OJHAS Vol. 10, Issue 4:
among Elderly People Living in Old Age Homes and
in the Community: A Comparative Study
Anil Kumar Mysore
Nagaraj, Senior Resident, Department of Psychiatry,
Joseph Mathew, Final year MBBS,
Raveesh Bevinahalli Nanjegowda,
Associate Professor and Head, Department of Psychiatry,
Sumanth Mallikarjuna Majgi, Assistant Professor, Department of Community Medicine,
Purushothama SM, Assistant Professor, Department of Physiology,
Mysore Medical College and Research Institute, Mysore- 570001, Karnataka, India.
Dr. Anil Kumar Mysore Nagaraj,
Address for Correspondence
Senior Resident, Dept of Psychiatry,
Mysore Medical College & Research Institute,
Nagaraj AKM, Mathew J, Nanjegowda RB, Majgi SM, Purushothama SM. Psychiatric Morbidity
among Elderly People Living in Old Age Homes and
in the Community: A Comparative Study. Online J Health Allied Scs.
Submitted: Nov 20,
2011; Accepted: Jan 4, 2011; Published: Jan 15, 2011
Disorders such as depression, anxiety, cognitive and psychotic disorders
have a high prevalence among elderly. There is some preliminary evidence
that life in old age homes is perceived by inmates as more supportive,
though the issue is not well studied. Aim: This project is
directed towards studying and comparing the psychiatric morbidity and
quality of life of elderly people residing in two unique settings: community
and old age homes. Method: It is a cross-sectional study where
the elderly subjects, 50 each in both the groups, were selected by simple
random sampling technique and assessed on Mini Mental Status Examination
(MMSE), Informant Questionnaire on Cognitive Decline in Elderly (IQCODE),
Brief Psychiatric Rating Scale (BPRS) and Quality of life visual analogue
scale. Result: On comparison using suitable statistical analysis,
there was no significant difference in the total scores on MMSE, IQCODE
and quality of life scale across the groups. Depression was present
in 22% of people in the community and 36% of old age home inmates. Psychosis
was present in 26% of people in the community and 20% of old age home
inmates. Conclusion: The psychiatric morbidity is high in elderly
irrespective of the setting in which they live.
Elderly people; Old age homes; Psychiatric morbidity; Cognitive disturbances; Quality of life.
Age is an important
determinant of mental illness. The overall prevalence of mental and
behavioural disorders tends to increase with age due to the normal ageing
of the brain, deteriorating physical health and cerebral pathology.(1) Lack of family support and restricted personal autonomy are other
important contributing factors. Psychiatric morbidity among elderly
people is frequent, severe and diverse. Disorders such as depression,
anxiety, cognitive and psychotic disorders have a high prevalence in
this segment of the population.(2) Studies show that up to 20% being
cared for in the community and about 37% being cared for at the primary
level are suffering from depression.(3)
aged population is currently the second largest in the world and is
projected to rise from 70 million, according to the National Census
of 2001, to almost 324 million by the year 2050, with serious social,
economic and public health consequences.(3) Global trends in the incidence and prevalence of geropsychiatric disorders
are reflected in India too. Dube, in 1970, reported the prevalence of
mental illnesses in the elderly to be 2.23%, Nandi and co-workers in
1975, as 33.3%, Ramachandran and co-authors in 1979, as 35% and Tiwari
SC in 2000, found it to be much higher in the geriatric group (43.32%,
compared to 4.66% in the non-geriatric group).(4-7) Sood and his team reported that the most common psychiatric morbidities
in the Indian set up were Depression, Adjustment Disorders, Anxiety
Disorders, Dementia and Delirium (Cognitive Disorders), Psychoses, Bipolar
Disorders and Substance-related psychiatric illnesses.(8) Further, multiple factors are known to affect mental health in old age.
Female sex, low education or illiteracy, being widow/widower/divorcee,
medical co-morbidities, poor socio-economic status and disability are
all well established as playing significant role in psychiatric illnesses
among elderly.(8,15-21) As the majority of elderly in India are illiterate,
their living conditions depend upon their co-residence with children
and/or their ability to work and earn an income beyond the officially
designated age of retirement.(9) In this scenario, due to the increased physical and economic dependence,
more and more elders are compelled to stay in old age homes. There is
some preliminary evidence that life in old age homes is perceived by
inmates as more supportive. Those in old age homes are psychologically
better and experience less cognitive impairment.(22,23) However, this
issue is not well studied and hence definitive evidence is lacking.
is directed towards studying and comparing the psychiatric morbidity
and quality of life of elders residing in two unique settings; elders
living in the community who still retained their family ties and those
residing in homes for the aged, whose families or caregivers, for some
reason, had enrolled them at the facility.
The study sample
was selected from two of the largest old age homes (one private and
the other philanthropic) and three different localities representative
of the community where elderly people lived along with their family
members. All the five locations are in urban Mysore
It is a cross-sectional
study where the psychiatric morbidity and quality of life of elderly
population in the two said living setups were compared. The study was
conducted in two months, from 15th Jul 2010 to 15th
Sep 2010. Subjects were selected by simple random sampling technique.
In old age homes, the subject on every alternate bed of the dormitory
was interviewed. When the candidate on a particular bed did not meet
the criteria to be included in the study, the candidate on the next
alternate bed was assessed. In case of community sample, every third
house in the given locality was looked into for an elderly subject.
If the candidate in a particular house was not found to be suitable
for this study, the next third house was selected. Elderly people
were defined as those aged 60 years or above.(10) All persons aged 60 years or above, who gave consent to participate
and those with an informant were selected to participate in the study.
The subjects having medical co-morbidities were also included in the
study provided it is not-severe enough to prevent him/her from participating
in the study. Persons aged less than 60 years, terminally ill patients,
uncooperative persons, those without informants and those who did not
give consent to take part in the study were excluded.
The total sample
size was 100, of whom 50 resided in the community (denoted as G1) and
50 stayed in Homes for the Aged (referred to as G2). Each group included
25 males and 25 females. Clearance was obtained from the Institution
Ethics Committee for carrying out this study. Elderly people were interviewed
either at their respective residences or in the Homes for the Aged.
The Authorities in charge of the Homes for the Aged where the study
was to be conducted were contacted prior and permission obtained. In
the community, a door-to-door survey was undertaken. Informed consent
was taken from all participants who volunteered for the study. After
obtaining consent, each person was interviewed on the socio-demographic
data sheet. Then all those included in the study were subjected to evaluation
by administering the four study questionnaires – Mini Mental Status
Examination (MMSE) (11), Informant Questionnaire on Cognitive Decline
in Elderly (IQCODE) (12), Brief Psychiatric Rating Scale (BPRS) (13)
and a quality of life visual analog scale called Delighted Terrible
Scale (DTS) (14) developed by Heinrichs and colleagues. The above
mentioned instruments were used in this study to compare Cognitive deficits
(MMSE and IQCODE), Psychiatric morbidity (BPRS) and the satisfaction
an elderly subject reports in his life (Quality of Life). Those recording
a score of 4 or more on the item of depressed mood were interviewed
by ICD 10. All assessments of one subject were finished in a single
session. The data was then analyzed.
Analysis: The Statistical Package for Social Sciences (SPSS 17.0) software
for Windows was employed for the statistical analysis. Descriptive statistics was applied to calculate means. Cross Tabs were
used for comparisons of age, education, marital status, medical co-morbidity.
BPRS scores between the two groups and associations were tested for
significance using Chi-square tests. T tests were used to compare the
scores of MMSE and IQCODE and Pearson correlations were used to examine
associations between these variables. Differences in MMSE scores by
education level and in cognitive function by years of stay in old age
homes were determined using one-way ANOVA and Tukey’s HSD post-hoc
test. Mann Whitney U test was used to compare the Quality of Life variables
between the two groups. A correlation was plotted between the MMSE scores
standardised for education and the IQCODE. Statistical significance
was set at p<0.05 for all comparisons.
of variables on the socio-demographic sheet and on the different tools
of assessment was done. The items on socio-demographic sheet that were
compared are age, years of education, marital status, and medical co-morbidity.
Most individuals (n=29) belonged to the 70-74 year category. The average
age of the individuals living in the community and in old age homes
was 72.96±7.63 and 72.70±7.62 years respectively. In both the groups,
majority belonged to the group of 6-11 years of education. The age distribution,
years of education and medical co-morbidities across the two groups
were evenly matched. The comorbidities we looked into were the presence
of some common chronic conditions like hypertension, diabetes mellitus,
bronchial asthama/bronchitis, cerebrovascular disorders and others.
For analysis, we further categorized it as the presence of nil, one,
two, three or more co-morbidities. More people in the community were
currently married and staying with the partner (n=30) compared to old
age homes (n=18). This differed significantly. The details are shown
in Table 1 and Figure 1.
Table 1: Comparison
of Socio-demographic variables across the two groups
Figure 1: Comparison of Marital Status in the two Groups
The data on
MMSE and IQCODE was normally distributed. The paired t test was used
to compare the scores of groups on these questionnaires. There was no
significant difference in the individual items as well as the total
scores on both the questionnaires. Table 2 represents this comparison.
There was no cognitive impairment recorded on MMSE in 34% of people
in both groups. Rest of them in both settings were classified as having
mild or severe impairment based on their total score ie 18-23 and 0-17
respectively. The groups were evenly matched with respect to cognitive
functioning. This is represented in Table 3. The scores on MMSE varied
with education, higher the education, better the score. This is depicted
in Figure 2. The groups were also evenly matched for their cognitive
abilities on IQCODE, which is an objective assessment. Table 4 gives
a comparison of this.
Table 2: Comparison of MMSE and IQCODE scores in the two Groups
G1 [n = 50] Mean
G2 [n = 50] Mean
||22.78 ± 4.76
||23.64 ± 4.92
||3.32 ± 0.28
||3.40 ± 0.33
G1: Community; G2: Home
for the Aged
3: Cognitive Impairment based on MMSE score in the two Groups
Cognitive Impairment based
G1: Community; G2: Home
for the Aged
4: Cognitive Impairment based on IQCODE score in the two Groups
Cognitive Impairment based
G1: Community; G2: Home
for the Aged
2: Variation of MMSE Scores with education across the groups
In BPRS, those
who scored ≥4 on individual items were considered for comparison.
Out of the 18 items of BPRS, three items differed significantly across
the groups, when compared by Chi-square test. Motor retardation was
the most common symptom in both groups (n= 21 for G1 and n=33 for G2)
and it differed significantly (p=0.01) favouring those in the community.
Other items that were differing significantly were grandiosity (n= 8
for G1 and n=2 for G2) (p=0.046) and emotional withdrawal (n=11 for
G1 and n=4 for G2) (p=0.05), both favouring those staying in old age
homes. The severity of grandiosity was moderate (score 4) in all cases
and it did not require hospitalization. Depressive mood, somatic concern,
anxiety and blunted affect were the other symptoms recorded frequently
in both the groups. However, none of the other 15 items of BPRS reveal
any significant statistical difference across the two groups. Those
who scored at least 4 on items of depression were further evaluated
on ICD 10. Twenty two percent of those in community were found to have
mild to moderate depression as compared to 36% of old age home inmates.
On comparison, it was not statistically significant (p=0.063). Further,
26% of elderly in community setting had psychosis as compared to 20%
in old age homes, as assessed by the items for psychosis (conceptual
disorganization, grandiosity, hostility, suspiciousness, hallucinatory
behavior, unusual thought content, excitement) on BPRS. On comparison,
there was no statistical significance (p=0.24). The quality of life
was assessed on the visual analogue scale –Delighted Terrible Scale,
by Mann Whitney U Test. The mean ranks were 51.69 for G1 and 49.31 for
G2. On comparison, they were evenly matched (p=0.676).
Thus on comparing
the total scores on MMSE, average scores on IQCODE and mean ranks of
Delighted Terrible Scale, there was no significant difference. In BPRS,
the three items namely emotional withdrawal, grandiosity and motor retardation
varied significantly but rest of items did not differ. Though both groups
revealed cognitive impairment, clinical depression and psychosis, there
was no significant difference between them.
This is a cross-sectional
study, in which we compared the psychiatric morbidity of elderly people
in two setups: community and old age home. It is an established fact
that among elderly, older the age, low education levels and past history
of psychiatric illness are all the predictors of cognitive disorders.
(15-18) Further female sex, medical co-morbidity, poor social-economic
status, widowed state, disability are some of the strong predictors
of geriatric depression.(8,15,19-21) However there is no substantial
evidence as to staying in community with one’s own people has a positive
impact on one’s psychological status than staying in old age homes.
On the contrary, the available scant literature favours residents of
old age home.(22, 23) Thus the study was carried out on a hypothesis
based on available literature.
Age is the
vital variable in geriatric mental disorders. The two groups were evenly
matched with respect to the age. In our study, marital status differed
significantly across the two groups. More number of elderly were currently
married and staying with their partners in the community setting. Marital
status is an important favourable factor associated with geriatric depression.
Many studies have revealed that depression in elderly is associated
with widowed state or staying alone.(15,19) In our study, old age
home inmates (38%) suffered depression more commonly than those in their
own homes (22%). One of the factors associated with this could be that
most of them stayed alone. Medical co-morbidities also did not differ
significantly in our study. Further, our study corroborated the earlier
studies that inferred higher the education, better the cognitive function.(7,15,17,19)
the cognitive function, both objective (IQCODE) and subjective (MMSE)
assessment tools were used. MMSE identified mild cognitive impairment
in 20% of elderly living in community as compared to 24% in old age
home inmates. Severe impairment was seen in 12% and 8% respectively.
The IQCODE determined 36% of community dwelling elderly to have significant
cognitive impairment. It was 46% in case of the old age home inmates.
The cognitive impairment on both these instruments was not statistically
significant across the groups. Recent studies suggest that over half
of the residents of old age homes have some degree of dementia.(24,25) We did not determine dementia in those with cognitive decline, using
diagnostic manuals. We have come across many studies that have used
MMSE alone for assessment of cognitive impairment.(26-28) In a prospective
study, over eight years, it was identified using MMSE that 53% of the
elderly suffered minor cognitive decline and 16% major cognitive decline.(26) Though ours is a cross-sectional study, the rate of cognitive impairment
detected is comparable to other studies.
nine percent of the total sample had depression. Twenty two percent
of those in community were found to have mild to moderate depression
as compared to 36% of old age home inmates. On comparison, it was not
statistically significant. Many studies have found depression to be
a common psychiatric morbidity in elderly.(6,8,29-31) Worldwide,
a number of studies have estimated the prevalence of depression in non-demented
elderly to be 40%.(32,33) Some community based studies have revealed
that the point prevalence of depressive disorders among the geriatric
population in India varies from 13% to 25%.(19,34) However cognitive
impairment often co-exists with depression in elderly patients. Thus
due to high prevalence of dementia and the difficulties in assessing
mood in people with severe dementia, it is difficult to predict the
exact prevalence of depression.(35) Further, 23% of the sample population
was found to have psychosis. When classified under groups, 26% of those
in community and 20% of those in old age homes had psychosis. This
difference across the groups was not statistically significant. According
to the existing literature, the overall prevalence of psychosis in the
elderly living in community is about 5%. It ranges from 10 to 63% in
nursing home populations.(36,37) In our study the presence of psychosis
in community is 26% which is higher than that reported in other studies.
However this is based on scores on BPRS and no diagnostic manual was
used. Also for a community based study, the sample size could have been
larger. We did not compare males and females for psychiatric morbidity
as our primary objective was to compare the influence of two different
settings for cognitive impairment and psychological well being. Also,
we did not administer any diagnostic schedule to assess and diagnose
other possible psychiatric disorders. However, for treatment purposes,
a psychiatrist consultation was suggested to the authorities of old
age homes and to the family members of elderly living in the community.
Ours is a cross-sectional
community based study where subjects were recruited by simple random
technique. The total sample size was 100, divided as 50 each from community
and old age homes. The authors did not come across studies done in similar
settings with similar methodology. However a relevant study that compared
psychiatric morbidity of elderly in old age home and those visiting
a hospital is also a cross-sectional study with a sample size of 92.
People in old age home had a significantly better perception of social
support and felt better than those living with their children’s family.(23) Another recent study undertaken to investigate the dependency and
health status of a cohort of older people admitted to long term nursing
and residential care compared the cognitive impairment of elderly in
the two settings. It is a retrospective cohort study with a sample size
of 205. In this study, again people in residential homes, despite having
more disability were found to have lesser cognitive impairment.(22)
Though the longitudinal studies are ideal for assessing the cognitive
impairment in elderly, attrition is high due to various reasons including
death. All in all, our results are comparable to these studies to the
extent that staying in old age homes is at least as good as staying
in their own homes.
morbidity is high in elderly irrespective of the setting in which they
live. Education and living with spouse are the factors associated with
better psychological health. It could not be established from our study
that living in old age home is associated with significantly better
psychological well being and cognitive abilities than living in community
with one’s own family members.
sincerely and graciously express their gratitude to Indian Council of
Medical Research, New Delhi, India, for funding this project under short
term studentship Reg No 2010-01234.
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