RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

A COMPARATIVE STUDY TO ASSESS THE MANIC

DEPRESSIVE DISORDER OF ELDERLY PEOPLE AGED 60

YEARS AND ABOVE LIVING IN INSTITUTONALISED

HOMES AND THOSE LIVING WITH THE FAMILY

MEMBERS IN THE SELECTED AREAS OF ANDHRA

PRADESH

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT

FOR DISSERTATION

Mrs. N.K. IDA NEELIMA

BANGALORE CITY COLLEGE OF NURSING

BANGALORE – 43, KARNATAKA

1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT

FOR DISSERTATION

1. NAME OF THE

CANDIDATE AND

ADDRESS

Mrs. N.K. IDA NEELIMA

Bangalore City College of Nursing, Bangalore – 560 043.

2. NAME OF THE

INSTITUTION

Bangalore City College of Nursing, Banswadi outer Ring Road

3. COURSE OF THE

STUDY AND SUBJECT

I Year M.SC(N)Mental Health Nursing

4. DATE OF ADMISSION 20.05.2008

5. TITLE OF THE

SUBJECT

“A COMPARATIVE STUDY

TO ASSESS THE MANIC

DEPRESSIVE DISORDER OF

ELDERLY PEOPLE AGED 60

YEARS AND ABOVE LIVING

IN INSTITUTONALISED

HOMES AND THOSE LIVING

WITH THE FAMILY

MEMBERS IN THE

SELECTED AREAS OF

ANDHRA PRADESH”.

2

6. BRIEF RESUME OF THE INTENEDED WORKINDRODCTION

Background of the Problem

“Life is not measured by the number of breath we take,

but the moments that take our breath away”.

(George Carlin)

Discoveries in medical science and improved sonic-economics conditions during the

past few decades have increased the life span of man. The numbers and proportions of the

elderly people are increasing in almost every country in the world.

Figures for the United Kingdom (UK) suggest an increase in the number of people over

pensionable age from nearly 11.4 million in 2006 to over 15.2 million by 2031 (National

statistics,2004). The fastest growing age group in the UK, however, I the over 85 years olds,

which is expected to be more than double to 2,479,000 by 2031 (National statitics,2005).

Similar trends are taking place in other western societies. While many older people are healthy

and live fully independent lives, a proportion are frail with arrange of physical and mental

health needs.1

A majority of older people aged 85 and over in the UK have a long term condition

(National statistics, 2005) and although many are able to continue to live in their homes with

the input of health and social services, a substantial number are resident in care homes. For

2003 indicate 13000 care homes for older people in England, with more than 370,000 resident

(alley et al, 2004).1

In the United States, the population of Americans aged 65 years and older is growing

rapidly creating an increase nee for social workers. Between 1980 and 2000, the population of

people aged 100 years and older triple, people aged 85 years and older

3

doubled, and the people age 65 years and older grew by 36%. Currently, the fastest growing

population is frail elders older than 85 years (Administration on aging). 2

The Indian age population is currently the second largest in the world. The absolute

number of the over 60 population in India will increase from 7.6 million in 2001 to 137 million

by 2021. It has been estimate that from 5.4% in 1951, the proportion of 60+ people grew to

6.4% in 1981 and is close to 8.1% in 2001. The elderly population for the period 1991-2001 is

close to 40%, more than double the rate of increase in the general Population.3

In most Gerotological literatures, people above 60 year of age are considered as ‘old’

constituting the ‘elderly’ segment of the population also called senior citizen. A per WHO

guideline people aged 60 to 74 are called elderly, between 75 to 84 years old and 85+ old-old.

Demographic changes influence health, economic activity and social condition of people. The

life expectancy which was 43 years in 1947 has increased to 65 years today, but sadly geriatric

care continues to be one of the neglected sectors.3

The process of ageing itself tends to create psychological and social problems for the

individual and society. In addition, the changing life styles of the young are also creating stress

and tension among the elderly. Many of the elderly in our country experience increasing

isolation from family ties, personal and social relationships.

Prevalence of mental morbidity among those 60+ was estimated to be 89 per 100

population, about 4 million for the country a whole. The risk of specific geriatric illness

increases with age. Overall prevalence rate rises to 71.5% for those over 60 years. The

4

degree of adaptation to the fact of ageing, means happiness, failure to adapt can result in

bitterness, inner withdrawal, depression, weariness of life and even suicide. The psychosocial

model of mental health posits that late-life depression arises from the loss of self-esteem, loss

of meaningful roles, and loss of significant other and diminished social contatacts.4

6.1 NEED FOR THE STUDY

Manic depression is complex syndrome that manifests itself in a variety of ways in

older people. Geriatric depression is widespread; affecting at least one of every six patients

treated in general medical practice and an even higher percentage of those in hospitals and

nursing homes. Certainly the most compelling consequence of depression in later life I

increased mortality from both suicide and medical illness.5

Manic depression is a mental illness, which if left untreated, may lead to functional

impairment, delayed recovery from medical conditions, and increased risk of illness, substance

abuse, and suicide. The world health organization predict that depression will rank a the second

most disabling condition after heart disease by 2025, and it will account for 15% of the disease

burden on society (Murray & Lopez, 1996). Depression is also the most common psychiatric

illness of late life. Although some older adults age successfully, many experiences losses

during the last stage of life an, consequently, have an increased risk of depression.6

Generations of older Indians have found shelter in the extended family system during

crisis, be it social, economic or psychological. However the traditional family is disappearing

even in rural area. With urbanization, families become nuclear, smaller,

5

and not capable of caring for older relatives. According to a national sample survey, 16.8% of

urban and 5.9% of rural elderly live alone mostly due to widowhood, childlessness or

immigration of children. With the modernization of the country, older values are being

replaced by individualization in non-organize societies. Older persons, who are economically

unproductive, do not have the same authority and prestige they used to have in the extended

families whereby had control over family resources.3

Although, many of the elderly are able to continue to live in their own homes with the

input of health and social services, a substantial number is resident in care homes. As for all

health service consumers, it is the right of the older people in care homes to receive high

quality care: a sense of security (attention to physical and psychological needs), a sense of

continuity (appreciation of one’s past as well a continuity of care-giving), a sense of belonging

(relationship forming opportunities, community and group membership), a sense of purpose

(opportunities to engage in purposeful activities), a sense of achievement (a sense of

significance (feeling value).1

A study conducted to describe the essential structure of the lived experience of feeling

at home for over adults relocate to alternative care settings revealed that, of the 10 participants

only three describe feeling at home in their present environments. Six participants clearly

stated that they did not feel at home, and one participant was ambivalent. One man residing in

long-term care facility stated: home is the freedom to o just as you please. Here I can’t do just

as I please and that will always distinguish this place from home. A woman’s remark was: I

have been here for four years and I am not at home, I miss my home. You are nothing but a

prisoner here…you can’t o anything, you are just here.7

Manic depression among elderly clients is often overlooked by professionals. A study

was conducted on more than 3,000 community- dwelling elderly to determine the association

6

between patients reported symptoms of depression and detection of this depression by primary

health care providers. The findings revealed that depressive symptoms are more covert in

elderly individual and they are often seen as “normal” in elderly individuals both by society

and by professional.8

Recognizing the ways in which depression is manifested in elderly individuals is very

important. However, recognizing that symptoms of depression are not simply apart of normal

aging process is even more important lack of this understanding by health care providers’

likely leas to lack treatment for many cases of depression and to missing early sings of

potential suicide. Therefore, conscientious screening and follow through on suspected

depression can make the lives of many elderly individuals and their families more fulfilling,

and in many cases suicide may be averted.8

6.2 REVIEW OF LITERATURE

“Unless you try to do something beyond what you

have already mastered, you will never grow’’

(Ronald E. Osborne)

Review of literature is a systematic and critical review of the most important published

scholarly literature on a particular topic. It is critical summary of research on a topic of interest,

often prepared to put a research problem in context/as the basis for an implementation

project.18

A review of literature is conducted to generate a picture of what is known about a

particular situation and the knowledge gaps that exits in the situation. Relevant

literature refers to those sources that are providing the in depth knowledge needed to make

changes in practice or to study a selected problem. The primary purpose of reviewing literature

7

is to gain a broad background or understanding of the information that is available related to a

problem.19

Acquaintance with the current state of knowledge enables those engage in research to

avoid unintentional duplication of study and to focus on aspects of the problem about which

there is relatively little knowledge. The review also provides additional rationale and credence

for conducting the study. It is a compilation of resources that provides the ground work for the

further study.20

To obtain adequate relate literature the investigator made an attempt to review the

books, journals, published and unpublished articles, and internet.

This chapter attempts to present an overview of studies and literature reviewed under

the following headings:

1. Meaning of Manic depression.

2. Prevalence of depression among elderly people.

3. Age, gender and depression

4. Socio economic status and depression

5. Physical health and depression

6. Institutionalization and depression

7. Depression and Suicidal tendency

MEANING OF MANIC DEPRESSION

Manic depression is the oldest and most common psychiatric illness. The word

depression is used in a various ways. It can refer to a sing, symptom, syndrome, emotional

state, reaction, disease, or clinical entity. The World Health Organization (WHO) has identified

depression as the number one psychiatric cause of disability in the world and projected that it

would rank second in the world as cause of disability by 2020.21

Everyone can feel sad, particularly if you experience loss or grief. Depression,

however, is more than feeling low and sad; it is a condition that requires treatment. People who

8

are depressed can experience symptom that affect their behaviour, thoughts, feelings &

Physical wellbeing. Everyone experiences some or all of these symptoms from time. However,

if you or someone close to you experiences persistent symptoms in at least three of these

categories, for two weeks or longer, help from doctor is needed.

Depression is not a normal part of ageing. It’s an illness that can have serious

consequences if it isn’t recognized and treated. Depression is often not well-recognized

detected in older people. Symptoms such as sadness, sleep and appetite problems or moo

change may be dismissed as ‘normal’ part of ageing. These symptoms may also be confused

with other conditions such as dementia. Depression can damage a person’s quality of life and

their relationships with friends and family. Severs depression can be life threatening as a risk

factor for suicidal thoughts and suicide.22

PREVAALENCE OF MANIC DEPRESSION AMONG ELDERLY PEOPLE

This section presents literature relate to prevalence of depression among elderly people

and its effect on their general well being. The older population is growing rapidly, and the

transition of the baby boomers to older age will accelerate this growth. In 2000, an estimated

35 million individuals were age 65 or older in the United States an this number is expected to

double during the next 30 years to projections of 70 million by the year 2030.23

Depression is common in late life, affecting nearly 5 million of the 31 million

Americans aged 65 and older. Both major and minor depression are reported in 13% of

community dwelling older adults, 24% of older medical outpatients, and 43% of both acute

care an nursing home dwelling older adults. Contrary to popular belief, depression is not

9

natural part of aging. Depression is often reversible with prompt and appropriate treatment.

However, if left untreated, depression may result in the onset of physical, cognitive and social

impairment as well as delayed recovery from medical illness and surgery increase health care

use and suicide.24

Late –life depression is one of the most common mental health problems in adults age

60 and over. Among elderly community residences, the prevalence of depressive symptoms

has ranged from 11% to 44%with the average at about 20%. Late –life depression has been

shown to be influenced by genetic, situational, illness-relate biological and psychosocial

factors. The psychosocial model of mental health fins that late-life depression arises from the

loss of self-esteem (helplessness, powerlessness, alienation), loss of meaningful roles (work

productivity), loss of significant others declining social contacts due to health limitations an

reduced functional status, dwindling financial resources, an a decreasing range of coping

options. 25

Garrard et al conducted a study to determine the association between self-reported

indications of depression by the community-dwelling elderly enrollees in managed care

organization and clinical detection of depression by primary care clinics. It was a two year

cohort study of 3,410 elderly people who responded to the Geriatric Depression Scale (GDS) at

the midpoint of the study period. A board measure of clinical detection was used consisting of

one or more of the three indicators: diagnosis of depression visit to a mental health specialist,

or antidepressant medication treatment. About half of the community-based people with self-

reported indications of depression did not have documentation of clinical detection by health

providers. Clinical detection of depression of elderly people living in the community continues

10

to be a problem. The failure to recognize the possibility of depression among elderly people

suggests a serious public health problem.25

AGE, GENDER AND DEPRESSION

This section presents research literature related to age, gender and occurrence of

depression. The literature reviewed in this section helped the researcher in identifying the role

of variables age and gender in the occurrence of depression in elderly people.

Palsson and Skoog conducted a population based study to find our whether the

incidence of first onset depression varies with age in the elderly. Study was conducted in

Sweden; a representative sample of individuals born between 1915-1916 (N=392) was

examined at the ages of 70, 75, 79, 81, 83 and 85 years by psychiatrists using a semi-structured

schedule. Information on depressive episodes was also collected from self-report and

examination of case records. Results showed that the incidence of first onset depression

increased from 17 per 1000 persons in the age group between “70 – 79” to 44 per 1000 in the

age group between “79 – 85”. Both the incidence and prevalence of depression increased with

age and the incidence was higher in women than in men.26

Jorm conducted a study to review the epidemiological studies across the adult lifespan

in order to find out whether old age reduces the risk of anxiety and depression. The study

involved a general population sample ranging from at least 60-8- years and over and used the

same assessment methods at each age. A total of 1120 samples were included in the study.

Centre for Epidemiological studies-Depression scale (CES –D) was used in order to find out

the age group differences in scores on depressive symptoms. The result showed that there was

no consistent pattern across studied for age difference in the occurrence of depression.27

11

Christenson, Jorm and Mackinnon conducted a longitudinal study to determine the

association of age difference and depression. A sample of 1622 participants aged 60-79 years

from Canberra (Australia) was drawn from the electoral roll. Data was collected by using

Anxiety and Depression scales of Godberg et al. The findings of the study suggests that the

nature of depression may differ across age that elderly have a depression picture that is

characterized by changes in two components: one, somatic-linked to physical change and the

other psychological-reflecting the recognition of contracting opportunities and a belief in the

fertility of life.28

Blazer D, Burchett B, Service C, George LK from Duke University Medical Center

conducted an epidemiologic study to find out the association of age and depression among the

elderly. They assessed 3,998 community-dwelling elders (65+) for depressive symptoms using

a modified version of CES-D and relevant control variables. Depressive symptoms were

associated in bivariate analysis with increased age, being female, lower income, physical

disability, cognitive impairment, and social support. In a multiple regression analysis, the

association of age and depressive symptoms reversed when the above confounding variables

were simultaneously controlled. The oldest old suffered fewer depressive symptoms when

factors associated with both increased age and depressive symptoms were taken into account.

Because many of these factors can be prevented (such as decreased income, physical disability,

and social support), the uncontrolled association between age and depressive symptoms can

potentially be modified.29

To investigate the effect of aging on rates of depression prospectively, Roberts RE &

other used two waves of data from a panel study of community residents 50 years old and

12

older. Data on symptoms of major depressive episodes were examined for the 1994 and 1995

cohorts of the Alameda County Study. The authors examined age, gender, marital status,

education, financial strain, chronic medical conditions, functional impairment, cognitive

problems, life events, neighborhood problems, social isolation, and social support. Depression

was measured with 12 items covering DSM-IV diagnostic criteria for major depressive

episodes. Results of the study showed prevalence of major depressive episodes as 8.7% in

1994 and 9.0% in 1995 among the subjects 60 years old and older. Subjects who were

depressed in 1994 were at greater risk for depression in 1995. when the effects of age and other

psychosocial risk factors in 1994 were due Multivariate analyses demonstrated that the initial

age effects were due mainly to chronic health problems with activities of daily living cognitive

problems, neighborhood problems, and social isolation in 1994 were all significant predictors

of depression in 1995. The study concluded that healthy, normally functioning older adults are

at no greater risk for depression than younger adults. What seem to be age-related effects on

depression is attributable to physical healthy problems and related disability.30

India is one of the few countries in the world where men outnumber women at all ages

till bout 70 years. Only in very old age group 80 plus, there are more women in population

than men. Women suffer more frequently from major depression and depressive symptoms

than men. The somatic and the atypical subtype of depression seem to be more prevalent

women.31

In the course of a family study conducted by Kockler M & Heun R, 236 subjects with a

lifetime diagnosis of major depression aged > 50 years and 357 control subjects from the

general population matched for age and gender were questioned using the Composite

International Diagnostic Interview (CIDI). Chi-square tests were used to compare the

individual depressive symptoms between men and women logistic regression analyses were

13

preformed to account for the subjects’ age, cognitive performance, family and employment

status. Results showed that women in the general population suffered from more depressive

symptoms than men and the more appetite disturbance and joylessness. These gender

differences could be entirely explained by gender differences in the family and the

employment status. Men and women with a major depressive disorder presented with a distinct

profile of symptoms that could not be explained by psychosocial factors. Elderly depressed

women presented with more appetite disturbances and elderly depressed men with more

agitation.32

Anstey and Mary A. Luszcz, of the School of Psychology and Center for Aging Studies

at Flinders University in Adelaide, South Australia, analyzed data from the Australian

Longitudinal Study of Aging, focusing on individuals aged 70 or older. More than 1,900

participants completed a questionnaire measuring depression in 1992; a subset of these

participants completed it in 1994. The researchers tracked the health of the participants until

2000. Participants were classified as having “incident depression” if their questionnaire scores

indicated that they were depressed the second time they took the test but not the first time.

They received a classification of “remitted depression” if their depression had relented the

second time they took the test and “chronic depression” if their scores were high on both

occasions. After taking into account factors such as smoking, alcohol and medical conditions,

depression was associated with mortality for men but not women, and the researchers found

that their findings confirm previous studies shoeing that late-life depression occurs more often

in women, but has greater negative outcomes for men. The significant effect of depression on

male mortality was small but “robust,” suggesting that depression may play a role in causing

health changes in men. Incident depression had the strongest association with death for men.33

SOCIO-ECONOMIC STATUS AND MANIC DEPRESSION

14

Whooley MA & others conducted a study to determine whether depressive symptoms

are associated with subsequent unemployment or loss of family income. They performed a

prospective cohort study on 2334 annual family income of $25,000 or more. Participants

completed the Center for Epidemiologic Studies Depression Scale and were considered to have

depressive symptoms if they scored 16 or higher on the 60-point scale. They evaluated self-

reported unemployment and annual family income during 5 years of follow-up. Results

showed that thirty-three percent (118/354) of participants with depressive symptoms in 1990-

1991 and 21% (335/1581) of participants without substantial depressive symptoms reported

new unemployment during the subsequent 5 years (odds ratio, 1.9; 95% confidence interval,

1.4-2.4; P<.001). This association remained strong after adjusting for potential confounding

variables, including marital status, education, history of unemployment, current part-time (vs.

full-time) employment, and cigarette smoking (odds ratio, 1.6; without substantial depressive

symptoms in 1990-1991 reported that their family income had decreased below $25 000 by

1995-1996 (odds ratio, 2.7; 95% confidence interval, 1.9-3.8; P<.001). This association also

remained strong after adjusting for potential confounding variables (odds ratio, 1.9; 95%

confidence interval, 1.3-2.7; P<.001). The study concluded that depressive symptoms are

associated with subsequent unemployment and loss of family income among working young

adults. Therefore, socioeconomic indicators, such as income and employment, should be

considered in evaluating the potential benefits of treatment for patients with depressive

symptoms.34

Fukukawa Y & co conducted a study to examine the effect of social support, self-

esteem and depressive symptoms. The subjects were 1,116 Japanese community-dwelling

adults aged 40-79 years, who were the first wave participants of the National Institute for

Longevity Sciences—Longitudinal Study of Aging (NILS-LSA). Exploratory and

15

confirmatory factor analyses were performed on the Rosenberg’s self-esteem scale that

supported the superiority of the bi-dimensional structure of the scale marked by self-

confidence and self-deprecation subscales. The subsequent causal analyses, using structural

equation modeling, demonstrated that social support reduced depressed affect through an

increase in self-confidence and a decrease in self-deprecation. By contrast, social support did

not show a direct effect on depressed affect. The findings suggest the importance of esteem-

improving elements of social support in reducing depressive symptoms.34

Low socioeconomic status (SES) is generally associated with high psychiatric

morbidity, more disability, and poorer access to heath care. Among psychiatric disorders,

depression exhibits a more controversial association with SES Lorant V & others carried out a

meta-analysis to evaluate the magnitude, shape, and modifiers of such an association. The

search found 51 prevalence studies, five incidence studies, and four persistence studies meeting

the criteria. A random effects model was applied to the odds ratio of the lowest SES group

compared with the highest, and meta-regression was used to assess the dose-response relation

and the influence of covariates. Results indicated that low-SES individuals had higher odds of

being depressed (odds ratio=1.81, p <0.001), but odds of a new episode (odds ratio = 1.24, p =

0.004) were lower than the odds of persisting depression (odds ratio = 2.06, p < 0.001).

A dose-response relation was observed for education and income. Socioeconomic inequality in

depression is heterogeneous and varies according to the way psychiatric disorder is measured,

to the definition and measurement of SES, and to contextual features such as region and time.

Nonetheless, the authors found compelling evidence for socioeconomic inequality in

depression.36

“The poorer, one’s socioeconomic conditions are, the higher one’s risk for mental

disability and psychiatric hospitalization,” said Christopher G. Hudson. This was found

16

regardless of what economic hardship or type of mental illness the person suffered. According

to a study that examined a database of 34,000 patients with two or more psychiatric

hospitalizations in Massachusetts during 1994-2000, unemployment, poverty and housing

unaffordability were correlated with a risk of mental illness. SES was assessed on the basis of

community income, education and occupational status. The study considered economic stress

as one of several possible explanations for the correlation between SES and mental illness, and

this was determined by hoe much the income was below the federal poverty level, the rate of

unemployment, and an index of rental housing unaffordability. This study provides strong

evidence that SES impact the development of mental illness directly, as well as indirectly

through its association with adverse economic stressful conditions among lower income

groups.37

West CG, Reed DM & Gildengorin GL conducted a cross-sectional analysis within a

prospective cohort study in an affluent Northern California county to determine if the inverse

association between depressive symptoms and income reported in predominantly low- and

middle-income older populations is present in more affluent population

of older adults and to determine if this pattern is independent of other known correlates of

depressive symptoms such as medical problems, physical disability and social support. The

participants included a total 1948 randomly selected, noninstitutionalized county residents 55

years of age and older who completed the baseline questionnaire and physical performance

tests. Measurements were done using the Center for Epidemiologic Studies-Depression scale

(CSE-D). Results showed that the prevalence of high levels of depressive symptoms (CES-D

score > or =16) was lower, than in most other population-based samples using an identical

17

CES-D scale. In age-adjusted, sex-specific analyses, increasing income level was associated

significantly with lower levels of depressive symptoms. In multivariate regression analyses

including potential confounding risk factors, the magnitude of the association between

depressive symptoms and income decreased and was not statistically significant when

measures of health conditions, physical disability, and social support were included in the

model. These findings suggest that poor health, physical disability and social isolation are the

major factors responsible for the observed inverse relationship between income and symptoms

of depression in affluent, as well as economically disadvantaged older populations.38

PHYSICAL HEALTH AND DEPRESSION

In later life, declining physical health is often thought to be one of the most important

risk factors for depression. Major depressive disorders are relatively rare, while depressive

syndromes which do not fulfill diagnostic criteria (minor depression) are common.

Brilman EI & others conducted a study on a community- based sample of older adults

(55-85 years) in the Netherlands. In multivariate analyses minor depression was related to

physical health, while major depression was not. General aspects of physical health had

stronger associations with depression than specific disease categories. Significant interactions

between ill health and social support were found only for minor depression. Major depression

was associated with variables reflecting long-standing vulnerability. The study concluded that

major and minor depression differs in their association with physical health.39

18

Life satisfaction and perceived health are two main components of quality of life.

Worry is a common phenomenon experienced by older adults that can affect both life

satisfaction and perceived health. Carolyn Fakouri & Brenda Lyon conducted a study on 100

individuals 65 years and older who were selected by convenience sampling technique. The

instruments used include “the worry scale” with 35 items, a “perceived health scale” and

“satisfaction with life” scale. The results of the study revealed that worry is the variable that

entered the most regression equations. The finding that most individuals (89%) considered

themselves well using a single, self rating of health suggests that aging individuals consider

discomforts to be expected and so common that they appraise them as normal. The data

obtained partially supported the study hypotheses, worry contributed to lower life satisfaction,

negative emotions, physical discomfort and decreased functional ability.40

Avoidance of certain risk factors in midlife contributes powerfully to healthy aging.

According to a study reported by Susan Aldrdge, nearky 6,000 Japaneses-American of average

age 54 years, were followed for up to 40 years for the purpose of determining which risk

factors need to be avoided to achieve healthy aging. Healthy aging was measured as

‘exceptional survival’ – which is survival 85 without incidence of any of six major diseases –

heart disease, stoke, cancer, chronic obstructive pulmonary disease, Parkinsons’s disease and

diabetes. In this group, eleven percent achieved healthy aging. The factors contributing were

high grip strength , and avoidance of overweight, high blood pressure, smoking and excess

drinking. High education and a good lipid profile were also important for healthy aging. Lack

of a marital partner was linked to death before 85. The probability of exceptional survival was

55 per cent without any of these risk factors and only nine per cent with six or more risk

19

factors. The findings represent real proof that physical strength and a prudent lifestyle in

middle age can help towards a healthier old age.41

Devanand DP & others conducted a study to evaluate the relationship between

depressed mood at baseline and the incidence of dementia, particularly Alzheimer’s disease, in

the elderly living in the community. A total of 1070 elderly individuals, aged 60 years or older,

were identified as part of a registry for dementia in the Washington Heights community of

North Manhattan, NY. In a prospective, longitudinal design with follow-up for 1 to 5 years,

annual physician evaluation and neuropsychological testing were used to assess levels of

cognitive impairment and to diagnose dementia. Depressive symptoms were evaluated with the

17-item Hamilton Rating Scale for Depression. Based on clinical considerations and a validity

study, a positive score for the depressed mood item was use in statistical analyses. To confirm

the results, the total Hamilton Rating Scale for Depression score was also evaluated the

“depression” variable. Results revealed that of the 1070 subjects, 218 met criteria for dementia

at baseline evaluation. In the 852 subjects without dementia, depressed mood was mood was

more common in individuals with greater cognitive impairment. The study concluded that

depressed mood moderately increased the risk of developing dementia, primarily Alzheimer’s

disease.42

Steinkopff conducted a study to identify the relationship between health and depression

in elderly. This has been found in both cross-sectional and longitudinal studies. In this study

the relation between four aspects of physical health and depressive symptom levels were

studied in a community-based sample of older inhabitants of small town in the Netherlands

(n=224). Results indicated that depression as measured with the CES-D is sufficiently different

from physical health to be relevant for it, and that it is sufficiently related to physical health to

be relevant for further study. The more subjective measures of physical health used in this

study (pain and subjective health) appeared to have a much stronger relation with depression

20

than the more objective health measures (chronic diseases and functional limitations. Physical

health and aspects of the social environment such as marital status appeared to have

independent effects on mood. In this study these effects were moderated by age and sex. In

women and the young-old (55-64) none of the associations between physical health and

depression were significant. In men and the old-old (75+) all associations were highly

significant.40

INSTITUTIONALIZATION AND DEPRESSION

Few individuals are born homeless, but may, at some points in their lives, will face the

prospect of being uprooted from familiar surroundings and forced to either move to new homes

or become homeless. The transition to such long-term care is a critical period for older adults.

An interpretive study conducted by Heliker D& Jaquish AS, examined the perspectives

and experiences of 10 newly admitted residents of the institution. Participants were

interviewed within one week of admission and then periodically during the next three months.

Thirty two verbatim interviews were analyzed using interpretive phenomenology. Themes that

emerged were becoming homeless, learning the rope and getting settled and creating a place.

Therefore, new possibilities for care must involve being present to the individuals as they

struggle to create new meanings of place.44

Louise Barder & others conducted a descriptive study to investigate the relationship

between both demographic characteristics and type of health care setting and elderly people’s

attributions for control, functional status, mood type of helplessness, and perception of self –

efficacy. Results of the study demonstrate that elderly people in long-term care settings are

more vulnerable to experiencing learned helplessness and depression than elderly people in

21

acute or rehabilitation settings. The findings indicate that the critical period for the

development of learned helplessness and depression is for subjects with length of stay of 7

weeks to 6 months. The study supports other research which concludes that depression in

elderly people is better explained by the original learned helplessness theory rather than being

related to attributions about the cause of loss of control.45

Wang JJ conducted a comparative study to assess the effectiveness among

institutionalized and non-institutionalized elderly people in Taiwan of reminiscence therapy as

a psychological measure. A quasi-experimental design was conducted, using pre and post-

intervention tests and purposive sampling. Rosenberg’s Self-Esteem Scale (RSE), health

Perception Scale (HPS), Geriatric Depression Scale Short Form (GDS-SF), and Apparent

Emotion Rating Scale (AER) were used as study instruments. Each subject was administered

pre and post –experimental tests at a four month interval, and all subjects underwent weekly

individual reminiscence intervention. Forty-eight subjects complete the study, with 25

institutionalized elderly people and 23 non-institutionalized home-based elderly people.

Independent t-tests and paired t-tests were conducted to measure the differences in variable

means between and within groups. A significant difference was found between groups, in

mood status post-test (t = 5.96, p < .001). And significant difference were noted in self-health

perception, depressive symptoms, and mood status (t = -2.56, 2.83, -3.02; p = .081, 0.009,

22

0.007) between the pre- and post-intervention test in the institutionalized group. These results

suggest that reminiscence therapy is especially appropriate for older people who reside in care

facilities. Implementing strategies that enrich the live of elderly people residing in long-term

cares is crucial, and reminiscence offer a method for promoting healthy aging.45

Siegfried Weyerer & others conducted a study to identify the prevalence and course of

depression among elderly residential home admissions in Mannheim and Camden, London.

Inclusion criteria were that the elderly persons (65 years old and older) came directly from

their own home or, if transferred from a hospital, had been three for less than 3 months. At

each site, 60 homes residents were interviewed at admission and 3 months and 8 months later.

Depression and dementia were assessed with the aid of the Brief Assessment Scale. The

prevalence of depression (Mannheim: 34.6%; over time. Residents in Camden were more

demented and more impaired in their activities of daily living at the time of admission, and the

percentage of those who died or were transferred to a hospital or nursing home within 8

months thereafter was higher in Camden (30%) than in Mannheim (5%). Multiple regression

analysis revealed that, in both study areas, depression at baseline was the best predictor for

depression 3 months and 8 months later. This relationship was particularly strong in Camden,

where a high percentage of the depressed at admission showed a chronic course of illness.

Sex , age, home visits, social isolation, activities of daily living, cognitive impairment, and

somatic symptoms at the time of admission were not significantly associated with depression 3

months later. Eight months after admission, a similar pattern was found in Mannheim. In

Camden, however, in addition to depression, a lack of home visits by relatives and friends, and

somatic symptoms at baseline, were significant predictors of depression 8 months after

admission.47

23

DEPRESSION AND SUICIDAL TENDENCY

Suicidal ideation is a common symptom associate with depression in elderly people. In

comparison with the older adults living in the community; elders who are institutionalized are

older, sicker, and more likely to have no living family members, factors that place them at risk

for suicide. Somatization, or physical suffering, is a frequently overlooked symptom of elderly

depression, perhaps because it is falsely assume that such symptoms expressed by the older

adult are normal concomitants of aging. Strengthening an extending existing family roles in

supporting the elder who is suicidal and depressed is vital to reducing loneliness, emotional

pain, loss of independence, an to increasing self –concept. An expanded knowledge of mental

health needs of older adults and their families is critical in suicide prevention. A major step

toward prevention is the recognition of depressive symptomatology and key elements and

clues to suicide in the institutionalized elderly.48

Yip PS & others conducted a study to ascertain estimates of the prevalence, and

associated risk factors for, suicidal ideation among community-dwelling older adults in Hong

Kong. The study was conducted as part of the General Household Survey (GHS), using face to

face interviews of ethnic Chinese people aged 60 or above living in the community. Elders

living in institutions or elderly homes were excluded from the study. The results showed that

poor physical health, including poor mental health, especially in the form of depression, are

predictors of suicidal ideation in the elderly population. Also, statistical analysis by linking

individual factors to depression showed that financial and relationship problems are significant

risk factors. Older adults who engage in active coping, that is, those who actively seek to

24

manage or control the negative events in their lives, fare better with lower levels of suicidal

ideation than those who use passive coping styles.49

Skoog I & others studied a population sample (N=345) of nondemented 85-year-olds in

Gothenburg, Sweden to identify the suicidal ideation in mentally healthy and those with mental

disorders. The participants were examined by a psychiatrist and suicidal feelings were rated by

the system of Paykel et al. Mental disorder were diagnosed according to DSM-III-R. Results of

the mentally healthy subjects (N =225), 4.0% had thought during the last month that life was

not worth living, 4.0% had death wishes, and 0.9% had thought of taking their own lives. None

had seriously considered suicide. The figures were higher among subjects with mental

disorders (N = 120); 29.2% had thought that life was not worth living, 27.5% had death

wishes, 9.2% ha thought about taking their lives, and 1.7% had seriously considered suicide.

The study concluded that mild suicidal feelings are common in elderly subjects with mental

disorders but infrequent in the mentally healthy.50

Tasi YF, Chung JW, Wong TK,& Huang CM Conducted a study to explore and

compare the prevalence and risk factors for depressive symptoms among elderly residents of

nursing homes in Taiwan and Hong Kong. Random sampling was used to recruit participants

from eight nursing homes in each region. A total of 150 elders Taiwan and 214 elders from

Hong Kong participated. Results of the study revealed that the prevalence of depressive

symptoms was significantly higher in participants from Hong Kong (65.4%) than in Taiwan

(43.3%). Logistic regression analysis indicated that gender, satisfaction with living situation,

perceived health condition, and perceived income adequacy significantly predicted depressive

symptoms in elderly nursing home residents in Taiwan. Significant predictors of depressive

symptoms in the Hong Kong sample were satisfaction with living situation, cognitive status,

25

and functional status. The study concluded that it is important to consider risk factors specific

to a target population when developing depression intervention programs.51

Jeffrey ML & others conducted a cohort study to compare outcomes among patients

with minor and subsyndromal depression, major depression, and no depression, and to examine

putative outcomes predictors. The study was conducted on patients from primary care practices

in greater New York City, Philadelphia, Pittsburgh, and Pennsylvania. A total of 622 patients

who were at least 60 years of age and presented for treatment in primary care practice were

selected and provide usual care in a randomized, controlled trial of suicide prevention. Of the

441 (70.9%) patients who completed one year of follow-up, 122 had major depression, 205 had

minor or subsyndromal depression, and 114 did not have depression a baseline. One year after

a baseline evaluation, data were collected by using the following tools: Hamilton Depression

Rating Scale, the depressive disorders section of the Structured Clinical Interview for DSM-IV

(Diagnostic and Statistical Manual of Mental disorders, fourth edition), Charlson Co-morbidity

Index, Multilevel Assessment Instrument for measuring instrumental activities of daily living,

Physical Component Summary of the Medical Outcomes Study Short From-36, and Duke

social Support Index. Results of the study revealed that patients with minor or subsynromal

depression ha intermediate depressive and functional outcomes. The implication of the study is

that minor or subsyndromal depression causes substantial morbidity and is a risk factor for

major depression.52

STATEMENT OF THE PROBLEM

A Comparative study to assess the manic depressive disorder of elderly people age 60

years an above living in institutionalize homes and those living with the family members in the

selected area of Andhra Pradesh.

26

6.3 OBJECTIVES OF THE STUDY

1) To determine the level of depressive feelings among the institutionalized elderly people a

measured by a structured interview schedule (GDS)

2) To identify the manic depressive disorder of the elderly people living with family member

as measured by a structure interview schedule (GDS).

3) To find out the association between depressive disorder among elderly people and the

selected variables (age, gender, education, occupation, marital status, income, type of

family and major illness) in both the groups.

4) To compare the two groups on the levels of depression an its association with selected

variables.

6.4 OPERATIONAL DEFINTIONS

1. ELDERLY PEOPLE:

According to WHO guidelines people age 60 to 74 are called elderly, between 75 to 84

+ old-old.

In this study elderly people refers to those age 60 years an above living in institutionalize

home (homes for the aged) and those living with their family members in selected areas of

Andhra Pradesh.

2. MANIC DEPRESSIVE DISORDER:

In this study depressive disorder refer to the feelings of sadness helplessness, hopelessness

and worthlessness that are expressed by the elderly.

3. INSTITUTIONALIZED HOME (HOME FOR THE AGED):

27

Institutionalized home refers to an institution run by private or government agency which

gives care, shelter and food for the elderly people on the basis of payment or free of charge.

In the present study institutionalized home refers to an institution run by a private

agency which gives care, shelter and food for the elderly people on the basis of payment or

free, in selected areas of Andhra Pradesh.

4. ELDERLY PEOPLE LIVINING WITH FAMILY:

Elderly people living with family refer to those men and women aged 60 years and

above living in their homes with family member.

In the study elderly people living with family refers to men and women who are above

60 years of age living in their homes with family members in the selected areas of Andhra

Pradesh.

1. EDUCATION:

Education refers to knowledge, ability etc. developed by educating or being educated.

In this study education refers to the intellectual, more and social standard the elderly

people under study have on account of the educational training they have received.

2. OCCUPATION:

Occupation defined as the principal activity in your life that you do to earn money.

In the present study occupation refers to the previous activity or job which an elderly

person was doing to earn money.

28

3. INCOME:

Income refers to the financial gain (earned or unearned) accruing over a given period of

time. In this study income refers to the financial gain the elderly people receive in the form of

pension.

4. HEALTH STATUS/ PRESENCE OF MAJOR ILLNESS:

Health status refers t the level of illness or wellness of population at a particular time.

In this study health status refers to the presences or absence of any major illness which

affect the well being of the elderly people.

5. FRIENDS:

Friends refer to persons whom one knows, likes and trusts.

In this study friends refer to persons who are close to the elderly people under study.

6. SCOIAL INTERACTION:

Social interaction is defined as a dynamic, changing sequence of social actions between

individuals (or group) who modify their actions and reactions due to the actions by their

interaction.

In this study social interaction refers to the social activities the elderly people under

study are engaged in.

6.5 ASSUMPTION:

He study assumed that:

1. Ageing process brings about bio-psycho-social changes in the individual.

2. The elderly people will experience depressive disorder.

3. The elderly subjects will vary in their mental status.

29

4. The elderly people will cooperate in participating in the study

5. The expressed mental depressive disorders are the perceived feelings of the elderly

people under study.

6.6 HYPOTHESIS:

H1 : There will be significant difference in the level of Manic depression in the elderly

people living in institutionalized homes and those living with family members.

H2 : There will be significant association between Manic depression in the elderly

people and the selected demographic variables: (age, gender, education,

occupation, income, marital status, type of family and major illness)

6.7 VARIABLES UNDER STUDY:

6.7.1. DEPENDENT VARIABLE: In this study the dependent variable is the levels of Manic

depression in the elderly people aged 60 years and above living in institutionalized homes and

those living with family member.

6.7.2. EXTRANEOUS VARIABLES: In this study the extraneous variables are age gender,

education, occupation, income, and marital status, type of family and major illness.

7. MATERIALS AND METHODS:

7.1 SOURCE OF DATA: Elderly people age 60 years and above living in Institutionalized

homes and those living with the family members in the selected Areas of Andhra Pradesh.

7.2 METHODS OF DATA COLLECTION:

30

7.2.1. RESEARCH DESIGN: Descriptive design

7.2.2. SETTING:

Research settings are the specific places from where the data are collected. The settings

for the present study were “Theresa Home for the aged” at Secunderabad, Medchal and

Toopran villages of Rangareddy District.

7.2.3. POPULATION:

Population refers to the entire aggregation of case in which the researcher is interested.

In the present study the population consist of the elderly people living in “Theresa Home for

aged, and those living with family members in Medchal and Toopran selected villages of

Rangareddy District

7.2.4. SAMPLE SIZE: 50

7.2.5. SAMPLING TECHNIQUE:

The sampling technique used for the study was non-probability purposive sampling.

7.2.6. SAMPLING CRITERIA:

I. INCLUSION CRITERIA:

1. Elderly people aged 60 years and above.

2. Elderly people who can communicate either in English or Telugu.

3. Elderly people who are willing with participate in the study.

31

II. EXCLUSIVE CRITERIA:

1. Older adults belonging to an age group less than 60 years.

2. Elderly people who can not hear/speak/comprehend the language.

7.2.7. TOOLS OF DATA COLLECTION:

The study was to assess the manic depressive disorder of the elderly people, a

structured interview schedule was considered to be an appropriate tool for the study as it

provides adequate information about the perceived subjective feelings of the elderly people.

The following were the tools use the present study:

Tool 1: Demographic Proforma

Tool 2: Geriatric Depression Scale (GDS)

7.2.8. METHODS OF DATA COLLECTION:

The Structured questionnaire will be distributed to the subject or Interviewed by the

investigator. Prior to the study, the purpose of the study will be explained to the participant

will be obtained to involve the study. Before the original study a Pilot study will be conducted

and then necessary modifications and further refinement of the tools will be done. Researcher

herself will collect the data.

7.2.9. DATA ANALYSIS AND INTERPREATATION:

The data collected to assess the depressive disorder of elderly people aged 60 years and

above living in institutionalized homes and those living with family members in selected of

areas of Andhra Pradesh. The analysis of the data was done based on the objectives and

hypotheses of the study.

32

7.3. DOSE THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVNTION TO BE CONDUCTE ON PATIENTS OR OTHER HUMANS OR ANIMALS?

Only the effectiveness of Structure Teaching Programme (STP) will be assessed. No

other invasive physical or laboratory procedures conducted on samples.

7.4. Has Ethical clearance been obtained?

-- Yes--

a. A written consent from college Authority will be obtained.

b. Confidentiality and anonymity of the subjects will be maintained.

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