Introduction: Depression will be the most common disease in the world by 2030, reaching about 350 million people, and caregivers of the elderly do not shy away from this growing trend, as they are known to use depression, anxiety and insomnia medications two to three times more than the general population.

Objective: To analyze the national literature on depression in caregivers of the elderly.

Method: Integrative review with the guiding question - What are the Brazilian studies that approach the theme about depression in caregivers of the elderly? The search for studies was carried out in the LILACS and MEDLINE databases, using the descriptors: depression, caregiver, elderly and quality of life grouped by means of the Boolean operator AND, in the time span of 2010-2017. We selected nine articles based on the inclusion and exclusion criteria adopted.

Results: There was a higher prevalence of depression in the family caregiver of the elderly, as well as the overload of the caregiver as the main risk factor for depression; these themes are delimited as thematic categories. There were also studies on the evaluation of quality of life and health of caregivers of elderly people with dementia.

Conclusion: The present relationship between the care of elderly caregivers and the emergence of depression associated with caring was evidenced.

Keywords: depression, caregiver, old man, quality of life

The definition of aging is based on the intrinsic process of life, culminating in neurophysiological, functional and chemical changes in the body. In addition, environmental and socio-cultural aspects are strongly related to the healthy or pathological maturation of the individual. Therefore, the functional classification of the elderly is not subject only to age, but also to gender, well-being, health, and social and economic conditions.¹

It is evident that the extension of life expectancy has always been a yearning for the community. As a more explicit fruit of this aspiration, we can observe the increase, in general and relative terms, of the population size of the elderly in several countries. Therefore, it is necessary to highlight the importance of providing this portion of the population with not only an increase in survival but also qualitative improvements in their standard of living.²

At this juncture, the global contingent has been participating in a gradual aging process, because of the decrease in fertility and mortality rates. Thus, the share of the elderly (people over 60 years) on the planet reached 770 million individuals in 2010, approximately 11% of society. This figure is likely to reach 1 billion in 2020 (around 13% of the world's population), of which 20% will reside in developing nations.³

However, in addition to the changes in the demographic profile, the increase in longevity led to strong changes in the epidemiological pattern, mainly due to the exorbitant increase of Non-Communicable Diseases (DANT), especially those with a chronic-degenerative nature, the major causes of most hospitalizations and deaths.⁴

Projections indicate that by 2050, six nations will have 10 million or more individuals aged 80 or older: China (99 million), India (48 million), the United States (30 million), Japan (30 million), Brazil (10 million) and Indonesia (10 million), thus accounting for 57% of the entire world society of this age group. This provision will increase the demand for social security and assistance factors, and therefore, overburdening the health system, thus increasing the complexity in the provision of services.⁵

However, dealing with a largely aging community is not something completely new to the economically developed nations, which over the past century have gradually observed the composition of a significant senile population. In these countries, this transformation has been followed by structural changes and improvements in the legal, social security and welfare areas. However, even for these nations, there are doubts about the changes in their age pyramids and the abrupt decrease in the economically active population. In addition, the continuous and marked increase in public and private spending in the health sector acts as an aggravating factor in this delicate context.⁶

Thus, to the genuine demographic aspect of population aging, there are countless precautions and difficulties, as well as economic, political and social changes. It is important to highlight the need to remodel the health system, so that it is focused on the identification and cure of diseases caused by aging. In this way, a great challenge arises for developing countries, like Brazil.⁷

As of 1970, Brazil had its demographic outline modified: from a predominantly rural and traditional social body with large families and high infant mortality, it was configured to a society mostly urban, with fewer children and a new family structure. From a young population profile in the recent past, there is now an increasing number of individuals aged 60 years or older.⁸

The decrease in fertility and mortality rates, increasing life expectancy, describes the process of demographic reorganization in Brazil. The increase in the number of elderlies is relevant in the Brazilian population, coupled with the need for claims and demands in the question of Republics PU policy sa Ude.⁹

Social, cultural and economic changes, as well as medical-sanitary advances, led to a decrease in mortality and an increase in the life expectancy of Brazilian inhabitants. However, an increasing number of these people reach a more advanced age, resulting in chronic diseases, characterized by a period of latency and a long period of time. Consequently, this can lead to consequences that limit the activities of the individuals.¹⁰

Interpreting the peculiarities of the aging process of the population and its results in urban space can help both in the elaboration of public policies that aim at long term care, as well as in the distribution and management of resources, aiming at the promotion of the quality of life.¹⁰

In this context, old-age transitions often encourage the senile to lack another person to assist them in practices that were once easily identified. Thus, the effigy of elderly caregiver emerges, which often passes us under an abstracted vision and without adequate preparation, leading to exhaustion for both the care and the care.¹¹

In the meantime, it is of the greatest magnitude to consider the respect of this office, which is indispensable in the current conjuncture. The individual who provides care to the elderly, known as caregiver, may or may not have family ties. In addition, there are two types of caregivers: the formal and the informal. These are people who will be in charge of advising and/or paying attention to elderly individuals who express weaknesses for basic and instrumental tasks of daily routine, fomenting independence and respecting their autonomy.¹²

In this sphere of home care, the image of the informal caregiver is manifested. This, as opposed to the formal one, is the one that exercises the non-professional care and its function without pocketing any remuneration, being individuals belonging to the family, friends and neighbours. In addition, primary, secondary and tertiary caregivers are differentiated. Primary caregivers are the central caregivers for the elderly and for the care and care of most services. Secondaries may even perform similar tasks, but what distinguishes them from primary ones is the question of not having the magnitude of duties and deliberation, often proceeding in an ephemeral way in a few simple charges, alternating with the primary caregiver. Tertiary caregivers are adjuncts and do not have duties for care, supplying the primary caregiver for brief intervals and making up, for the most part, punctual tasks such as paying bills and receiving pensions, purchases, among others.¹³

Family members taking the role of informal caregivers are more likely to initiate a situation of imbalance, whose salient manifestations are: tension, depression, frustration, stress, embarrassment, altered self-esteem, reduced conviviality, and fatigue, among others. This overload or tension can promote physical, psychological, emotional, social and financial problems, which, therefore, undermine the well-being of the patient and the caregiver.¹³

Depression is one of the most common mental disorders and represents a progressive disorder of public health. It can be understood as a mood disorder or an affective disorder, characterized by both physical and psychic symptoms, including depressed mood, negative thoughts, excessive guilt, suicidal ideation, and changes in sleep and appetite. These symptoms constitute a syndrome, characterized by dysfunction of the serotonin and noradrenaline pathways of the central nervous system.¹⁴

The World Health Organization (WHO) presumes that depression is established as the most common disease in the world by 2030, reaching some 350 million people.¹⁵ Caregivers do not shy away from this growing trend, as primary caregivers use medication for depression, anxiety, and insomnia two to three times more than the general population.¹⁶

Taking responsibility for the care of others promotes physical and mental overload.¹⁷ When an individual needs care, his needs become priorities, and other’s needs, including the caregiver, vanish. These changes can lead to great psychic suffering.¹⁸ In addition; caregivers tend to become more isolated from the social and leisure milieu, factors that worsen their quality of life.¹⁶

Thus, in association with the daily burden of the caregiver, depression is based more easily in this context, especially when there is no support from family and society to the difficulties faced by the caregiver and why he or she needs care.¹⁹ Thus, studies show that 94% of caregivers report some psychological problem, for example depression, resulting from chronic stress and psychological impact that prolonged care causes.²⁰

In this scenario, to compile information pertinent to elderly care and the impact of this activity on the mental health of the caregiver, we chose to write an integrative review, reported as a research method since 1980. Critically and systematically, we analyzed relevant scientific articles referring to depression in caregivers of the elderly, to understand available results. It was possible, therefore, to evaluate current knowledge on the subject in Brazil, since the list of articles studied was limited to Brazilian works. From this perspective, there was a relatively limited number of national articles compared to the number of articles in English. This enhances the relevance of the work in question since, in addition to synthesizing the findings, it exposes gaps that guide the development of deeper future research on the subject under investigation.

Moreover, the choice of writing an integrative review originated from the thought that knowledge must be plural, so that the various disciplines need to be integrated to produce broad knowledge. In fact, this research method made it possible to analyze depression in caregivers of the elderly, not only in the geriatrics field, but also in psychology and nursing. In addition, it is important to emphasize that the selected articles are not based on the same approach; on the contrary, quantitative and qualitative studies are visualized. This fact ratifies the methodological rigor of the integrative review, making it consistent with the practice based on evidence. This study is based on several epistemological matrices, with the purpose of contributing to the understanding of depression in caregivers of the elderly, and thus to cooperate positively to overcome this problem.²¹

To analyze the Brazilian literature on depression in caregivers of the elderly.

Integrative literature review method. Literature and research reviews are already made by all researchers who, when meeting a subject or question, seek to raise all the information in bibliography or personal testimonies with the goal of building a body of knowledge. However, the so-called integrative review of research is a method that structures this task and therefore increases conclusions’ reliability and depth.²²

Six steps were taken to carry out this study: the elaboration of the research question, definition of the inclusion and exclusion criteria, search in the database, data analysis, and discussion of selected articles and presentation of the review.²³

The guiding question of the study was: what are the studies of Brazilian authors that address the issue of depression in caregivers of the elderly?

For that, articles of Brazilian authors, in Portuguese language, with full text available, online and free, were included in the time span of 2010-2017. The research was carried out in the months of May and June of the year 2018. The exclusion criteria were based on the thematic applied to the guiding question and duplicity of articles. Also excluded were theses, dissertations, and monographs.

In order to guarantee reliability in the article, the search was carried out by five researchers, based on the selection process of articles in the databases of Latin American and Caribbean Literature in Health Sciences (LILACS) and the Online Search System and Medical Literature Analysis (MEDLINE), in May 2018, with standardized and available descriptors in the descriptors in Health Sciences (DeCS): 'depression' [and] ‘caregiver’ and ‘old’.

The results showed that 5 (56%) titles of scientific papers were centered on caregivers of elderly people with dementia, mainly Alzheimer's. Three publications (34%) focused on assessing caregiver's health in several social contexts.

Regarding the time frame of the studies, the year 2010 is highlighted with three articles (34%), 2013 (22%) and in the following years only one (11%) article, closing the publications in the year of 2017. The level of evidence observed was the VI for 7 (78%) of the articles and V for the remaining 2 (22%) (Table 1). The figure below shows the national journals in which the articles were published (Table 2).

Regarding studies’ goals, articles predominated aiming to evaluate the quality of life and health of caregivers of elderly people with dementia, a subject present in 5 (56%) of the articles. Then, three articles (34%) aimed to understand the quality of life of caregivers in different sociodemographic contexts.

Only one article (11%) outlined the existence of factors potentially associated with domestic neglect in the situation of domestic care provided by relatives. These data are shown in Table 3.

About the participants of the publications, we highlight carers of the elderly in general, without any specific restriction (33%). Then, the predominance of elderly caregivers (22%) was emphasized, followed less frequently by the emphasis on caregivers of older people aged over 60 (11%), elderly caregivers and non-caregivers (11%), informal caregivers (11%) and primary caregivers (11%) (Table 4).

Regarding results 5 of them (56%) have as one of their main themes the elderly with Alzheimer's or dementia, diseases that present as aggravating factors for care, since they are progressive and, in most cases, prevent the elderly from performing most basic activities of daily life, a factor that overwhelms their caregiver.
Regarding the gender of caregivers, 8 articles (89%) highlighted the prevalence of female caregivers, who are mostly daughters or wives of those they care for. In addition, 3 (33%) of the publications emphasize that caregivers have evidence of mild and moderate depression or do not present depressive signs.
The synthesis of results is shown in Table 5.

The discussion will be approached in analytical categories, which were selected after a thorough reading of the articles chosen and the results obtained.

Selected categories

The predominance of depression in the family-type caregiver

This category represents the items A1²⁴ A2²⁵ A3¹⁹ A4²⁶ A5^20,27 A6, A7 and A8^28,29, which relate to higher rates of depression in family caregivers. Articles A1, A2, A4 and A8 emphasize higher rates of women, of the family nucleus of the dependent elderly, exercising this role. In addition, A3, A4, A5, A6, A7 and A8 show the worrying incidence of psycho-depressive problems in family caregivers.

Articles A1, A2, A3 and A8 elucidate that caring has been exercised by an informal 'mechanism' that includes friends, neighbours, but above all, family members. The middle-aged women preponderated the execution of the caretaker post, although the older women also performed this work. The low level of schooling, the long time taken to care and the lack of relay in the function, are factors that constitute the context of the family caregivers. In addition, there are indications that caregivers demonstrate low dominance over health problems and the basic care demanded by the dependent elderly. The description of participants profile in the caregiver role in another study,³⁰ also encompasses positive factors such as sense of mission accomplished, self-satisfaction, and reciprocity; negative points, such as disagreements, insecurity and overload, are also present.

Another study,³¹ is consistent with the ideal referred to in A3, in saying that the action of caring normally has a continuous character, which imposes on the family hours of work and causes them to be subjected to exhausting activities. Moreover, the two works mentioned above indicate that the environment conducive to culminating in the overload is formed when joining to this prolonged work the unpreparedness of family members and the financial expense originated by dependency. Another consonance factor identified in A3 is the occurrence of cohabitation, which is common in this context of the family caregiver. This often implies an unbalance caregiver of dependent elderly people, whose health usually worsens when they live with the patient.

Brazil still does not have enough public service system to meet population demand and demographic change, since it is still a developing nation and, therefore, does not have enough institutions to guarantee the care of the dependent elderly. In this way, the family lacks formal support and has become the primary source of care along with friends. According to several studies about family caregivers, the daughters of the elderly are highlighted, followed by the wives of the dependents.³² Articles A1, A2, A3, A4, A5, A6, A7 and A8 also confirmed this prevalence.

Articles A5 and A6 report that the absence of independence of the elderly implies that some family member will appropriate the functions of caregiver. Searches³³ about the influence of gender, inquired about differences between men and women regarding the degree of overload felt in their role as caregiver and the most affected spheres of life of these two groups. Most studies pointed out that among caregivers, women predominate.²⁰

A topic addressed by A7 shows that family caregiver, in most cases, lacks professional qualification for this practice. In a research based on the analysis of individuals caring for elderly people with Alzheimer's disease, out of 101 caregivers, 95 were family members and 6 practiced this professionally; 65 had no previous experience of care and did not undertake training courses.²⁸ Nevertheless we know that intervention projects aimed at empowering elderly family caregivers are effective in promoting healthy aging, by reducing the number of elderly people who are victims of illnesses due to imperceptions committed by the caregiver.³⁴

In another perspective, A8 emphasizes the relationship between the reality existing between the extreme tension experienced by the family caregiver and the occurrence of abuse and elder abuse. Faced with this situation of intense tension, abuses and mistreatment may occur. As factors that foster this problem, ratified by a study,³⁵ show up anxiety and caregiver burden, the prospect that the receiver shown aggressive and a bad previous relationship.

According to the expressed junctures A1, A2, A3, A4, A5, A6, A7 and A8, an integrative review³⁶ confirms that the profile the elderly caregiver is guided in the prevalence of female relatives, which have a higher incidence of psychological problems, especially depression.

Caregiver overload as a risk factor for depression

This category is present in A1, A2, A3, A4, A5, A6, A7, A8 and A9³⁷, showing the existence of overhead as a predetermining factor for depression in elderly caregivers. Therefore, given the rationale in the intrinsic relationship between overwork and the decrease in the quality of life of caregivers, this topic is established.

All the selected articles (A1, A2, A3, A4, A5, A6, A7, A8 and A9) present the act of caring as a trigger for stress, overload and other imbalances. Similarly, a study 24 characterizes the task of caring as repetitive and usually uninterrupted, which negatively affects the health and quality of life of the caregiver, who may present with psychiatric disorders such as depression, usually associated with stress and anxiety. By demanding time and very broad efforts, the act of caring can also lead to the social isolation of the caregiver, who stops performing leisure activities, causing great damage to their quality of life.

It is approached by A1, A3, A4, A5, A6 and A9 that the caring function, which is commonly developed by family members, is complex, and that playing this role can aggravate physical and mental well-being, since caregivers tend to neglect self-care. Agreeing with this statement, a search³⁸ reported that complications such as depression and reduced quality of life are often observed, aspects that, for them, coupled with the absence of home services and the joint residence with the elderly dependent, collaborate for the psychological stress present in the day to day. However, it is pointed out that the central source of overload is the level of dependence of the person receiving care. Other important aspects are the information provided by A3, which point out that the burden of caring has an association with acts of family violence and in the intake of alcoholic beverages, but that the relationship between overload and inadequate consumption of alcohol use by caregivers has been little explored by public health institutions.

The article A6 grants that care is an episode of life that can lead to negative consequences such as depression, physical health deterioration and lowered levels of well-being in adults and the elderly. However, innumerable caregivers can handle their tasks well without feeling overwhelmed. Some studies analyzed a group of women patients’ sociodemographic factors, demonstrating the fact that the patient does not have practices outside home was the only determinant of overload.³³

As reported by article A5, the limitation of the elderly's ability to perform activities of daily life (ADLs) into greater dependence is an event that requires the caregiver to pay more attention to his or her health. Thus, a study³⁹ related to the performance of activities of daily life is useful as a criterion for defining the functional status of the individual. For didactic purposes, these activities are divided into basic activities of daily life (ABVD); instruments of daily life (AIVD) and advanced daily life (AAVD). Adequate functional performance establishes the individual's ability to nurture a community life without limitations and safety.

Articles A1, A3, A4, A6, A7 and A9 indicate that, in large part, by applying the greater portion of the time to care, the caregiver forgets his or her health, the most vulnerable to health obstacles being the elderly. The elderly caregiver goes through transformations in their experience of the burden influence, that is, there is less space for rest and social life, and the situation can be exacerbated when framed in a sphere of social fragility. Thus, a survey on the burden and quality of life of caregivers,⁴⁰ harmonizes with this theme, showing that caregivers whining often overload and, repeatedly, anxiety, depression and stress, abstaining from many social aspects which were once present in their lives.

This same research⁴⁰ dialogues with the mentioned articles, so that it denotes that the overload needs to be treated as a multidimensional concept, which involves the biopsychosocial scope, due to the search for harmony among the following aspects: financial resources, time available for care, psychological, physical and social conditions, attributions and distribution of roles. In the meantime, a great obstacle for health professionals to face new illnesses in the elderly caregiver underlies the lack of assistance of other individuals in care giving care for the elderly.

Still about the articles described, it is mentioned that the assiduity of depressive manifestations is high in circumstances of extensive difficulty in which these professionals are immersed. The transformations in their experience, with less space for rest and social life can trigger depressive thoughts, sensitizing unfavorably the quality of life of the caregiver. In the meantime, according to meta-analysis, ⁴¹ it is noted that elderly caregivers express greater depressive manifestations and decreased satisfaction with life in relation to elderly people who are not caregivers.

Finally, A7 expresses the importance of developing personal perseverance strategies to cope well with circumstances that promote overload and mental exhaustion. In this context, the article describes a study assessing the degree of resilience among caregivers of elderly patients with Alzheimer's disease, by means of Depression Inventory Beck (BDI) and Resilience. It was observed a correlation between the high resilience and the reduced somatization disorder and depression,⁴² characterized psychosocial adaptation in the face of adverse experiences. In view of this, it is evident that spirituality and religion act as effective support mechanisms.

Considering the aspects presented, a study³¹ revalidates the information obtained in the articles of this category, since it associates the extensive workload that the caregiver dedicates to his function, a factor that generates overload, with higher depression rates due to the higher incidence of health problems and declining general well-being.

The research demonstrated the relationship between the work performed by the caregiver of the elderly and the development of depressive disorders. The selected nine Brazilian articles were classified by results into two categories. Thus, a higher prevalence of depression was found in the caregiver of the family type. In addition, the elderly caregiver's overload was analyzed as one of the factors that trigger depression in this professional.

Undeniably, the present work, by giving emphasis to the caregiver's role of the elderly, shows substantial importance in relation to society. In fact, it is necessary to emphasize the relevance of the care of the elderly caregiver, since the responsibilities of this caregiver have been increasingly demanded in view of the increase in life expectancy in Brazil. These practitioners are working to ensure that people over the age of 60 not only experience increased survival but also experience worthy senescence. In view of this, any position of negligence in relation to this professional should be combated, especially regarding his mental health, insofar as his dignity also deserves focus.

Despite the great value of addressing depression in caregivers of the elderly, in the search for articles, there was a lack of national studies on the subject. Thus, the present integrative review, besides synthesizing the knowledge built on this subject, also instigates the academic community to expand related research. This would represent an important step in overcoming the problem of caregiver overload and, therefore, offering these individuals an integral existence.

In addition, the monetary, social and health-related harm caused by the act of caring for the elderly, generates long-term complications for their caregivers, who need to be included in the conducts directed to the treatment of the patients. Therefore, it is essential to closely examine the aspects associated with the burden of caregivers to recognize those in threat of adverse outcomes, as well as the targets for possible interventions, to safeguard the health of the caregiver and the family nucleus and thus enrich the quality of care.

Although informal care is essential for the population, the burden on caregivers of the family type demands greater caution of health workers and managers. Habits such as questioning the caregiver about their level of stress, during the consultation of a dependent elderly, should be adopted. In addition, state funding of formal support services is a key factor in reducing informal assistance. The professionalization of family caregivers should also be included in this perspective.

It is evident that the tension involved in the responsibility of caring for affected elderly can be reduced through social support. This is associated with the individual’s satisfaction with his or her network of relationships and must include the following elements: affective, emotional, material, informational support and positive social interaction. As a result, mechanisms for reducing depression and aimed at improving the mental well-being of caregivers will be created. We hope that with these measures it is possible to provide a burden reduction, generating caregivers and their respective dependents’ quality of life improvements.

None.

 The authors declare there is no conflict of interest.

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