Change in sense of coherence (SOC) and symptoms of depression among old non-demented persons 12 months after hospitalization

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Abstract

We studied whether SOC of older adults (≥65 years) without cognitive impairment had changed 1-year after medical hospitalization (T2) and to examine what factors were associated with the change. At baseline (T1) and (T2), the 13-item version of the SOC scale assessed coping, and the Hospital Anxiety and Depression (HAD) Scale assessed symptoms of depression and anxiety. The cognitive state was assessed by means of the mini-mental state examination (MMSE). Physical health was measured with the Charlson Index and functional status with Lawton and Brody's scales for physical self-maintenance (PSMS) and the instrumental activities of daily living (I-ADL). In all, 97 (51 men) persons with a mean age of 75.3 (SD 6.3) years and Mini Mental State Evaluation (MMSE) score of 28.0 (SD 1.6) participated. The SOC improved significantly from baseline to 1-year later (mean 76.5, SD 11.4 vs. mean 79.1, SD 9.1, p  0.01). Improved SOC was associated with a low SOC at baseline and living without assistance during the study period. The prevalence of depression (HAD-D  8) and the mean depression (HAD-D) score did not change between the first and second data collection (HAD-D  8: 3.1% vs. 4.1% and HAD-D score: mean 1.8, SD 2.3 vs. mean 2.4, SD 2.4). However, an improved SOC and reduced anxiety symptoms at the second time point were associated with reduced HAD-D. The mean SOC improved 1-year after hospitalization. The symptoms of depression did not change, but reduction of symptoms of depression at the second time point was associated with improved SOC.

Introduction

Depression is common in people aged 65 years or older, both at the level of depressive symptoms and the level of diagnosed depression. The prevalence is normally estimated to be higher in those being hospitalized and living with physical health problems compared with the general population of older adults (Barca et al., 2009, Copeland et al., 1999, Djernes, 2006, Helvik et al., 2010b, Rosenvinge and Rosenvinge, 2003). In view of growing interest and awareness of the needs of older adults with mental health problems, resilience against and coping with depression and its symptoms in this age group are of great interest in our society.

There are theories about the role of coping in relation to promoting health (Antonovsky, 1987, Lazarus and Folkman, 1984). According to Antonovsky (1987), personal coping resources may facilitate and contribute to resisting stress and promoting health. In the Salutogenic model, personal coping characteristics are grouped together as a ‘SOC’ (Antonovsky, 1987). The SOC is understood to be a life orientation focusing on problem-solving, and it reflects the individual's ability both to comprehend the whole situation and to have the capacity to use the resources available to move in a health promoting direction (Lindstrom & Eriksson, 2005). The SOC reflects the extent to which a person finds life to be meaningful (a motivational and emotional disposition), manageable (readiness to control and influence) and comprehensible (a cognitive disposition). A person with a strong SOC is more likely to define a stressor as benign or irrelevant and define stimuli as non-stressors; consequently, they may adapt to the demand without turning it into health-damaging stress (Volanen, Suominen, Lahelma, Koskenvuo, & Silventoinen, 2007). For those with a weak SOC, life seems more chaotic, unmanageable, and meaningless; moreover, balancing the stressors adequately may become difficult. A strong SOC may predict future good health in adults (Suominen, Helenius, Blomberg, Uutela, & Koskenvuo, 2001).

According to Antonovsky, 1979, Antonovsky, 1987, at the age of about 30 years, when one might expect a consistent pattern of experiences of successful/unsuccessful management of stressors to have been established, the level of SOC is assumed to attain stability, at least in those with a strong SOC. This theory is partly supported by new research (Feldt et al., 2007, Hendrikx et al., 2008). A review has summed it up as follows: the SOC is quite stable, but not as stable as Antonovsky assumed (Eriksson & Lindstrom, 2005). The SOC tends to increase somewhat with age (Eriksson & Lindstrom, 2005) and over the entire lifespan (Lindmark et al., 2010, Nilsson et al., 2010). Furthermore, studies have demonstrated that the SOC may decline as a consequence of stressful life events (Kivimaki et al., 2002, Volanen et al., 2007), but the results are conflicting (Vahtera et al., 2006), and the studies that have been carried out are for the most part in samples without older adults. Two studies reported the SOC to be stable over time at group level in adults who had undergone acute health traumas, but with large individual variations over time among the respondents (Bergman et al., 2011, Snekkevik et al., 2003).

A systematic and comprehensive review explored the associations between the SOC and depression in both cross-sectional and longitudinal studies. It found a strong SOC convincingly correlated with good mental health and absence of depression (Eriksson & Lindstrom, 2006). The review included 33 studies of depression from the period 1992 to 2003, but only one of these studies had been performed among older adults.

A standardized SOC questionnaire exists, but it is rather complicated (Antonovsky, 1996) and it is not well suited for persons with dementia, even a mild degree of dementia makes it difficult to fill in the questionnaire according to its intentions (Naaldenberg, Tobi, van den Esker, & Vaandrager, 2011). Therefore, newer studies on older adults have excluded persons with a cognitive impairment of any degree. Cross-sectional studies carried out among cognitively intact older adults receiving psychiatric care, living at home or in nursing homes, have generally concluded that no or slight depressive symptoms or good mental health is correlated with a stronger SOC (Chimich and Nekolaichuk, 2004, Ekman et al., 2002, Nygren et al., 2005, Rennemark and Hagberg, 1999), but not all the studies agree (Thome & Hallberg, 2004). One small cross-sectional study among hospitalized older adults (Ekman et al., 2002) found good mental health and SOC positively correlated. Longitudinal studies exploring the relation between SOC and change of SOC and symptoms of depression in older adults are few. Longitudinal studies are needed to understand these complex phenomena in later life more thoroughly (Chimich & Nekolaichuk, 2004) and to develop rehabilitation and health care after hospitalization for fragile older adults.

In this study, we wanted to explore whether the SOC had changed among older adults without cognitive impairment 1 year after hospitalization at a medical care-unit, and to examine which factors were associated with the change. Additionally, we wanted to explore which factors were related to changes in symptoms of depression (HAD-D score) between hospitalization and 1 year later. Based on the theoretical framework and the literature review for adults, we hypothesized that the SOC would be relatively unchanged 1 year after at the group level, but with a considerable individual variation, and that a reduced level of symptoms of depression would be associated with a stronger SOC.

Section snippets

Method

The study used a longitudinal methodology extending over two time points. Over a 2-year period (1 September 2006–30 August 2008) the first data collection was performed among patients (≥65 years) at a general public hospital in Norway (Helvik et al., 2010a, Helvik et al., 2010b). The patients, living in the region admitted to the internal medical inpatient service of the Tynset Division of the Innlandet Hospital Trust with an acute medical condition and hospitalized for at least 48 h were

Results

In all, 51 men and 46 women participated in the study (see Table 1). At T1 the participants’ mean age was 75.3 years (SD 6.3, range 65–89) and 60.8% (n = 59) of the participants had been readmitted to the hospital before T2 (mean 0.8, SD 1.4, range 0–8 hospitalizations). At T1, women lived alone more frequently than men (56.5% vs. 25.5%, p < 0.01). Those who dropped out prior to the second data collection were significantly older (mean 80.0, SD 6.9 vs. 75.3, SD 6.3; p < 0.01), had a higher Charlson

Discussion

In this first Norwegian study of SOC and symptoms of depression in the cognitively well-functioning previously medically hospitalized older adults, we found that the mean SOC score had improved 1 year after hospitalization, while the mean score for symptoms of depression (assessed by HAD-D) remained unchanged.

The mean SOC score in the present study was found to be similar to the results of comparable studies in Scandinavia of older adults living at home (Jakobsson, 2002, Nygren et al., 2005),

Conclusion

SOC improved 1 year after hospitalization and the improvement was associated with living without assistance and with a low score on SOC at baseline. Symptoms of depression did not change over 1 year. However, an individual reduction of depressive symptoms was associated with improved SOC. The results of the study indicate that change of SOC after hospitalization is important for symptoms of depression in older adults and, that health personnel could promote the conditions important for

Conflict of interest statement

None.

Acknowledgements

The research was funded by collaboration between the Norwegian Ministry of Health and Care Services, and Innlandet Hospital Trust. The authors would like to thank the Medical Department at DivisjonTynset, Inlandet Hospital Tryst, Randi Helene Skancke and the surrounding municipalities, whose collaboration made the research possible, as well as Elizabeth E. Peacock for a helpful review of the English text.

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