|  | Feature: “ICSEMIS Researchers Award” | No.56 May 2009 |
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Factors Underlying the Association Between Depressed Mood and Mobility Limitation in Customer-Oriented Counseling Study for Physical Activity in Older People M. Hirvensalo., R. Sakari-Rantala, R. Leinonen, M. Kallinen, T. Lintunen & T. Rantanen |
Introduction Developing effective interventions to increase physical activity and prevent disability of older adults is a public health priority (Ferrucci et al., 2004). People who are not yet disabled but are at risk of becoming disabled are probably the group that benefits more than others from exercise prescriptions tailored for their needs and abilities (Guralnik et al., 2003; King, Rejeski & Buchner, 1998). Among older people, difficulties in mobility are often the first noticeable signs of decline in functional ability, increasing the risk of further disability and the development of dependency (Guralnik et al., 2003). Depressed mood has been found to predict mobility limitation, a decline in physical performance and physical disability (Blazer, 2003; Prince et al., 1997). Also, disability and decreased functional abilities have been named as possible risk factors for depressive symptoms (Penninx et al., 1998). Factors underlying the association between depressed moods and deteriorating function have not been systematically studied. The information was needed in the physical activity intervention targeting on maintaining functional ability (Leinonen et al., 2007). The aim was to study the relationship between depressed mood and mobility limitation during an early phase of functional decline and to explore factors explaining this association in a community-living older population. Methods This article is based on the earlier publish article (Hirvensalo et al., 2007). The cross-sectional study used data from the baseline of an intervention study Screening and Counseling for Physical Activity and Mobility, SCAMOB (Leinonen et al., 2007), on the effects of exercise counseling on community-living, 75-81-year-old residents in the city centre of Jyväskylä, central Finland (N=1310). Cognitively intact older people who were able to walk at least 500 meters without assistance and whose physical activity level ranged from moderate to sedentary were eligible for this study. The eventual sample size was 657 persons, of whom 645 answered mobility questions and completed the depression questionnaire. Depressed mood was assessed using the Centre for Epidemiologic Studies Depression Scale (CES-D, cut-off score16, Radloff 1977); difficulty in walking 500-meters was assessed by self-report. Those reporting difficulty were categorised as having manifest mobility limitation. Those with no difficulty but reporting task modifications, such as reduced frequency of walking, were categorised as having preclinical mobility limitation. The association between depressed mood and mobility limitation was analysed using logistic regression analysis with gender, age, economic situation, the availability of a confidant, chronic conditions, and widespread pain as covariates. Results Depressed mood was found in 34% of subjects with manifest mobility limitation, in 26% of those with preclinical mobility limitation and in 13% of those without mobility limitation. The mean CES-D score was 13.7 among people with mobility limitation, 11.3 among those with preclinical mobility limitation and 8.5 among those without mobility limitation (p<0.001). The unadjusted OR for depressed mood was 3.43 (95% CI=2.04-5.76) among subjects with manifest mobility limitation and 2.38 (95% CI=1.52-3.73) among those with preclinical mobility limitation, compared to those without mobility limitation. Adjustment for covariates reduced the risks to 2.10 (95% CI=1.15-3.82) and 1.99 (95% CI=1.24-3.20), respectively. Widespread pain explained 28% of the increased risk of depressed mood among those with manifest mobility limitation. (Table 1.) Table 1. Odds ratios (OR, 95% CI) for depressed mood, after adjustment for confounding variables, according to mobility limitation category (those with no limitation as the reference group).
| Preclinical mobility limitation OR 95% CI | Manifest mobility limitation OR 95% CI
|  |  | Percentage reduction from basic model odds ratio % |  |  | Percentage reduction from basic model odds ratio %
Basic model* | 2.38 | 1.52-3.73 |  | 3.43 | 2.04-5.76 |
+Education† | 2.37 | 1.52-3.75 | - | 3.29 | 1.89-5.42 | 4
+Economic situation‡ | 2.40 | 1.53-3.76 | - | 3.28 | 1.94-5.54 | 4
+Number of chronic conditions§ | 2.27 | 1.44-3.59 | 5 | 3.11 | 1.76-5.47 | 9
+Availability of confidant|| | 2.13 | 1.34-3.38 | 11 | 2.93 | 1.71-5.01 | 16
+Widespread pain ¶ | 2.20 | 1.39-3.46 | 8 | 2.46 | 1.41-4.27 | 28
Fully adjusted model # | 1.99 | 1.24-3.20 | 16 | 2.10 | 1.15-3.82 | 39
* Basic model: adjusted for age and gender † Adjusted for basic model and education ‡ Adjusted for basic model, education, and economic situation § Adjusted for basic model and number of chronic conditions || Adjusted for basic model and availability of confidant ¶Adjusted for basic model and widespread pain #Fully adjusted model: adjusted for basic model, education, economic situation, availability of confidant, number of chronic conditions, and widespread pain Discussion The results suggest that mood disorders and limitations in walking may develop simultaneously, emphasising the need for early diagnosis in both conditions. The stage of preclinical mobility limitation and the increased CES-D score may serve as indicators for identifying older adults at risk of becoming disabled, both psychologically and physically. Adjustment for the expected covariates showed that the presence of widespread pain explained a substantial part of the association between depressed mood and manifest mobility limitation, suggesting that pain may be an underlying factor in depressed mood and mobility limitation. The importance of exploring the cause of the pain together with effective pain treatment is significant. Also, the availability of a confidant was strongly connected with the degree of depressed mood and mobility limitation. This association may reflect the contribution of mobility limitation to social isolation and loneliness which may cause mood disorders. There are many possible explanations for the reciprocal relationship between depressed mood and mobility limitations.Depression is associated with the inflammatory responses that influence chronic conditions such as cardiovascular diseases and arthritis and may cause frailty and functional decline (Dentino et al., 1999; Glaser et al., 2003) Also, depressed mood may cause behavioural changes originating in fatigue or lack of self-efficacy which are common feelings among depressed people. This begins to become apparent in the preclinical stage of mobility limitations, exemplified in the modification of tasks such as reducing the frequency of walking or a distance walked because of fatigue, but is also apparent in those with manifest mobility limitations. Persons with depressed mood may also be less active and their sedentary lifestyle may cause functional decline as functional tasks are practiced less often. Conclusion These results are important observations in trying to develop targeted interventions to manage functional decline and disability. References Ferrucci, L., Guralnik, J.M., Studenski, S, Fried, L.P., Cutler, Jr. G.B. & Walston, J.D. (2004). Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. Journal of the American Geriatrics Society, 52: 625–634. Guralnik, J.M., Leveille, S., Volpato, S., Marx, M.S. & Cohen-Mansfield J. (2003). Targeting high-risk older adults into exercise programs for disability prevention. Journal of Aging and Physical Activity, 11: 219–228. King, A.C., Rejeski, W.J., & Buchner, D.M. (1998). Physical activity interventions targeting older adults: a critical review and recommendations. American Journal of Preventive Medicine, 15: 316-333. Guralnik, J. M., Ferrucci, L., Simonsick, E. M., Salive, M. E. & Wallace, R. B. (1995). Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability. New England Journal of Medicine, 332, 556-561. Blazer, D. G. (2003). Depression in Late Life: Review and commentary. Journal of Gerontology: Medical Sciences, 58A, M249-265. Prince, M. J., Harwood, R. H., Blizard, R. A., Thomas, A. & Mann, A. H. (1997). Impairment, disability and handicap as risk factors for depression in older age. The Gospel Oak Project V. Psychological Medicine,27, 311-321. Penninx, B.W., Guralnik, J.M., Ferucci, L, Simonsick, E.M., Deeg, J.H. & Wallace, R.B. (1998). Depressive symptoms and physical decline in community-dwelling older persons. JAMA 279: 1720-6. Leinonen, R., Heikkinen, E., Hirvensalo, M., Lintunen, T., Rasinaho, M., Sakari-Rantala, R., Kallinen, M., Koski, J., Mottonen, S., Kannas, S., Huovinen, P. & Rantanen, T. (2007). Customer-oriented counseling for physical activity in older people: Study protocol and selected baseline results of a randomized-controlled trial (ISRCTN 07330512). Scandinavia Journal of Medicine and Science in Sports, 17, 156-164. Hirvensalo, M., Sakari-Rantala, R., Kallinen, M., Leinonen, R., Lintunen, T., Rasinaho, M. & Rantanen, T. (2007) Underlying factors for the association of depressed mood and mobility limitation in older people. Gerontology, 53:173-178. Radloff, LS. (1977). The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement, 1: 385-401. Dentino, A.N., Pieper, C.F., Rao, K.M.K., Currie, M.S., Harris, T., Blazer, D.G. &Cohen, H.J. (1999). Association of interleukin-6 and other biologic variables with depression in older people living in the community. Journal of the American Geriatrics Society, 47: 6-11. Glaser, R., Robles, T.F., Sheridan, J., Malarkey, W.B. & Kiecolt-Claser, J.K. (2003). Mild depressive symptoms are associated with amplified and prolonged inflammatory responses after influenza virus vaccination in older adults. Archives of General Psychiatry, 60: 1009-14. Contact Dr. Mirja Hirvensalo Faculty of Sports and Health Sciences University of Jyväskylä Jyväskylä , Finland Email: mirja.hirvensalo@jyu.fi icsspe.org/index.php?m=15 Factors Underlying the Association Between Depressed Mood and Mobility Limitation in Customer-Oriented Counseling Study for Physical Activity in Older People M. Hirvensalo., R. Sakari-Rantala, R. Leinonen, M. Kallinen, T. Lintunen & T. Rantanen