Byline: Riddhi. Desai, Deepti. Abraham, Devavrat. Harshe, Aparna. Ramakrishnan, Rashmin. Cholera, Sanjiv. Kale
Context: Old age homes are on the rise in India. Older people staying in such institutions have specific psychosocial issues that may affect their cognitive performance and daily living. Materials and Methods: 71 older people, 39 institution based and 32 community-based were recruited with serial sampling after screening on mini-mental state examination and were evaluated with geriatric depression scale, University of California, Los Angeles scale, Lawton's instrumental activities of daily living scale and montreal cognitive assessment scale. Results: Prevalence of depression was significantly higher in older people who were institution based, widowers and females. The severity of perceived loneliness was higher in females, institution based and depressed older people. The severity of depression correlated with independence in daily activities, cognition, and perceived loneliness only in institution based older people. Discussion: Older people in institutions have a higher psychosocial burden than the community-based older people. Family support prevents the attrition effect of depression on cognition and independence in daily activities in the community-based older people.
INTRODUCTION
The 2011 census of India showed a total population of 1.21 billion of which, ~8% was above the age of 60 years. This population growth has also resulted in a spectrum of economic and social ramifications such as urbanization [sup][1] and formation of nuclear families. [sup][2] In addition, the increasing employment of women, particularly in the urban sector has led to growing issues concerning community care and support for the older people [sup][3] and the emergence of old age homes throughout India. [sup][4]
The older people in old age homes need to adjust to a changed environment leading to serious psychosocial problems particularly loneliness and dependency, also innately present in the community-based older people. This only exaggerates the psychological burden associated with aging, particularly geriatric depression, which has a prevalence of 10-20% [sup][5] according to the WHO. Data from indigenous projects shows the prevalence of geriatric depression to range from 8.9 to 98%. [sup][6],[7],[8],[9],[10],[11],[12]
Like depression, loneliness is also a companion of old age. Loneliness implies being in a state where an individual's emotional and psychosocial needs are not fulfilled to one's satisfaction. [sup][13] Many factors have been implicated for loneliness in old age, such as loss of spouse and social circle, dependency on others, health related problems and stay at an institution. [sup][14]
Loneliness and depression are interlinked in a dynamic relationship. Singh and Misra [sup][4] showed a direct correlation between depression and loneliness in the elderly, which was higher in women than men, whereas Raut et al . [sup][13] showed that loneliness predicts as well as preceeds depression in the elderly. Both loneliness and depression have been associated with a poor quality of life and a higher risk for physical as well as psychological morbidities. Both depression and loneliness can affect cognitive functions, which will negatively affect daily living and lead to dependency and poor quality of life.
Although a lot of research has emanated from India focusing on psychiatric morbidity, particularly depression in old age, literature is scarce on loneliness in the elderly. Most of the researches have been conducted in community- and hospital-based settings, and there is a need for studies assessing psychiatric comorbidity and its sequelae in individuals staying in old age homes. We thereby planned this study to assess the burden of loneliness on depressive and cognitive psychopathology in old age homes and family based older people.
MATERIALS AND METHODS
Sample
This was a cross-sectional study conducted by the Psychiatry Department of a Tertiary Care Teaching Hospital. Institutional Ethics Committee approval was obtained, and a written informed consent was obtained from all the study participants.
The study sample of 71 [Table 1], (mean age 73.04 [+ or -] 8.00 years, range 60-93 years) consisted of 39 older people living at various registered old age homes in Navi Mumbai, and 32 individuals staying with their families in Navi Mumbai through outreach with the help of the Senior Citizens Association of Navi Mumbai.{Table 1}
Individuals who were (1) above the age of 60 years, (2) Indian by birth and domicile, (3) married and (4) educated till standard 12 [sup]th and above were recruited in the study after informed consent. Individuals suffering from previously diagnosed chronic neurological or psychiatric disorders including dementia were excluded.
Tools and procedure
After approval from the Institutional Ethics Committee and written informed consent from the participants, relatives, and the concerned old age home, participants were recruited in the study. Basic socio-demographic and medical history was obtained with a self-designed semi-structured proforma. Mini-mental state examination [sup][15] was used to screen participants on orientation and attention span participants were then assessed with English versions of geriatric depression scale (GDS) [sup][16] for severity of depressive symptoms, The revised University of California, Los Angeles (UCLA) [sup][17] loneliness scale for assessment of perceived severity of loneliness, the montreal cognitive assessment scale (MoCA) [sup][18] to assess cognitive functions and Lawton instrumental activities of daily living scale (IADL) [sup][19] to assess the independence in activities of daily living.
Statistical analysis
Data were analyzed with independent samples t -test and Mann-Whitney U-test for quantitative variables wherever applicable. Chi-squared test and crosstabs analysis were used for dichotomous variables. Pearson's correlation was used to study the association between study variables.
RESULTS
Depression and loneliness
45 (63%) of the study sample were nondepressed, 22 (31%) were mildly and 4 (6%) were severely depressed. Depression was found to be significantly more prevalent in females than males (54 vs. 19%, odds ratio [OR]: 4.919, 95% confidence interval [CI]: 1.704-14.199), institutional stay (50 vs. 19%, OR: 4.561, 95% CI: 1.537-13.530) and being a widower (60 vs. 25%, OR: 4.666, 95% CI: 1.613-13.498). Educational status did not affect the prevalence (43 vs. 33%, ?[sup]2 = 1.276, P = 0.189) or severity ( t = −1.370, P = 0.175) of depressive symptoms. [Table 2]{Table 2}
UCLA scores showed that moderate to high levels of loneliness was significantly more associated with widowers than those staying with their spouse (79 vs. 46%, ?[sup]2 = 10.302, P = 0.006), with those staying in an old age home than those staying with their families (77 vs. 31%, ?[sup]2 = 15.300, P < 0.001). There was no significant age difference ( F = 0.867, P = 0.425) and gender distribution (?[sup]2 = 4.227, P = 0.121) UCLA scores.
MoCA scores revealed showed the prevalence of normal cognition to be significantly higher in those staying with their spouse (44 vs. 13%, ?[sup]2 = 6.552, P = 0.009) and in community based elderly (50 vs. 20%, ?[sup]2 = 6.830, P = 0.009). There was no significant age difference (71.45 [+ or -] 8.86 vs. 73.85 [+ or -] 7.50 years, t = −1.195, P = 0.236), or gender distribution (?[sup]2 = 0.844, P = 0.252) between patients with and without normal MoCA scores.
Participants from the old age home showed a significant correlation between GDS scores and UCLA scores (0.736, P < 0.001), IADL scores ( r = −0.563, P < 0.001) and MoCA scores ( r = −0.405, P < 0.05). Participants in the community setting, however, showed a significant positive correlation only between GDS scores and UCLA scores ( r = 0.714, P < 0.001) [Table 3].{Table 3}
DISCUSSION
There is a need for scientific literature studying psychological morbidity in older people staying at old age homes. Geriatric population is vulnerable to stress, adjustment problems, depression and other psychological burden, which can be exaggerated by the loneliness, sudden change in the environment and dependency issues at an old age home.
A significantly higher prevalence and severity of geriatric depression in the institution based than the community-based elderly was the key finding in this study. This finding is in concordance with existing literature from India. [sup][3],[4],[10],[11],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32] It has been hypothesized that, the feeling of isolation in OAH population is the causal factor for depression. [sup][30] Our study supports this hypothesis with a strong correlation between depression and loneliness scores. It is worth noting that, elderly often perceive a better support and care in an old age home than community. [sup][22] They may prefer inmates from the institution to their own family members as company! [sup][31] Singh and Misra [sup][4] showed a strong relationship between depression and loneliness in a community-based elderly sample! It can, therefore, be hypothesized that feeling of loneliness in old age is present even when surrounded by their kins! Our study supports this, with comparable severity of loneliness between widowers and those staying with their spouses. Thus, loneliness and depression in old age are 2 components of a vicious cycle, with one leading to the other. They depend on many biological and psychosocial variables such as personality [sup][33] and have a dynamic relationship rather than a linear causal one!
Aging, which is invariably associated with numerous physical and psychological adjustments, leading to dependence on family members, caregivers for simple day to day activities due to physical constrains. We found the significantly higher level of dependence in daily activities in an institution based older people than the community based, and the widower population than those staying with their spouse. Depression, loneliness and cognitive impairment [sup][34],[35] have been identified as predictors of dependence in daily activities. Interestingly, this effect was observed only in institution based older people. It is possible that care and emotional support by the family environment helps in maintaining activities of daily living in community-based older people despite depression, loneliness, and cognitive impairment.
Small sample size is an important limitation in the study. This study recruited individuals with educational status equal to or higher than secondary school certificate, a precaution taken since all the assessment tools were in English. Hence, findings from this study may be limited to a demographic-strata with higher education. Another issue that needs to be considered is, the sampling bias. In this as well as many other studies, it has been shown that elderly staying in OAH are more frequently widowers than CBE. [sup][25],[29],[30],[32] Loss of a spouse is perhaps the most stressful life event [sup][36] and may have influenced the observations from this study.
To conclude depression and loneliness coexist in both institutions based and home based older people. The severity of depression and loneliness worsen the age-related cognitive decline and dependence on daily activities in the institution based older people. Community-based older people are protected from this attrition effect despite perceiving some loneliness.
Future directions
Community-based as well as institution-based elderly population perceive loneliness. Therefore, future research can focus on various multimodal interventions focusing on loneliness in these populations. Evaluation of depressive symptoms in a day-care OAH versus a residential OAH may answer few of the questions on this topic as well as pave the way for future research.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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