## 4 Discussion  
Frequency and Co-Existence of Depressive Symptoms and Cognitive Impairment in Users of Municipal Home Care Services  
Our research delves into the prevalence of depressive symptoms and cognitive impairment among older users of municipal home care services, a population particularly vulnerable due to disability, chronic disorders, loneliness, lack of family, or professional care. Compared to the prevalences of depressive symptoms and cognitive decline in older individuals in Greece (19.5% and 18.1%, respectively), which have been recently reported that such symptoms were detected in significantly more users of home care services, and particularly in 58.3% and 76.8% of study participants. Notably, the prevalence of moderate to severe depressive symptoms had been found to be lower in the general population of older adults compared to that in home care service users (6.4% vs. 20.2%). In line with our observations, a study focusing on low-income, homebound, middle-aged and older adults underlined the common occurrence of depression within this population [28].The higher frequency of depressive symptoms in users of home care services can pertain to the high number of their physical comorbidities, since they suffered from 3.71 somatic diseases on average, while the prevalence of at least two co-existing diseases in the 60-74 age group of the general population does not exceed 50% [29] and there is a significant dose-response relationship between the number of medical comorbidities and the prevalence of depression in older adults [30]. In addition, the low education levels, the old age, and experiences of loneliness may also explain the high frequency of depressive symptoms detected in our sample. In particular, the low educational level is a positive predictor of depressive symptoms in older adults, since it is a marker of low cognitive and brain reserve, a risk factor for late-life depressive events [31]. The detected high frequency  
Figure 2: Heatmap of factors influencing psychogeriatric service utilization which was generated using Python (v3.10), employing the seaborn and matplotlib libraries. [PERSON]’s rank-order correlation was applied to quantify associations; heatmaps were used to visualize the strength and direction of these relationships.  
of cognitive impairment can also be related to the low cognitive and brain reserve of home care service users [32]. Further factors possibly linked to the high frequency of cognitive impairment in our sample are the loneliness and the low physical activity related to the presence of many comorbidities and disability, since physical activity and social connection are important in maintaining and fostering healthy brain aging [33; 34; 35].  
Depressive symptoms were found to co-exist with cognitive deficits in almost half of the home care service users that participated in the study. The relationship between depression and dementia is complex and has not been fully disentangled yet. Depressive symptoms are thought to be a risk factor for cognitive decline and dementia, while they can also embody an early sign or prodrome of dementia, since brain degenerative changes precede the onset of cognitive impairment by several years [36]. This complex relationship is possibly explained by the fact that the pathogenesis of depressive symptoms in aging is interlinked with core aspects of the pathomechanism of Alzheimer's disease (AD) [36].