Introduction
The increase in the percentage of the elderly population has led to its emergence as a pervasive issue [1, 2]. One of the chronic problems of the elderly that threaten their independence and quality of life (QoL) is cognitive disorders [3], which include disorders in learning, memory, feeling, perception, and problem-solving [4]. Most elderly people are prone to depression due to chronic illness [5], which can lead to disability in the activities of the elderly’s daily life [6]. Also, after reaching the one-quarter retirement age, people cannot do their activities. Therefore, providing social support to these people is very important [7]. 
One of the significant challenges of the elderly is the physical limitation and inability to perform daily life activities, which can be caused by experiencing negative consequences such as reduced psychological and cognitive abilities and lack of social support [8, 9, 10].
This study was conducted to determine the relationship between social support, cognitive status, and depressive symptoms with daily living activities in the elderly in Amirkola City.
Materials and Methods
The current study is a case study and part of the first phase of the elderly cohort plan, approved by the Ethics Committee of Babol University of Medical Sciences (IR.MUBABOL.HRI.REC.1397.054) and performed on all people 60 years older and above living in Amirkola City in 2019. Of the 1,616 elderly people surveyed in the first phase, 59 had a disability in daily living activities (i.e., the prevalence of disability was estimated at 3%), which was considered as the case group, and more than three times (212 people) were considered as the control group. Inclusion criteria for the Amirkola cohort study were people’s consent to participate. Exclusion criteria were incomplete completion of questionnaires and unwillingness to continue the investigation.
Data collection was completed by completing questionnaires through interviews with elderly person or their companions. The first questionnaire included demographic questions; the second was the geriatric depression scale (GDS), which Malakouti et al. reported its alpha coefficient and reliability as 0.96 and 0.85, respectively [11]. The third questionnaire was a brief assessment of mental status as Mini-Mental State Examination (MMSE), which has good capability and reliability and is effective for differentiating people with the cognitive disorder [12]. The fourth questionnaire consists of the duke social support index (DSSI), which shows good enough validity and reliability with an alpha-Cronbach coefficient of 0.69 [13]. The fifth questionnaire includes activity daily living (ADL) which was evaluated using the Katz criterion [14], whose content validity was reported to be 0.82 [15]. Questionnaire 6 uses the instrumental activities of daily living (IADL) and was assessed using the Lawton Questionnaire [16] with a content validity of 0.82. IADLs are those activities that allow an individual to live independently in a community. Although not necessary for functional living, the ability to perform IADLs can significantly improve the QoL.
Data were analyzed by descriptive statistics (frequency, relative frequency, mean and standard deviation) and analytical tests (independent t-test, conditional logistic regression) at a significant level (P<0.05) using SPSS v. 21 software.
Results
In this study, most people were 75-79 years old (27.7%). The majority of the elderly were illiterate (80.8%), women (58.3%), and married (72.3%), and only 13.7% reported living alone. The majority of participants (51.7%) had depressive symptoms, of which 8.5% had severe depression. 32.1% of patients were cognitive, and 67.4% were healthy. Regarding social support, the majority (78.6%) believed they have good social support.
Ability to perform activities of daily living, including eating, getting dressed and undressing, walking, doing activities related to appearance, bathing or showering, going to bed or going out, controlling urination and defecation, and going to the bathroom. It divides people into two groups without disabilities and with disability. The study variables in these two groups were not significantly different regarding age, gender, level of education, and age groups. However, in the group with a disability, the number of people with depressive symptoms (72.9%), low cognitive status (52.5%), inability to perform daily life instrumental activities (96.6%), and moderate social support (49.2%) was significantly higher.
The results showed that the mean cognitive status of the elderly who were not disabled in daily activities was significantly higher than those with disabilities in daily living activities (P=0.039). The results also showed that in the elderly with disability in daily life activities, the mean score of depression and the presence of disease were significantly higher, and social support and the ability to use tools in daily life activities were significantly lower (P<0.05).
In conditional logistic regression with a 95% confidence interval (CI) (with independent variable ADL), adjustment was made based on marital status, level of education, and independent variables of depressive symptoms, social support, cognitive status, and chronic status diseases. Data in the raw model show that the elderly with depressive symptoms, cognitive disorders, and chronic diseases are more likely to be disabled. But in the modified model in the elderly with cognitive disorders (P=0.040, 95% CI (5.88-0.4), OR=2.47) and with chronic diseases (P=0.026, 95 % CI (9.15-1.74), OR 3.34) the chances of becoming disabled are higher. Elderly people with higher social support also have a lower chance of being unable to perform daily activities (P=0.001, 95% CI (0.41-0.6), OR=0.16).
Discussion
The presence of cognitive disorders and chronic diseases in the elderly has a positive and significant relationship with the disability to perform daily life activities. However, increasing social support has been effective in increasing the ability to perform daily activities in the elderly; so, annual screening of the elderly for chronic diseases and cognitive status and improving and expanding the social support network for the elderly can play an influential role in preventing functional disabilities and maintaining the level of activity of the elderly. Based on the findings of this study, it can be hoped that by carefully examining the health of the elderly in terms of chronic diseases and cognitive status, and social support by health teams and their family members, their disability to perform daily life activities can be prevented. With more emphasis on their psychological, cognitive, and social support, it can be possible to improve the daily activities of the elderly. 

Ethical Considerations
Compliance with ethical guidelines
The present research was carried out after being approved by the ethics committee of Babol University of Medical Sciences with code IR.MUBABOL.HRI.REC.1397.054.

Funding
This article is the result of the research project of the first author's master's degree thesis on geriatric health, in the Department of Social Medicine and Faculty of Medicine, Babol University of Medical Sciences, and was carried out with the financial support of the University's Research Vice-Chancellor.

Authors' contributions
Conceptualization: Samane Porhadi, Seyed Reza Hosseini, Shima Sam and Farzan Khairkhah; Research and review: Sima Khodadadi, Samane Porhadi and Seyed Reza Hosseini; Editing and finalization: All authors.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
We appreciate and thank the respected officials of the university and all the seniors who cooperated with us in this research.


References

1. Golchin Z, Mosallanezhad Z, Rahmati Yami M, Abootalebi M, Shahab A. [The relationship between BMI and muscle strength in elderly people living in Tehran (Persian)]. Physical Treatments: Specific Physical Therapy Journal (PTJ). 2013; 2(2):29-36. [Link]
2. Mirzaie M, Darabi S. [Population aging in Iran and rising health care costs (Persian)]. Salmand: Iranian Journal of Ageing. 2017; 12(2):156-69. [DOI:10.21859/sija-1202156]
3. Ahmadi M, Noudehi M, Esmaeili M, Sadrollahi A. [Comparing the quality of life between active and non-active elderly women with an emphasis on physical activity (Persian)]. Iranian Journal of Ageing. 2017; 12(3):262-75. [DOI:10.21859/sija.12.3.262]
4. Joghataei MT, Nejati V. [Assessment of health status of elderly people in the city of Kashan (Persian)]. Salmand: Iranian Journal of Ageing. 2006; 1(1):3-10. [Link]
5. Maghsoudi A, Koohshoorinia Y, Hoseini M, Karami P, Atbaee M, Bahadori Z, et al. [Comparison of quality of life among elderly people living in homes and nursing homes in Lar (Persian)]. Sadra Medical Journal. 2017; 5(3):119-29. [Link]
6. Dev MK, Paudel N, Joshi ND, Shah DN, Subba S. Psycho-social impact of visual impairment on health-related quality of life among nursing home residents. BMC Health Services Research. 2014; 14:345. [DOI:10.1186/1472-6963-14-345] [PMID] [PMCID]
7. Bastami F, Salahshoori A, Shirani F, Mohtashami A, Sharafkhani N. [Risk factors of depression on the elderly: A review study (Persian)]. Journal of Gerontology. 2016; 1(2):54-65. [DOI:10.18869/acadpub.joge.1.2.54]
8. Sadock BJ, Sadock VA, Kaplan HI. Kaplan and Sadock’s concise textbook of child and adolescent psychiatry. Philadelphia: Lippincott Williams & Wilkins; 2009. [Link]
9. Nourhashémi F, Andrieu S, Gillette-Guyonnet S, Vellas B, Albarède JL, Grandjean H. Instrumental activities of daily living as a potential marker of frailty: A study of 7364 community-dwelling elderly women (the EPIDOS study). The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2001; 56(7):M448-53. [DOI:10.1093/gerona/56.7.M448] [PMID]
10. Mesgar S, Amini Nasab Z, Nakhaei MH, Sharifzadeh G, Javadinia SA. [Study of quality of life, depression, and daily routines in rural elders in Birjand city, Iran, in 2013 (Persian)]. Iranian Journal of Ageing. 2015; 10(3):142-7. http://salmandj.uswr.ac.ir/article-1-753-en.html
11. Wong ST, Wu A, Gregorich S, Pérez-Stable EJ. What type of social support influences self-reported physical and mental health among older women? Journal of Aging and Health. 2014; 26(4):663-78. [DOI:10.1177/0898264314527478] [PMID] [PMCID]
12. Kazemi H, Ghasemi S, Sharifi F, Fakhrzadeh H, Ghaderpanahi M, Mirarefin M, et al. [The relationship between mental state and functional status in elderly residents of Kahrizak (Persian)]. Iranian Journal of Ageing(Salmand). 2010; 4(2):16-25. [Link]
13. Aliakbari-Dehkordi M. Growth psychology. Tehran: Payam Noor University; 2021. [Link]
14. Malakouti SK, Fatollahi P, Mirabzadeh A, Salavati M, Zandi T. Reliability, validity and factor structure of the GDS-15 in Iranian elderly. International Journal of Geriatric Psychiatry. 2006; 21(6):588-93. [PMID]
15. Folstein MF, Folstein SE, McHugh PR. Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research. 1975; 12(3):189-98. [DOI:10.1016/0022-3956(75)90026-6] [PMID]
16. Seyedian M, Falah M, Nourouzian M, Nejat S, Delavar A, Ghasemzadeh HA. [Validity of the Farsi version of mini-mental state examination (Persian)]. Journal of Medical Council of IRI. 2008; 25(4):408-14. [Link]
17. Faramarzi M, Hosseini SR, Cumming RG, Kheirkhah F, Parsaei F, Ghasemi N, et al. A negative association between social support and depression in the elderly population of Amirkola City. Journal of Advances in Medicine and Medical Research. 2015; 8( 8):707-16. [DOI:10.9734/BJMMR/2015/15111]
18. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: The index of ADL: A standardized measure of biological and psychosocial function. JAMA. 1963; 185:914-9. [DOI:10.1001/jama.1963.03060120024016] [PMID]
19. Tanjani PT, Azadbakht M. [Psychometric properties of the Persian version of the activities of daily living scale and instrumental activities of daily living scale in elderly (Persian)]. Journal of Mazandaran University of Medical Sciences. 2016; 25(132):103-12. [Link]
20. Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist. 1969; 9(3):179-86. [DOI:10.1093/geront/9.3_Part_1.179] [PMID]
21. Hosseini SR, Zabihi A, JafarianAmiri SR, Bijani A. The relationship between chronic diseases and disability in daily activities and instrumental activities of daily living in the elderly. Journal of Babol University Of Medical Sciences. 2018; 20(5):23-9. [Link]
22. Golden J, Conroy RM, Lawlor BA. Social support network structure in older people: Underlying dimensions and association with psychological and physical health. Psychology, Health & Medicine. 2009; 14(3):280-90. [PMID]
23. Stuck AE, Walthert JM, Nikolaus T, Büla CJ, Hohmann C, Beck JC. Risk factors for functional status decline in community-living elderly people: A systematic literature review. Social Science & Medicine. 1999; 48(4):445-69. [DOI:10.1016/S0277-9536(98)00370-0]
24. Seyfzadeh A, Hagighatian M, Mohajerani A. [The relationship between social isolation and health among the Tehranian elderly (Persian)]. Journal of Education and Community Health. 2017; 4(3):19-25. [DOI:10.21859/jech.4.3.19]
25. Hekmatipour N, Hojjati H, Sharifnia Sh, Akhondzade G, Nikjou A, Mirabolhasani M. [Impact of routine exercises on elderly’s depression rate (Persian)]. Journal of Health Education and Health Promotion. 2013; 1(3):23-32. [Link]
26. Khalili F, Sum S, Sharifirad G, Hassanzadeh A, Kazemi M. [The relationship between perceived social support and social health of elderly (Persian)]. Journal of Health System Research. 2012; 6(7):1216-25. [Link]
27. Kunz R, Minder M. COVID-19 pandemic: Palliative care for elderly and frail patients at home and in residential and nursing homes. Swiss Medical Weekly. 2020; 150:w20235.[DOI:10.4414/smw.2020.20235] [PMID]
28. Najafi M, Baseri A. [Relationship of perceived social support and self-actualization with life expectancy in the elderly in Tehran (Persian)]. Journal of Education and Community Health. 2018; 4(4):56-64. [DOI:10.21859/jech.4.4.56]
29. Maresova P, Javanmardi E, Barakovic S, Barakovic Husic J, Tomsone S, Krejcar O, et al. Consequences of chronic diseases and other limitations associated with old age- a scoping review. BMC Public Health. 2019; 19(1):1431. [DOI:10.1186/s12889-019-7762-5] [PMID] [PMCID]
30. Portela D, Almada M, Midao L, Costa E. Instrumental Activities of Daily Living (iALD) limitations in Europe: An assessmant of SHARE DATA. International Journal of Environmantal Research and Public Health. 2020; 17(20):7387. [DOI:10.3390/ijerph17207387] [PMID] [PMCID]
31. Lee MT, Jang Y, Chang WY. How do impairments in cognitive functions affect activities of daily living functions in older adults? PloS One. 2019; 14(6):e0218112. [DOI:10.1371/journal.pone.0218112] [PMID] [PMCID]
32. Mazloomy-Mahmoudabad SS, Soltani T, Morowatisharifabad MA, Fallahzadeh H. [Activities of daily living and prevalence of chronic diseases among elderly people in Yazd (Persian)]. Toloo-E-Behdasht. 2014; 13(3):42-53. [Link]
33. Mehta KM, Yaffe K, Covinsky KE. Cognitive impairment, depressive symptoms, and functional decline in older people. Journal of the American Geriatrics Society. 2002; 50(6):1045-50. [DOI:10.1046/j.1532-5415.2002.50259.x] [PMID] [PMCID]
34. Gold DA. An examination of instrumental activities of daily living assessment in older adults and mild cognitive impairment. Journal of Clinical and Experimental Neuropsychology. 2012; 34(1):11-34. [PMID]
35. Lin LP, Hsu SW, Hsia YC, Wu CL, Chu C, Lin JD. Association of early-onset dementia with activities of daily living (ADL) in middle-aged adults with intellectual disabilities: The caregiver’s perspective. Research in Developmental Disabilities. 2014; 35(3):626-31. [DOI:10.1016/j.ridd.2013.12.015] [PMID]
36. Alizadeh-Khoei M, Khosbin S, Khavarpour F. [Assessing quality of life, well being and depression among Iranian ederly in Australia (Persian)]. Iranian Journal of Ageing. 2010; 4(4):15-26. [Link]
37. Nourbakhsh SF, Fadayevatan R, Alizadeh-Khoei M, Sharifi F. [Determining the status of activity of daily living (ADL) and instrumental activity of daily living (IADL) in healthy and cognitive impaired elderlies (Persian)]. Jorjani Biomedicine Journal. 2018; 5(2):63-77. [Link]
38. Vafaei Z, Haghdoost AA, Alizadeh M, Dortaj E. [Prevalence of disability and relevant risk factors in elderly dwellers in Isfahan province-2012 (Persian)]. Iranian Journal of Ageing. 2014; 8(4):32-40. [Link]
39. Schoevers RA, Deeg DJ, van Tilburg W, Beekman AT. Depression and generalized anxiety disorder: Co-occurrence and longitudinal patterns in elderly patients. The American Journal of Geriatric Psychiatry. 2005; 13(1):31-9. [DOI:10.1097/00019442-200501000-00006] [PMID]
40. Shahbazi M R, Foroughan M, Salman Roghani R, Rahgozar M. [The relationship between disability and variables of depression, cognitive status, and morale among older people (Persian)]. Iranian Journal of Ageing. 2016; 11(1):132-41. [DOI:10.21859/sija-1101132]
41. Scott KM, Collings SC. Gender and the association between mental disorders and disability. Journal of Affective Disorders. 2010; 125(1-3):207-12. [DOI:10.1016/j.jad.2010.06.022] [PMID] [PMCID]
42. Mohamadzadeh M, Rashedi V, Hashemi M, Borhaninejad V. [Relationship between activities of daily living and depression in older Adults (Persian)]. Iranian Journal of Ageing. 2020; 15(2):200-11. [DOI:10.32598/sija.13.10.180]
43. Wada T, Ishine M, Sakagami T, Okumiya K, Fujisawa M, Murakami S, et al. Depression in Japanese community-dwelling elderly-prevalence and association with ADL and QOL. Archives of Gerontology and Geriatrics. 2004; 39(1):15-23. [DOI:10.1016/j.archger.2003.12.003] [PMID]
44. Bozo O, Toksabay NE, Kürüm O. Activities of daily living, depression, and social support among elderly Turkish people. The Journal of Psychology. 2009; 143(2):193-205. [PMID]
45. Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. The Lancet Public health. 2020; 5(5): E256. [DOI:10.1016/S2468-2667(20)30061-X]
46. World Health Organization. Mental health and psychosocial considerations during the COVID-19 outbreak. Geneva: World Health Organization; 2020. [Link]