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.
REFERENCES
1) Guest editorial. International Journal of nursing studies 2005; 42: 841-42.
2) Rizzo VM, Rowe JM. Studies of the cost-effectiveness of social work services in aging: A
review of literature. Research on social work practice. 2006 Jan; 16(1): 67-73.
33
3) Dhar HL. Emerging Geriatric Challenge (Review article). Available from
http://www.google.com.
4) Reker GT. Personal meaning, optimism and choice: existential predictors of depression in
community and institutional elderly. Available from htpp://www.google.com.
5) Reynolds CF, Upfer DJ. Depression and aging: A look to the future. Psychiatric Services.
1999 Sep; 50(9): 1167-69.
6) Suen LJ, Morris DL. Depression and gender difference. Journal of gerontologial nursing.
2006 April; 28-35.
7) Hammer RM. The lived experience of being at home. Journal of gerontological nursing
1999 Nov; 10-17.
8) Whall AL. Gurevich LH. Missed depression in elderly individuals. Journal of
Geronotological nursing. 1999 Jun; 44-46.
9) hpttp://www.answers.com/depressive.
10) hpttp:///www.the free dictionary.com.institutions.
11) http://www.google.co.in/search.
12) en.wikipedia.org/wiki/Education.
13) http:///www.google.co.in/search.
14) www.dph.state.ct.us/OPPE/sha99/glossary.htm.
15) www.4homeschool.info/vaentinesDay/definitions.htm.
16) en.wikipedia.org/wiki/socialinteraction.
34
17) Tomey AM. Nursing theorists and their works. 3rd ed. St. Louis: Mosby; 2000.
18) Polit DF, Hungler BP. Nursing research principles and methods. 6th ed. Philadelphia:
Lippincott; 1999.
19) Burns N, Groove SK. Study guide for the practice of nursing research. St. Louis: Mosby;
1997.
20) Talbot LA. Principles and practice of nursing research. 1st ed. St. Louis: Mosby; 1995.
21) Stuart GW, Laraia MT. Principles and practice of psychiatric nursing. 8 th ed. St. Louis:
Mosby; 2005.
22) Depression & Ageing-Better health channel. Available from
23) http://www.betterhealth.viv.gov.au.
24) Marsh MJ. Fictive Kin-Friends as family supporting older adults as they
i. age. Journal of gerontological nursing Ce article: 2005; 25-30.
25) Kurlowicz L. The Geriatric Depression Scale. Journal of gerontological
i. nursing. July 1999; 8.
26) Cole, Martin G, Bellavance, Francis, Monsour. A prognosis of depression in elderly
community and primary care populations: A systematic review and meta-analysis.
American Journal of Psychiatry. 1999.
27) Palsson SP. Ostlong S, Skoog L. The incidence of first onset depression in a population
followed from the age of 70-83.
28) Jorn AF. Does old age reduce the risk of anxiety and depression? A review of
Epidemiological studies across the adult life span. Journal of Psychological medicine.
2000: 30: 11-22.
35
29) Christenson H, Jorn AF, Mackinnon AJ, Kortan AE, Jacomb PA, Henderson AS et al. Age
differences in depression and anxiety symptoms: A structural equation modeling analysis
of data from a general population sample. Journal of Psychological medicine. 1999; 29;
325-39.
30) Blazer D, Burchett B, Service c, George Lk. Association of age and depression among the
elderly: an epidemiologic exploration. Journal of gerontological nursing. 1991 Nov; 46(6):
210-15.
31) Roberts RE, Kaplan GA, Shema SJ, Strawbridge WJ. Prevalence and correlates of
depression in an aging cohort: Almameda county stud. Journal of gerontologival nursing.
32) Dhar HL. Emerging geriatric challenge (Review article). Available from
htpp://www.google.com.
33) Kockler M, Heun R. Gender differences of depressive symptoms in depressed and non-
depressed elderly persons. Available from http://www.google.com.
34) Anstey & Mary Al. Depression more dangerous for elderly men than women. Health
Behaviour New Service. 2002; 202-17.
35) Whooley MA, Kiefe CI, Chesney MA, Markovitz, Mathews K, Hulley SB. Depressive
symptoms, unemployment and loss of income. Arch Intern Med. 2002 Dec; 162(22): 2614-
20.
36) Fukukawa Y, Tsuboi S, Niino N, Ando F, Kosugi S Shimokata H. Effects of social support
and slf-estem on depressive symptoms in Japanese middle-aged elderly people. J
epidemiology. 2000 Apr; 10(1suppl): S63-69.
37) Lorant V, Delige D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic
inequalities in depression: A meta-analysis. American J epidemiology. 2003; 157: 98-112.
38) Hudson CG. Socioeconomic status and mental illness: Test of the social causation and
selection of hypotheses. American J orthopsychiatry. 75(1): 3-18.
36
39) West Cg, Reed Dm, Gildengorin Gl. Can money buy happiness ? Depressive symptoms in
an affluent older population. Available from hptt:///www.google.com.
40) Brilman EI, Ormel J. Life events, difficulties and onset of depressive episodes in later life.
Psychological medicine. 2001 Jul; 31(5): 859-69.
41) Fakouri C, Lyon B. Perceived health and life satisfaction among older adults. Journal of
gerontological nursing. 2005 Oct; 17-22.
42) Aldrige Susan. Healthy aging is a matter of minimizing risk factors. Journal of the
American Medical Association. 2006 Nov 15th, 296: 2343-50.
43) Devanand DP, Sono M. Tag MX, Taylor S, Gurland BJ, Wilder D et al. Depressed mood
and alzimeris disease in the elderly living in the community. Arch Gen Psychiatry. 1996
Feb; 53(2): 178-82.
44) Steinkopff. The association of physical health and depressive symptoms in the older
population: age and sex differences. Social Psychiatry and Psychiatric epidemiology. 1995;
30(10: 32-38).
45) Heliker D, Jquish As. Transition of new residents to long-term care. Journal of
gerontological nursing. 2006 Sep; 34-41.
46) Louis Barder, Slimmer I, Lesage j. depression and issues of control among elderly people
in health care settings. Journal of advanced nursing. 1994; 20 (4): 597.
0Wang JJ. The comparative effectiveness among institutionalized and non-institutionalized
elderly people in Taiwan of reminiscence therapy as a psychological measure. Journal of
nursing research. 2004 Sep; 12(3): 237-45.
47) Weyerer S, Hafner H, Mann Hm, Anes D, Graham n. Prevalence and course of depression
among elderly residential home admissions in Manneheim and Camden, London Journal of
gerontological nursing. 1990 Feb;. Research and reviews. Available from
http://www.nimh.nih.gov.
37
48) Brant BA, Osgood NJ. The suicidal patient in long term care institutions. Journal of
gerontological nursing. 1990 Feb; 16(2): 15-18.
49) Yip SS, Chi I, Chiu H, Chi WK, Conwell Y, Caine E. A prevalence study of suicidal
ideation among older adults in Hong Kong. Geritric Psychiatry. 2003 Nov; 18(11): 1056-
62.
50) Skoog I, Aevarsson O, Beskow J, Larsson L, Palsson S, Waern M et al. Suicidal feelings in
a population sample of non-demented 85 year olds. American Journal of psychiatry. 1996;
153: 101-20.
38
Top Related