Pattern of neuropsychiatric illnesses in older age group population: an inpatient study report from Nepal.

BACKGROUND: Inpatient institution-based geropsychiatric study reports are rare in the world psychiatric literature. AIMS: To study the pattern of neuropsychiatric illnesses seen in older age group population and to study how the advancing age influences the pattern of physical and neuropsychiatric illnesses in these geriatric people.
MATERIALS AND METHODS: This was a retrospective review of the charts of all patients of age 60 years and above, during a specified period of 3.5 years. The present study reports the findings of 138 patients (83 males and 55 females) admitted during the said period. For comparison purpose, 194 patients, in the age range of 50-59 years, who were admitted during the same period, were taken up specially to study the changing pattern of diagnosis, if any, as well as to study the significance of increased rate of physical illness in the geriatric study group.
RESULTS: Our geriatric inpatients (138) formed only 3.73% of the total patient population (3698) admitted during the said period, which is in sharp contrast to 23-44% geriatric inpatients, the range that has been usually reported in the western literature. Common clinical diagnoses amongst male geriatric patients were alcohol dependence with or without various complications (27.7%), followed by mood disorder-mania (18.1%), organic mental disorders (18.1%), psychosis (16.9%), and mood disorder-depression (14.5%). Common clinical diagnoses amongst geriatric females were mood disorder-depression (36.4%) and psychosis (25.5%). Comorbid physical illness was seen to be present at a very high percentage (61.4%) in geriatric male patient population than in female patients (40%). Alcohol dependence in male and depressive disorder in female stood out as distinctive illness in patients above 50 years of age (including both study and comparative groups). In sharp contrast to elderly comparison group's 14.9% cases of comorbid physical illness, geriatric study population had a staggering 52.9% cases of additional burden of physical illness diagnosis.
CONCLUSIONS: Being elder by a decade poses a significant threat in developing an additional physical illness to an already existing psychiatric illness in the geriatric community. Though the prevalence of mental illness in the geriatric age group is similar in developed and developing countries, poor inpatient attendance of geriatric neuropsychiatric patients probably indicates a poor delivery of healthcare facilities to our senior citizens.

INTRODUCTION

According to united nations population fund (UNFPA), 1 out of every 10 persons is now 60 years or older.[1] As per the global trend, Nepal is also witnessing a surge in the percentage of population in elderly age group, with gradual rise in life expectancy rate. Life expectancy of Nepalese population has changed from 50 years in 1981 to 60 years by the beginning of this century. The Nepalese population is growing at a rate of 2.17%. Total population of Nepal at the beginning of this century (reported during last census) was 227 million (males: 113.5 million, females: 113.7 million). Elderly population of 60 years and above form 6.5% (15 million) of the total population.[2]

Latest census in India revealed that it is home to more than 76 million people aged 60 years and over.[3] This age group currently constitutes 7.4% of the Indian population. The life expectancy of an average Indian has increased from 54 years in 1981 to 64.6 years by 2002. This elderly population is likely to increase to 137 million by 2021.

As the population of older people in the world is steadily growing, mental health conditions are becoming an important cause of morbidity and premature mortality in this age group. Among the neuropsychiatric disorders, dementia and major depression are reported to be the two leading contributors of morbidity in this group.[4] It is estimated that there are already about 1.5 million people affected by dementia in India and this number is likely to increase by 300% in the next four decades.[5]

Authors from India report 22-35% prevalence rate of psychiatric disorders in their elderly study population.[6-8] In a prevalence study of psychiatric disorder amongst French elderly population, 46% of the study population was reported to have had experienced at least one mental disorder in their lifetime.[9] Lifetime prevalence of major depression was 26.5% and that for anxiety disorder was 30%.[9] The prevalence of significant depressive symptoms in community dwelling elderly individuals ranged from 11 to 44%, with an average of about 20%.[10] In a geropsychiatric morbidity survey in rural Uttar Pradesh, India, psychiatric morbidity was found in 42.2% of geriatric population, in comparison to only 3.97% psychiatric morbidity in non-geriatric population (with overall psychiatric morbidity in general population being 6.9%).[11]

In an institution-based study of elderly psychiatry outpatients over a period of 3 years, mood disorder was reported to be the most common illness (48.07%), followed by anxiety spectrum disorder (15.47%) and organic mental disorders (14.36%).[12] Medical comorbidity was a significant finding of this study as additional physical illness diagnosis was found to be present in more than half (56.35%) of these patients.[12] In a retrospective study of elderly patients attending a psychiatric clinic, psychotic disorder was reported in 33.6% and affective psychosis in 31.6% of geriatric patients.[13] Prasad found 43% of his elderly patient population had non-organic psychoses while 22% of had organic psychosis.[14] In a psychiatry outpatient-based study, mood disorder was reported to be the commonest clinical diagnosis (44%), followed by psychotic disorder (33.3%) and dementia (9.5%).[15]

Inpatient institution-based geropsychiatric study reports are rare even in world psychiatric literature, which prompted us to take up the present study.[16]

MATERIALS AND METHODS

This study was conducted at the Department of psychiatry, universal college of medical sciences teaching hospital (UCMS-TH), Bhairahawa, Nepal. All the elderly inpatients of age 60 years and above, admitted from January 2005 to June 2008 (3 years and 6 months), were taken up for the present study.

This study was done by the retrospective chart review method. Initially, we screened the cases through our “admission-discharge case registrar” of the department. Registration numbers all the cases of age 60 years and above were noted. Our department has a policy of writing discharge sheet in triplicate: one sheet is handed over to the patient at the time of discharge, second one is attached to the case sheet and deposited to the hospital record section, and third one is being kept back in the department for departmental record and future study purpose. Thus, in the present study, after screening out the cases from the admission-discharge registrar, discharge sheets of these patients were taken out from departmental record book. Finally, case sheets of all these patients were taken out from the hospital record section to validate, cross-check, and/or add/delete the information that was already recorded in the discharge summary sheet.

Diagnoses are based on International Classification of Diseases-10 guidelines.[16] We have one professor and head (R Muthuswamy), one associate professor (Tapas Kumar Aich - first author), one registrar (Manoj Dhungana) working as specialist, and two medical officers working full-time in the department. Joint round is carried out daily and all the new admissions of the previous day are discussed in detail to reach an initial provisional diagnosis. Diagnoses are being reviewed intermittently, during inpatient stay period, and if needed diagnoses are revised/modified during later date. Final diagnosis is written on the case sheet at the time of discharging the patient from the ward.

During the study period, 138 patients of age group 60 years and above were admitted. They formed our study group.

To study whether advancing age has any distinct effect on the pattern of neuropsychiatric and physical illnesses, we included elderly patients in the age group of 50-59 years as the comparative group. Case files of all those patients in the age group of 50-59 years, who were admitted during the same study period, were taken out and information available recorded in a similar manner as that of the study group. Thus, 194 patients (males=101 and females=93) formed our comparative group.

As our case records and discharge sheets have a printed, semi-structured format, complete and reliable information was available in all the records. Information was collected on socio-demographic and clinical variables and data thus obtained were noted in a specially designed data sheet prepared for the present study. Descriptive analysis of these data was performed using simple frequency distribution.

RESULTS

During the study period, a total number of 3698 patients (males=1690, females=2008) were admitted. One hundred and thirty-eight of them were in the geriatric age group (≥60 years) bracket. These 138 patients formed 3.73% of the total patient population (3698) admitted during the study period and they formed our geriatric study group. During the same period, 194 patients (males=101 and females=93) were admitted in the age range of 50-59 years. They formed our elderly comparative group.

Table 1 shows the socio-demographic profiles of our study population. As seen from the table, majority of our subjects (64.5%) were in the age range of 60-69 years. Forty-three (31.5%) of them were in the age range of 70-79 years and the remaining 7 (5.1%) patients were aged 80 years or above. Male patients contributed 60.1% (83) and females 39.9% (55) of our study population. As our institute is a comparatively newly established teaching hospital, with only 10 years of existence behind it, a steady growth of psychiatric inpatients over the years is normally expected and is reflected by year-wise distribution of patients. Nepal has two distinct geo-political divisions: sub-Himalayan Tarai region and the other that includes all mountain terrains. Feeding area of our hospital is from south-central region of Nepal including districts from both mountain and Tarai belt. We have equal distribution of patients from both the regions, thus possibly reflecting a more or less homogenous and representative sample of the Nepalese society.

Table 1

Socio-demographic profile

Table 2 shows the distribution of broad neuropsychiatric diagnoses across the gender. Common clinical diagnoses amongst male patients were alcohol dependence with or without various complications (27.7%), followed by mood disorder-mania (18.1%), organic mental disorders (18.1%), psychosis (16.9%), and mood disorder-depression (14.5%). Common clinical diagnoses amongst female patients were mood disorder-depression (36.4%) and psychosis (25.5%). Overall, the common clinical diagnoses were depressive illness (23.2%) followed by psychoses (20.3%), alcohol dependence (18.1%), organic mental disorder (15.9%) and mood disorder-Mania (15.9%).

Table 2

Broad neuropsychiatric diagnoses

Table 3 presents the further diagnostic sub-classification of dementia, alcohol-dependence syndrome, and Parkinsonism. We had almost equal distribution of primary (47.1%) as well as secondary dementia (52.9%). We received alcohol-dependent patients with all possible diagnostic sub-classifications: intoxication syndrome, uncomplicated withdrawal, withdrawal seizure, withdrawal delirium, with dementia, mood disorder, hallucinosis, and Parkinsonism. Most alcohol-dependent patients were males (23) and the remaining 2 patients were females. We took utmost care to level a diagnosis of Parkinsonism, excluding all possible cases of drug-induced Parkinsonism. We had a significant 11.6% (16) cases diagnosed as having Parkinsonism, mostly comorbid with some other neuropsychiatric illnesses.

Table 3

Diagnostic breakup of dementia, alcohol dependence syndrome, and Parkinsonism plus syndrome

Table 4 shows the presentation of comorbid physical illness diagnoses in our geropsychiatric patients. We took cognizance of only those cases where the patients were already diagnosed of an additional physical illness by the specialists of various other departments and where diagnoses and drug treatments were recorded in the case sheets. A total of 73 patients (52.9%), including 51 (61.4%) male and 22 (40%) female patients, were found to have some comorbid physical illness. Hypertension (18.8%), Parkinsonism (11.6%), and cerebro-vascular accidents (CVA) leading to various stroke syndromes (5.8%) were the common clinical comorbid diagnoses across both genders.

Table 4

Comorbid physical illness diagnoses

Table 5 shows a comparison of broad neuropsychiatric diagnoses across the genders in geriatric study group vis-à-vis elderly comparison group. As expected, comparative group had significantly less organic mental illness (2.6% against 15.9% in geropsychiatric patients). However, overall distribution of psychotic illness, mood disorder (mania), and mood disorder (depression) did not differ much in the two groups. But when we considered gender-wise distribution, we found a higher representation in alcohol dependence and related syndromes both in the study (27.7%) as well as in the comparison (42.6%) groups amongst male patients. Similarly, female patients had high percentage of depressive disorder both in the study (36.4%) as well as in the comparison groups (41.9%). Representation of neurotic, anxiety disorder spectrum was almost doubled in the comparative group (12.9% against 6.5% in the study group).

Table 5

Comparison of neuropsychiatric illnesses

Table 6 shows the distribution of comorbid physical illness across both the study and comparison groups. Seventy-three (52.9%) patients amongst the study population had some comorbid physical illness, whereas amongst the comparison group, only 29 (14.9%) patients had additional physical illness diagnosis.

Table 6

Comparison of comorbid illnesses

DISCUSSION

This retrospective case file based study was undertaken to analyze the socio-demographic and clinical profiles of geriatric psychiatric inpatients in a general hospital psychiatry set-up in Nepal.

Type of study

We have yet to come across any similar study from Nepal. Studies that were reported from India were either rural field based surveys or geropsychiatric morbidity survey in a semi-urban area.[71117] Most of the institution-based study reports from India are on outpatient geropsychiatric patient population.[12131518] We have already mentioned that inpatient-based geropsychiatric study reports are rare, even in world psychiatric literature.[19] Thus, it was a difficult task for us to compare and discuss our study findings with reference to the existing literature. Our discussion is based mostly in relation to the available hospital outpatient-based study reports as well as community-based prevalence reports on geropsychiatric population.

Prevalence of geropsychiatric patients

Our geropsychiatric patients constituted 3.7% of the total inpatient population admitted during the study period. Hospital outpatient-based studies from India usually reported little higher percentage of attendance from geriatric patient population, with the percentage varying between 4 and 7%.[131418] Regmi et al. from Nepal reported that 3.2% of their psychiatric outpatient attendance, over a period of 1 year, was 60 years or older.[20] In general, in the western countries, the prevalence for elderly inpatients is higher than that of elderly people in the community, with estimates of 14% for patients in emergency departments, 18% for medical inpatients, and 23-44% for psychiatric inpatients.[21] In an inpatient study reported from Australia, Draper[19] found that 23% of total hospital admissions were in the age group of 65 years or more.

Community-based studies from India and abroad have consistently shown much higher prevalence of psychiatric morbidity in the geriatric population,[7-911] with prevalence rate varying from as low as 22.3%[6] to as high as 46%.[9]

Thus, we see a significant difference between the community prevalence rate of geropsychiatric morbidity in the Indian sub-continent and that of hospital attendance of this geriatric age group. This was in spite of higher percentage of physical illness detected in the elderly age group. Factors that influence treatment seeking behavior are a debatable issue. But with a national figure of 6.5% of the total population constituting geriatric age group in Nepal, and an expected high rate of neuropsychiatric morbidity in this group, an inpatient attendance of 3.7% is definitely a low figure and is a cause for concern. Though we provide enough lip service for our elders in the society and we have placed them in very high esteem in our culture and religion, probably we are failing to provide adequate health care facility to our elderly citizens.

Age and sex, and illness distribution

Majority of our subjects (64.5%) were in the age range of 60-69 years. This is in accordance with that reported by others in the hospital outpatient-based studies.[12141518]

Male patients contributed 60.1% (83) and females 39.9% (55) of our study population. Percentage of geriatric female patients was significantly less than that of overall attendance of female patients (52.3%) during the study period. Outpatient studies reported wide variation in the ratio of male and female patient population.[121518]

Largest diagnostic group amongst males was alcohol dependence and related syndromes, constituting 27.7% (23) of all male patients, while depressive disorder formed the largest diagnostic category in female patients (36.4% of all females). This trend in diagnosis persisted even in the elderly comparison group, with 42.6% of elderly males being diagnosed as having alcohol-dependence syndrome and 41.9% of elderly females with depressive disorder.

Comorbid physical illness was seen to be present at a very high percentage (61.4%) in geriatric male patient population than in female patients (40%).

Mood disorder

Mood (affective) disorder was the largest diagnostic rubric in our study, constituting 39.1% (54) of the total study population. This is at par with other studies done with outpatient psychogeriatric patients.[1518] Considering depressive disorder separately, 23.2% (32) of our patients had a diagnosis of depressive illness. This figure is again at par with other studies reported from various geographic locations and over different decades in time.[8111517] Ritchie et al. reported a lifetime prevalence of 26.5% of major depression in their geropsychiatric patients.[9] Martha et al. found that 13.5% of newly admitted elderly home care patients suffered from major depression.[22] But Draper reported a very high 53% depressive disorder (43% major depression plus 10% dysthymia) in his series of inpatient geropsychiatric patients.[19]

Reported prevalence of mania amongst geriatric psychiatric patients was found to be low (1-2%) in both inpatient as well as community prevalence studies from western countries.[919] Most Indian studies also did not elaborate much on the prevalence of mania in this age group, although one study reported 7.1% mania in their geropsychiatric patient population.[15] In comparison, our study finding showed a much higher (15.9%) inpatient attendance of mania amongst geriatric psychiatric patients.

Psychosis

Twenty-eight patients (20.3%) in our study had diagnosis of schizophrenia and/or other psychotic disorders. Most common pattern of presentation was the late-onset psychotic disorder. While one epidemiologic survey found this rate to be 22.2%,[11] rates from various hospital OPD-based studies vary between 17 and 33%.[121518]

Organic mental disorder

Our study revealed that 15.9% (22) of geropsychiatric population had organic mental disorders. Existing literature also supports the above finding.[1218] More specifically, 12.4% (17) patients in our study group were diagnosed to be suffering from dementia. This rate is a bit higher than that of hospital outpatient-based study reports from India, which varies from 6 to 9%.[111518] This high inpatient attendance probably can be explained by the fact that dementia patients need more intense medical care, thus leading to their higher admission rate. Findings of Draper (1994), who reported 10% inpatient admission rate of dementia,[19] also support this hypothesis.

The prevalence of dementia in subjects 65 years and older is reported between 6 and 10%, with alzheimer's disease (AD) accounting for two-thirds of these cases.[23] The next most common forms of dementia are usually vascular dementias and the dementias associated with Parkinson's disease, accounting for approximately 10-15% of all cases.[24] We had 47.1% (8) primary dementia cases and the rest 52.9% (9) were secondary dementia cases, mostly vascular dementias. Though only two patients had alcohol-induced dementia, the condition needs a special mention as a rarer form of dementia in a routine clinical diagnosis. In fact, warning bell has already been sounded by some researchers, that alcohol-related dementia could be a possible 21st-century hidden epidemic.[25]

Anxiety disorder

Overall prevalence of neurotic disorders is found to be lower among the elderly than among all age groups combined and the range varies from 0.7 to 18.6%.[2627] The number of anxiety disorder patients (6.5%) in our study was less than that commonly reported in the published literature from India. Also, 7-16% of the geriatric outpatient population in India has been reported to have anxiety spectrum disorders.[121518] But in a community survey, a very high 53.9% of geropsychiatric patients were reported to be suffering from neurotic disorder according to International Classification of Diseases-9.[11] Ritchie et al. reported lifetime prevalence of anxiety disorder to be 30% amongst the French elderly population.[9] Amongst the various diagnostic rubrics in psychiatry, anxiety disorders are probably treated mostly at OPD level and they need less inpatient care. Nevertheless, it is a fact that neurotic, stress-related, and somatoform disorders in the elderly have received lesser attention than mood disorders and organic mental disorders, especially dementia.[12] Thus, it is possible that these patients do not present themselves to healthcare services, leading to only a fraction of hospital admissions of geriatric psychiatric patients belonging to anxiety spectrum disorders. These disorders are considered as hidden morbidity and have not been addressed adequately by various studies in India and abroad.[12]

Alcohol dependence

Possibly, the most important finding in our study was a very high attendance of alcohol-dependent inpatient population. The present study revealed that 18.1% (25) of the total patients had a diagnosis of alcohol-dependence syndrome, majority (23) of them being males and the remaining 2 were females. This finding is in sharp contrast to all those outpatient studies reported earlier from India, which reported an alcohol-dependence rate ranging from 1 to 3%.[121518] Pattern of alcohol dependence in Nepal probably conforms more to that reported in the western literature. The substance use/abuse data on the elderly population is sparse globally; the available data are mostly from the West.[28] Elderly male gender is established as an important risk factor for drinking related problems.[29] In USA, alcohol and substance abuse have been reported to be the third leading health problem among those aged above 55 years, constituting 10% of all cases treated by geriatric mental health facilities.[30-32] In the United Kingdom, a household survey reported that 17% men and 7% women aged ≥65 years consumed more than the recommended limit of alcohol and 3-9% were heavy alcohol users.[33] Indian research in this area is mostly on the prevalence of alcohol abuse.[34-36] We received alcohol-dependent patients with all possible diagnostic sub-classifications. Delirium tremens (DT) and withdrawal seizure were present in 12% (3) of alcohol-dependent patients, with 1 (4%) patient having both seizure and DT. Similar high prevalence of severe withdrawal has been reported both in the West and in India.[37-39] Alcohol use disorders in the elderly people may prove to be a silent epidemic, yet, media attention and public health initiatives related to alcohol use disorders tend to focus almost exclusively on younger populations.[4041]

It is a fact that the treatment seekers are an indirect indicator of the actual community load of the alcohol abusers. Assuming that our patient group was more or less a representative sample, the above findings become all the more important as a high 42.6% (43) of the male patients and an overall 23.7% (46) patients in the comparison group had diagnosis of alcohol dependence and related syndromes. If this result can be replicated and generalized, then probably Nepal is sitting on a dormant volcano, ready to erupt at any moment, which will have some devastating social and economic consequences on this small Himalayan nation. It is encouraging that the newly elected democratic Government of Nepal probably realizes this potential hazard in the Nepalese society and has taken some concrete steps recently in curbing the national trend in problem drinking behavior.

Physical illness

Associated comorbid physical illness seen in our geriatric study population was similar to that reported by earlier researchers.[1218] Seventy-three patients (53.9%) in the study group had some physical illness, hypertension being the commonest (18.8%). Parkinsonism (11.6%), CVA (5.8%), and diabetes (3.6%) were the other common diagnoses. The reported rate of hypertension varied from 15 to 27%.[121518]

One interesting finding of our study was that a significant 11.6% (16) of the geropsychiatric patients was diagnosed to have Parkinsonism.

Comparison of geriatric vs. elderly group

The innovative part of our study was having the elderly age group (50-59 years) patients as the comparative group. We thought it was better to have a comparative group, who were on an average a decade younger than our study population. The findings have been discussed in detail in the section “Results.”

Alcohol dependence in males and depressive disorder in females stood out as distinctive illness in patients above 50 years of age (including both study and comparative groups). Representation of neurotic, anxiety disorder spectrum was almost doubled in the comparative group (12.9% against 6.5% in the study group). This finding again, probably, supports the hypothesis that geriatric patients either undertreat themselves or get undertreated for their anxiety symptoms. In contrast to the existing literature in the East and the West, we found a higher representation of mood disorder-mania in both study and comparative groups.

Seventy-three (52.9%) patients amongst the study population had some comorbid physical illness, whereas amongst the comparison group, only 29 (14.9%) patients had additional physical illness diagnosis. This is a very important finding in the overall context of the geropsychiatric patient population. With the progress of age by a decade, there was sharp decrease in the level of physical well-being, thus making this patient group more vulnerable to illness, morbidity, and overall mortality.

Improved healthcare promises increased life expectancy, but social and economic conditions like poverty, increasing breakup in joint family system, and poor services for the elderly in developing countries like Nepal pose higher susceptibility of the geriatric age group to neuropsychiatric illness. In recent decades, the traditional joint family system that cared for the elderly has been breaking down in the Indian sub-continent including Nepal, without a public social security system replacing it; resulting in elderly citizens being either less cared for or forced to live on their own. Thus, as they are growing older, the psychological and the physiological changes in our senior citizens render them more vulnerable to illness.

Sincere and more robust involvement of government and non-governmental agencies is needed in this sub-specialty of mental health field, to be able to tackle the dual problem of mental and physical illnesses in our geriatric population. Mental health clinicians also need more training in diagnosis and management of common mental and physical health problems of the elderly. In fact, It has been strongly advocated that geriatric psychiatry should be given due importance during postgraduate training in psychiatry.[42] In a presidential address to Indian Psychiatric Society, Ghosh[43] also stressed the need to put more focus on geriatric psychiatry. Finally, a conscious, consorted, multidisciplinary team effort should be there to approach the overall health status of this group of patient population which probably needs special care and training to be able to overcome their physical as well as mental ailments.