Depression and the quality of life among people of the third age

Depression is a widespread problem in third age (> 60 years old)� A considerable number of elderly people and their relatives fail to recognize the symptoms for a variety of reasons� The presence of depression increases the risk of death and has a negative effect on the life of the elderly� The relationship between depression and the quality of life has often been investigated over the past years� However, in Albania studies concerning third age are very scarce� Therefore the following literature review might contribute to a better understanding of the relationship between depression and the quality of life� The study also aims to identify other aspects or factors affected by this relationship, which in turn will help service providers to promote a better quality of life, identify risk factors leading to depression and implement treatment in due time� This literature review entails articles which meet established criteria and have as their object the quality of life, depression and third aged people� The studies under consideration are cross-sectional, longitudinal etc� Mental health has an impact on the physical health, while the reverse is also true� The elderly exhibiting depression symptoms have generally speaking a poorer quality of life as compared to those who do not experience depression� Also people having a low quality of life, due to factors such as social support and physical health, are more prone to develop depression� In conclusion, studies have found a link between the level of depression and the quality of life among the elderly�


Introduction
Individuals over 65 are currently classified as elderly. Aging is an inevitable process of any living organism and is associated with the reduction of organ system capacity reserves, the ability to adapt to environmental factors and the capacity to respond to stress and stressful situations.
Besides being an inevitable physiological process, aging is one of the main factors reducting the quality of life due to its chronological, biological, social and psychological dimensions. The high prevalence of chronic diseases and disabilities in the elderly, compared to any other age group, along with a limited social life on their part, leads to the reduction of the quality of life.
Quality of life is defined as the "individual's" perception of their position in life, in the context of the culture and value system they live in, as regards their goals, expectations, standards and concerns. Studies on life quality in relation to health have assessed the quality of life and report that it a multi dimensional concept, including physical functioning, social and psychological factors, life satisfaction, well-being, and awareness on the state of health. The physical functioning dimension includes daily life activities and effects of chronic illness (if present). The dimension of social functioning involves relationships with family members, friends and society. The dimension of psychological functioning includes emotional states such as depression, anxiety, fear, anger, and happiness.
Depression is one of the most frequent psychiatric disorders that affect third age. In studies conducted in different countries, the prevalence of depression in the elderly has been reported to reach up to 15%. Risk factors to depression in the elderly are not very different from those of the youngest population; however exposure to these factors varies with age. Being female, problems with physical health, neurotic characteristics of personality, a history of depression, living in elderly homes, inadequate life events, and lack of social support are significant risk factors for the development of depression in the elderly. Also, depression is often associated with an increased mortality risk and low treatment levels of physical health disorders. Thus, depression can negatively affect the quality of life. Several studies have investigated the relationship between depression symptoms and quality of life in the third age. This literature review can serve to better understand this relationship and to provide an overview to quantitative studies on this subject.

Methodology
As above mentioned, the purpose of this literature review is to understand the relationship between the quality of life and symptoms of depression in the elderly. The objectives of this paper are as follows: • Investigate the relationship between depression and quality of life • Understand factors that affect depression • Discuss the role that environmental factors have on the manifestation of depression and whether these factors affect the quality of life.
In addition to the objectives, a number of research questions have been built, which we aim to address as follows.
• What is the relationship between depression and quality of life?
• What are the factors that influence the appearance of depression symptoms and do these factors affect the quality of life? • Gender differences in psychosocial factors that lead to the onset of depression symptoms.
Keywords such as depression, quality of life, other elderly were used to select different studies. After finding a number of articles, several criteria were set to shortlist the studies that would be included in the literature review, namely: • Extracting studies from scientific websites such as MEDLINE, PubMED, PsychINFO, etc. • Quantitative studies • Studies involving individuals of the third age (≥60 years) • Studies that show which variables may lead to depression in the third age. • Studies that highlight the factors that affect the quality of life of the elderly. • Studies that have as their objective the quality of life, depression levels or the symptoms of depression in the elderly.

Third age
According to Erik Erikson, individuals develop throughout their lives. He was among the leading theorists in psychosocial theories, studying individuals to the end of their lives. According to him, individuals develop at certain stages, where they face certain conflicts, which the individual either successfully or unsuccessfully resolves. At this stage, individuals begin to think about death. This might also be due to life events such as retirement, spouse's death, change of dwelling place, and changes in social dynamics. At the final stage, the psychosocial task is Integrity against Despair. At this stage, questions on the meaning of life arise, what has been achieved, a reflection on lost or seized opportunities. Integrity to Erikson, refers to the feeling an individual experiences when s/he feels proud of their achievements and is pleased with them. With the experience of integrity, the individual feels little regret about things that could have been done. Having enough self-confidence, the integrity person appreciates the course of life and accepts the idea of closure, which makes death less frightening. Failure to accept and like oneself and the world regardless of the flaws leads to a tendency to depression. A person disposed to despair is not satisfied with his / her memories or self-image. S/he has an insufficient sense of belonging and has little time left to try again to mature or fulfill his / her desires. These people feel that they have misused their lives and experience much regret. They feel angry about those things they could not do in their lives while hoping they could turn back the time and be given a second opportunity.

Psychosocial factors affecting the onset or intensification of depression symptoms in the third age
Psychosocial variables that are most prevalent in the third age as compared to younger age groups can be characterized as newer stressors emerging or intensified at the third age. These may include: being widowed, living alone, illness, cognitive decline, financial difficulties / poverty and caring. Each of these variables increases at the third age, so we can observe if there are gender differences in these variables at the third age.

Being widowed/ living alone
Marital status and life style are the most studied variables regarding depression among the elderly. The data show that women are less likely to be married and more likely to be widowed compared to older males. Although the literature clearly states that older people who are married are less depressed than elderly people who are separated / widowed, there is little evidence whether there is a gender difference when it comes to marital status affecting depression.
Depressive symptoms are an expected reaction to loss, but if these symptoms persist for more than two months then they may indicate a depression disorder. Older people are more likely than younger ones to choose sorrow as the best way to adapt to loss (Torges, Steeeart & Nolen-Hoeksema, 2008). Compared to women, men are more likely to fall into depression after losing their spouse and being affected by it for a longer time. This may be due to the fact that the loss of a spouse can have different consequences for men and women, linked to the different roles they have in marriage: for widowed women, financial hardship is the first mediator to depressive symptoms, meanwhile for men housekeeping is the first mediator (Umberson, Wortman & Kessler, 1992).

Illness / poor physical health
Depression in sick patients usually leads to higher levels of inability and mordibity. For many physical ills, related experiences, such as the need to manage the disease, limited functions or pains resulting from illness, hearing or vision loss, may provoke the onset of depression. Depression on its part makes it more difficult to treat the disease.
Since physical health is measured in a number of ways: the number of chronic illnesses, the ability to perform everyday tasks, etc., gender differences can be observed in men and women. There are gender differences in the elderly, where women experience more chronic illnesses, demonstrate less ability to perform in day-to-day tasks, and in questionnaires self-report poorer health. In a study conducted by Noh et al. (2016), found that there was no difference in score regarding depression between males and females who had not been diagnosed with any disease. On the other hand, women who were diagnosed with at least one disease were more depressed than men who were diagnosed with at least one disease.

Cognitive decrease/ dementia
Studies concerning cognitive decline / dementia and depression in the elderly vary depending on other variables. In a study conducted by Geda et al., (2006), found that those who suffered from depression were more likely to develop mild cognitive impairment (MCI) or incidence of dementia with a stronger impact for those who did not have a prior history of depression.
Dementia can be a risk factor for depression as a result of psychological reactions to the congitive and behavioral changes associated with dementia. Since depression adds another burden to the quality of life of patients suffering from dementia (and their caregivers), it is very important to treat it.
Data on depression as a risk factor for the onset or a correlation of cognitive decline are mixed. In studies conducted by Sevick, Rolih and Pahor (2000), data on depression as a predictor or correlator of dementia or cognitive decline were mixed, and no gender differences were reported. In a meta-analysis by Jorm (2000), there was a small but significant link between a history of depression and the passing of dementia or cognitive decline within a period of less than a decade, but again there is no gender difference. In a study among individuals with dementia, elderly women with mild dementia have more depressive symptoms than older men with light dementia. However, it is not clear whether a history of depression is a risk factor for dementia or cognitive decline.

Financial hardship/ Poverty
Financial status is one of the most stressful events experienced by the elderly. Old people who are economically disadvantaged are more likely to experience depressive symptoms, due to exposure to chronic stressors, such as low income, exposure to unsafe and unprotected environment. Such issues can complicate treatment for low-income elderly people who suffer from depression. Moreover, socioeconomic disadvantages in early life may increase vulnerability to depression throughout life due to effects of poor nutrition, reduced educational opportunities, less access to healthcare, etc. All these disadvantages become more evident with time. Though financial difficulties and poverty are thought to be more prevalent in females than men, throughout their lives, however, few studies on depression indicate that women experience more financial difficulties and poverty than old men.

Care
Caring for other people is often a must among old people. Pinquart and Sorenson (2006) in a meta-analysis showed that women caregivers reported higher levels of depression symptoms compared to male caregivers. Moreover women reported higher levels of responsibility, more care hours, greater variety of caring tasks, and more personal care.

Problems with social support
Deficiencies in social support, the negative aspects of the social network, and even excessive social support have been studied as risk factors for the elderly, either when they are causes or effects of depression. In particular, problematic relationships can be a factor to explain depression in the third age, including marriage conflicts, perception of family criticism, and spouse's depression. Despite the fact that old people are less lonely than young or middle aged people, loneliness is associated with depression at this age. Social support that is perceived as unnecessary or excessive may be a risk factor for depression. Increasing the level of depression symptoms associated with receiving social support is found in the elderly with physical disabilities who have a great desire for independence.

Loneliness and quality of life
Despite the fact that females live 6-8 years longer than men, they have lower life quality. According to Kirchergast and Haslinger (2008), the low quality of life in old women comes as a result of social and behavioral factors. Old women may be widows, socially inactive, have income problems, and experience a series of health problems that make them feel unhappy with their lives.
Moreover, cultural habits and socio-economic factors can explain the effect of gender differences in the quality of life. Women in particular seem to experience more stress about their health, family and display low self-esteem. Also, the majority of old women cite that the inability to perform their daily tasks and pursue social activities limits their lives. On the other hand, it is known that women's body weakens faster than men's. Consequently, at the third age, they have more functional disabilities, health problems, dependence on others, and experience cognitive decline (e.g. Alzheimer) that make them feel miserable. In European countries the number of widowed women is higher than their male counterparts.
Being widowed produces a lot of negative feelings in a person: they feel stressed, frightened, worried. Moreover, the majority of widowed women become socially inactive and refuse to participate in activities. They note that their income is lower than their spouses' , which makes them feel dependent on their families.
Loneliness is another problem at the third age. Abuse is one of the many factors that affect it. Often, the elderly are forced to tolerate unpleasant behavior on the part of their family members because they fear ending up being alone in a time they will most need care.
Health problems are observed more among old women the men. Age-related disabilities impair their ability to perform daily activities independently. This lack of independence or autonomy deprives them from communication or pursuing activities outside the home; they feel that their life has no longer a meaning. The death of friends (a likelihood which increases with age) increases social isolation because it is very difficult at this age to make new friends. Their income mostly goes to buy medications. Due to such a lifestyle, the elderly are vulnerable to exhibit depression and spiritual degradation. Consequently, old women stand lower in the social ladder, either because of loss of the spouse or poor relationship with other family members. Loneliness grows even more over 75 years of age because of an increased prevalence of depression and being widowed.
So, the elderly who live near their family members have social support, exhibit better mental health and less solitude. All of these lead to a better quality of life.

Physical illness, depression and quality of life
Chronic pain seriously affects a person's daily activities and at the same time even the quality of their life. Chronic pain and psychological disorders are highly interrelated, affecting physical and psychosocial functioning. Various studies have shown that chronic pain is related to severe symptoms of depression. Moreover, factors such as economic disadvantage, medical complications are related to the low level of quality of life.
In a study by Akyol, Durmuş, Doğan, Beck, Cantürk (2010), the objective was to investigate the effects of overall health and personal characteristics on the quality of life of the elderly and to assess the relationship between the level of depression symptoms, pain intensity of quality of life. There was a negative correlation between quality of life, pain intensity and depression level. The presence of a chronic illness and poor education status reduced the quality of life and increased the level of depression in the elderly. The quality of life is negatively affected by the level of depression and intensity of pain. However, a number of studies have focused on being widowed as a life event that affects third age.

Studies that link depression to the quality of life
The study conducted by Cao et al., (2016) aimed to look at the relationship between life quality and depression. The study included 1168 Chinese elderly. The findings of this study showed that the highest scores in terms of life quality dimensions concerned social support, followed by the environment, physical health and psychological health. Results showed that there was a negative correlation between physical health, the environment and depression in elderly people. Those who suffered from depression were older, less educated, had lower monthly incomes and were likely to report insomnia. All dimensions of the questionnaire on life quality, except for the social dimension, had a negative correlation with depression.
In their study in Portugal, Becker et al., (2018), identified the link between depression and life quality, but in this case the effect of sleep quality served as a mediator variable. The study showed that the elderly who had 6-9 hours of sleep had a better cognitive functioning, lower levels of physical and mental illness and better quality of life compared to those who slept less or more.
The study conducted by Demura & Sato (2003) had as its objective the analysis of the relationship between depression life quality characteristics of elderly living in community and compare them later by gender and age. 1302 people participated. The results of the study showed that the characteristics of depression in the elderly differed according to age groups and gender. Depression was higher among those who were advanced in age compared to those who were about to enter adult age and was higher among very old women. The main factors associated with the elderly who lived in the community were the number of friends and spirits. In particular, the increase in the number of friends was associated with reduced depression.
The study conducted by Diefenbach, Tolin, Gilliam intended to look at the symptoms of depression and quality of life in the elderly who received homebased home care services through home care programs. The study involved 66 elderly. They suffered from chronic diseases and needed home care. The results of the study showed that the link between depression symptoms and impairment of life quality dimensions was quite strong and widespread. Symptoms of depression were almost linked to damages of life quality in all dimensions.
Halvorsrud L, Kirkevold M, Diseth A, Kalfoss M. (2010) aimed at looking how symptoms of depression, physical function, health satisfaction, age and environmental conditions affect the quality of life based on Wilson and Cleary's model. The study conducted in Norway stratified the population by age, gender and living area. The results showed that the quality of life is directly dependent on environmental conditions and health satisfaction. In addition, environmental conditions indirectly affect the quality of life, mainly through symptoms of depression that the elderly display. Xiao, YoungYoon, Bowers (2015), in their study aimed to show how way the elderly organized their lives (the comparison between elderly people living in homes vs. those living in elderly homes) had a direct effect on the quality of life of the elderly and if daily activities and depression have an indirect effect on the relationship between the way of life's organization and quality of life. Psychological factors have been identified as very important in the quality of life of elderly people who live in their homes (Baernholdt et al., 2012;Wicke et al., 2014), namely on psychological factors, depression causes poor quality of life due to low levels of social engagement and behavioral and verbal concerns (Dow, Lin, Tinney, Haralambous, & Ames, 2011). Differences in the link between the way of life organization and depression have always been shown. For example, a previous study reported that elderly people who had cognitive impairments and lived at home were less depressed compared to those who lived in elderly institutions (Nikmat et al., 2015). In contrast, another study showed that those living at homes and communities experienced more depression than those who lived in elderly homes (Chung, 2008). The findings of this study showed that individuals living in community reported better daily activity and less depression, which are related to a better quality of life compared to those who lived in the homes of the elderly. These data suggest that elderly homes themselves do not bring about low life quality, but mediating factors, daily activities and depression have a significant impact on the quality of life.
Treating depression symptoms can lead to life improvement. The study conducted by Wang, Tzeng, Chung (2014), focused on the effects of group psychotherapy on symptoms of depression and quality of life in the elderly, who live in elderly homes. Therapy was conducted once a week for 8 weeks among 96 elderly in Japan. The results of this intervention showed that depression was significantly reduced for the group who had participated in the therapy compared to the control group. Also, data analysis showed significant differences in social and psychological dimensions, but not physical and environmental ones.

Religion and quality of life
A large number of studies have shown that religion is positively associated with mental health and well being at the third age (Ardelt, 2003;Koenig, McCullough, & Larson, 2001;Nelson-Becker, 2005). Various studies have pointed out that high levels of religious inclusion predict a greater satisfaction in the lives of third-aged people (Moberg, 2008, Roh, 2010. As mentioned above, social support is very important. Studies have shown that social support is also positively linked to life satisfaction in the third age (Roh, 2010;Yoon & Lee, 2007). Social support is not only a predictor of life satisfaction in the elderly (George, 2006) but has been found to be a positive result of faith in the elderly (S.J. Jang & Johnson, 2004, E. O. Lee & Sharpe, 2007. The study conducted by Park, Roh, and Yeo, (2011) among old Korean emigrants in America aimed to find out whether strong religious faith was positively related to a greater life satisfaction and whether the relationship between them was mediated by social support. Results showed that strong religious beliefs are associated with greater enjoyment of life and that social support partly explains the relationship between religion and life satisfaction. These data may indicate that religious involvement and social support can be important factors to improve the quality of life of the elderly.
One of the dimensions of life quality measurement is social support and in the elderly it is seen as an indicator of their well-being. On the other hand depression is one of the major problems in the third age. The spiritual and religious part also serves as a strategy to cope with the various losses that the elderly experience during their lives (González-Celis, 2012a; González-Celis & Araujo, 2010). Following their previous study, Gonzales-Celis, Gómez-Benito (2013), conducted a study among the elderly in Mexico, which aimed at assessing whether social support and spirituality are indicators of life quality in the elderly and investigate their effects on depression. Individuals with higher levels of depression had poorer life quality and vice versa. There was also no change in the quality of life depending on the type of depression. There was no meaningful connection between scores in the dimension of spirituality and participation in a religious group. It was noted that individuals who participated in a group had higher scores in the dimension of spirituality, which means that affiliation in a group helps increase spirituality level, which in turn can affect the quality of life of people.
Regarding spirituality and quality of life, we can say that spirituality can be a defensive factor when used as a source to fight depression symptoms. In this way the quality of life of the elderly can be improved through psychological interventions to reduce the presence of depression symptoms. Spirituality can also be used as a source, as well as a coping strategy to strengthen other aging fields.

Conclusions
At the end of this literature review, what we can say is that there is a negative relationship between depression and quality of life. Severe depression symptoms are associated with a poor quality of life and this relationship seems to remain stable over time. Depressed people have a poorer quality of life than those who do not suffer from depression. Based on past studies, an improvement in quality of life has been observed in people who have fully or partially recovered compared to those who have a persistent depression. Elderly people who had two or more physical illnesses had a poorer quality of life compared to people with fewer physical disabilities. In general, life quality dimensions were negatively affected by depression or symptoms of depression.