Hostname: page-component-6bf8c574d5-8gtf8 Total loading time: 0 Render date: 2025-02-16T22:41:50.710Z Has data issue: false hasContentIssue false
  • English
  • Français

The complex relationship between depressive symptoms and functional limitations in community-dwelling older adults: the impact of subthreshold depression

Published online by Cambridge University Press:  09 April 2009

C. F. Hybels ,
C. F. Pieper  and
D. G. Blazer
C. F. Hybels*
Affiliation:
Department of Psychiatry and Behavioral Sciences, Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
C. F. Pieper
Affiliation:
Department of Biostatistics and Bioinformatics, Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
D. G. Blazer
Affiliation:
Department of Psychiatry and Behavioral Sciences, Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
*
*Address for correspondence: C. F. Hybels, Ph.D., Duke University Medical Center, Box 3003, Durham, NC 27710, USA. (Email: [email protected])
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Depressive symptoms above screening thresholds have been shown to predict functional decline in older adults. Less is known about the impact of subthreshold depression, and whether more symptoms confer significantly greater risk compared to fewer symptoms.

Method

Using data from the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE) collected over 10 years, we used repeated-measures mixed models to predict functional change by depression status at the prior (index) in-person interview. Depressive symptoms were measured using a modified version of the Center for Epidemiologic Studies Depression Scale (CES-D). Subthreshold depression was operationalized as 6–8 symptoms and CES-D-defined depression as 9–20 symptoms in the previous week. Three domains of functional status were assessed at the subsequent in-person interview: limitations in basic activities of daily living (ADL), instrumental ADL (IADL) and mobility.

Results

Controlling for race, sex, age, education, marital status, cognitive status, health status, self-perceived health, perceived social support and functional status at the index interview, having ⩾6 depressive symptoms predicted an increase of 0.12 IADL limitations 3–4 years later (p=0.03). The incremental effect of CES-D-defined depression (⩾9 symptoms compared to 6–8 symptoms) was not significant, suggesting that the effect of more symptomatic depression did not add to that of subthreshold depression. CES-D score modeled as a continuous variable predicted functional change for all domains, but the relationship was not linear, supporting a possible threshold effect.

Conclusions

The relationship between depressive symptoms and functional change is complex, not necessarily linear, and may vary by tasks assessed.

Keywords

Functional statussubthreshold depression
Type
Original Articles
Information
Psychological Medicine , Volume 39 , Issue 10 , October 2009 , pp. 1677 - 1688
Copyright
Copyright © Cambridge University Press 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Beekman, ATF, Deeg, DJH, Braam, AW, Smit, JH, van Tilberg, W (1997). Consequences of major and minor depression in later life: a study of disability, well-being, and service utilization. Psychological Medicine 27, 1397–1409.CrossRefGoogle ScholarPubMed
Beekman, ATF, Deeg, DJH, van Tilberg, T, Smit, JH, Hooijer, C, van Tilberg, W (1995). Major and minor depression in later life: a study of prevalence and risk factors. Journal of Affective Disorders 36, 65–75.CrossRefGoogle ScholarPubMed
Berkman, LF, Berkman, CS, Kasl, S, Freeman, DH, Leo, L, Ostfeld, AM, Cornoni-Huntley, J, Brody, JA (1986). Depressive symptoms in relation to physical health and functioning in the elderly. American Journal of Epidemiology 124, 372–388.CrossRefGoogle ScholarPubMed
Blazer, D, Burchett, B, Service, C, George, LK (1991). The association of age and depression among the elderly: an epidemiologic exploration. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 46, M210–M215.Google ScholarPubMed
Blazer, DG (2003). Depression in late life: review and commentary. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 58, 249–265.CrossRefGoogle Scholar
Bruce, ML (2001). Depression and disability in late life: directions for future research. American Journal of Geriatric Psychiatry 9, 102–112.CrossRefGoogle ScholarPubMed
Bruce, ML, Seeman, TE, Merrill, SS, Blazer, DG (1994). The impact of depressive symptomatology on physical disability: MacArthur Studies of Successful Aging. American Journal of Public Health 84, 1796–1799.CrossRefGoogle ScholarPubMed
Carbonare, LD, Maggi, S, Noale, M, Giannini, S, Rozzini, R, Cascio, VL, Crepaldi, G; ILSA Working Group (2009). Physical disability and depressive symptomatology in an elderly population: a complex relationship. The Italian Longitudinal Study on Aging (ILSA). American Journal of Geriatric Psychiatry 17, 144–154.CrossRefGoogle Scholar
Cornoni-Huntley, J, Blazer, DG, Lafferty, ME, Everett, DF, Brock, DB, Farmer, ME (1990). Established Populations for Epidemiologic Studies of the Elderly: Resource Data Book, vol. 2, NIH Publication No. 90–495. National Institutes of Health: Washington, DC.Google Scholar
Cornoni-Huntley, J, Brock, D, Ostfeld, A, Taylor, JO, Wallace, RB (1986). Established Populations for Epidemiologic Studies of the Elderly: Resource Data Book, NIH Publication No. 86–2443. National Institutes of Health: Bethesda, MD.Google Scholar
Cronin-Stubbs, D, Mendes de Leon, CF, Beckett, LA, Field, TS, Glynn, RJ, Evans, DA (2000). Six-year effect of depressive symptoms on the course of physical disability in community-living older adults. Archives of Internal Medicine 160, 3074–3080.CrossRefGoogle ScholarPubMed
Dodge, HH, Du, Y, Saxton, JA, Ganguli, M (2006). Cognitive domains and trajectories of functional independence in nondemented elderly persons. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 61, 1330–1337.CrossRefGoogle ScholarPubMed
Duke University Center for the Study of Aging and Human Development (1978). Multidimensional Functional Assessment: The OARS Methodology, 2nd edn. Duke University: Durham, NC.Google Scholar
Dunlop, DD, Manheim, LM, Sohn, M, Liu, X, Chang, RW (2002). Incidence of functional limitation in older adults: the impact of gender, race, and chronic conditions. Archives of Physical Medicine and Rehabilitation 83, 964–971.CrossRefGoogle ScholarPubMed
Dunlop, DD, Semanik, P, Song, J, Manheim, LM, Shih, V, Chang, RW (2005). Risk factors for functional decline in older adults with arthritis. Arthritis and Rheumatism 52, 1274–1282.CrossRefGoogle ScholarPubMed
Everson-Rose, SA, Skarupski, KA, Bienias, JL, Wilson, RS, Evans, DA, Mendes de Leon, CF (2005). Do depressive symptoms predict declines in physical performance in an elderly, biracial population? Psychosomatic Medicine 67, 609–615.CrossRefGoogle Scholar
Fillenbaum, GG, Leiss, JK, Pieper, CF, Cohen, HJ (1998). Developing a summary measure of medical status. Aging (Milan, Italy) 10, 395–400.Google ScholarPubMed
Gallo, JJ, Rabins, PV, Lyketsos, CG, Tien, AY, Anthony, JC (1997). Depression without sadness: functional outcomes of nondysphoric depression in later life. Journal of the American Geriatrics Society 45, 570–578.CrossRefGoogle ScholarPubMed
Gallo, JJ, Rebok, GW, Tennsted, S, Wadley, VG, Horgas, A; Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Study Investigators (2003). Linking depressive symptoms and functional disability in late life. Aging and Mental Health 7, 469–480.CrossRefGoogle ScholarPubMed
Geerlings, SW, Beekman, ATF, Deeg, DJH, Twisk, JWR, Van Tilberg, W (2001). The longitudinal effect of depression on functional limitations and disability in older adults: an eight-wave prospective community-based study. Psychological Medicine 31, 1361–1371.CrossRefGoogle ScholarPubMed
Gill, TM, Allore, HG, Hardy, SE, Guo, Z (2006). The dynamic nature of mobility disability in older persons. Journal of the American Geriatrics Society 54, 248–254.CrossRefGoogle ScholarPubMed
Hebert, R, Brayne, C, Spiegelhalter, D (1999). Factors associated with functional decline and improvement in a very elderly community-dwelling population. American Journal of Epidemiology 150, 501–510.CrossRefGoogle Scholar
Ho, SC, Woo, J, Yuen, YK, Sham, A, Chan, SG (1997). Predictors of mobility decline: the Hong Kong old-old study. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 52, M356–M362.CrossRefGoogle Scholar
Hybels, CF, Blazer, DG, Pieper, CF (2001). Toward a threshold for subthreshold depression: an analysis of correlates of depression by severity of symptoms using data from an elderly community sample. The Gerontologist 41, 357–365.CrossRefGoogle Scholar
Ishizaki, T, Watanabe, S, Suzuki, T, Shibata, H, Haga, H (2000). Predictors for functional decline among nondisabled older Japanese living in a community during a 3-year follow-up. Journal of the American Geriatrics Society 48, 1424–1429.CrossRefGoogle Scholar
Judd, LL, Akiskal, HS (2002). The clinical and public health relevance of current research on subthreshold depressive symptoms in elderly patients. American Journal of Geriatric Psychiatry 10, 233–238.CrossRefGoogle Scholar
Katz, S, Downs, TD, Cash, HR, Grotz, RC (1970). Progress in development of the index of ADL. The Gerontologist 10, 20–30.CrossRefGoogle ScholarPubMed
Kempen, GIJM, Ranchor, AV, van Sonderen, E, van Jaarsveld, CHM, Sanderman, R (2006). Risk and protective factors of different functional trajectories in older persons: are these the same? Journals of Gerontology. Series B, Psychological Sciences and Social Sciences 61, P95–P101.CrossRefGoogle ScholarPubMed
Kempen, GIJM, Sanderman, R, Scaf-Klomp, W, Ormel, J (2003). The role of depressive symptoms in recovery from injuries to the extremities in older persons: a prospective study. International Journal of Geriatric Psychiatry 18, 14–22.CrossRefGoogle Scholar
Kempen, GIJM, Sullivan, M, van Sonderen, E, Ormel, J (1999 a). Performance based and self-reported physical functioning in low-functioning older persons: congruence of change and the impact of depressive symptoms. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences 54, P380–P386.CrossRefGoogle ScholarPubMed
Kempen, GIJM, van Sonderen, E, Ormel, J (1999 b). The impact of psychological attributes on changes in disability among low-functioning older persons. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences 54, P23–P29.CrossRefGoogle ScholarPubMed
Kivela, S-L, Pahkala, K (2001). Depressive disorder as a predictor of physical disability in old age. Journal of the American Geriatrics Society 49, 290–296.CrossRefGoogle ScholarPubMed
Korn, E, Graubard, B (1991). Epidemiologic studies utilizing surveys: accounting for sampling design. American Journal of Public Health 81, 1166–1173.CrossRefGoogle ScholarPubMed
Landerman, LR, Fillenbaum, GG (1997). Differential relationships of risk factors to alternative measures of disability. Journal of Aging and Health 9, 266–279.CrossRefGoogle ScholarPubMed
Lenze, EJ, Rogers, JC, Martire, LM, Mulsant, BH, Rollman, BL, Dew, MA, Schulz, R, Reynolds, CF (2001). The association of late-life depression and anxiety with physical disability: a review of the literature and prospectus for future research. American Journal of Geriatric Psychiatry 9, 113–135.CrossRefGoogle ScholarPubMed
Lenze, EJ, Schulz, R, Martire, L, Zdaniuk, B, Glass, T, Kop, WJ, Jackson, SA, Reynolds, CF (2005). The course of functional decline in older people with persistently elevated depressive symptoms: longitudinal findings from the Cardiovascular Health Study. Journal of the American Geriatrics Society 53, 569–575.CrossRefGoogle ScholarPubMed
Lyness, JM, Heo, M, Datto, CJ, Ten Have, TR, Katz, IR, Drayer, R, Reynolds, CF, Alexopoulos, GS, Bruce, ML (2006). Outcomes of minor and subsyndromal depression among elderly patients in primary care settings. Annals of Internal Medicine 144, 496–504.CrossRefGoogle ScholarPubMed
Lyness, JM, King, DA, Cox, C, Yoediono, Z, Caine, EC (1999). The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability. Journal of the American Geriatrics Society 47, 647–652.CrossRefGoogle ScholarPubMed
McConnell, ES, Pieper, CF, Sloane, RJ, Branch, LG (2002). Effects of cognitive performance on change in physical function in long-stay nursing home residents. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 57, M778–M784.CrossRefGoogle ScholarPubMed
Mehta, KM, Yaffe, K, Covinsky, KE (2002). Cognitive impairment, depressive symptoms, and functional decline in older people. Journal of the American Geriatrics Society 50, 1045–1050.CrossRefGoogle ScholarPubMed
Mendes de Leon, CF, Beckett, LA, Fillenbaum, GG, Brock, DB, Branch, LG, Evans, DA, Berkman, LF (1997). Black–white differences in risk of becoming disabled and recovering from disability in old age: a longitudinal analysis of two EPESE populations. American Journal of Epidemiology 145, 488–497.CrossRefGoogle ScholarPubMed
Murray, C, Lopez, A (eds) (1996). Summary: The Global Burden of Disease. Harvard University Press: Cambridge, MA.Google Scholar
Ormel, J, Rijsdijk, FV, Sullivan, M, von Sonderen, E, Kempen, GIJM (2002). Temporal and reciprocal relationship between IADL/ADL disability and depressive symptoms in late life. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences 57, P338–P347.CrossRefGoogle ScholarPubMed
Penninx, BWJH, Deeg, DJH, van Eijk, JT, Beekman, ATF, Guralnik, JM (2000). Changes in depression and physical decline in older adults: a longitudinal perspective. Journal of Affective Disorders 61, 1–12.CrossRefGoogle ScholarPubMed
Penninx, BWJH, Guralnik, JM, Ferrucci, L, Simonsick, EM, Deeg, DJH, Wallace, RB (1998). Depressive symptoms and physical decline in community-dwelling older persons. Journal of the American Medical Association 279, 1720–1726.CrossRefGoogle ScholarPubMed
Penninx, BWJH, Leveille, S, Ferrucci, L, van Eijk, JTM, Guralnik, JM (1999). Exploring the effect of depression on physical disability: longitudinal evidence from the established populations for epidemiologic studies of the elderly. American Journal of Public Health 89, 1346–1352.CrossRefGoogle ScholarPubMed
Pfeiffer, E (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society 23, 433–441.CrossRefGoogle Scholar
Pincus, HA, Davis, WW, McQueen, LE (1999). ‘Subthreshold’ mental disorders: a review and synthesis of studies on minor depression and other ‘brand names’. British Journal of Psychiatry 174, 288–296.CrossRefGoogle ScholarPubMed
Radloff, LS (1977). The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement 1, 385–401.CrossRefGoogle Scholar
Radloff, LS, Locke, BZ (2000). Center for Epidemiologic Studies Depression Scale (CES-D). Handbook of Psychiatric Measures. American Psychiatric Association: Washington, DC.Google Scholar
Rosow, I, Breslau, N (1966). A Guttman health scale for the aged. Journal of Gerontology 21, 556–559.CrossRefGoogle ScholarPubMed
SAS Institute (2004). Statistical Analysis System, Version 9. SAS Institute: Cary, NC.Google Scholar
Sinclair, PA, Lyness, JM, King, DA, Cox, C, Caine, ED (2001). Depression and self-reported functional status in older primary care patients. American Journal of Psychiatry 158, 416–419.CrossRefGoogle ScholarPubMed
Stuck, AE, Walthert, JM, Nikolaus, T, Bula, CJ, Hohmann, C, Beck, JC (1999). Risk factors for functional status decline in community-living elderly people: a systematic literature review. Social Science and Medicine 48, 445–469.CrossRefGoogle ScholarPubMed
van Gool, CH, Kempen, GIJM, Penninx, BWJH, Deeg, DJH, Beekman, ATF, van Eijk, JTM (2005). Impact of depression on disablement in late middle aged and older persons: results from the Longitudinal Aging Study Amsterdam. Social Science and Medicine 60, 25–36.CrossRefGoogle ScholarPubMed
Wang, L, van Belle, G, Kukull, WB, Larson, EB (2002). Predictors of functional change: a longitudinal study of nondemented people aged 65 and older. Journal of the American Geriatrics Society 50, 1525–1534.CrossRefGoogle Scholar