Geriatric Depression Among Elderly People Residing in Old Age Homes

INTRODUCTION

The United Nations Population Fund found the number of over-60s will increase from around 100 million today to more than 300 million by 2050 and warned the government to prepare for the additional strain this will put on families and health and welfare services. It also predicted the number of over80s will increase sevenfold.¹

India will soon become home to the second largest number of older people in the world. The challenges are unique with this population in India. A majority 80% of them are in the rural areas, making service delivery a challenge, feminization of the elderly population 51% of the elderly population would be women by 2016, increase in the number of the older persons above 80 years and 30% of the elderly are below poverty line,” the internal ministry note said. WHO report, patients over 55 years with depression have a four times higher death rate than those without depression. According to the 2006 World Population Prospects, the number of Indians aged above 80 will increase more than six times from existing 78 lakh to about 5.14 crore by 2050. 20% of this category suffers from Alzheimer’s. WHO says around 4%-6% of elderly people experience some form of maltreatment at home. Elder maltreatment can lead to serious physical injuries and long-term psychological consequences. Maltreatment of elder citizens is an important public health problem. One in every four among India’s elderly population is depressed, and one in three suffers from arthritis, while one in five cannot hear. While one in three suffers from hypertension in rural India and one in two in urban areas, almost half have poor vision. Around one in 10 experiences a fall that results in fracture, while two in five are anemic. One in 10 in rural India and two in five in urban areas suffer from diabetes, with nearly 31% suffering from bowel disorders.²

The elderly population will increase to 12% of the total population by 2025, 10% of whom would be bedridden, requiring utmost care. The ministry’s revised National Program for the Healthcare of the Elderly (NPHCE) expects to have 20 institutions with capacity to produce 40 post-graduates in MD(Master Degree) in geriatric medicine per year, additiona l 6,400 beds in district hospitals and 1,000 beds in medical colleges for the elderly by 2017. It also envisages geriatric clinics in OPD and physiotherapy units in 640 district hospitals with more than 2,000 geriatric clinics in community and primary health centers. The group has suggested setting up of the National Institute of Aging in New Delhi and Chennai attached to AIIMS and Madras Medical College, respectively. Under the proposal, 12 additional Regional Geriatric Centers will be developed in Chandigarh, Lucknow, Jharkhand, Kolkata, Hyderabad, Bangalore, Ahmadabad, Nagpur, Cuttack, Agartala, Bhopal and Patna.2 Life expectancy having increased from 40 years in 1951 to 64 years today, a person today has 20 years more to live than he would have 50 years back.³

Mental disorders induce functional disability, disturb rehabilitation, burden the health system and impair life-quality of old patients and their relatives. Geriatric patients are characterized by suffering from multiple diseases, being acutely at risk in the case of somatic disorders. Among all mental disorders faced by the elderly, depression is the most common one.⁴ 

It’s natural to feel down sometimes, but if that low mood lingers day after day, it could signal depression. Major depression is an episode of sadness or apathy along with other symptoms that lasts at least two consecutive weeks and is severe enough to interrupt daily activities. Depression is not a sign of weakness or a negative personality. It is a major public health problem and a treatable medical condition. As of yet, there is no lab test for depression. To make an accurate diagnosis, doctors rely on a patient’s description of the symptoms. You’ll be asked about your medical history and medication use since these may contribute to symptoms of depression. Discussing moods, behaviors, and daily activities can help reveal the severity and type of depression. This is a critical step in determining the most effective treatment.⁵

OBJECTIVE

• To assess the level of geriatric depression among elderly people in selected rural old age homes.

METHODS

This was a cross sectional descriptive study that was conducted in rural old age homes inTumkur district, Karnataka, India for a period of two months between June and August 2017. Out of the total population of 5037 in the village, geriatric population was 554. Out of these 554 people, only 80 were taken for the study. Cluster random sampling Rural old age homes survey was done for collection of data. Four old age homes in rural area was visited by the investigator and all elderly persons aged 60 years and above were included in the study, after obtaining informed consent. Data collection instrument included a short demographic questionnaire with items on on age, gender, educational status, marital status, minor ailments. In order to assess the depression status of the study population, data was collected using a predesigned and pre-validated 30 item Geriatric Depression Scale (GDS), which is developed by Yesavage JA in 1983¹¹. It screens for seven characteristics of depression in elderly, which are somatic concerns, lower affect, cognitive impairment, feelings of discrimination, impaired motivation, lack of future orientation and lack of self-esteem.⁶ 

Geriatric Depression Scale (GDS) : This scale is one of the most widely used scales for assessing depressed mood among elderly.⁸ It is composed of 30 self-rating items with a yes/no response option. Score of 0–10 indicates no depression, 11– 20 indicates mild depression and 21–30 indicates severe depression.⁹ This scale can be administered to healthy, medically ill and mild to moderate cognitively impaired elderly.¹⁰ It has demonstrated 92 percent sensitivity and 89 percent specificity. Its psychometric properties have been found to be consistently good in clinical as well as research settings.¹¹ Present study used the 30 item version of the scale. 

Ethical consideration: The ethical approval for the research was obtained and Official permission was also sought from concerned authorities at Old age homes, Participants were informed about the objective of the study. A written consent was obtained from participants. Participants were interviewed by researcher. Average time for one interview was 40 minutes Data collected was analyzed using EpiInfo software.

RESULTS

I. Overall prevalence of depression in Elderly People

The overall prevalence of depression in elderly in the study population was estimated to be 62.16% (p-value=0.4396). The most commonly endorsed symptom (83.01% of all subjects) was a positive response to the question, “Do you feel that your life is empty?”. The second most commonly endorsed symptom was a positive response to the question, “Have you dropped many interests and hobbies?” (75.87% subjects) which was also the second most common endorsed symptom in the study conducted by Ganguli M et al(12) and was 57.2% in their study. More than half of the study population endorsed symptoms that they often get bored and helpless. Slightly less than half of them but more than 30% endorsed other symptoms like lack of energy, memory problems, feeling of hopelessness, dissatisfaction, unhappiness, feeling of worthlessness. (Table 1) 

DISCUSSION

Depression is an important condition in older adults that is often overlooked as a clinical diagnosis and assumed to be a normal response to aging, physical losses or other life events.⁴ Serious depressive symptoms were found in 8 – 20% of elderly in community and 37% of elderly in primary care setting (U.S Public health service 1999). Presence of co-morbid depression greatly increases health care cost with decrement in function and well being, that are similar to those associated with chronic medical disease.¹⁵

In this study, the estimated overallprevalence of depression in elderly people is 62.16%, almost consistent with another study conducted in urban Steffens DC et al 14. Our results differed from the studies conducted by Steffens DC et al 15 where overall prevalence of depression in the elderly was estimated to be 43.32%, respectively. This difference in the prevalence of depression amongst the elderly could be most likely due to the difference in study settings, family composition and support, as well the basic customs and traditions prevalent in the area that influence the support systems in place. The elderly population in rural setting have increased risk of depression due to lack of awareness and lack of availability of health services and confusing as it is the part of aging. Also, prevalence of depression was highest in the elderly age group 60-70 years. Communitybased mental health studies conducted in India have revealed a variable prevalence of depressive disorders. The point prevalence of depressive disorders in the elderly Indian population varies between 13% and 25%.^16-17 

Symptoms of depression were misunderstood and suffering by depression and less than 50% of the study population know about this misconceptions consider these as aspects of normal ageing.¹⁴

The other reason for higher prevalence in the current study could be that most of our study participants were in the age range of 60–70 years (younger elderly) and depression is reported to be more common among younger elderly. Further research is recommended to better understand theseassociations.Although our study due to its limited sample does not allow a conclusive estimate, it does however, contribute to the repertoire of research identifying an increasing urgent need to address the mounting problems related to the well-being of elderly. 

Our study does not have an equal proportion of female representation sample therefore, although the findings show that male respondents are more likely to be depressed we must interpret the results with caution. Further research must be carried out to explore this association which is in contrast with the previous findings. It is perhaps not surprising that there were very few females. Therefore even under dire circumstances it is less likely for the families to send their female elderly, and It might also be plausible that relatives are more likely to provide support to female elderly as compared to males. This is in contrast to West where more females than males are likely to go to care homes because they marry older men who die earlier. In the current study there was no significant association between depression and death of spouse before adjusting for respondent’s residence which is in contrast to the literature suggesting that spousal bereavement is a significant risk factor for late life depression¹². The possible reason for this could be that the elderly spouse might not be able to provide adequate level of support. Furthermore, in the current study we do not have information about the marital relationships of the respondents. The literature supports that people who are not happy with their relationships are more likely to be depressed as compared to those without partners.¹³ The fact that old age home respondents with living spouse had a higher chance of depression might be explained in terms of them missing their spouses and feeling that they were better off with their spouses as compared to living alone in old age home. In future studies this feeling of abandonment should be explored further.

CONCLUSION

This study was a small step towards establishing and recognizing the prominent role of familial support in later life. The results of the present study suggest that for effective elderly care arrangements and socio-demographic characteristics must be taken into account as these play a significant role in elderly mental health. They highlight the importance of providing consistent social support to facilitate transition from community to old age homes. Thus this study despite its limitations provides important preliminary evidence for designing health care facilities intended for elderly people.