Psychiatric morbidity in elderly patients attending OPD of tertiary care centre in western region of Nepal.

CONTEXT: Aging of population is currently a global phenomenon. At least one in 5 people over the age of 65 years will suffer from a mental disorder by 2030. Study of psychiatric morbidities in this age group is essential to prepare for upcoming challenges. AIMS: To find out the prevalence of different psychiatric morbidities in elderly population and to find out if there are any age and gender specific differences. SETTINGS AND
DESIGN: Retrospective review; Psychiatric outpatient department of Manipal Teaching Hospital, Pokhara, Nepal.
MATERIALS AND METHODS: Data for patients ≥ 65 years of age attending the psychiatric outpatient department of Manipal Teaching Hospital, Pokhara, Nepal, from 1(st) January 2012 to 15(th) January 2013 were collected retrospectively in a predesigned proforma. STATISTICAL ANALYSIS USED: Risk of having different psychiatric disorders was estimated using odds ratio.
RESULTS: The mean age of 120 patients included in this study was 69.67 (SD = 5.94) years. Depressive disorder (26.7%) was the most common diagnosis. There was no statistically significant difference in psychiatric disorders in >75 years compared with ≤75 years except for dementia [odd ratio (OR) (≤75 years/>75 years)=0.055, 95% confidence interval (CI)=0.016; 0.194]. Alcohol dependence syndrome [OR (male/female)=7.826, 95% CI = 1.699;36.705] and dementia [OR (male/female)=3.394, 95% CI = 1.015;11.350] was more common in males.
CONCLUSIONS: Depressive disorder was the most common psychiatric morbidity among the elderly patients. The odds suffering from dementia increased with increasing age. The odds of having alcohol related problems and dementia were more in males compared with females.

Aging of population is currently a global phenomenon. The number of elderly requiring mental health services will rise, because of increased incidence of certain disorders, for example, dementia.[1] A plan is needed for provision of services to elderly persons with major mental disorder.[2]

Age and gender affect the onset, course, treatment and outcome of most psychiatric disorders. Their effect on psychiatric morbidity of elderly patients has received little attention. There have been a few studies in elderly patients in Nepal;[345] however, none has focused on age and gender specific differences. This study is designed to fulfill this research gap.

MATERIALS AND METHODS

A retrospective review of departmental records from 1st January 2012 to 15th January 2013 was carried out. Data regarding age, gender and diagnosis of all the patients ≥ 65 years of age visiting the out patient department (OPD) of psychiatry, Manipal Teaching Hospital, Pokhara, Nepal, were collected. All patients were diagnosed by consultant psychiatrist using International Classification of Disease-10 (ICD-10) criteria. Out of a total 8482 patients who visited OPD of Psychiatric department in the study period; 125 patients were new cases of age 65 years or older. Out of 125 patients who visited the department data from five patients were excluded from analysis because of inadequate information, hence a total of 120 patients were included in the study. Data from all the patients included in the study was entered in predictive and analytical software (PASW) version 18.0. After analyzing the data for demographic and clinical profiles, the risk of having different psychiatric illness was estimated using odds ratio (OR). Different psychiatric diagnoses were treated as dependent variable; age and gender were treated as independent variable.

RESULTS

The mean age of study group was 69.67 (SD = 5.94; range = 23). Almost equal patients from both groups [male = 58(48.3%); female = 62(51.7%)] were included in the study. The clinical profile of the study population is shown in Table 1.

Table 1

Distribution of psychiatric disorder among the study population

The distribution of psychiatric disorders was further analyzed in two different subgroups created by age (≤75 years and >75 years) and gender (male and female). Among patients younger than 75 years of age; 47 (45.6%) were male and 56 (54.4%) were females making a total of 103 patients in that group. Total of 11 (64.7%) male patients and 6 (35.3%) female patients comprised the 17 patients included in older than 75 years age group. The relationship between age groups and psychiatric disorders is shown in Table 2 and the relationship between gender and psychiatric disorders is shown in Table 3. Two female patients had history of suicidal attempt by consumption of organophosphorous compound. Both patients belonged to ≤ 75 years age group and were diagnosed to have depressive disorder.

Table 2

Relationship between age groups and psychiatric disorders

Table 3

Relationship between gender and psychiatric disorder

DISCUSSION

Current study was carried out with the aim of estimating the prevalence of various mental and behavioral disorders in the elderly patients visiting the psychiatric OPD of a tertiary care center. It further aimed to analyze whether there were any age or gender specific differences in psychiatric morbidity in these patients.

In the current study organic including symptomatic mental disorders was found in 15% of patients. Dementia (12.5%) was the most common diagnosis followed by delirium (1.7%) and organic mood disorder (0.8%). Similar findings have been reported from other parts of Nepal.[46] However, delirium was more frequent than dementia in one of the studies,[6] which may have been due to difference in sampling technique. The risk of having dementia increased with increase in age [OR (≤75 yrs/>75 yrs) =0.055,95% CI = 0.016;0.194]. This finding was expected and is in accordance to previous studies.[1] Dementia was more frequent in males in our study. This finding is in contrary to expectation as dementia is usually found to be more prevalent in older women even after adjusting for their longer survival.[7]

Previous studies from Nepal have reported alcohol dependence syndrome in 5% of elderly patients,[8] and alcohol related disorders in 14%.[4] Similar high prevalence of alcohol related problems (11.7%) was found in our study. Alcohol related problems were more in males and younger subgroup in our study, which was similar to findings reported earlier.[9] However, only the gender specific difference was statistically significant [OR (male/female) = 7.826,95% CI = 1.699; 36.705]. The decrease in prevalence of alcohol related disorders with increasing age may in part be due to maturing out of subjects or selective mortality.[10] Part of this might also be due to under reporting of substance related problem by older adults or under detection by physicians.[11]

Schizophrenia and related psychotic disorders was present in 13.3% of our sample which is higher than the earlier finding of 6% from Nepal.[4] Rates of schizophrenia similar to our study have been reported from India and other parts of the world.[1213] Schizophrenia and related psychotic disorders were equal in both sexes and odds did not differ in different age subgroups of our study. Though the prevalence of psychotic symptoms tend to increase with age, this is not true for primary psychosis. Slightly higher prevalence in females is expected as late onset schizophrenia is more common in them.[14]

The prevalence of depression in current study is lesser than that reported by a study where depression was screened for using geriatric depression scale.[5] Depressive symptoms are no more frequent in elderly when compared with young adults,[1516] though some studies suggest that it may be due to bias induced by selective mortality and difficulty in case finding.[15] when factors like more physical disability, higher proportion of females, more cognitive impairment were controlled for there was no relationship between age and depressive symptoms.[17] Some studies suggest that major depression decreases with age whereas minor depression rises concurrently.[16] In current study the odds of having depressive disorder was higher in females and younger subgroup of the elderly patient.

The prevalence of bipolar affective disorder (BPAD) in outpatients is estimated to be 6.1% (SD = 1.5).[18] The overall prevalence was similar in current study. The BPAD was not seen in patients of older subgroup. This might be due to the selective mortality of patients with BPAD. Male preponderance was seen in current study, which may be due to increase in late onset mania in males and,[19] however, this difference was statistically not significant.

Although anxiety disorders are less common in elderly when compared to young adults,[20] they are highly prevalent in this population. Among elderly patients the prevalence seems to be lesser in older subgroup and males.[2122] Similar pattern was observed in current study with odd of suffering from anxiety disorder being more in younger subgroup and females. The differences were however not statistically significant.

Somatoform disorder was seen in 2.5% of our sample. This rate is lower than reported previously.[4] This lower rate could be artifactual because of less referral of elderly patients with somatic complaints to psychiatry OPD for the fear of missing “organic cause”, the masking effect of comorbid physical condition. The tendency of psychiatrist to limit psychiatric diagnosis based on traditional hierarchy has been noted earlier as barrier to diagnosis of somatoform disorder.[23] As expected the prevalence was higher in females.

Two out of 120 patients (1.7%) in our sample had attempted suicide. Both were females and belonged to the younger subgroup and were diagnosed to be suffering from depressive disorder. Similar rate of suicide attempt in elderly subject with female preponderance has been reported earlier from Nepal.[424] Association of suicidal attempt with depression is also well known.[25] Previous studies suggest that risk of completed suicide increases with age but non-fatal suicidal attempts tend to decrease with increasing age.[26] Lethality of attempt is also more in older males compared with females.[27] In our study completed suicide had not been taken into account so the profile of younger females attempting more suicide is an expected pattern since older males might have completed suicide and hence been excluded from the study.

The findings of this study have to be interpreted against the background of its limitations. Its retrospective design and small size are the two most important limitations. A prospectively designed study using structured or semi-structured questionnaires would help eliminate the interviewers’ bias. Subgroup analysis of this study was particularly hampered by the small sample size of the study as comparisons could not be done for several disorders. Even in cases where comparisons were feasible the confidence intervals obtained were wide; limiting the confidence in our findings. It is also important to note that the use of standard diagnostic manuals like ICD may underestimate the prevalence of psychiatric disorders in older population because they have not been validated in this population. As the knowledge base of psychiatric disorders in the elderly increases age specific diagnostic criteria may be available in future. The strength of this study lays in the fact that it the first study done in Nepal which has tried to explore the relationship of age and gender with psychiatric morbidity in elderly patients.

CONCLUSION

Depressive disorder was the most common psychiatric disorder (26.7%) followed by anxiety disorder (23.3%). There was no statistically significant difference in psychiatric disorders in >75 years age group compared to ≤75 years except for dementia, which was more common in older age group. As for gender, alcohol dependence syndrome and dementia were found to be more common in males and the difference was statistically significant. The odds of male patient suffering from depression, anxiety, mixed anxiety depression, somatoform disorder was around half when compared to females but the difference was not statistically significant.