The prevalence and risk factors of

depression in elderly nursing home

residents in Yogyakarta province, Indonesia
Bayu A. Pramesona

Adviser: Prof. Surasak Taneepanichskul, MD.

Introduction
Introduction
Asia-Pacific Region
• Over 52 % the world’s older
population are concentrated
in this region.
• Ranked 3rd amongst 25
Asia-Pacific countries with
almost 22 million of total
elderly population was
counted in 2015
Percentage of elderly age group in Global, Asia,
and Indonesia (1950-2050)
• Total Population in 2010 = 237,641,326 people
• (Population Census Data - Statistics Indonesia)
Life Expectancy at birth in Indonesia, 2015

• Life Expectancy at birth 2015 = 69.1 (both sexes)

• Males = 67.1
• Females = 71.2
Current Situation in Indonesia

In 2015, Indonesia has become the 5th largest elderly population in worldwide
(BPS - Statistics Indonesia, 2010a).
Elderly Population in Indonesia and Yogyakarta Province
Population of Yogyakarta Province was
around 3,457,491 people (BPS, 2010)

Total elderly aged ≥60 years =

448,223 people
Elderly Population in Indonesia and Yogyakarta
Province
Population of Yogyakarta Province is
around 3,457,491 people (BPS, 2010)
Depression and Ageing
• Ageing is resulted from the accumulation of the molecular and
cellular damage over time. This gradual damage declines the physical
and psychological ability, increase the risk of getting disease,
eventually death (WHO, 2015).
• Mental health and emotional well-being are considered as crucial things
in older age community. Mental disorder is a problem amongst older adults
aged 60 and above whereas the 15% to over 20% of older adults
suffer from it (WHO, 2016).
• It means approximately 2 billion of the older adults have physical and
mental health problems which need to be solved (WHO, 2016).
Depression and Ageing
• Depression is one of common mental health problems related
ageing process among elderly population (WHO, 2015), depicted by
sadness, loss of interest or pleasure, feelings of guilt or low self-worth,
sleep or appetite disturbance, feelings of tiredness, and lack of
concentration (WHO, 2016c).
• Depression also considered as a feeling of suffering and depth of sadness
which impacts on sleep, appetite, quality of life, self-esteem, and attitude
pertaining own atmosphere (Carp, 2001).
• Depression is a kind of mental disturbance due to imbalance in emotional
aspect and effects on quality of life decrease which can influence the work
and interpersonal relations in different times (Beck, 1970)
• Healthcare providers and older adults rarely recognize toward
the mental health illness, and it impacts to the unwilling to seek the
treatment (WHO, 2016).
Prevalence of depressive elderly
• Prevalence of depression among elderly are various in worldwide, the rates
varied from different settings of study site such as in the community-
dwelling or clinical settings. Studies revealed that around 16% aged 65 and older
with clinically significant depressive symptoms in America, in Myanmar was
22%, Japan was ranged of 17.8%-53.8%, in Iran 23.5%, in Malaysia ranged from
14-30.1%, in Taiwan was 21.3%, in South Korea was varied from 15.2%-63%, in
Pakistan was 19.8%, in Thailand 6%, in India was 31.7%-72.4%, in Saudi Arabia
was 63.7%, in Egypt was 72%, and in Nepal was 57.1%.
• Major depression was rated as 8%-16% in community-dwelling older adults,
5%-10% in outpatients in primary care setting, and 10%-12% in hospitalized
(Blazer, 2009).

• The prevalence of major depression also varied from 0.9% to 9.4% in private
households, 14% to 67% in nursing homes, 1% to 16% among elderly living
in private households or in institutions (Djernes JK, 2006; M Al Jawad, AK Rashid, & KA Narayan,
2007).
Depression and Ageing
• Depression is not a normal part of aging process. Depression can be handled
through appropriate treatment with fast responses. If it is untreated well, the
remain effects can be occurred such as physical, cognitive, functional and social
impairment. Another following impacts for instance decreasing of quality
of life, prolonging patient’s health recovery, increasing the
healthcare utilization, and even suicide (Greenberg S. A, 2012).
• Although the treatment of depressive symptoms already well-known widely,
however less than 10% of depressive elderly who received the
treatments in many countries. Some barriers to receive the appropriate care
for instance lack of resources, lack of trained health care providers,
and social stigma related to mental health disorders are still existed.
Another barrier to adequate care is inaccurate assessment. It impacts on
misdiagnosing and antidepressant prescribing (WHO, 2016b).
Depression elderly in nursing homes
• The depression prevalence in the nursing home was higher three to four times
compared to the prevalence of depression in the community-dwelling elderly (K. Jongenelisa et
al., 2004).
• Approximately 54% elderly people suffer from depression especially those who live in a
nursing home (Arifianto, 2006; Borza, et.al., 2015; Lampert & Rosso, 2015), because living in a
nursing home substantiates the feeling of being neglected by the family (Natan, 2008).
• It can decrease their health status, daily living ability,quality of life , and lead to a
reduction in cognitive abilities and an increase in mortality (Mansbach, Mace & Clark, 2015;
Meeks, Van Haitsma, Schoenbachler & Looney, 2015).
• Research findings describe that the risk
factors for depression in nursing
home residents are older age, poor physical health, cognitive
impairment, lower income, lack of care from the nursing home
staff, lack of social support and loneliness (Barca, Engedal, Laks & Selbaek,
2010; Jongenelis et al., 2004).
 Introduction (cont..)
• Numerous studies have examined depression in the general
community. However, studies of depression in the elderly who live in
Indonesian nursing homes have generally been small and limited.
• Yogyakarta is a province with around 11.81% of 3.5 million people
were elderly (BPS - Statistics Indonesia, 2010b) and places Yogyakarta as a province
with the highest of elderly population in Indonesia
However, the current data
(BPS - Statistics Indonesia, 2010a, 2010b).

regarding prevalence rates and risk factors related with

depression in NH residents in Yogyakarta is still limited.
RESEARCH GAP
1.Lack of knowledge pertaining the prevalence of
depressive elderly nursing home residents in
Yogyakarta, Indonesia.
2.Lack of information regarding the risk factors that
related with depression in NH residents in Yogyakarta,
Indonesia.

•
 Research Objectives
General Objective
• This study aimed to determine the prevalence rates of depression and
identify the risk factors associated with depression in elderly NH residents
in Yogyakarta province, Indonesia.
Specific Objective
• To describe demographics data of depressive elderly nursing home
residents in Yogyakarta, Indonesia
• To assess the health-related characteristics of depressive elderly nursing
home residents in Yogyakarta, Indonesia
• To assess the social support of depressive elderly nursing home residents in
Yogyakarta, Indonesia
• To analyze the association of demographics, health-related characteristics
and social support with depression.
Research Questions
1. What is the prevalence rates of depression in elderly NH
residents in Yogyakarta, Indonesia?
2. What are the risk factors that associated with depression in
elderly NH residents in Yogyakarta, Indonesia?
Research Hypothesis
• The prevalence rates of depression in elderly NH residents in
Yogyakarta province, Indonesia is still high
• The demographics data (age, gender, length of stay, marital status,
educational background, reason for living in NH), health-related
characteristics (physical illness), social support (family support,
financial support) , and perceived of care has correlation with
depression in elderly NH residents in Yogyakarta province, Indonesia
Conceptual Framework

Independent Variables Dependent Variables

Gender
Age
Marital status Prevalence rates
Education Level (Depression Level
Family support and mean scores)
Financial support
Physical illness
Length of stay
Reason for living in NH
Perceived of care
TERM OPERATIONAL DEFINITION
Depression A serious mental disorder with the sign and symptoms such as lack of interest and pleasure in
daily activities, significant weight loss or gain, insomnia or excessive sleeping, lack of energy,
inability to concentrate, feelings of worthlessness or excessive guilt and recurrent thoughts of
death or suicide (American Psychological Association (APA), 2016).

Depression The level of depression amongst elderly nursing home residents which derived from Geriatric
level Depression Scale 15-item (GDS) score; scores of 0-4 are considered normal; scores of 5-8 indicate
mild depression; scores of 9-11 indicate moderate depression; and scores of 12-15 indicate severe
depression (Sheikh JI & Yesavage JA, 1986).

Depression The mean scores of depression amongst elderly nursing home residents which derived from
mean scores Geriatric Depression Scale 15-item (GDS) score; scores are started from 0-15 (Sheikh JI & Yesavage
JA, 1986).
TERM OPERATIONAL DEFINITION
Elderly Older adults those aged 60 or above based on identification card, medical record or self-reported
(Badan Pengawasan Keuangan dan Pembangunan (BPKP), 1998; World Health Organization
(WHO), 2016a)
Nursing A place of elderly residents who require continual nursing care and have significant difficulty
home coping with the required activities of daily living.
 Research Methodology
• Study Design : A Cross Sectional Study
• Study Area
2 govern’ nursing homes (NH) in
Yogyakarta Province, Indonesia
1. Abiyoso Nursing Home (Sleman
District)
2. Budi Luhur Nursing Home (Bantul
District)
Study Site
Study Site (cont)
Research Methodology (cont)
• Study Period
• 27 February 2017 to 24 March 2017 as target (on progress)

• Study Population
• The elderly residents in two government nursing homes which
are located in Sleman and Bantul district of Yogyakarta Indonesia are
recruited in this study. Total population of elderly nursing home
residents in this study is 214 respondents. (88 in Budi Luhur NH; 126
in Abiyoso NH)
Sampling Technique

Total sampling was

used in this study, but
survey progress not
covered all of the
elderly NH residents
yet. So far 139
respondents already did
face-to-face interviews
one by one. 75
respondents remain to
be assessed.
Inclusion and Exclusion Criteria
Inclusion
1) Elderly who had to be 60 years
old or older
2) Both elderly who have or have no
physical illness
3) Elderly are living in the nursing
home for at least one month
4) Were able to communicate their
opinions meaningfully
impairment
5) Willing to participate
Exclusion
1) Have severe cognitive
impairment or dementia
2) Experiencing psychotic
disorders
3) Experiencing of alcohol/drug
misuse
4) Under antidepressants
medication treatment
Recruitment and Data Collection Procedures
Eligible (n = 2 nursing
Enrollment homes,
2 districts, 214 respondents)
1 province)
Excluded
 Have severe cognitive
impairment or dementia
 Experiencing psychotic
disorders
Total sampling (n = 2  Experiencing alcohol/drug
nursing homes, 2 misuse
districts, 139  Under antidepressants
respondents) treatment

Flow chart of recruitment studies setting and participant

 Data Collection Process
• Data collection process in this study will be carried out within 12 weeks, during 27
March to 16 June 2017:
• 1) Preparation and Database collection ; Asking the permission, GDS
score or depression level and quality of life level measurement will be noted as baseline
data. Information from medical record also will be collected to accomplish the baseline
data. This step is running now, started from 27 February 2017.
• 2) Implementation
• The intervention group ; Religiously intervention which is consisted of hearing the
Qur’anic recital in 36 sessions and combined with once a month lecture from religious
moslem leader which commonly called ustadz (male) or ustadzah (female). Both
intervention will be performed within 12 weeks. The qur’anic recital will be performed
in 30 minutes per session and the lecture related depression in Islamic perspective from
ustadzah will be performed in 20-30 minutes in each session. A 6236 verrses among 114
Surahs (Chapters) in the Qur’an will be choosen randomly as the qur’anic recital
intervention.
 Research Instrument
Part 1: Socio-demographics of respondents such as gender, age, marital status, education level,
family support, financial support, physical illness, length of stay in NH, reason for living in NH,
and perceived of care
Part 2: Depression level measurement will use a short form Geriatric Depression Scale (GDS)
which is consisted of 15 questions and has been tested and extensively used in community,
acute and long-term care settings with the older population (Sheikh JI & Yesavage JA, 1986).
The 15-item questionnaire in which participants are asked to respond by answering yes or no in
reference to how they felt over the past week. Of the 15 items, 10 indicated the presence of
depression when answered positively, while the rest (question numbers 1, 5, 7, 11, 13)
indicated depression when answered negatively. Scores of 0-4 are considered normal; 5-8
indicate mild depression; 9-11 indicate moderate depression; and 12-15 indicate severe
depression. The Short Form is more easily used by physically ill and mildly to moderately
demented patients who have short attention spans and/or feel easily fatigued. It takes about 5
to 7 minutes to complete.
Validity and Reliability
1. The Geriatric Depression Scale questionnaire
In a validation study comparing the Long and Short Forms of the
GDS for self-rating of symptoms of depression, both were successful in
differentiating depressed from non-depressed adults with a high
correlation (r = .84, p < .001) (Sheikh JI & Yesavage JA, 1986).
The GDS questionnaire in English version has been translated
into Bahasa Indonesia. Forward-translations and expert panel
back-translation has been conducted as the content validity
consideration for this used questionnaire, pre-testing to ensure the
GDS questionnaire in Bahasa Indonesia version will be done as well
before disseminating the final version within data collection period.
Data Analysis
SPSS 16.0 Version will be used
Descriptive statistic
Variables Measurement scales Statistical analysis
Socio-demographics: Descriptive statistics
1) Gender, marital status, Nominal and ordinal Frequency and percentage
education level, physical
illness, and reason for living
in NH, perceived of care Frequency, mean, median, SD,
2) Age, monthly income, Ratio minimum and maximum,
length of stay in NH. percentage
Depression score Interval Descriptive statistics
Frequency, mean, median, SD,
minimum and maximum,
percentage
Depression level Ordinal Descriptive statistics
Frequency, percentage
Inferential statistics
Variables Measurement Scale Statistical analysis

1) Independent: Dichotomous and continuous

- Gender, Age, Marital Status,
Educational level, physical illness,
Length of stay, reason for leaving Multiple linier regression
in NH, Perceived care
Continuous
2) Dependent:
- Depression Score
1) Independent: Dichotomous and continuous
- Gender, Age, Marital Status,
Educational level, physical illness,
Length of stay, reason for leaving
in NH, Perceived care Multiple logistic regression

2) Dependent: Dichotomous
- Depression Level
Ethical Consideration
The ethical approval were obtained from the Ethical Committee of
Research in the Medical Health Faculty of Medicine, Gadjah Mada
University, Indonesia. The purpose, benefits, data collection process,
and ethical issues in this study had confidentially informed to the
ethical committee. The permission were obtained from the local
governments and the nursing homes authority. The meeting with the
director of nursing homes and local staffs had performed in briefly
explanation pertaining this study purposes.
Results :Prevalence rates of depression was 36,7% (95% CI)
Characteristics of elderly NH residents
Characteristics n %
Age 60-69
70-79
≥80
Gender Male
Female
Length of Stay in NH ≤2 years
3-5 years
6-9 years
≥10 years
Marital status Single
Married
Widowed
Divorced
Education level No formal education
Elementary school
Junior high school
Senior high school
 Characteristics of elderly NH residents
Characteristics n %
Social support Spouse
Family
Healthcare workers
No one
Others
Type of support Psychological support
Financial support
No support
Physical illness None
1-2
3-4
≥5
Reason for living in NH Lonely
Less family care
No support income
Others
Perceived good care from NH Yes
staff No
Conclusions
• The prevalence rates of depression were still high
among elderly NH residents in Yogyakarta, Indonesia.
Alternative approach is needed to solve this particular
problem.
• To be continued…..
•Terima kasih
•Khop Khun Ma
Krub..