Journal of Nursing Research h VOL. 19, NO.

4, DECEMBER 2011

Relationship Between Elderly Depression

and Health Status in Male Veterans
Tsai-Yun Chang1 & Ke-Hsin Chueh 2*
1

RN, MSN, Department of Nursing, Song Shan Armed Forces General Hospital & 2RN, PhD, Assistant Professor,
Department of Nursing, Fu Jen Catholic University.

ABSTRACT
Background: Elderly depression affects the overall health
and quality of life of institutionalized men.
Purpose: This study explored the relationship between depression and health status in institutionalized male veterans in Taiwan.
Methods: This survey study used a cross-sectional research
design and recruited 152 elderly male residents of a veterans
home in northern Taiwan. A validated questionnaire assessed
depression, health status, and demographic characteristics.
Results: More than one fifth of the subjects (21.7%) exhibited depression. Those with poor general health status
(odds ratio [OR] = 7.9, p G .001), relatively high levels of
dependence on others for daily physical activities (OR = 4.6,
p = .002), or self-perceived negative influences of chronic
diseases on daily living (OR = 11.7, p G .001) faced the
highest prevalence of depression. Subjects with hypertension (OR = 2.3, p = .034), cataracts (OR = 3.7, p = .007), or
liver disease (OR = 8.1, p = .006) had the highest prevalence
of depression. Identified risk factors of depression among the
elderly male veterans included self-perceived negative influence of chronic diseases on daily living (adjusted OR = 10.2,
p G .001) and cataracts (adjusted OR = 4.3, p = .023).
Conclusions/Implications for Practice: Geriatrician nurses
should develop strategies to maintain general patient health and
reduce the negative impact of chronic diseases and cataracts on
daily life to reduce depression in institutionalized male veterans.

KEY WORDS:
older people, elderly depression, male veterans, health status,
cataracts.

Introduction
Most elderly Taiwan veterans came to Taiwan from throughout Mainland China during their teenage years toward the
end of the 1940s (Lin, 2003). Most of them are men, have a
minimal education, and live in government-sponsored longterm care institutions known as veterans homes. Because
of the passage of time and changing social structures, elderly
veterans now lack a support system and have become a distinct minority group in Taiwan (Chang et al., 2010).
298

Depression and health among Taiwans institutionalized

older people is an important public health issue (Weyerer
et al., 2008). Although worldwide studies have shown that
institutionalized residents face greater depression and lower
life quality than older people living in the community
(Chung, Chiou, & Chou, 2009; Karakaya, Bilgin, Ekici,
Kose, & Otman, 2009; Wang, Su, & Chou, 2010), the
coverage of factors related to depression and health status
among veterans home residents is scarce. Studies of depression in older people have shown that personal characteristics, such as advanced age, female gender, divorce,
lower education, ethnicity, and living alone, are high-risk
factors for depression (Shin, Jung, Jo, & Kang, 2009; Suen
& Morris, 2006; van der Wurff et al., 2004; Wang et al.,
2010; Weyerer et al., 2008). Other critical factors associated with depression include fewer activities in daily living,
poorer health, and certain chronic diseases (Huang, Dong,
Lu, Yue, & Liu, 2010; Kim, Choe, & Chae, 2009; Shin
et al., 2009, Suen & Morris, 2006).
Once diagnosed with depression, older people are more
likely to experience social isolation, loneliness, deteriorating
life quality, poor social function, deficits in cognition, inactive daily living, increased medical burdens, and, possibly,
increased suicide and death rates (Hsiao, Lin, & Yeh, 2004;
Wang et al., 2010). Older people often describe physical symptoms and ignore their emotional well-being, which makes diagnosing depression in older people more difficult than in
other age groups (Wu, Hou, & Sheu, 2004). Because clinical
symptoms of depression are manifested in atypical ways, depression in older people is often underappreciated. The authors
are unaware of any prior comprehensive evaluation of elderly
male veterans in Taiwan. The aims of this study were to (a)
identify the prevalence of elderly male depression in a veteran
home and (b) investigate the influence of demographic characteristics and health status on depression risk. Our findings can
Accepted for publication: August 23, 2011
*Address correspondence to: Ke-Hsin Chueh, No. 510, Zhongzheng
Rd., Xinzhuang District, New Taipei City 24205, Taiwan, ROC.
Tel: +886 (2) 2905-3400; Fax: +886 (2) 2905-3400;
E-mail: kchueh@gmail.com
DOI: 10.1097/JNR.0b013e318236cf89

Elderly Depression and Health Status

serve as a foundation for future prevention and intervention programs for elderly men with depression living in veterans homes to help them live longer and happier lives.

Methods
The Research Design
This survey study was conducted using a cross-sectional
research design. A structured questionnaire and two open
questions (How is your mood today? What makes you
depressed?) were used to conduct face-to-face interviews with
the subjects. The two interviewers were registered Taiwan
nurses studying at Yuan-Pei University. Before conducting
the interviews, interviewers were trained with the interview
guide and a 90% correct response rate was confirmed between the two.

Sampling
We included in this study all elderly men among the 200
living at a veterans home in northern Taiwan who volunteered to participate and were not defined by at least one
of the following two exclusion criteria: (a) impaired mental capacity and (b) inability to communicate in Mandarin.
A total of 162 qualified subjects were enrolled, and 152
subjects (93.8%) completed the questionnaire. This study
was approved the institutional review board at Yuanpei
University.

Study Questionnaire
The questionnaire included four parts:
1. The 10-item Short Portable Mental State Questionnaire developed by Pfeiffer (1975) was associated with
clinical diagnosis and intended to address large community populations, multipurpose clinics, and institutions. The consistency of results with organic brain
syndrome was 92%, with a Cronbachs alpha value
between .82 and .83. Each question is worth one point,
for a total possible 10 points. Lower scores correlate
with higher levels of cognitive impairment. Subjects
scoring less than 8 were classified as exhibiting unfit
mental functions (Pfeiffer, 1975).
2. The personal demographic questions gathered data
on the subjects age, education background, marital
status, diagnosed chronic disease, daily activities, and
self-perceived negative influences of chronic diseases
on daily living activities.
3. The Taiwan Geriatric Depression Scale was developed
by Liao et al. (2004) to measure depression based on
the Geriatric Depression Scale (Liao, Yeh, Ko, Luoh,
& Lu, 1995). The 30-item scale rated on a dichotomous score, with 0 for no and 1 for yes, with a potential Taiwan Geriatric Depression Scale score range
of 0 to 30 and higher scores indicating more severe

VOL. 19, NO. 4, DECEMBER 2011

depression. The Cronbachs alpha for the total scale

was .94, and the testYretest reliability was .95. A total
score higher than or equal to 15 provided a strong
indication of elderly depression at a diagnostic sensitivity of 93.3% and a specificity of 92.3% (Liao et al.,
2004). The Cronbachs alpha of internal consistency for
elderly men in veterans homes was .91 (Chung et al.,
2009). The results of our study showed a Cronbachs
alpha of .93.
4. The Self-Perceived Health Scale was developed by
Chao (2003) to measure general health. The threeitem scale was scored on a 5-point Likert scale, ranging
from 1 (very poor) to 5 (very good). The Cronbachs
alpha of internal consistency for the elderly men
among veterans homes was .80. We added a fourth
question to the questionnaire (Compared with your
expected ideal health standard, what do you think of
your current health status?) and used a 5-point Likert
scale. Total possible scores ranged between 4 and
20, with higher scores correlating to better perception of health. The Cronbachs alpha value for this
study was .85.

Analysis
SPSS 15.0 (SPSS, Inc., Chicago, IL, USA) for Windows software analyzed data to determine demographic characteristic
percentages, means, standard deviations (SD), health status,
and depression. The chi-square (2 2) test analyzed the odds
ratio (OR) to explain the relationship between depression
and its related factors. Binominal logistic regression analyzed the adjusted OR (AOR) to determine the risk factors.

Results
Demographic Characteristics, Health
Status, and Depression
This study sampled 152 male veterans between 70 and
99 years of age, with a mean age of 82 years (SD =
5.8 years). Most (71%) did not complete elementary education. Ninety-one (60%) held no religious belief, and 93
(61%) were unmarried. The average score of general health
among these subjects was 10.7 (SD = 3.0), with a median
score of 11. Sixty-four (42%) subjects had poor general
health based on a cutoff point of 11. Only 18 (12%) were
severely dependent on others for daily physical activities.
Sixty (39%) felt that chronic health problems currently affected their daily life (Table 1). Sixty-three subjects (41%)
were diagnosed with hypertension, 46 (30%) with arthritis, 40 (26%) with cardiovascular disease, 31 (20%) with
digestive diseases, 27 (18%) with diabetes, 20 (13%) with
eye cataracts, 11 (7%) with gout, 6 (4%) with liver disease,
and 3 (2%) with malignant tumors. Furthermore, 137 subjects (90%) had more than one chronic disease, whereas 79
(52%), 38 (25%), and 16 (11%) had more than two, three,
299

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Tsai-Yun Chang et al.

TABLE 1.

Relevance of Demographic Characteristics and Health Status to Elderly

Depression Among Subjects (N = 152)
Elderly Depression
Subject

Yes
(n = 33)

No
(n = 119)

Age (years)
70Y79
Q80

52
100

34
66

12
21

36
64

40
79

34
66

Elementary education
No (e6 years)
Yes (96 years)

108
44

71
29

23
10

70
30

85
34

71
29

Religious
No
Yes

91
61

60
40

17
16

52
48

74
45

62
38

Single marriage
Yes
No

93
59

61
39

21
12

64
36

72
47

61
39

Poor general health

Yes
No

64
88

42
58

26
7

79
21

38
81

32
68

Variable

Dependent on others for daily

physical activities
Yes (severe)
No (minor, independent)
Self-perceived negative influences
of chronic diseases on daily living
Yes (significant/much)
No (little/none)

#2

0.09

.768

0.04

1.22

0.11

23.27

9.61
18
134

12
88

9
24

27
73

9
110

60
92

39
61

27
6

82
18

Relevance of Demographic Characteristics

and Health Status to Elderly Depression
Subjects with overall poor general health (OR = 7.9, p G
.001) were more severely dependent on others for help
with daily physical activities (OR = 4.6, p = .002). Those
with high self-perceived negative influences of their chronic
diseases on daily living (OR = 11.7, p G .001), hypertension
(OR = 2.3, p = .034), eye cataracts (OR = 3.7, p = .007), or
liver disease (OR = 8.1, p = .006) were more likely to experience depression. When the number of chronic diseases
was more than two, three, or four, those subjects had, respectively, a 2.6-fold (95% confidence interval [CI], 1.1Y5.9),
4.2-fold (95% CI, 1.8Y9.5), or 8.2-fold (95% CI, 2.7Y24.8)
increased risk of elderly depression (Tables 1 and 2).
Table 3 shows the association between elderly depression and significant factors examined by binominal

33
86

28
72

Odds Ratio

95% Confidence
Interval

1.1
1

0.5Y2.5

0.9
1

0.4Y2.1

1.5
1

0.7Y3.4

1.1
1

0.5Y2.5

7.9
1

3.2Y19.9

4.6
1

1.7Y12.8

11.7
1

4.4Y31.0

.846

.269

.744

G.001

.002

8
92
31.63

and four diseases, respectively (Table 2). Their average elderly depression score was 9.0 (SD = 6.8), ranging between
5 and 26. Thirty-three had a score higher than 15, indicating that 21.7% experienced depression.

300

G.001

logistic regression analysis. Independent factors include

poor general health, stronger dependence on others for
daily physical activities, self-perceived negative influences
of chronic diseases on daily living, hypertension, eye cataracts, and liver disease. The factor of poor general health
was dropped because of its collinearity with the factor of
self-perceived negative influences of their chronic diseases
on daily living. An analysis of the remaining five factors
found significant risk factors, which include self-perceived
negative influence of chronic diseases on daily living (AOR =
10.2, p G .001) and having eye cataracts (AOR = 4.3,
p = .023).

Discussion
Prevalence of Elderly Depression Among
Male Veterans
This study found that 21.7% of the subjects had elderly
depression. This result is similar to a previous study of
male veterans (21.5%; Chung et al., 2009). These findings

Elderly Depression and Health Status

VOL. 19, NO. 4, DECEMBER 2011

TABLE 2.

Relevance of Chronic Diseases to Elderly Depression Among Subjects (N = 152)

Elderly Depression
Subject
Variable

Hypertension
Yes
No

63

41

Arthritis
Yes
No

46

Cardiovascular disease
Yes
No

Yes
(n = 33)

No
(n = 119)

14

42

75

63

30

13
20

39
61

33
86

28
72

40

26

11
22

33
67

29
90

24
76

Digestive disease
Yes
No

31

20

9
24

27
73

22
97

18
82

Diabetes
Yes
No

27

18

9
24

27
73

18
101

15
85

Cataracts
Yes
No

20

13

9
24

27
73

11
108

9
91

Gout
Yes
No

11

2
31

6
94

9
110

8
92

Liver disease
Yes
No

4
29

12
88

2
117

2
98

Malignant tumor
Yes
No

1
32

3
97

2
117

2
98

91 chronic disease
Yes
No

137
15

90
10

31
2

94
6

106
13

89
11

92 chronic diseases
Yes
No

79
73

52
48

23
10

70
30

56
63

47
53

93 chronic diseases
Yes
No

38
114

25
75

16
17

48
52

22
97

18
82

94 chronic diseases
Yes
No

16
136

11
89

10
23

30
70

6
113

5
95

#2

4.52

.034

1.67

1.07

1.23

2.61

7.35

0.09

7.43

0.24

0.69

5.30

12.40

17.50

indicate that male veteran residents have a higher prevalence of depression than faced by elderly men in Taiwan
community settings (7.8%; Wang et al., 2010). Karakaya
et al. (2009) and Valenstein et al. (2009) demostate that
institutionalized residents face a higher risk of depression.
Because of long-term institutionalization and lack of

Odds Ratio

95% Confidence
Interval

2.3
1

1.1Y5.1

1.7
1

0.8Y3.8

1.6
1

0.7Y3.6

1.7
1

0.7Y4.1

2.1
1

0.8Y5.3

3.7
1

1.4Y9.9

0.8
1

0.2Y3.8

8.1
1

1.4Y46.2

1.8
1

0.2Y20.8

1.9
1

0.4Y8.9

2.6
1

1.1Y5.9

4.2
1

1.8Y9.5

8.2
1

2.7Y24.8

.197

.301

.268

.106

.007

.768

.006

.622

.407

.021

G.001

G.001

positive stimulation, elderly residents can easily become

dispirited, hopeless, and depressed (Hsiao et al., 2004).
Because most veterans stay in a veterans home until the
end of their lives, geriatric nurses should develop services
that are able to provide intensive monitoring and positive
stimulation to avoid depression in the residents.
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Tsai-Yun Chang et al.

TABLE 3.

Risk Factors of Elderly Depression Among Subjects (N = 152)

Adjusted Odds
Ratio

95% Confidence
Interval

0.5

0.1Y1.6

.228

10.2

3.6Y29.3

G.001

Hypertension (yes/no)

1.6

0.6Y4.0

.323

Cataracts (yes/no)

4.3

1.2Y15.2

.023

Liver disease (yes/no)

4.8

0.7Y35.4

.126

Variable
Severely dependent on others for daily physical activities (yes/no)
Self-perceived negative influences of chronic diseases on daily living
activities (yes/no)

Note. Model is a fully entered binominal logistic regression; poor general health was dropped because of collinearity.

Relevance of Demographic Characteristics

and Health Status to Elderly Depression
Among Male Veterans
Results of this study show factors associated with elderly
depression to include poor general health, stronger dependence on others for help with daily physical activities, and
self-perceived negative influences of chronic diseases on
daily living. These results dovetail with those of several
other studies (Huang, 2004; Jongenelis et al., 2004). Moreover, our elderly male veterans with chronic diseases, such
as hypertension, eye cataracts, and liver disease, were found
at risk of elderly depressionVa finding also reported in
other studies (Bianchi et al., 2005; Huang et al., 2010;
Jongenelis et al., 2004; Scuteri et al., 2011). This study
proposes that the more chronic diseases an elderly male
veteran has, the more likely he is to have elderly depression.
This mirrors the findings of Huang (2004), who studied
elderly residents of public institutions. In addition, this study
found elderly male veterans with more than two, three,
or four chronic diseases have, respectively, a 2.6-, 4.2-, or
8.2-fold greater chance of experiencing depression. These
results agree with Unsar and Sut (2008). In our study,
some male veterans were without hands and were dependent on nurses to feed them. They complained about the
need to wait for others to be fed, which hurt their selfesteem and sense of control over daily living activities. These
situations made subjects depressed in a manner similar to the
study of Hsiao et al. (2004). Moreover, some male veterans
reported feeling they had no freedom to choose their desired
lifestyle. If long-term care institutions cannot provide this freedom, elderly residents are more likely to lose a sense of control over their lives, which could further deteriorate their
abilities (Tu, 1996). Therefore, geriatric nurses should develop strategies to increase residents control over their lives
to maintain health and reduce elderly depression.
Finally, our results indicated elderly male veterans with
eye cataracts and self-perceived negative influences of their
chronic diseases on daily living to be at higher risk of elderly depression. As our subjects had a generally low level
of education and lacked a family support system, most of
302

them had no choice but to depend on the care of geriatric

nurses. In addition, few admitted understanding or being
worried about depression. They were unlikely to disclose
their feelings to others and trusted their ability to cope without external help. These reasons cause rates of depression in
men to be higher than in women (Wang et al., 2010; Wong,
Lee, & Tung, 2006). Therefore, nurses in clinical institutions for older people should pay greater attention to men
with elderly depression, especially among men with eye cataracts and self-perceived influences of chronic diseases that
make daily living activities more difficult.
Constrained financial resources limited the completeness
of this study, which may contain selection bias because of
our focus on one veteran home only.

Conclusions
Around 22% of subjects exhibited elderly depression. Selfperceived negative influence of chronic diseases on daily
living and cataracts were identified as risk factors of elderly depression. These results provide insight to nurses
working in veteran homes, researchers in the field of geriatrics, and educators into the particular care needs of elderly male veterans in Taiwan.

Acknowledgments
We thank Li-Chu Cheng, the nursing chief, and the nursing staff at the institution where this study was conducted
for their support to our study, Li-Hui Chen and Che-Chen
Li for their help in conducting the questionnaire survey
and collecting the data, the institutionalized older people
for their approval and cooperation with the researchers,
and Dr. Shu-Feng Kao for his advice to the researchers. In
particular, we thank Dr. Robert H. Glew for editing earlier
versions of this manuscript.

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12*
1

152

21.7%OR = 7.9, p <

.001OR = 4.6, p = .002
OR = 11.7, p < .001OR = 2.3, p
= .034OR = 3.7, p =.007OR = 8.1, p = .006

adjusted OR = 10.2, p < .001adjusted OR = 4.3, p =

.023

100823
*24205510
0229053400E-mail: kchueh@gmail.com

304