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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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Prevalence of psychiatric morbidity in elderly hospitalized patients
Aslam Khan, Pooja Vijay, AV Sowmya, Suprakash Chaudhury, Bhushan Chaudhari, Daniel Saldanha, Preethi Menon
Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| Date of Submission | 26-Nov-2021 |
| Date of Decision | 29-Jan-2022 |
| Date of Acceptance | 22-Feb-2022 |
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Correspondence Address:
Suprakash Chaudhury,
Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/mjdrdypu.mjdrdypu_922_21
Background: Improved healthcare extends life expectancy, but social and economic issues including poverty, family breakdown, and insufficient help for the elderly put people's mental health in danger. Because of feelings of loneliness and natural age-related decline in physiological and physical performance, the elderly are more prone to psychological disorders. With this aim in mind, the study of the prevalence of psychiatric morbidity in elderly hospitalized patients was taken up. Methods: A cross-sectional analytical study was carried out in a tertiary hospital in Pune on 200 hospitalized patients of 65 years of age and more from July 2019 to July 2021. Subjects with known psychiatric disorders were excluded. Subjects were evaluated with a sociodemographic proforma, mini-international neuropsychiatric interview (MINI), depression anxiety stress scale-21 (DASS-21), and the multidimensional scale of perceived social support (MSPSS). Results: A total of 35.5% of elderly subjects admitted to non-psychiatric wards were found to be suffering from psychiatric disorders, most commonly major depressive disorder, generalized anxiety disorders (GADs), and social anxiety disorders. On DASS-21, 55.5% of patients had stress, 24% anxiety, and 15.5% had depression. On the MSPSS scale, 53% had a high level of support. A mean score of 5.94 was obtained for family support, 5.413 for support from friends, and 3.486 for support from significant others. Males received higher support. Conclusion: We found that elderly patients admitted in non-psychiatric wards had psychiatric disorders. The most common psychiatric disorders were GAD (16.5%) and major depressive disorder (15%). It is more beneficial when physicians/surgeons also screen or refer their elderly patients to their psychiatrist colleagues to help alleviate their suffering to the extent possible.
Keywords: Elderly, hospitalized, psychiatric co-morbidities, support system
How to cite this URL:
Khan A, Vijay P, Sowmya A V, Chaudhury S, Chaudhari B, Saldanha D, Menon P. Prevalence of psychiatric morbidity in elderly hospitalized patients. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2023 Mar 20]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=344181 |
| Introduction | |  |
The geriatric population is defined as those above the age of 65. By 2025, those aged 65 and above are anticipated to account for 10.2 percent of the global population. In industrialized nations, the aging population is already a serious social and health issue. Typical Indian's life expectancy has grown from 54 years in 1981 to 65 years in 2002. By 2025, India's population of persons aged 65 and over is expected to rise to 18.4 percent of the total population.[1]
Aging is an inescapable part of life. It has ramifications not just in terms of social issues, but also in terms of economics, politics, and health. This rapidly growing age group requires specialized medical attention. The psychological evaluation should be part of a geriatric patient's full functional health assessment. Problems connected to old age have gained attention in recent years.[2]
Nandi et al.[3] conducted research in two West Bengal villages to measure mental illness among elderly people aged 60 and more. It was shown that 61 percent of these elderly people require mental support. Most were depressed. Dementia was found to be prevalent in 1.6 percent of the population.
In a rural community in UP Srivastava and Tiwari[4] found the prevalence of psychiatric disorders among people aged 60 years and above was 42.21% compared to 3.97% in non-geriatric group. The most common disorders were neurotic anxiety and depressive states.
Anxiety disorders, sleep difficulties, and psychosis all have similar characteristics in the elderly. Medical co-morbidity rises with age; 40% of men and over 50% of women over 70 have two or more chronic illnesses, and the majority of persons over 80 have a range of health issues that require professional care. Nielsen looked at mental disease in the elderly in a Danish community and discovered that those living with a spouse had the lowest percentage of psychiatric illnesses; those who lived with family or children had the highest rate, while those who lived in a nursing facility had the highest risk.[5]
Improved healthcare promotes lifespan, but social and economic problems such as poverty, family disintegration, and insufficient assistance for the elderly pose a psychological risk. The elderly are more vulnerable to psychological problems due to feelings of loneliness and the normal age-related deterioration in physiological and physical functioning. Functional dependence is widespread among the elderly, and many would require support with everyday activities. Long-term care has emerged as one of the most pressing issues confronting an aging population.[6]
As in the west, as India's preference for nuclear families shifts, the number of people staying in old-age homes is increasing. There are few studies on record to assess mental diseases in the elderly population. The present study was designed to look into the mental morbidity of the elderly in a semirural background.
| Materials and Methods | | |
This cross-sectional analytical study was done in a multiple specialty ward of a 2000-bed tertiary care center located in western Maharashtra. After obtaining permission from the institutional ethics committee (vide I.E.S.C./PGS/2019/58 dt 08/11/2019), the cases were recruited. A written informed consent was obtained for participation in the study from all subjects taken for the study after explaining the purpose and design of the study.
Period of study: July 2019 to July 2021.
Sample
By purposive sampling, all patients aged >65 years and admitted in multiple specialty wards in a tertiary care center were taken.
Inclusion criteria:
- All hospitalized in-patients, 65 and above years of age.
- Patients who had given written informed consent for the study.
Exclusion criteria:
- Patients not giving consent.
- Patients with known psychiatric disorders or on any psychotropic medications.
- Patients with other medical illnesses, which prevents the subjects from cooperating or participating in the study.
Sample size
According to a study, the prevalence of psychiatric morbidity in elderly patients is 13%.
- To calculate sample size, the following formula was used
- As a result, the study's sample size
- 1.96 × 1.96 × 0.13 (0.87)/0.05 × 0.05
- = 173.79.
According to the above formula, the calculated sample size was 173.79. Keeping into account all general issues, a sample size of 200 was taken.
Tools
- Sociodemographic proforma: A specially designed proforma was used to document background details and sociodemographic profile
- “Mini-International Neuropsychiatric Interview (MINI)”:
The MINI was created as a short-structured interview for DSM-IV and ICD-10's main Axis I mental illnesses. MINI has acceptable validation and reliability ratings, but it can be administered in far less time. With the exception of generalized anxiety disorder (GAD) (kappa = 0.36), agoraphobia (sensitivity = 0.59), and bulimia (kappa = 0.53), all diagnoses had strong or very good kappa coefficients, sensitivity, and specificity.[7] - “Depression Anxiety Stress Scale-21 (DASS-21)”:
The DASS-21 short version was created to offer a self-report assessment of anxiety, depression, and stress symptoms. Low self-esteem, despair, devaluation of life, self-deprecation, and lethargy were identified as the major signs of depression during the growth process. The reliability of the DASS-21 was demonstrated by Cronbach's alpha values of 0.81, 0.89, and 0.78 for the depressive, anxiety, and stress subscales, respectively.[8] - “Multidimensional Scale of Perceived Social Support (MSPSS)”:
A measure of how many families, friends, and significant others assist a patient. The sum of all 12 elements is then divided by 12 to get the overall score. Low support is defined as a score of 1–2.9; moderate support is defined as a score of 3–5; and strong support is defined as a score of 5.1–7. The majority of studies have shown MSPSS to be a three-factor construct with good to outstanding internal consistency and test-retest reliability in clinical samples, with a Cronbach's alpha of 0.92 to 0.94.[9]
Methods
Before the start of the study, the institute ethics committee approval was taken.
After describing the research's aim and design, all individuals recruited for the study signed a written informed permission form to participate in the investigation.
Two hundred subjects, admitted in multiple specialty wards of age group >65 years in a tertiary care center attached to a medical college, hospital, and research center, located in a semi-urban area of western Maharashtra, were taken. Subjects were evaluated for the sociodemographic proforma, MINI, DASS-21, and MSPSS. All the questionnaires were scored as per the test booklets and the results were tabulated.
Statistical analyses
SPSS software (IBM, Chicago, USA) was used to analyze the data. The mean, standard deviation, percentage, and other descriptive statistics were provided, and the Chi-square test of significance was performed. Both descriptive and inferential statistics were used to conduct the statistical status of the study.
| Results | | |
The mean age of 200 subjects was 70.5 years. 51% were females and 49% of them males. The age distribution is summarized in [Table 1]. On MINI, 36.5% were diagnosed with psychiatric disorders, which included GAD (16.5%), followed by MDD (15%), and panic disorder (7.5%) [Table 2]. On DASS-21, 55.5% of patients had stress, with a majority of patients having a mild level of stress, 24% of patients had anxiety, with a majority having a moderate level of anxiety, and 15.5% had depression, with a majority of patients having moderate depression, all the details are illustrated in [Table 3]. | Table 1: Distribution of male subject total 98 and female subject total 102 in hospitalized in-patient`s subjects out of 200, according to age
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 | Table 2: Distribution of hospitalized in-patient's subjects according to their psychiatric co-morbidity by MINI
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 | Table 3: Scores obtained on the depression, anxiety, and stress scale by patients medical and surgical illness after applying DASS-21, and their social support on MSPSS
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53% of the subjects received a high level of support followed by moderate levels of support on the MSPSS. A mean score of 5.94 was obtained for family support, 5.413 for support from friends, and 3.486 for support from significant others. Males received higher support than females at a P value of 0.038, as illustrated in [Table 4] and [Table 5]. | Table 4: Scores obtained on the depression, anxiety, and stress scale by patients with and without co-morbid psychiatric disorders after applying DASS-21, and their social support on MSPSS
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 | Table 5: Scores obtained on the depression, anxiety, and stress scale by patients male and female sex after applying DASS-21, and their social support on MSPSS
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| Discussion | | |
Most of the mental-health research has focused on dementia and to a lesser extent, depression in the aged. Depression, anxiety disorders, and stress have received far less attention than it deserves. Old people are usually brought in by their children or their relatives with complaints of forgetfulness, sleep disturbance, and behavioral disturbances where the likely diagnosis would lead to dementia or psychosis at the outpatient department. Geriatric cases are referred to the psychiatrist mainly with the above-listed chief complaints but rarely on symptoms of depression, anxiety, or even stress. In an individual who is above 65 years of age, who is considered normal physically, his/her mental health is ignored by everyone in their close range including themselves. This present study was taken up with a view to find the prevalence of anxiety, depression, and stress and assess its severity in individuals aged 65 years and above. It was also structured to study their sociodemographic correlates and to evaluate the subjects on their support systems using standardized scales as a measure of assessment. The subjects were chosen from the medical and surgical wards of a tertiary hospital who did not actively report any psychiatric symptoms. [Table 1] depicts the age distribution of the patients.
India is undergoing a demographic shift and is presently in the latter stages of its expansion. People are living longer as health care improves, and they have a right to a long life of good health rather than one of suffering according to life expectancy trends. According to the World Health Organization, the number of elderly people over 60 years old is anticipated to quadruple between 2000 and 2050, from 11 percent to 22 percent.[10],[11]
The “twilight years,” or the last years of a person's life, are a delicate time. Old age should be a period of enjoyment, leisure, and satisfaction, but for many of the elderly, this is not the case.
Many characteristics linked to mental illnesses become more prevalent as people become older, including loss of close relatives, social network, former social position, sensory abilities, functional capacity, and health. The existence of many organic variables, such as brain atrophy, cerebrovascular illness, serotonergic transmission underactivity, cortisol hypersecretion, and low testosterone levels, also rises with age.[12] Physical impairment has repeatedly been identified as a risk factor for depression in later life.[13]
The incidence of mental illness in a study's senior population of a community in India was relatively high, with a trend toward a higher prevalence of cognitive impairment as people get older. Depressive disorders were the most common mental disorder, with dementia, bipolar disorders, alcohol-related disorders, GADs, and schizophrenia spectrum disorders.[14] Several cross-sectional research, both old and new, show that the prevalence of depressive disorders is highest in persons between the ages of 50 and 65, and thereafter declines furthermore.[15],[16] This study revealed depression in 31 individuals among the 200 individuals taken up for the study [Table 2]. Although not statistically significant, it was prevalent among the subjects. Depression may become more common in those aged 75 and above, and it is more common in those aged 95 and over than in those aged 90 to 94.[17] Even though the prevalence of depression does not rise with age, the prevalence of depressive symptoms is consistently observed to rise in a study where the incidence of depression was calculated over 3 years.[18] This might be due to the fact that older persons with depression have fewer symptoms than younger people. Age has been shown to either increase or have no effect on the occurrence of depression as recorded by two similar studies.[19]
Female old people were shown to be more depressed than male elderly people. This conclusion is in line with the findings of other research.[20] In a research by Nandi et al. in West Bengal, depression was overwhelmingly the most frequent ailment of old age, with a prevalence of 522/1000 people. Women suffer from depression at a greater rate than men: 704 per 1000 people.[3] The present study could not statistically prove any notable major correlation between males and females for depression. Seventeen females among 102 and 14 out of 98 males reported symptoms of depression in this study probably due to its being hospital-based and the size of the sample being modest.
Late-life depression manifests itself in a variety of ways. Weight loss, a lack of responsiveness to pleasant stimuli, or objective changes in mood may be present, although they are not expressed spontaneously.[21] In a community-based research, depression was shown to be prevalent in 49.4% of the elderly.[22] Aich et al.[23] observed depression in 15.2% of geriatric individuals, whereas Ritchie et al.[24] discovered a 26.5 percent lifetime incidence of severe depression among senior mental patients in a French community. The current study finds that depression is substantially higher in the rural geriatric population than urban, which is backed up by a study in Karnataka.[25] Illiteracy, lack of knowledge, low socioeconomic position, and limited access to healthcare among the elderly in remote areas might all be the factors. In contrast, research conducted in Ludhiana by Sengupta and Benjamin found that urban elderly were more depressed than rural old, with important indicators including female sex, rising age, nuclear family, and poverty.[26]
Anxiety is a common symptom of medical diseases in the elderly, such as thyroid and vascular problems. It can be a primary symptom of anxiety illness or a component of personality problems in many cases. The total number of people having anxiety in the present study was 48 out of 200 [Table 2]. Anxiety problems are said to be less common as people get older.[26] The pattern, on the other hand, varies depending on the anxiety condition. Panic disorder is quite uncommon among the elderly. The information on GAD is inconclusive. According to some sources, the prevalence of GAD rises with age, at least until the age of 55, or remains steady. Others believe that the peak prevalence of GAD occurs in persons around the age of 40 and then diminishes after that,[27] which could be a possible explanation for the statistical non-significance of our study.
Mild anxiety affects 44.2 percent of the elderly, moderate anxiety affects 27 percent, moderately severe anxiety affects 18.5 percent, and severe anxiety affects 10.3 percent [Table 3]. Some researchers have shown anxiety in the range of 6.4 percent to 57.3 percent.[10],[11] When comparing male and female old people, females were shown to experience more severe anxiety. The findings of Machado et al. back this observation. Possible causes for the high frequency of anxiety among females who are primarily jobless include housewives' lack of economic independence, their lack of social support, and the challenges that persons with lower education levels have in overcoming their issues.[28]
It is surprising to find the number of elderly suffering from stress. One hundred and eleven out of 200 elderly people were stressed [Table 2]. In Iran's Khoy County study, 1.3 percent of the elderly had extreme stress, 1.3 percent suffered from severe depression, and 3.1 percent suffered from severe anxiety, all of which are consistent with our findings.[29] But due to the discrepancy between the male and female, it was hard to establish sex predominance of stress. Fifty-eight females and 52 males faced stress.
In one of the Indian studies, respondents who lived alone had a higher degree of perceived stress than those who lived with their adult children or other family members.[30] The living conditions of elderly individuals were shown to be linked to perceived stress and health in a Korean study. Perceived stress, as well as other mental health issues such as depression, suicidal ideation, and so on, were shown to be more common among older individuals who lived alone than among those who lived with others in the community.[31]
There are a number of biologically plausible pathways that might relate stress to aging and cognitive impairments as people become older.[32] Stress activates the HPA axis and increases the release of glucocorticoids when it is experienced repeatedly or over time. Elevated glucocorticoid levels can cause long-term functional and anatomical changes in the brain, which might be noticeable or persistent during key phases of life, such as old age.[33]
Out of the 200 individuals, 26 (13%) received low support, 68 (34%) received moderate support, and 106 (53%) received high support [Table 4]. Social support is defined as the actual or potential support and contribution of personal resources, as well as persons, groups, communities, and systems with whom an individual has a relationship. The phrase “social support” is derived from clinical and therapeutic approaches in the field of social psychology, which examines how individuals cope with stress and crises, as well as the value of social ties and societal change. Sarason, et al.[34] define social support as the existence or accessibility of people we can trust and rely on, as well as those who care about us.
Family networks have an indirect effect through family support. Surprisingly, friendships had both direct and indirect effects on older family support. Healthy aging is influenced by health-promoting activities, which are critical in controlling the relationship between family and friendship support and healthy aging.[35] According to the findings of a study, MSPSS explained 22.1% variation in the quality of life when using regression analysis to assess the influence of MSPSS on quality of life. As a result of the enhanced MSPSS, quality of life improved.[36] Golden et al.[37] discovered that social networks have independent effects on older people's mood and well-being and that the risk of depression rises with the degree of loneliness of people in Dublin. According to another study, older individuals with a weak social network had a lower quality of life.[38] According to Kahn et al.,[39] there are substantial links between perceived social support and psychological well-being (depression, loneliness, and life satisfaction).
In India, the family remains the primary source of emotional and social support. Even though Indian society is undergoing comparable sociodemographic and familial change as in the west, the bonds between family members and significant others remain strong. This has been a part of traditional family culture since ancient times, and this link creates stronger social networks, which improves the quality of life of elderly people. Individuals received a high family support with a mean score of 5.9 and friends support of 5.4, and from significant other 3.4 mean score. Supportive family behaviors, according to Garousi et al.,[40] are essential sources of social support and may be associated with depression and anxiety in diabetes patients.
Another study of 108 elderly adults showed a positive relationship between social support and their quality of life.[41] A total of 60 (61.22%) males out of 98 received a high support, and 46 (45.09%) females received high support. A mean score of 5.7 was obtained by the males for the support received from friends, and females gave a 5.1 average score for the support from friends. Males received a higher family support than females with a greater average score of 6.1, versus females scored 5.7. In a study by Alipour and Melchiorre, rates of social support were reported to be greater in males than women,[42] while Cornwell indicated a higher rate of social support in women than men, all of which contradict the findings of this study. Cornwell argues that older women have a greater percentage of social support because of their capacity to form and sustain social ties and networks.[43]
In contrast to the findings of western studies, our data indicated that friend support was not as effective as family support in decreasing negative affect.[44] This could be due to cultural variations and societal constructs. The family was viewed as crucial to the support of the Chinese old from a cultural standpoint, as it may be in other cultures. It is often assumed that family members have a responsibility to care for the elderly when they are in need, but unpleasant experiences are rarely shared with others since no one wants to bother others.[45]
There is a strong link between perceived social support and psychiatric illnesses. As a result, enhancing social support for older individuals, particularly from their adult offspring, can enhance their quality of life and well-being while also lowering their chance of developing mental illnesses. Lack of social integration and social support has been linked to poor mental health outcomes and has been theorized to limit an individual's resources for dealing with social stress. It is also a protective factor for adult populations' mental and physical health.
| Conclusion | | |
In this study, psychiatric co-morbidities were found in 36.5% of elderly patients who were admitted to the medical and surgical wards. Anxiety disorders followed by mild-moderate depressive symptoms were the common diagnoses made in these patients. A significantly high-perceived stress was associated with their support system. 53% received high social support and hence perceived less stress. Male elderlies received more support than females.
As elderly people are the most neglected group of people in our society, a good support system plays a key role in reducing their hidden sufferings. It is more beneficial when physicians/surgeons also screen or refer their elderly patients to a psychiatrist so that the psychiatric morbidity can be reduced to a certain extent.
Limitations
- The study was conducted in a single center. A multi-center study is preferred.
- A bigger sample size can conclude more accurate values and prevalence rates.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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