International Journal of Gerontology 10 (2016) 81e85

Contents lists available at ScienceDirect

International Journal of Gerontology

journal homepage: www.ijge-online.com

Original Article

Prevalence and Determinants of Depressive Disorders among

Community-dwelling Older Adults: Findings from the Towards Useful
Aging Study*
Divya Vanoh 1, Suzana Shahar 1 *, Hanis Mastura Yahya 2, Tengku Aizan Hamid 3
1
Dietetics Programme, 2 Nutrition Programme, School of Healthcare Sciences, Faculty of Health Sciences, University Kebangsaan Malaysia, Kuala Lumpur,
3
Malaysian Research Institute on Ageing, University Putra Malaysia, Serdang, Selangor, Malaysia

a r t i c l e i n f o s u m m a r y

Article history: Background: Geriatric depressive disorders affect the physical and emotional well-being of older adults.
Received 14 August 2015 Therefore, this study aims to identify the prevalence of geriatric depressive disorders and their risk
Received in revised form factors in a large-scale study comprising community-dwelling older adults in Malaysia.
5 January 2016
Methods: A total of 2264 older adults consisting of 1083 (47.8%) men and 1181 (52.2%) women were
Accepted 3 February 2016
Available online 11 June 2016
recruited in this study. An interview-based questionnaire was used to obtain information on socio-
demography, presence of comorbidities, nutritional status, dietary habits, lifestyle, practice of calorie
restriction, cognitive function, social support, and psychosocial aspects. Geriatric depressive disorder was
Keywords:
calorie restriction,
confirmed if a participant obtained a score of 5 or more in the Geriatric Depressive Scale.
education, Results: The prevalence of depressive symptoms is 16.5%, and it is higher in women (56.6%) than in men
geriatric depressive disorders, (43.4%). Individuals who are at a higher risk of depressive disorders are most likely to be less educated
neurotic disorder and to have neurotic disorder, a lower score of instrumental activities of daily living , poor fitness level,
hypertension, and osteoarthritis.
Conclusion: Depression affects 16.5% of Malaysian older adults and is associated with factors such as
sociodemography, comorbidities, psychosocial function, calorie restriction, physical function, and fitness.
There is a need to screen and treat depressive symptoms to prevent their progression to severe mental
health problems.
Copyright © 2016, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier
Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction Geriatric depressive disorder is a serious public health prob-

lem worldwide, as it contributes to increased health care cost and
The prevalence of geriatric depressive disorders in Asian coun- mortality6. Systematic reviews have identified several risk factors
tries is in the range of 12e34% and that in Sri Lanka, Indonesia, of geriatric depressive disorders, including gender, functional
Japan, Vietnam, Indian and Malaysia is 27.8%, 33.8%, 30.3%, 17.2%, limitations, low education level, poor social support, lack of
12.7% and 27.8% respectively1e4. In Malaysia, Sherina et al5 have religious practice, chronic diseases, loneliness, and personality
compared the levels of geriatric depressive disorders among the abnormalities7,8.
urban and rural elderly, and the findings have revealed that the The risk of geriatric depressive disorders is greatly reduced with
rural elderly (7.6%) tend to be more depressed than the urban religious practice. Muslim elderly who practice occasional calorie
elderly (6.3%). restriction (omitting foods and drinks every Mondays and Thurs-
days) have gained numerous health benefits9. Hence, this current
study aims to determine the efficacy of a 1-month practice of
*
Conflicts of interest: The authors declared that they have no conflicts of interest. religious calorie restriction toward reducing the risk of geriatric
* Correspondence to: Dr Suzana Shahar, Dietetics Programme, School of depressive disorders. Meanwhile, the study by Ibrahim et al10
Healthcare Sciences, Faculty of Health Sciences, University Kebangsaan Malaysia, among older adults residing in government-aided settlement
Jalan Raja Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia.
known as Federal Land Development Authority (FELDA), has shown
E-mail address: suzana.shahar@ukm.edu.my (S. Shahar).

http://dx.doi.org/10.1016/j.ijge.2016.02.001
1873-9598/Copyright © 2016, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
82 D. Vanoh et al.

that information and emotional support lower the risk of geriatric (CMS Weighing Equipment, London, United Kingdom) was used to
depressive symptoms, which is essential for psychological well- measure height. Body mass index was calculated using the World
being. Health Organization formula of body weight (in kilograms) divided
This study aims to screen community-dwelling Malaysian older by square of standing height (in meters)22.
adults for the presence of geriatric depressive disorders and asso- Dietary pattern was assessed using open-ended questions that
ciated risk factors using a wide range of parameters. This study has focused on the frequency of intake of fresh fruits, 100% fruit juices,
obtained permission from local authorities and ethical approval and vegetables. Respondents were asked of their practice of occa-
from the Medical Research Secretariat Ethics Committee of Uni- sional calorie restriction due to religious practice (this included
versity Kebangsaan Malaysia. omitting food but allowing drinks, omitting animal-based food, or
avoidance of both food and drinks for a specified duration of the
2. Materials and methods day) for the past 1 month.
Lifestyle questionnaire was adapted from the Victoria Longitu-
2.1. Study population dinal StudydActivity Lifestyle Questionnaire23. The Victoria Lon-
gitudinal StudydActivity Lifestyle Questionnaire focused on
This large-scale study was part of the “Towards Useful Aging” physical, social, and mental lifestyle activities. The original 70-item
longitudinal study, the methodology of which was described else- questionnaire had been simplified to a 26-item questionnaire for
where (Suzana et al 2015, accepted for publication)11. The multi- the purpose of this current study, and it had reliability of 0.66.
stage random sampling method was used. Maps of living quarters,
and name and address of individuals residing in the randomly
2.3. Statistical analysis
selected living quarters were provided by the Department of Sta-
tistics. The inclusion criteria for this study were older adults aged
Statistical Package for Social Sciences (SPSS) software version
60 years and above without dementia and no severe mental ill-
20.0 (IBM Corporation, Armonk, New York, USA) was used to
nesses. Eligible participants were given a brief description of the
analyze the collected data. The association between GDS categories
study, and written consent was obtained from them. Data were
and categorical variables was determined using Pearson chi-square
collected by several trained enumerators from May 2012 till
test. Independent t test was employed to explore the relationship
February 2013.
between GDS categories with continuous variables. Risk factors for
the symptoms of geriatric depression were identified using binary
2.2. Research tools
logistic regression with GDS categories as dependent variable
(without depressive disordersdreference group and with depres-
An interview-based approach was used using questionnaires.
sive disorders). Adjusted odd ratio was obtained by controlling the
The questionnaires used in this study were validated and
influence of several confounding variables such as age, income,
comprised several sections, namely, sociodemography, health sta-
gender, alcohol, and living arrangement. The significance value was
tus, fitness, psychosocial factor, functional status, anthropometry,
set at p < 0.05.
lifestyle, dietary pattern, and practice of calorie restriction.
Sociodemographic characteristics included age, gender, religion,
marital status, education level, total monthly income, total house- 3. Results
hold income, and living arrangement (living alone or with spouse,
children, relatives, or friends). Furthermore, information on health The prevalence of geriatric depressive disorders in this study
status was obtained by asking respondents whether they were was 16.5%, with 15% in men and 17.9% in women. Individuals with
suffering from several common chronic diseases such as diabetes depressive disorders were older (69.8 ± 6.4 years old), and had
mellitus, hypertension, hypercholesterolemia, heart diseases, lower household income (MYR 1018.38 ± 136.49) and lower edu-
osteoarthritis, and cataract or glaucoma. cation levels (3.9 ± 3.6 years old) (p < 0.05). Hypertension (57.9%),
A 15-item geriatric depression scale (GDS) with a reliability of osteoarthritis (34.0%), and swallowing problems (8.3%) were more
0.81 was used to assess the level of depressive disorders among prevalent in respondents with depressive disorders than in those
older adults. A score of
5 indicated a high risk of suffering from free of depressive symptoms, as shown in Table 1 (p < 0.05).
depressive disorder12. Functional status was measured using ac- Table 2 shows that respondents without depressive disorders
tivities of daily living13 and instrumental activities of daily living had better performance in Mini Mental State Examination
(IADL)14. (23.0 ± 4.8), Rey Auditory Verbal Learning Test (26.3 ± 12.2), and
The Medical Outcome Study Social Support (MOSS) survey, the entire fitness test administered, compared to those with
which had reliability of 0.84, was used for assessing social sup- depressive disorders (p < 0.05). The IADL score was lower among
port15. Neurotic disorder was identified using neuroticism subscale individuals with depressive disorders (11.7 ± 2.9) compared with
of the Eysenck Personality Questionnaire (EPQ) with reliability of their counterparts (12.5 ± 2.3). Furthermore, MOSS scores were
0.7216. Meanwhile, loneliness was assessed using a “three-item higher among individuals without depressive symptoms
loneliness scale” and it had reliability of 0.7217. Perceived Stress (40.04 ± 14.7), and this group had further demonstrated a lower
Scale, which had reliability of 0.72, was used to assess the score in EPQ-Neuroticism (1.96 ± 2.8), loneliness (3.25 ± 0.9), and
perception of stress18. perceived stress scale (3.06 ± 3.0) (p < 0.05).
Cognitive status was assessed using several test batteries. Global Moreover, alcohol intake was higher among individuals with
function was measured using the Malay version of Mini Mental depressive disorders (5.9%) compared with those without depres-
State Examination with good reliability (more than 0.70)19. The Rey sive disorders (3.6%; p < 0.05; Table 2). People without depressive
Auditory Verbal Learning Test was conducted to assess verbal disorders had more frequent consumption of fruits (3.8 ± 2.5 d/wk)
memory20. The Digit Span Test, which consisted of Digit Span For- and vegetables (5.8 ± 2.1 d/wk) compared with those with
ward and Backward, was used for measuring attention and working depressive disorders (3.5 ± 2.5 d/wk for fruits and 5.5 ± 2.1 d/wk for
memory21. vegetables). In addition, practice of calorie restriction was more
Body weight was obtained using a digital weighing scale (Tanita common among older adults without depressive disorders (48.1%)
Corporation of America, Illinois, USA). Leicester Height Measure than among those with depressive symptoms (only 38.1%; Table 2).
Predictors of Depressive Disorders among Older Adults 83

Table 1 Table 2
Sociodemographic and health status according to depressive disorders. Nutritional, fitness, functional, cognitive, psychosocial, dietary, smoking and alco-
holic status of participants according to depressive disorders.
Characteristic Without depressive With depressive
disorders (n ¼ 1891) disorders Characteristic Without depressive With depressive
(n ¼ 373) disorders disorders
(n ¼ 1891) (n ¼ 373)
Religion
Muslim 1232 (65.2) 192 (51.5) Weight (kg) 60.9 ± 12.3 60.3 ± 12.2
Christian 78 (4.1) 15 (4.0) Height, m (mean ± SD) 1.56 ± 0.1 1.56 ± 0.1
Buddhist 467 (24.7) 141 (37.8) Waist circumference (cm) 88.3 ± 11.3 88.0 ± 11.0
Hindu 77 (4.1) 15 (4.0) Hip circumference (cm) 96.5 ± 9.5 96.7 ± 9.8
Others 37 (2.0) 10 (2.7) Calf circumference (cm) 33.3 ± 3.8 33.3 ± 3.9
Marital status Mid upper arm circumference (cm) 28.4 ± 3.5 28.4 ± 3.6
Single 30 (1.6) 8 (2.1) BMI category
Married 1303 (68.9) 250 (67.0) Underweight 94 (5.0) 22 (5.9)
Divorced 28 (1.5) 10 (2.7) Normal 880 (46.5) 175 (46.9)
Widow/widower 530 (28.0) 105 (28.2) Overweight 646 (34.2) 128 (34.3)
Age (y) 68.9 ± 6.2 69.8 ± 6.4* Obese 271 (14.3) 48 (12.9)
Education level (y) 5.4 ± 4.0 3.9 ± 3.6** Fitness
Household income (MYR) 1317.70 ± 2532.99 1018.38 ± 1361.49** 2 min step test (steps) 62.0 ± 25.2 52.7 ± 28.1***
Total monthly income (MYR) 828.87 ± 1867.97 573.48 ± 624.00** Hand grip (kg) 23.3 ± 7.7 21.7 ± 8.2***
Living arrangement Chair stand test (stand) 10.0 ± 3.1 9.6 ± 3.3**
Alone 191 (10.1) 44 (11.8) Chair sit and reach (cm) 0.8 ± 11.3 5.4 ± 13.7***
With others 1700 (89.9) 329 (88.2) Time up and go (s) 10.9 ± 3.2 11.7 ± 3.7***
Hours of sleep/d 6.4 ± 1.50 6.7 ± 1.50** Back scratch test (cm) 14.7 ± 13.2 17.9 ± 14.4***
Health status Functional status
Diabetes mellitus IADL 12.5 ± 2.3 11.7 ± 2.9***
Yes 492 (26.0) 100 (26.8) ADL 6.0 ± 0.4 6.0 ± 0.4
No 1399 (74.0) 273 (73.2) Cognitive
Hypercholesterolemia MMSE 23.0 ± 4.8 21.8 ± 5.3***
Yes 563 (29.8) 121 (32.4) Total score RAVLT 26.3 ± 12.2 23.9 ± 11.7**
No 1328 (70.2) 252 (67.6) Digit span 7.6 ± 2.4 7.6 ± 2.5
High blood pressure/hypertension Personality (EPQ-Neuroticism) 1.96 ± 2.8 2.90 ± 3.7***
Yes 925 (48.9) 216 (57.9)** Loneliness 3.25 ± 0.9 3.39 ± 1.1*
No 966 (51.1) 157 (42.1) MOSS survey support 40.04 ± 14.7 37.04 ± 14.9***
Heart disease Perceived stress scale 3.06 ± 3.0 3.68 ± 3.2***
Yes 166 (9.7) 48 (14.5) Dietary habit
No 1542 (90.3) 283 (85.5) Vegetable intake(d/wk) 5.8 ± 2.1 5.5 ± 2.4*
Cataract/glaucoma Fruit intake (d/wk) 3.8 ± 2.5 3.5 ± 2.5*
Yes 171 (9.0) 45 (12.1) Fresh fruit juice (d/wk) 0.5 ± 1.3 0.5 ± 1.2
No 1720 (91.0) 328 (87.9) Do you practice calorie restriction?
Swallowing problem Yes 895 (48.1) 138 (38.1)*
Yes 100 (5.3) 31 (8.3)* No 966 (51.9) 224 (61.9)
No 1791 (94.7) 342 (91.7) Smoking status
Osteoarthritis Smoker 321 (17.0) 62 (16.6)
Yes 437 (23.1) 127 (34.0)** Ex-smoker 241 (12.7) 45 (12.1)
No 1454 (76.9) 246 (66.0) Nonsmoker 1329 (70.3) 266 (71.3)
Alcohol
Data are presented as n (%) or mean ± SD.
Yes 69 (3.6) 22 (5.9)*
Pearson chi-square test is employed for categorical variables and independent t test
No 1822 (96.4) 351 (94.1)
for continuous variables.
* p < 0.05. Data are presented as mean ± SD or n (%).
** p < 0.001. Pearson chi-square test is employed for categorical variables and independent t test
MYR ¼ Malaysian ringgit (currency of Malaysia); SD ¼ standard deviation. for continuous variables.
* p < 0.05.
** p < 0.01.
*** p < 0.001.
Table 3 shows participation of individuals in physical, mental, ADL ¼ activities of daily living; BMI ¼ body mass index; EPQ ¼ Eysenck Personality
and social lifestyle activities. Poor participation in physical activ- Questionnaire; IADL ¼ instrumental activities of daily living; MMSE ¼ Mini Mental
ities such as gardening (56.1%) and exercising (65.1%) are signifi- State Examination; MOSS ¼ Medical Outcome Study Social Support; RAVLT ¼ Rey
cantly higher among individuals with depressive disorders. People Auditory Verbal Learning Test; SD ¼ standard deviation.
without depressive disorders actively attend religious classes
(58.0%) compared with their counterparts (43.1%). Reading is also
more common among older adults without depressive symptoms by a higher EPQ score (adjusted OR 1.10, 95% CI 1.03e1.14, p < 0.001)
(81.2%) than in those with depressive symptoms (63.5%). are the predictors of geriatric depressive symptoms in this study,
Binary logistic regression has revealed that higher education after being adjusted for age, gender, monthly income, alcohol
level [adjusted odds ratio (OR) 0.91, 95% confidence interval (CI) intake, and living arrangement (Table 4).
0.87e0.95, p < 0.001] and good functional status as indicated by a
higher IADL score (adjusted OR 0.92, 95% CI 0.87e0.98, p < 0.01) 4. Discussion
lower the risk of geriatric depressive symptoms. Meanwhile,
limited practice of calorie restriction (adjusted OR 1.39, 95% CI The prevalence of geriatric depressive disorder obtained from
1.06e1.82, p < 0.05), poor lower body flexibility as indicated by a this large-scale cross sectional study, which has been conducted
higher score in the chair sit and reach test (adjusted OR 1.03, 95% CI across four states in Malaysia, is 16.5%. Findings from the European
1.02e1.04, p < 0.001), hypertension (adjusted OR 1.32, 95% CI population-based study (EURODEP) study showed a rate of 11.9% in
1.02e1.71, p < 0.05), osteoarthritis (adjusted OR 1.57, 95% CI Dublin, 12.0% in Amsterdam, 16.5% in Berlin, 17.3% in London, and
1.19e2.06, p < 0.01), and presence of neurotic disorder as indicated 18.3% in Verona24. Variations in the prevalence of depressive
84 D. Vanoh et al.

Table 3 Environmental changes and use of assistive devices will be able to

Participation in physical, mental, and social lifestyle activities. improve functional status via better IADL performance, which will
Parametera Without depressive With depressive reduce the risk of depression1. Dunlop et al25 and Chong et al26
disorders (n ¼ 1891) disorders (n ¼ 373) have reported that the risk of depressive disorders among older
Physical domain adults is higher if functional limitations are burdened with chronic
Gardening diseases.
Not active 873 (46.5) 206 (56.1)** The novel finding of this current study is the protective effect of
Active 1003 (53.5) 161 (43.9)
calorie restriction toward geriatric depressive disorders. This is in
Exercise
Not active 1112 (59.3) 239 (65.1)* agreement with the findings by Nur Islami et al9, which have
Active 764 (40.7) 128 (34.9) demonstrated that elderly Muslim people who frequently practice
Housework calorie restriction have significant decrease in depressive disorders,
Not active 417 (22.2) 94 (18.4)
body weight, fat mass, and body mass index. Calorie restriction in
Active 1459 (77.8) 273 (74.4)
Mental domain
the form of fasting has a close relationship with better spiritual and
Brain games emotional well-being27,28. Findings of the study by Braam et al29
Not active 1823 (97.2) 358 (97.5) have shown that European elderly who are devoted to religious
Active 53 (2.8) 9 (2.5) practices experienced less depressive disorders.
Reading
Furthermore, lower education plays an important role in late-
Not active 353 (18.8) 134 (36.5)***
Active 1523 (81.2) 233 (63.5) life depressive disorders, and it is very closely associated with
TV viewing poor socioeconomic background. Older adults with a lower edu-
Not active 138 (7.4) 29 (7.9) cation level tend to earn less than their highly educated counter-
Active 1738 (92.6) 338 (92.1) parts. Education-related financial problems are often risk factors for
Using modern gadgets
Not active 1758 (93.7) 352 (95.9)
geriatric depressive disorders30.
Active 118 (6.3) 15 (4.1) Chronic diseases such as hypertension and osteoarthritis have
Furthering studies/being involved in share market significant association with geriatric depressive disorders. Luch-
Not active 1841 (98.1) 366 (99.7)* singer et al31 have found an increased risk of depressive symptoms
Active 35 (1.9) 1 (0.3)
among elderly with hypertension. Cerebrovascular diseases
Social domain
Eating out including hypertension cause disruption of basal gangliaefrontal
Not active 1060 (56.5) 215 (58.6) cortical circuits, which may lead to depression32. Besides that, the
Active 816 (43.5) 152 (41.4) current study has also found that osteoarthritis is one of the risk
Visiting friends/relatives factors of depression. This is in parallel with the study by Hawker
Not active 1243 (66.3) 246 (67.0)
Active 633 (33.7) 121 (33.0)
et al33, which revealed that chronic pain due to osteoarthritis leads
Religious class to fatigue and disability, and finally causes depressed mood.
Not active 787 (42.0) 209 (56.9)*** Findings from the current study suggest that personality-related
Active 1089 (58.0) 158 (43.1) disorders, as indicated by a higher EPQ score, are among the risk
Shopping
factors for geriatric depressive disorders. Neurotic symptoms such
Not active 827 (44.1) 175 (47.7)
Active 1049 (55.9) 192 (52.3) as irritability, moody behavior, and impulsiveness are very closely
Joining voluntary activities linked to geriatric depressive disorders34. Mayberg35 has hypoth-
Not active 1736 (92.5) 347 (94.6) esized a biological association between neuroticism and geriatric
Active 140 (7.5) 20 (5.4) depressive disorders. Neuroticism is predicted to affect the region
Data are presented as n (%). of brain responsible for modulation of the affectiveecognitive
* p < 0.05, significant using Pearson chi-square. domain of depression, which results in poor mood regulation.
** p < 0.01, significant using Pearson chi-square.
This current study has several strengths. This is a large-scale
*** p < 0.001, significant using Pearson chi-square.
a
Only 13 out of 26 activities are mentioned in this table. study involving a wide range of parameters covering several do-
mains such as fitness, cognitive function, anthropometry, body
composition, dietary pattern, psychosocial function, religious
disorders are widely attributed to the differences in the study practice, and lifestyle. Conversely, the limitation of this study is that
methodology, culture, and socioeconomic background. it included only four states among 14 states in Malaysia. Future
In addition, functional status is one of the predictors that have large-scale studies should consider involving more states to obtain
significant association with geriatric depressive disorders. precise results representing the older adult population in Malaysia.

Table 4
Determinants of geriatric depressive disorders.

Variables B Adj. OR 95% CI Wald (df) p

Education level e0.10 0.91 0.87e0.95 21.54 (1) <0.001

Calorie restriction 0.33 1.39 1.06e1.82 5.83 (1) 0.016
Poor fitness (score from chair sit and reach test) 0.03 1.03 1.02e1.04 22.12 (1) <0.001
Having hypertension 0.28 1.32 1.02e1.71 4.51 (1) 0.034
Having osteoarthritis 0.45 1.57 1.19e2.06 10.41 (1) 0.001
IADL score e0.09 0.92 0.87e0.98 7.78 (1) 0.005
Neuroticism (EPQ) 0.09 1.10 1.03e1.14 21.63 (1) <0.001
MOSS score e0.01 1.00 0.99e1.00 1.49 (1) 0.222
Loneliness e0.00 1.00 0.88e1.14 0.00 (1) 0.971
Exercise 0.17 1.19 0.90e1.56 1.52 (1) 0.217

Adj. OR ¼ adjusted odds ratio; B ¼ logistic regression coefficients; CI ¼ confidence interval; df ¼ degree of freedom; EPQ ¼ Eysenck Personality Questionnaire;
IADL ¼ instrumental activities of daily living; MOSS ¼ Medical Outcome Study Social Support.
Predictors of Depressive Disorders among Older Adults 85

5. Conclusion among Malaysian Older Adults. Aging Clin Exp Res. 2015. http://dx.doi.org/
10.1007/s40520-015-0511-4.
12. Suzana S, Junaidah H, Vatana VS, et al. Determinants of depression and
About 16.5% of elderly involved in this large-scale study have insomnia among institutionalized elderly people in Malaysia. Asian J Psychiatr.
geriatric depressive disorder. Geriatric depressive disorder is 2011;4:188e195.
closely related to lower education level, poor fitness level, func- 13. Katz S, Ford AB, Moskowitz RW, et al. Studies of illness in the aged, the index of
ADL: a standardized measure of biological and psychosocial function. J Am
tional limitations, neurotic disorder, and chronic diseases such as Geriatr Soc. 1963;37:267e271.
hypertension and osteoarthritis. Calorie restriction due to religious 14. Lawton MP, Brody EM. Assessment of older people: self-maintaining and
practice has been proven to be protective against depressive dis- instrumental activities of daily living. Gerontologist. 1969;9:179e186.
15. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med.
orders. Healthy older adults are recommended to practice occa- 1991;32:705e714.
sional calorie restriction for better physical and mental health. 16. Eysenck HJ, Eysenck SBG. Manual of the Eysenck Personality Questionnaire (Adult
Depressive disorders among elderly must be diagnosed earlier, and and Junior). London: Hodder & Stoughton; 1982.
17. Hughes ME, Waite LJ, Hawkley LC, et al. A short scale for measuring loneliness
proper treatment should be given to increase quality of life and in large surveys. Res Aging. 2004;26:655e672.
prevent mental health deterioration. 18. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress.
J Health Soc Behav. 1983;24:385e396.
19. Ibrahim N, Shohaimi S, Heng-Thay C, et al. Validation study of the Mini-Mental
Acknowledgments State Examination in a Malay-speaking elderly population in Malaysia. Dement
Geriatr Cogn Disord. 2009;27:247e253.
We would like to thank the Ministry of Education for funding 20. Lezak MD. Neuropsychological Assessment. New York: Oxford University Press;
2004.
our study under the grant Long Term Research Grant Scheme
21. Wechsler D. Administration and Scoring Manual: Wechsler Adult Intelligence
(LRGS; LRGS/BU/2012/UKM-UKM/K/01). The staff, fieldworkers, Scale. 3rd ed. San Antonio: Psychological Corporation; 1997.
respondents, and local authorities involved in this study are 22. World Health Organization. Obesity: Preventing and Managing the Global
appreciated for their efforts in making this study a success. Epidemic. Report of a WHO consultation of obesity. Geneva: World Health
Organization; 1998.
23. Hultsch DF, Hertzog C, Small BJ, et al. Use it or lose it: engaged lifestyle as a
References buffer of cognitive decline in aging? Psychol Aging. 1999;14:245e263.
24. Copeland JRM, Beekman ATF, Braam AW, et al. Depression among older people
1. Malhotra R, Chan A, Østbye T. Prevalence and correlates of clinically significant in Europe: the EURODEP studies. World Psychiatry. 2004;3:45e49.
depressive symptoms among elderly people in Sri Lanka: findings from a na- 25. Dunlop DD, Lyons JS, Manheim LM, et al. Arthritis and heart disease as risk
tional survey. Int Psychogeriatr. 2010;22:227e236. factors for major depression. Med Care. 2004;42:502e511.
2. Wada T, Ishine M, Sakagami T, et al. Depression activities of daily living and 26. Chong MY, Chen CC, Tsang HY, et al. Community study of depression in old age
quality of life of community-dwelling elderly in the three Asian countries: in Taiwan. Br J Psychiatry. 2001;178:29e35.
Indonesia, Vietnam and Japan. Arch Gerontol Geriatric. 2005;41:271e280. 27. Azizi F. Research in Islamic fasting and health. Ann Saudi Med. 2002;22:
3. Rajkumar AP, Thangadurai P, Senthilkumar P, et al. Nature, prevalence and 186e191.
factors associated with depression among the elderly in a rural south Indian 28. Toda M, Morimoto K. Effects of Ramadan fasting on the health of Muslims.
community. Int Psychogeriatr. 2009;21:372e378. Nihon Eiseigaku Zasshi. 2000;54:592e596 [In Japanese].
4. Izzuna Mudla MG. Depression among elderly Malays community in Kuala Langat 29. Braam AW, van den Eeden P, Prince MJ, et al. Religion as a cross-cultural
District, Selangor State. MPH Dissertation. Malaysia: University of Malaya; 2006. determination of depression in elderly Europeans: results from the EURODEP
5. Sherina MS, Rampal L, Mustaqim A. The prevalence of depression among the collaboration. Psychol Med. 2001;31:803e814.
elderly in Sepang, Selangor. Med J Malaysia. 2004;59:45e49. 30. Stanley P. Risk factors for depressive illness among elderly GOPD attendees at
6. Hyman SCD, Kessler R, Patel V. Mental Disorders in Priorities in Developing UPTH. IOSR-JDMS. 2013;5:77e86.
Countries. New York: Oxford University Press; 2006. 31. Luchsinger JA, Honig LS, Tang MX. Depressive symptoms, vascular risk factors,
7. Cole MG, Dendukuri N. Risk factors for depression among elderly community and Alzheimer's disease. Int J Geriatr Psychiatry. 2008;23:922e928.
subjects: a systematic review and meta-analysis. Am J Psychiatry. 2003;160: 32. Alexopoulos GS, Schultz SK, Lebowitz BD. Late-life depression: a model for
1147e1156. medical classification. Biol Psychiatry. 2005;58:283e289.
8. Blazer DG. Depression in late life: review and commentary. J Geriatr Psychiatry. 33. Hawker GA, Gignac MAM, Badley E. A longitudinal study to explain the pain-
2009;7:118e136. depression link in older adults with osteoarthritis. Arthritis Care Res.
9. Nur Islami MFT, Suzana S, Zahara AM, et al. Efficacy of fasting calorie restriction 2011;63:1382e1390.
on quality of life among aging men. Physiol Behav. 2011;104:1059e1064. 34. Liang LC, Huei CK, Jo YWW. The five-factor model of personality and depressive
10. Ibrahim N, Che Din N, Ahmad M, et al. Relationships between social support symptoms: one-year follow-up. Pers Individ Dif. 2007;43:1013e1023.
and depression, and quality of life of the elderly in a rural community in 35. Mayberg HS. Modulating dysfunctional limbic-cortical circuits in depression:
Malaysia. Asia Pac Psychiatry. 2013;5:59e66. towards development of brain-based algorithms for diagnosis and optimised
11. Shahar S, Omar A, Vanoh D, et al. Approaches in methodology for population- treatment. Br Med Bull. 2003;65:193e207.
based longitudinal study on neuroprotective model for healthy longevity (TUA)