences, University of Pécs (UP), Pécs, Hungary.
https://orcid.org/0000-0002-5323-1211
IIPhD. Nurse and Full Professor, Department of
Health II, Universidade Estadual de Santa Cruz
(UESC), Ilhéus (BA), Brazil.
https://orcid.org/0000-0001-5766-413X
IIIPhD. Nurse Researcher and Professor,
Department of Health II, Universidade Estadual
do Sudoeste da Bahia (UESB), Jequié (BA), Brazil.
https://orcid.org/0000-0002-4389-7810
KEYWORDS (MeSH terms):
Depression.
Primary health care.
Osteoporosis.
Diabetes mellitus.
Diabetes complications.
AUTHORS’ KEYWORDS:
Depressive symptoms.
Diabetic complications.
Geriatric depression.
ABSTRACT
BACKGROUND: Diabetes mellitus is a chronic diseasewith long-term consequences that is often associ-
ated with depressive symptoms. This relationship predicts increasedmorbidity and mortality rates, leading
to serious health consequences.
OBJECTIVE: To identify the prevalence and health factors associated with depressive symptoms among
older adults with diabetes mellitus.
DESIGN AND SETTING: An observational cross-sectional study was conducted among 236 older adults in
the Basic Healthcare Units of Jequié, Brazil.
METHODS: A survey containing sociodemographic, behavioral, and health conditions was used as a data
collection instrument, in addition to the Geriatric Depression Scale. The main inclusion criterion was older
adults diagnosed with diabetes mellitus. To identify the risk factors associated with depressive symptoms
among older adults with diabetes mellitus, logistic regression analysis was conducted for calculating the
odds ratio (OR), and a 95% condence interval (CI) was considered statistically signicant.
RESULTS: The prevalence of depressive symptoms was 24.2% among older adults with diabetes, corrob-
orating the Brazilian average of 30%. The nal multivariate analysis model for the risk of depressive symp-
toms showed a signicant association with diabetes complications [OR = 2.50, 95% CI1.318–4.74)] and
osteoporosis [OR = 2.75, 95% CI 1.285–5.891)].
CONCLUSION: A high prevalence of depressive symptoms was observed among older adults with diabetes.
Critically examining older adults with diabetes mellitus is necessary, and screening for depressive symptoms
is highly recommended, especially for those with complications resulting from diabetes mellitus and mus-
culoskeletal comorbidities, such as osteoporosis, as it seems to be associated with depressive symptoms.
Sao Paulo Med J.

ORIGINAL ARTICLE | Andrade DMB, Rocha RM, Ribeiro IJS
2 Sao Paulo Med J. 20XX; XXX(X):xxx-xxx
erefore, this study is important because, globally, depres-
sive symptoms and diabetes in older adults are becoming the
leading causes of disability, with greater frailty and vulnerability.
us, the presence of depressive symptoms associated with DM
can seriously impact an individual’s physical health and quality of
life, since both increase their risk for mortality and poor disease
management. Furthermore, primary care is the gateway to iden-
tifying and monitoring individuals with DM. us, this study is
relevant to help identify risk factors, establish early interventions,
and plan appropriate care for these individuals. Our research ques-
tions were: “What is the prevalence of depressive symptoms among
older adults with DM?” and “What is the relationship between
depressive symptoms and health conditions in older adults?” We
hypothesized that a signicant proportion of depressive symptoms
among older adults with DM would be related to their health status.
OBJECTIVE
is study aimed to identify the prevalence of and health factors
associated with depressive symptoms in older adults with DM.
METHODS
Study design and setting
is cross-sectional study was conducted among 236 older adults
enrolled and registered in theMonitoring and Control Service
of Hypertension and Diabetes at four Basic Healthcare Units
(BHU) in the city of Jequié, in the southwest region of the State of
Bahia, Brazil. e estimated population of Jequié is 156,277, with
approximately 17,000 older adults aged 60 years or older. Among
them, more than 10,000 were assisted under the BHU, and the
remaining older adults were distributed between family health
strategy units and private healthcare.21
Sample
To compose the sample, the E-SUS Component Individual Care
Form was used to group individuals with diabetes aged 60 years
or older. is is an online registration form that contains patients’
personal information regarding their health problems/conditions
and is acquired during individual consultations with primary care
professionals. Aer grouping, a sample of 813 individuals was
identied. Adopting a 95% condence level, 5% error, factor prev-
alence(i.e., depressive symptomatology) of 30.0%,22 and 20% loss
replacement rate, a sample of 236 individuals was calculated.
e research was conducted in four BHU areas, containing a
total of 91 micro-areas.We conducted a simple random draw from
themicro-areas, and the respective community health agent was
recruited to help during the home visits and assist the research team
in locating the residences. In case of the unavailability or absence of
older adults with diabetes in themicro-area, the nextmicro-areawas
selected, following the survey for older adults with diabetes until
saturation was reached for the number of individuals by BHU.
Inclusion criteria were older adults with DM type 2, aged 60
years or older, and who were enrolled in the BHU area and reg-
istered in the Monitoring and Control Service of Hypertension
and Diabetes. Exclusion criteria were older adults with cognitive
diculties as established by the Mini-Mental State Examination.
Data collection
For data collection, a form comprising two survey sets was
applied, including sociodemographic, behavioral, and health
conditions, along with the Geriatric Depression Scale (GDS-15).
Dependent variable
For analysis, depressive symptoms were used as the depen-
dent variable. e Brazilian version of the GDS, abbreviated
to 15 items, was used in this study.Regarding the denition of
depressive symptoms, scores of ≤5points = negative (absence
of depressive symptoms) and≥ 6 points = positive (presence of
depressive symptoms).23
Independent variables
e sociodemographic variables collected were sex (maleand
female); age in years tabulated in age groups (60–69, 70–79,
and 80 years or older); ethnicity (white, brown, black, and oth-
ers); marital status (with partner, without partner); and edu-
cation level divided into two groups (elementary school and
above, primary school and below).
e behavioral variables collected were physical activity (yes or
no); smoking habits (never smoked, former smoker, and smoker);
alcohol habits (non, moderate, excessive consumer); practicing any
religion (Catholic, Protestant, and not practicing); and nancial
diculty (yes or no).
e health conditions were assessed dichotomously (yes or
no), pertaining to family history of diabetes; diabetes complica-
tions; rheumatism; osteoporosis; systemic hypertension; circula-
tion problems; heart problems; diculty sleeping; vision problems;
chronic pain; type of DM complications (renal, ocular, circulatory,
diabetic foot, and amputation); and prescribed treatment (oral,
insulin, non-medicated, none).
Data analysis
Descriptive analysis of population characteristicswas performed
for all continuous variables (described as mean and standard devi-
ation values) and categorical variables (presented as absolute num-
bers and percentages). We conducted Chi-square and Fisher’s
exact tests for categorical variables and Student’s t-test for con-
tinuous variables. IBM SPSS for Windows statistical package, ver-
sion 22.0, was used for data analysis (SPSS, Inc., Chicago, Illinois,
Andrade DMB, Rocha RM, Ribeiro IJS
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Depressive symptoms among older adults with diabetes mellitus: a cross-sectional study | ORIGINAL ARTICLE
Sao Paulo Med J. 20XX; XXX(X):xxx-xxx 3
United States). To test the hypothesis that a signicant proportion
of depressive symptoms are related to health factors in older adults
with DM, the association between depressive symptoms andthe
possible risk factors among individuals with DM was assessed
using Pearson’schi-squaretest in bivariate analysis.e indepen-
dent variables with P < 0.2 in the bivariate analysis were entered
into a binary logistic regression model using the stepwiseregres-
sionmethod. e calculation of the odds ratio (OR) and statistically
signicant dierences (P < 0.05) were considered in the absence of
overlapping 95% condence interval (CI) for all analyses.
Ethical considerations
e study was approved by the Research Ethics Committee of the
Ana Nery Hospital, under protocol number 1.953.841, on March
8, 2017, and adhered to the Helsinki guidelines at all times. All
participants signed an informed consent form before participat-
ing in the study.
RESULTS
e nal sample comprised 236 older adults with DM. Most were
female (76.7%). e mean age was 71.6 years (± 8.03). Of the
sample, 64.0% declared brown ethnicity, 81.4% did not have a
partner, and 61.9% received primary or lower education.
Depressive symptoms were reported in 24.2% of older adults
with DM. Tab le 1 shows the characteristics of the study population
according to depressive symptoms. Being female without a part-
ner was predominant, although it was not signicantly associated
with depressive symptoms. Brown ethnicity among older adults
was primarily associated with depressive symptoms.
Tab l e 2 presents the behavioral characteristics of the study
population. Only alcohol consumption was associated with depres-
sive symptoms.
Tab l e 3 shows the characteristics of the population’s health con-
ditions. e existence of any diabetes complications and ocular and
circulatory types of DM complications were signicantly associated
with depressive symptoms. Amongcomorbidities, rheumatism,
osteoporosis, and heart and circulation problems were associated
with depressive symptoms. Diculty sleeping and severe chronic
pain were predominant among those with depressive symptoms
and were signicantly associated with depressive symptoms. e
nal multivariate analysis model is presented in Figure 1, which
shows the 95% condence indices of each variable that remained
in the model as well as theOR. Notably, the 95% CI coecients
were attenuated; however, DM complication along with osteopo-
rosisremainedassociated with depressive symptoms.
DISCUSSION
is study identied a 24.2% prevalence of depressive symp-
tomsin older adults with diabetes and demonstrated a signicant
association between DM complications and osteoporosis as a
health comorbidity.
Studies conducted among older adults in Brazil have shown
a prevalence of depressive symptoms ranging from 13% to 39%
among community-dwelling older adults. In the present study, the
prevalence of depressive symptoms among older adults with DM
was24.2%, which is within the Brazilian average range. Studies
reported a 30% and 34.4% prevalence of depressive symptoms in
older adults enrolled in the Hiperdiaprogram
22
andthose assisted
Table 1.Distribution and association of sociodemographic
characteristics of older adults with diabetes mellitus according to
depressive symptoms
Depressive symptoms P value
No[n (%)] Yes[n (%)]
Sex
Female 132 (73.7) 49 (86.0) 0.057
Male 47 (26.3) 8(14.0)
Ethnicity
Brown 117 (34.0) 34 (59.6)
0.037*
Black 34 (19.0) 9(15.8)
White 28 (15.6) 11 (19.3)
Other 0(0.0) 3(5.3)
Marital status
Without partner 144 (80.4) 48 (84.2) 0.525
With partner 35 (19.6) 9(15.8)
Education level
≥ Elementary school 72 (40.2) 18 (31.6) 0.242
≤ Primary education 107 (59.8) 39 (68.4)
*P < 0.05.
Table 2.Distribution and association of behavioral characteristics of
older adults with diabetes mellitus according to depressive symptoms
Depressive symptoms P value
No[n (%)] Yes[n (%)]
Religion
Catholic 70 (39.1) 18(31.6)
0.076Protestant 80 (44.7) 22 (38.6)
Not practicing 29 (16.2) 17 (29.8)
Financial diculty
Yes 82 (45.8) 21(36.8) 0.234
No 97(54.2) 36(63.2)
Physical activity
Yes 52 (29.1) 13(22.8) 0.358
No 127(70.9) 44 (77.2)
Smoking
Smoker 6(3.4) 8(8.8)
0.164Former smoker 68(38.0) 24(42.1)
Never smoked 105(58.7) 28(49.1)
Alcohol consumption
Excessive 2(1.1) 4(7.0)
0.032*
Moderate 13(7.3) 2(3.5)
Non-consumer 164(91.6) 51(89.5)
*P < 0.05.
Depressive symptoms among older adults with diabetes mellitus: a cross-sectional study
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ORIGINAL ARTICLE | Andrade DMB, Rocha RM, Ribeiro IJS
4 Sao Paulo Med J. 20XX; XXX(X):xxx-xxx
by the Family Health Strategy, respectively.
24
Both studies were
conducted in primary care and used the GDS-15 to investigate
the prevalence of depressive symptoms. is shows that the prev-
alence rates of depressive symptoms among older adults with DM
are signicantly higher than in those without any chronic disease.
Importantly, this can leadtodebilitating conditions because of poor
metabolic control and the emergence of otherhealth complications
resulting from the absence or decrease of treatment adherence,
decreased social bonds, and inadequate diet. ese negative out-
comes have been consistently observed in the relationship between
depressive symptoms and poorer self-care among older adults
with diabetes, and could be explained by diculties in maintain-
ing proactive and eective self-care behaviors.25,26 In the present
study, older adults with DM complications were more susceptible
to developing depressive symptoms than those without compli-
cations. Diabetes complications and depression are reportedly a
bi-directional relationship, and the risk of depression is higher
in people with diabetes complications, and vice versa.27 Meta-
analysis studies indicate that diabetes increases the risk of devel-
oping depression by approximately 25%.28,29 Moreover, the risk of
complications is higher when both diabetes and depression are
present. Individuals with DM have a 36% higher risk of develop-
ingmicrovascular complications, such asnephropathy, retinopathy,
and neuropathy. Researchers observed a 25% increase in the risk of
developing macrovascular complications, such as peripheral vas-
cular disease, erectile dysfunction, and coronary arterydisease.
30-32
Asnoted, there is strong evidence that these comorbidities are linked
with disability and loss of years of life.33 Notably, people with dia-
betes and symptoms ofdepression have higher levels of diastolic
blood pressure, triglycerides, glycatedhemoglobin, higher body
mass index, and worse glycemic control. erefore, older adults
are considered at risk for DM complications and othercomorbid-
ities that cansignicantlycompromisetheir health and quality of
life.
19,20
Moreover, depressive symptoms may appear even before the
diagnosis of DM or during the onset of complications, depending
on the individual or the course of the disease.34,35
Among thehealth comorbiditiesevaluated in this study, oste-
oporosis remained in the nal model even aer adjustment, show-
ing an increased risk for depressive symptoms in older adults with
DM. iscomorbidityis predominantly cited by older adults in
aging studies,
7,36
including being associated with diabetes itself.
37,38
e presence of osteoporosis combined with connective tis-
sue problems, neuropathies, andvasculopathiesmay increase the
incidence of complications in older adults with diabetes. is
further contributes to their limitations and restricted autonomy,
functional disability, fragility, and the potential development
ofdepressivesymptoms.39,40
Osteoporosis commonly causes pain, which directly aects the
quality of life of older adults with diabetes. Furthermore, comple-
mentary data in this study showed that 77.2% of older adults with
depressive symptoms had self-reported chronic pain. Whether this
pain is linked to musculoskeletal pain or complications of DM,
it remains a primary reason for older adults to seek healthser-
vices.37,41,42 us, this study expands the knowledge that the pres-
ence of osteoporosis and diabetes complications in older adults
can be associated with depressive symptoms. Moreover, when
Table 3.Distribution and association of health conditions of older
adults with diabetes mellitus according to depressive symptoms
Depressive symptoms P value
No[n (%)] Yes[n (%)]
DM family history
Yes 80 (59.8) 38(66.7)
0.550No 11(6.1) 4(7.0)
Do not know 61 (34.1) 15 (26.3)
Treatment
Oral 156(77.2) 53(79.1) 0.228
Insulin 32(15.8) 11(16.4) 0.809
Non-medicated 3(1.5) 0(0.0) 0.325
None 11(5.5) 3(4,5) 0.806
DM complication
Yes 69(38.5) 34(59.6) 0.005*
No 110(61.5) 23(40.4)
Complication type
Renal 7(7.5) 4(7.4) 0.333
Ocular 31(33.0) 26(48.1) 0.000*
Circulatory 42(44.7) 21(38.9) 0.047*
Diabetic foot 10(10.6) 2(3.7) 0.534
Amputation 4(4.2) 1(1.9) 0.826
Rheumatism
Yes 50 (27.9) 29(50.9) 0.001*
No 129(72.1) 28 (49.1)
Osteoporosis
Yes 26 (14.5) 20 (35.1) 0.001*
No 153(85.5) 37 (64.9)
Hypertension
Yes 146 (81.6) 49 (86.0) 0.445
No 33(18.4) 8(14.0)
Circulation problems
Yes 76 (42.5) 35 (61.4) 0.013*
No 103(57.5) 22 (38)
Heart problems
Yes 33 (18.4) 19 (33.3) 0.018*
No 146(81.6) 38 (66.7)
Diculty sleeping
Yes 82 (45.8) 37 (64.9) 0.012*
No 97(54.2) 20 (35.1)
Vision problems
Yes 80 (44.7) 32 (56.1) 0.132
No 99(55.3) 25 (43.9)
Chronic pain
Yes 81 (45.3) 44 (77.2) 0.000*
No 98(54.7) 13 (22.8)
*P < 0.05; DM = diabetes mellitus.
Andrade DMB, Rocha RM, Ribeiro IJS
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Sao Paulo Med J. 20XX; XXX(X):xxx-xxx 5
older adults seek health services, health professionals must criti-
cally examine these associations and employ a holistic approach,
for example, by testing for depressive symptoms.
In this context, testing for depressive symptoms in individu-
als with diabetes to enable early detection and treatment is one of
the challenges faced by primary healthcare professionals. Lack of
screening may be attributed to absent or limited training in mental
health issues, inability or lack of skills to use mental health assess-
ments, and diculties in distinguishing depression symptoms or
diabetes complications from symptoms of physical illness. Ideally,
patients with diabetes should be referred to mental health consul-
tations and supported in self-management education, which can
provide them with an increased ability to maintain their treat-
ments and identify coping strategies for depressive symptoms.43,44
CONCLUSION
e present study ndings are broadly consistent with data from
national and international literature, showing a signicant preva-
lence of depressive symptoms in older adults with type2DM. In
conclusion, this study provides strong evidence that complications
of DM signicantly increase the risk of depressive symptoms in
older adults, especially those with DM and osteoporosis. is per-
spective suggests that, by identifying groups at greater risk, primary
care professionals can develop care strategies and refer older adults
with DM for a mental health consultation to reduce complications
and improve prognosis. In the present study, individuals with DM
at a higher risk for the development of depressive symptoms were
represented among those with complications arising from DM and
musculoskeletalcomorbidities, suchas osteoporosis.
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Figure 1. Odds ratio and 95% condence interval (CI) of nal regression model for risk of depressive symptoms.
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Authors’ contributions: Andrade DMB: conceptualization (lead), data
curation (lead), formal analysis (equal), investigation (lead), methodology
(equal), project administration (lead), resources (equal), software
(supporting), supervision (equal), validation (equal), visualization (equal),
writing-original draft (lead) and writing-review and editing; Rocha
RM: conceptualization (supporting), data curation (equal), funding
acquisition (supporting), investigation (supporting), methodology
(supporting), project administration (lead), resources (equal), supervision
(lead), validation (equal), visualization (equal) and writing-review and
editing (equal); and Ribeiro IJS: conceptualization (supporting), data
curation (supporting), formal analysis (lead), methodology (supporting),
software (lead), supervision (equal), validation (equal), visualization
(equal) and writing-review and editing (equal). All authors actively
contributed to the discussion of the study results and reviewed and
approved the nal version of the manuscript
Sources of funding: This study was nanced in part by the Coordenação
de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) –
nance code 001
Conicts of interest: The authors declare no conicts of interest
Date of rst submission: September 17, 2021
Last received: July 11, 2022
Accepted: August 9, 2022
Address for correspondence:
Diego Micael Barreto Andrade
Faculty of Health Sciences, Doctoral School of Health Sciences, University
of Pécs (UP), Pécs, Vörösmarty Mihály Street 4, 7621, Hungary
Tel. (+36) 30 6804012
E-mail: andrade.diego@etk.pte.hu
© 2022 by Associação Paulista de Medicina
This is an open access article distributed under the terms of the Creative Commons license.
Depressive symptoms among older adults with diabetes mellitus: a cross-sectional study
Sao Paulo Med J.