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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 44-50

Mental health, functional ability, and health-related quality of life in elderly patients attending a tertiary hospital of Patna


1 Department of Orthopaedic, AIIMS, Patna, Bihar, India
2 Department of Community and Family Medicine, AIIMS, Patna, Bihar, India

Date of Web Publication4-Jul-2019

Correspondence Address:
Pragya Kumar
Department of CFM, AIIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCFM.IJCFM_1_19

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  Abstract 

Background: With changing socioeconomic, demographic, and development scenario, there is a cultural shift in looking after the elderly population which may lead to depression in this age group.
Materials and Methods: The study was a hospital-based cross-sectional study conducted in the orthopedic department of a tertiary care setting on 157 elderly individuals. This study was conducted with objectives to estimate the proportion of depression using the Geriatric Depression Scale Short Form (GDS-SF) questionnaire along with its associated factors in geriatric population coming to the orthopedic department of the institute. The study tools were GDS-SF, Katz Index of Independence in activities of daily living (ADL), the Lawton instrumental ADL, and health-related quality of life by the Centers for Disease Control.
Results: The proportion of depressed individuals was 70/157 (44.6%) using GDS as a tool. The maximum number was in the age group of 60–74 years. Women outnumbered men (51.3% vs. 38.31%) for depression. The depression using GDS score was more prevalent in rural elderly, illiterate, and elderly who were economically dependent on their children and who belonged to lower middle socioeconomic status. Approximately 98% of the study participants were found to be independent using ADL. Approximately 60% males and 68% females were dependent for the instrumental ADL using Lawton score. Most of the study participants had arthritis as a major impairment sharing almost equal proportion among males and females.
Conclusion: The current study concludes that there is a very high proportion of elderly subjects who are experiencing depression using the GDS-SF tool. There should be regular screening for this disease in this age group even in a tertiary care setting.

Keywords: Activities of daily living, geriatric depression, geriatric depression scale short form, health-related quality of life, instrumental activities of daily living


How to cite this article:
Kumar S, Kumar P, Ahmad S, Kumar A. Mental health, functional ability, and health-related quality of life in elderly patients attending a tertiary hospital of Patna. Indian J Community Fam Med 2019;5:44-50

How to cite this URL:
Kumar S, Kumar P, Ahmad S, Kumar A. Mental health, functional ability, and health-related quality of life in elderly patients attending a tertiary hospital of Patna. Indian J Community Fam Med [serial online] 2019 [cited 2019 Jul 20];5:44-50. Available from: http://www.ijcfm.org/text.asp?2019/5/1/44/262113


  Introduction Top


The increase in life expectancy has resulted in an increase in the population of elderly, and in India, the share of the population over the age of 60 years is projected to increase from 8.3% in 2011[1] to 19% in 2050. By the end of the century, the elderly will constitute nearly 34% of the total population in the country.[2] In India, it is a cultural practice for families to take care of the needs of older persons, including economic and social needs. With the changing socioeconomic, demographic, and development scenario, now, there is a cultural shift in this practice which is leading to some form of psychological stress among elderly.[2] According to the WHO, mental health disorders account for 13% of the global burden of diseases and are particularly common among older adults.

Vulnerability among older persons increases with declining functional abilities. Activities of daily living (ADL) are the basic tasks of everyday life such as feeding, bathing, dressing, mobility, use of the toilet, and continence and when older persons are not able to perform these activities, they require assistance. ADL limitations are indicative of the care burden in any society. ADL limitations are more for older women than men with 9% of the older women and 6% of the older men needing assistance with at least one activity. This indicates a high care burden considering the sheer number of older persons in the country.[3] Therefore, this study was conducted with objectives to estimate the proportion of depression using Geriatric Depression Scale Short Form (GDS-SF) questionnaire along with its associated factors in geriatric population coming to the orthopedic department of the institute and to assess the functional ability and health-related quality of life (HRQOL) in the same population.


  Materials and Methods Top


Study design, area, and study group

The study was a hospital-based cross-sectional study conducted in the Orthopaedic Department of AIIMS Patna, for 1 year (from October 2016 to September 2017).

Sample size, sampling method, and recruitment of study participants

The sample size for this study was calculated using Taro Yamane formula with a 95% confidence level. According to hospital record, 9800 patients consulted in the orthopedic outpatient department (OPD) during the year 2016. The calculation formula for Yamane is as follow where n = sample size required. N = Population size, e = Allowable error (%). We took allowable error to be 10%; the required minimal sample size was calculated to be 99. Finally, 157 participants were included over the study period. The final precision of this study was 8%. The power of this study was calculated using G*Power Version 3.1.9.4, (Fraz Faul Universitat Kiel, Germany) statistical software. A post hoc power analysis was applied using an exact test for proportion difference from constant. A similar study by Prakash et al.,[4] using GDS-15 tool in geriatrics patients in the hospital reported a proportion of 22%. We assumed an effect size of +10% in our study setup. The power of study thus calculated to be 87%.

Sampling technique

All the elderly study participants visiting the OPD were included who met the following inclusion criteria: age ≥60 years, not having a current history of fracture of any part (nontraumatic), no history of tumor/cancer, and free from debilitating conditions.

Conduction of interview

The interview was conducted in Hindi. The semi-structured questionnaire was translated in Hindi and pilot tested in 20 patients. It was back translated by an independent person well versed with both languages to ensure the validity of the translation. The interview was conducted in a separate room, by one orthopedic senior resident after the training by the principal investigator. It was a half day training which was subsequently reinforced periodically.

Ethical approval

Ethics approval of the institutional ethics committee was obtained before the commencement of the study. The purpose of the study was explained to the study individuals and their signed consent was obtained. All the study participants who were depressed using the GDS were referred to the psychiatry department for further assessment and treatment.

Study tool

A predesigned and pretested semi-structured questionnaire containing various sociodemographic parameters and other assessment tools was used. The Whisper test was performed to assess hearing impairment.[5] Standard methods were used for anthropometric measurement. The mental health status, functional ability, and HRQOL were measured using the following tools.

Mental health status

GDS-SF was used to estimate the depression in the study participants.[6] The GDS: SF consists of 15 questions requiring “yes” or “no” answers and can be completed quickly. The depression was assessed using the 15-item GDS,[7] which is a 15-item self-report assessment used as a basic screening measure of depression in the elderly. The accuracy of the GDS-15 is not influenced by the severity of medical burden, age, or other sociodemographic characteristics and even the “very old” and ill can be screened appropriately.[8] Moreover, the presence of a major depressive episode among elderly home-bound adults can be reliably detected. In a validation study, comparing the long and SFs of the GDS for self-rating of symptoms of depression, both were successful in differentiating depressed from nondepressed adults with a high correlation (r = 0.84, P < 0.001). Hence, this scale is better suited for identifying depression in the elderly. Those with a GDS score >5 were categorized as depressed. Using this cutoff, high sensitivity and specificity of the 15-item GDS have been reported.[9]

Functional ability

The ADL was assessed using the Katz Index of Independence in ADL (Katz, 1970).[10] The Index ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding. Client's responses were scored yes/no for independence in each of the six functions. A score of 6 indicates full function, 4 indicate moderate impairment, and 2 or less indicates severe functional impairment.[11]

The Lawton Instrumental ADL (IADL) (Lawton, 1969) Scale assesses a person's ability to perform tasks such as using a telephone, doing laundry, and handling finances.[12] Measuring eight domains, it can be administered in 10–15 min. The scale may provide an early warning of functional decline or signal the need for further assessment. These skills are considered more complex than the basic ADL as measured by the Katz Index of ADLs. The instrument is most useful for identifying how a person is functioning at present, and to identify improvement or deterioration over time. There are eight domains of function measured with the Lawton IADL scale. Women are scored on all eight areas of function. For men, the areas of food preparation, housekeeping, and laundering are excluded. Clients are scored according to their highest level of functioning in that category. A summary score ranges from 0 (low function, dependent) to 8 (high function, independent) for women and 0 to 5 for men.

Health-related quality of life

This includes a total of 14 questions. It has three parts – healthy days core module (4 questions), activity limitation module (5 questions), and healthy days symptoms modules (5 questions). It enquires regarding the health in general, about the physical health, which includes physical illness and injury in the past 30 days, about the mental health, which includes stress, depression, and problems with emotions in the past 30 days and whether this physical or mental health prevented them from doing the usual activities. These questions also ask about recent pain, depression, anxiety, sleeplessness, vitality, and the cause, duration, and severity of a current activity limitation an individual may have in his/her life.[13]

Unhealthy days are an estimate of the overall number of days during the previous 30 days when the respondent felt that either his or her physical or mental health was not good. To obtain this estimate, responses to questions 2 and 3 are combined to calculate a summary index of overall unhealthy days, with a logical maximum of 30 unhealthy days.[14]

Statistical analysis

The data were entered and analyzed into IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. (IBM Corp., Armonk, NY). To test the significance in the difference of proportion, a Chi-square test was performed. The ANOVA was applied to test the difference in the mean score across various groups. The P < 0.05 was considered statistically significant. The reliability of the GDS tool was tested using Cronbach's alpha.


  Results Top


The proportion of depressed individuals was 44.6% (36.7–52.7) using GDS as a tool. The maximum number was in the age group of 60–74 years. Women outnumbered men (51.3% vs. 38.31%) for depression. The depression (using GDS score) was more prevalent in elderly who inhabited the rural area, illiterate, were economically dependent on their children and belonged to lower middle socioeconomic status [Table 1]. Cronbach's alpha of GDS tool in the current study is 0.69.
Table 1: Geriatric Depression Scale score-category according to sociodemographic parameters of study individuals (n=157)

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The distribution of the mean GDS score among nondepressed and depressed groups across sociodemographic parameters is presented in [Table 2]. Among the nondepressed group, the mean GDS score was below 2, across the majority of variable categories except for secondary education level, widow/widower, those living alone, partially dependent, and those belonged to lower strata. Among the depressed group, the mean GDS score ranged from 8.2 to 11.6 for all variable categories. The statistical analysis using F-test showed that there was no significant difference in mean GDS score across sociodemographic parameters in nondepressed as well as depressed group, except across socioeconomic levels in the depressed group (<0.002) [Table 2].
Table 2: Mean Geriatric Depression Scale score according to sociodemographic parameters of study individuals (n=157)

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The proportion of depressed individuals were more in the obese category as compared to their normal counterparts.[Table 3]. The distribution of study participants taking the waist circumference as risk criteria was almost similar in both the categories. The prehypertension category of people was more depressed than Stage I and II hypertension. The maximum proportion of nondepressed individual belonged to a normal category. Although the proportion of individuals who reported hearing impairment was very low (4.4%) the majority of them were depressed [Table 2].
Table 3: Geriatric Depression Scale score category across various clinical parameters of study participants (n=157)

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The mean GDS score among the nondepressed group for various categories of body mass index, waist circumference, blood pressure, and hearing assessment was reported to be <2 except for Stage II hypertension (3.55 ± 2.16) whereas among the depressed group, it was between 9.2 and 11.6 [Table 4].
Table 4: Mean Geriatric Depression Scale score category across various clinical parameters of study participants (n=157)

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The unhealthy days were ranging from 15.9 days to 22.6 days. The maximum unhealthy days were due to sleeplessness (22.6 days) which was statistically significant, followed by anxiety (22.3 days) in men. The women had a smaller number of unhealthy days as compared to their male counterparts [Table 5].
Table 5: Average unhealthy and activity limitation days across gender (n=157)

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Approximately 98% of the study participants were found to be independent using ADL. Approximately 60% males and 68% females were dependent for the instrumental ADL using Lawton score [Table 6].
Table 6: Distribution of Instrumental Activities of Daily Living dependency by sex (n=157)

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The study participants were interviewed regarding one major impairment or health problem that limited their activities. Most study participants had arthritis as a major impairment sharing almost equal proportion among males and females. The same pattern was observed across other health conditions also [Figure 1].
Figure 1: Gender-wise distribution of major health problems in the study participants (n = 157)

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  Discussion Top


It is a myth in the community that depression in the elderly is due to normal aging phenomenon. This leads to the under diagnosis and treatment of the disease.

The proportion of elderly suffering depression in the current study is 44.6%. This was relatively high as compared to other studies[15],[16],[17],[18] which reported the proportion ranging from 10.4% to 16%. The shorter version GDS-15 tool was used in the current study. The use of this shorter version tool for screening depression in geriatric population was found to report high prevalence.[15] Such a high prevalence was reported earlier by Sanghamitra Maulik[19] among 82 elderly in a rural area of Hooghly district of West Bengal as 53.7%, by Reddy et al. from the rural area of Valadi, Tamil Nadu, as 47%,[20] and by Ghimire et al. in 289 elderly as 57.4%.[21]

Boyanagari et al. used the GDS-15 scale in their study and reported a Cronbach's alpha reliability of this tool as 0.81.[22] In the current study, it is 0.69. A value of Cronbach's α between 0.6 and 0.7 indicates acceptable reliability and a moderate degree of correlation between items. An item-total statistics table showed a very high degree of a positive correlation between all items.

Respondent's age, sex, marital status, educational status, living status, and economic dependency were not found to be associated with depression in earlier studies.[14],[15] In another study, female preponderance, illiteracy, and staying alone were significant risk factors for depression,[19] whereas in the current study, no such significant association of depression with various sociodemographic profile was reported.

The current study observed no relationship between blood pressure level and depressed state which is in line with the findings of Rajkumar et al.[16] The normotensives have a low proportion of depression, but this association was not significant. A very low proportion, 4.6% of study individuals were undernourished in our study whereas other authors reported much higher proportion.[18],[21],[22] Unilateral hearing impairment showed higher odd for the presence of depression in bivariate analysis.[16] While another study reported higher odd for depression in bilateral hearing impairment,[15] the current study reported 4.6% hearing impairment in elderly, which is in contrast to the finding of Boyanagari et al.[22] where hearing impairment was more than 30%.

The current study reported mean GDS score above 8.2 across various categories of sociodemographic variables without any significant association. Whereas in another study, the mean score for GDS was more in literate people and high score was associated with older age.[7]

The current study reported only 2% of the respondents to be fully dependent using the ADL tool. The UNFPA report documented[2] that ADL limitation was more for older women than men with 9% of the older women and 6% of the older men, needing assistance with at least one activity. Among the activities, the highest proportion of the elderly faced some difficulty in bathing followed by going to the toilet.[2] Disability status was not associated with depression.[16] Shanbhag et al. assessed the functional ability of 181 elderly and found out that 97% were partially dependent for ADL and 45% were not freely mobile.[18] Kavya et al.[23] in her study on 91 elderly found out that 25% of the elderly had decrease ability in performing ADL. Boyanagari et al. in their study observed that 98% of the elderly were dependent for ADL.[22] Ohri et al. assessed ADL and IADL on 215 elderly people and reported maximum inability in breathing and dressing, and female elderly being more dependent than male.[24]

The current study observed that the maximum unhealthy days were due to sleeplessness (22.6 days) followed by anxiety (22.3 days) in men. The women reported less number of unhealthy days.


  Conclusion Top


The current study concludes that there is a very high proportion of elderly participants who are experiencing depression using the GDS-SF tool, and this depression was not associated with sociodemographic factors or their clinical parameters. The ADL limitation was very low and the majority of them were independent in their activity of daily living. Hence, there should be regular screening and treatment for depression in this age group even in a tertiary care setting.

Limitations

  • It was a hospital based study. Therefore the external validity of the the findings are limited
  • The majority of the study participants were in the age group of 60–74 years and the proportion of the oldest old was very low
  • The other clinical departments were not included in the study setting.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Census of India Website : Office of the Registrar General & Census Commissioner, India. Available from: http://censusindia.gov.in/. [Last accessed on 2019 Jan 18].  Back to cited text no. 1
    
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Whisper Test. Available from: https://www.unmc.edu/media/intmed/geriatrics/reynolds/pearlcards/functionaldisability/whisper_test.htm. [Last accessed on 2019 Jan 22].  Back to cited text no. 5
    
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Yesavage JA. The use of self-rating depression scales in the elderly. In: Handbook for Clinical Memory Assessment of Older Adults. Washington, DC, US: American Psychological Association; 1986. p. 213-7.  Back to cited text no. 6
    
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Ganguli M, Dube S, Johnston JM, Pandav R, Chandra V, Dodge HH, et al. Depressive symptoms, cognitive impairment and functional impairment in a rural elderly population in India: A Hindi version of the geriatric depression scale (GDS-H). Int J Geriatr Psychiatry 1999;14:807-20.  Back to cited text no. 7
    
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Wallace M, Shelkey M, Hartford Institute for Geriatric Nursing. Katz Index of Independence in Activities of Daily Living (ADL). Urol Nurs 2007;27:93-4.  Back to cited text no. 11
    
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The Lawton Instrumental Activities of Daily Living Scale | Ovid. Available from: https://oce.ovid.com/article/00000446-200804000-00023/HTML. [Last accessed on 2019 Jan 09].  Back to cited text no. 12
    
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Health-Related Quality of Life | Centers for Disease Control and Prevention; 2018. Available from: https://www.cdc.gov/hrqol/index.htm. [Last accessed on 2019 Jan 12].  Back to cited text no. 13
    
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Healthy Days Methods and Measures | Health-Related Quality of Life | Centers for Disease Control and Prevention; 2018. Available from: https://www.cdc.gov/hrqol/methods.htm. [Last accessed on 2019 Jan 12].  Back to cited text no. 14
    
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Kavya C, Santosh A. Geriatric health: assessment of nutritional status and functional ability of elderly living in rural area of Bangalore, Karnataka, India. Int J Community Med Public Health 2016;3:3460-4.  Back to cited text no. 23
    
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Ohri P, Gupta SK, Upadhyai N. A study of daily living dependency status among elderly in an urban slum area of Dehradun. Indian J Community Health 2014;26:417-22.  Back to cited text no. 24
    


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