A study of dementia in old age homes.

BACKGROUND: By 2040, dementia is projected to rise exponentially by 300% in India. Studies addressing the need for psychiatric care in the community being few and those focusing in old age homes even fewer, a study was undertaken to study the prevalence of dementia and the association with sociodemographic factors and psychiatric morbidity.
MATERIALS AND METHODS: A total of 558 elderly aged 60 years and above, residing in old age homes in Pune were studied. 179 inmates were included based on the inclusion and exclusion criteria. Those who scored a predetermined cut-off score on the screening tool were included to undergo a detailed physical and neurological examination, cognitive profile using subtests from the cognitive test (community screening instrument for Dementia of 10/66 group).
RESULTS: Mean age of the sample was 75.02 years majority (39.7%) was in the 60-70 years group. Males 25.7% versus females 74.3%. The sample consisted of the following socioeconomic groups: 40.2% middle, 26.3% low middle, 24% high middle, 8.4% high income, and 1.1% in low income. 60.3% widow/widower category, 36.3% never married, 4.5% had family history of dementia. Mean scores of mini mental state examination in the overall sample was 26.02 compared to 18.02 in those cut-off point of 23. The prevalence of dementia in the sample was 22.9%. There was the high prevalence of psychiatric symptoms and psychiatric morbidity in the dementia group than the rest. Frontal lobe dysfunction and impairment of orientation with increasing severity of dementia were observed.
CONCLUSIONS: Sociodemographic factors, which were considered protective against the prevalence of dementia, identified were less restriction in physical activity and having fish in the diet regularly. Copyright:

There is no greater certainty in life than death. The biological process of aging is steady and unidirectional. With decreasing mortality and people living to a riper age, dementia is projected to reach epidemic proportions.[1] Alzheimer's disease (AD) together with Parkinson's disease and brain injury in strokes, is a threat to the wellbeing of the elderly.[2] Currently, 24·3 million people have dementia and with 4·6 million new cases added every year the number affected would double every 20 years, expected to increase 81·1 million by 2040 which is a 100% between 2001 and 2040 and more than 300% in India, China, and their South Asian Pacific neighbors.[1] In poor countries, the extended family can no longer act as a safety net for the elderly. Old age homes have shown more rates of depression and generalized anxiety disorder.[3] Since epidemiological reports in old age homes from India are few[4] the present work was undertaken to study the prevalence of dementia in old age homes in the city of Pune.

MATERIALS AND METHODS

The study was carried out in 12 old age homes in Pune. Institutional Ethical Clearance was obtained before starting the study. All the subjects gave written informed consent. The diagnosis was made based on ICD-10 diagnostic research criteria.

Sample

A total of 558 elderly aged 60 years and above in 12 old age homes in Pune were studied.

Out of them, 179 inmates were included based on inclusion and exclusion criteria.

Inclusion criteria

Age >60 years

Resident of “old age home”

Willingness to participate.

Exclusion criteria

Inability to follow the instruction in Hindi/English

Physical disability/medical illness.

Methods

Data were collected on a structured pro forma, sociodemographic, and geriatric mental state (GMS) questionnaire. After a brief mental state examination, they were screened by mini-mental state examination (MMSE) and a cut-off score of 23 and below were made to undergo a detailed cognitive profile using subtests from “cognitive test” (community screening instrument for dementia [CSI-D] of 10/66 group).[5] i.e. CSI-D, “Consortium to Establish a Registry for Alzheimer's disease” (CERAD) 10-word list (CWL), the delayed recall test and a verbal fluency test.

CWL test ten words (culturally appropriate) were read out to the participants, and were asked to recall the words, the process repeated three times.

”Animal naming verbal fluency task:” participants were asked to name as many different animals as they can in 1 min

”Delayed recall of word list” to recall the 10 words (in any sequence) which was presented earlier. The evaluation was aimed at obtaining a cognitive profile for each subject.

The questionnaire of “sociodemographic and risk factor” and “GMS AGECAT 'B' package” were used to collect data on psychiatric morbidity and demographic data.

Statistical analysis

Data were analyzed using SPSS Version 16 (IBM, Chicago, USA) using appropriate statistical tests.

RESULTS AND DISCUSSION

Based on the findings of the epidemiological study which reported an average of 20.5% psychiatric morbidity in older adults, it is estimated that 17.13 million older adults (total population, 83.58 million) may be suffering from psychiatric disorders in India.[6]

Sociodemographic risk factors

Age

179 residents above the age of 60 years completed the study. The mean age was 75.02 ± 8.78 years. The majority of the sample fell into the age group of 66–70 (24%). In the number of elderly 39.7% was below 71 years, 36.3% in 71–80 age group, and 24% in 80 + age group. The mean age in this sample is lower when compared to the mean from the care facilities from developed countries (83.9 years).[7] The mean age of the residents without dementia/with dementia was 73.06 years (standard deviation [SD] = 7.6)/81.06 years (SD = 9.1) (odds ratio [OR] = 3.73 (95% confidence interval [CI] = 2.27–6.16, P ≤ 0.001). As in the present study increasing prevalence of dementia with age has been reported from the Indian community.[8]

Prevalence of dementia

The prevalence of dementia varies higher in the developed than in the developing countries. Indian studies have reported a prevalence rate of 1.3–3.6 from rural areas and 2.4–2.7 in urban areas.[9] This association of increase in proportion of people with dementia with increasing age was statistically significant (OR = 8.73, 95% CI = 3–27.21) χ2-23.529 [P < 0.001; Table 1].

Table 1

Prevalence of dementia stratified according to age

Age group	Dementia		χ2	P
	Absent, n (%)	Present, n (%)
60-70	64 (90.1)	7 (9.9)	23.529 (df 2)	P<0.001 significant
71-80	52 (80.0)	13 (20.0)
81 and above	22 (51.2)	41 (48.8)
Total	138	41

Gender

Most studies have found that the risk of AD is greater in women. Although studies show the presence of estrogen as a protective factor,[10] higher survival rates in women than men, could also be a reason.[11] The proportion of males to females who are likely to have dementia was 12/46 (26.1%) as opposed to 29/133 (21.8%). The risk of dementia was higher in men (OR = 1.27, 95% CI = 0.7–2.25, P > 0.551), but the difference is not statistically significant.

Socioeconomic status and education

Socioeconomic status also influences the various available health facilities. When the data was compressed into two groups, with the first group comprising of those from high to the middle group and the second low middle and low group, the association was worked out to be significant. The study compared the effect of education on cognitive decline. Some studies show no relation to the age of onset or rate of progression but others find a positive correlation to increased incidence of dementia.[12] The study reflects the latter [Table 2].

Table 2

Educational status of the study group cross tabulated with dementia

Education	Total	Dementia		Fisher’s exact test
		Absent	Present
Illiterate (n)	35	14	21	P=0.000
Middle school or lower (n)	93	76	17
Higher secondary (n)	34	34	None
Graduation or higher (n)	17	14	3
Total (n)	179	138	41

Religion

Representation by religion among those with dementia revealed that the majority of them were Hindus, followed by Christians, Buddhist, and Muslims. Though the association seems to be lower in the Christians, statistically not relevant.

Marital status

Marital status showed a higher number of people with dementia among the “never married” group (29.2%) as compared to the “widow/widower” group, (20.4%). The risk of dementia in the “never married” is higher than widowed but statistically not relevant. OR = 1.36, (95% CI = 0.6–3.01, P > 0.414).

Family history

Genetic factors, notably the ApoE4 gene may be responsible for late-and early-onset cases. In this study, those with family history of dementia 75% (6/8) had dementia. There was an increased association of dementia in those with family history than those without [Table 3 and Figure 1].

Table 3

Family history of dementia cross-tabulated prevalence of dementia

Family history of dementia	Dementia		Total
	Absent	Present
No, n (%)	136 (79.5)	35 (20.5)	171 (100.0)
Yes (n)	2	6	8

OR was 0.09 (95% CI=0.01-0.52, P<0.002). OR – Odds ratio; CI – Confidence interval

Figure 1

Family history of dementia and presence of dementia

Co-morbidity

Co-morbidity with diseases like diabetes and hypertension and Stroke is common in the aged. The observed association between stroke and AD might relate to an underlying systemic vascular disease process. Increase in risk of dementia is independently associated with stroke, diabetes, and HIV.[131415] In this study, the risk of dementia in those with diabetes mellitus or stroke, independently is not statistically significant. When combining the factors of hypertension and stroke together in this study the risk increases significantly [Table 4].

Table 4

Composite table depicting association of dementia and group with hypertension/DM/stroke

	Dementia
	Present	Absent
With a history of hypertension (on AHA)	14	28
With a history of diabetes (on OHA)	3	22
With a history of stroke	2	4

OR=3.67 (95% CI=0.8-21.62, P<0.05). OR – Odds ratio; CI – Confidence interval, AHA – Anti-hypertensive agents, OHA – Oral hypoglycemic agents

Restriction in activity, poor vision, and hearing loss

”Staying active is important to healthy aging.” In the aged “communication” is the most affected. Sensory loss (visual and/or hearing loss) is prevalent in older adults. People with sensory loss frequently experience communication breakdown.[16] There were 31.8% of residents of old age homes who had restricted physical activity. With decreasing mobility, there is an increase in risk of dementia. The risk of dementia is less in those with less restriction in physical activity [Table 5]. With poor vision/hearing and attendant restricted activity, there is an increased percentage of people with dementia. The risk of having dementia increases with increasing disability [Tables 6 and 7].

Table 5

Age wise decrease in mobility

Age group	None	Mild	Moderate	Severe	Total
60-70 (n)	61	7	2	1	71
71-80 (n)	44	13	7	1	65
81 and above (n)	17	11	13	2	43
Total, n (%)	122	31	22	4	179
	Value	df		Asymp.Sig.(2sided)
Pearson Chi-Square	41.022	15		0.000

OR=0.08, (95% CI=0.03-41.022, P<0.001). OR – Odds ratio, CI – Confidence interval

Table 6

Decreased mobility cross-tabulated with dementia (n=179)

	Dementia
	Present	Absent
Mild or no restriction in physical activity	23	130
Moderate to severe restriction in physical activity	18	8
Total	41	138

OR=3.10, 95% CI=1.2-7.5, P<0.005. OR – Odds ratio; CI – Confidence interval

Table 7

Correlation of restricted activity due to visual/hearing impairment with dementia

Restriction in activity due to visual impairment	Dementia		Total (n)
	Absent (n)	Present (n)
Visual/hearing problem	116/134	4/16	120/150
No interference	4	24	28
Interferes a little	14/2	8/3	22/5
Interferes a lot	4/0	5/7	9/7
Total, n (%)	138 (77.1)	41 (22.9)	179 (100.0)

OR=22, 95% CI=4–210, P<0.0001. OR – Odds ratio; CI – Confidence interval

Nutrition

Nutrition plays an important role in the process of aging. One study showed that having fish >3 times/week increases the availability of docosahexaenoic acid which is found to be lower in the brain of people with dementia.[17] Analyzing the study group for intake of fish it was found that of all surveyed 62.6% did not take fish and the prevalence of dementia in those who did not take fish as against those who did was significantly higher [Table 8].

Table 8

Fish in diet cross-tabulated with the prevalence of dementia

Frequency of eating fish	Dementia		Total (n)
	Absent (n)	Present (n)
Never	76	36	112
Some days	24	4	28
Most days	38	1	39
Total	138	41	179

OR=4.89 (95% CI=1.86-15.03, P<0.0003). OR – Odds ratio; CI – Confidence interval

Screening instrument scores

The mean MMSE found in our study sample was 26.02 (SD = 3.98) and those with dementia were 18.02 (SD = 5.81). A cut-off score of 23 on MMSE was taken for dementia and 41 (22.9%) of the study sample had dementia. To remove the effect of depression on cognitive score a subcategory of depression was analyzed. The mean score of 26.50 in this category is quite similar to those without depression (25.96) and in the total sample (26.02) [Table 9].[18] Table 10 shows a trend of decreasing MMSE scores for more severe grade of dementia, which is statistically significant [Table 10].

Table 9

Variation of mini-mental state examination scores in various subcategories

MMSE scores	Minimum	Maximum	Mean±SD
MMSE scores in those with dementia (n=41)	2	23	18.02±5.81
MMSE scores in those with depression (n=16)	17	29	26.50±3.50
MMSE scores in those without depression (n=163)	2	30	25.96±4.04
MMSE scores (n=179)	2	30	26.02±3.98

MMSE – Mini-Mental State Examination; SD – Standard deviation

Table 10

Mini-mental state examination scores in various grades of dementia

Grades of dementia	Score of MMSE (mean±SD)
Mild dementia (n=23)	21.30±1.893
Moderate dementia (n=14)	16.07±4.731
Severe dementia (n=4)	6.00±5.831
Total	18.02±5.812

MMSE – Mini-mental state examination; SD – Standard deviation

Consortium to establish a Registry of Alzheimer's Disease Word List

Consortium to Establish a Registry for AD (CERAD) is a widely used test that has shown high accuracy in dementia. Predetermined cut-off “13” has been found to have specificity of “96%” and sensitivity of “91%.”[18] In our study, the mean was 8.10 (SD 3.7) and differentially across the grades of dementia they were 9.61 (SD 3.5), 6.29 (SD 3.3) and 5.75 (SD 2.5) in mild, moderate, and severe dementia, respectively, which was statistically significant [Table 11].

Table 11

Mean of delayed recall, word fluency with increasing grades of dementia

Grades of dementia	Mean±SD
	CERAD word list	Word fluency	Delayed word list recall
Mild dementia	9.61±3.577	6.27±2.511	1.96±1.609
Moderate dementia	6.29±3.338	4.64±1.216	1.00±0.877
Severe dementia	5.75±2.500	3.67±0.577	0.50±1.000
Total	8.10±3.760	5.49±2.211	1.49±1.434

CERAD – Consortium to establish a registry of Alzheimer’s disease; SD – Standard deviation

Word fluency

Word fluency test has been used in a few studies and a predetermined cut off “11” was found to be having a sensitivity of “73.8%” and specificity of “87.1%.”[19] The mean scores for word fluency, among the participants with dementia, in our study, were 5.49 (SD = 2.2), and differentially across the grades of dementia were 6.2 (SD = 2.5), 4.6 (SD = 1.2), and 3.6 (SD = 0.5) in mild, moderate and severe dementia which was statistically significant [Table 11].

Delayed word list recall

Delayed recall tests have high accuracy for dementia diagnosis, especially for AD.[19] In an American study, the cut-off to determine dementia was “3” with a sensitivity of “74.2%” and specificity of “82.4%.”[20] In our study, the mean value of delayed recall was 1.4 (SD 1.4), and tabulated across the grades of dementia it was found to decrease from 1.96 (SD 1.6), 1 (SD 0.8) to 0.5 (SD 1.4) [Table 11]. The study found statistically significant deterioration in cognitive profile with increasing severity of dementia.

Prevalence of psychiatric morbidity

The prevalence of depression ranges from 13% to 14%. Higher prevalence rates of depression have been found in females.[21] Psychomotor retardation to aggressive stance was found to have a more male preponderance in Western studies.[22] GMS AGECAT data showed that the commonest symptom was worry (38.5%) followed by depression (21.2%), generalized anxiety (16.7%), change in behavior (12.8%), change in affect (4.4%), problems with orientation (3.3%) and persecutory delusion (0.5%). Our findings are in agreement with studies from India that show a preponderance of depressive disorders (7%–13.4%) followed by dementia (6.7%), schizophrenia (3%), and generalized anxiety disorders (2%–8%).[23]

Comorbidity in those with dementia (n = 41) and those without (n = 138) statistically relevant morbidity was highest with “generalized anxiety disorder,” and the risk is higher in dementia – OR = 2.95 (95% CI 1.21–7.02, P < 0.006). The risk for depression was found to be higher in those with dementia than in those without [Table 12]. Statistically significant increase in risk was seen in “generalized anxiety disorder” (OR = 2.95, P < 0.006).

Table 12

Psychiatric co-morbidity in those with dementia

	General anxiety disorder	Depression	Delusional disorder
In those with dementia (n=41), n (%)	14 (35)	10 (25)	1 (2.5)
In those without dementia (n=138), n (%)	16 (11.6)	28 (20)	None
OR	2.95	1.20	Cannot be calculated
95% CI	1.21-7.02	0.48-2.81
P	0.006	0.663	0.00

OR – Odds ratio; CI – Confidence interval

Neurological findings

Frontal lobe dysfunction was seen in 22 cases (55%) [Table 13]. When cross-tabulated with the severity of dementia it was found that in mild dementia it was only in 43.5% of the total, whereas increased to 64.3% in those with moderate dementia and all the patients with severe dementia had frontal lobe dysfunction. This shows the trend that frontal lobe dysfunction increases with the severity of dementia and was nearing statistical significance (P < 0.08). 15% of the population with dementia had impaired orientation. People with impaired orientation are older, with more severe grades of dementia.

Table 13

Description of neurological signs present in those with dementia (n=41)

	Frontal lobe function, n (%)	Parkinsonism, n (%)	Orientation, n (%)	Primitive reflex, n (%)	Gaze palsy
Number deranged	22 (55)	3 (7.5)	6 (14.6)	1 (2.5)	None
Number not deranged	19 (45)	38 (92.5)	35 (85.3)	40 (97.5)	None

CONCLUSIONS

The overall prevalence of dementia aged above 60 years was 22.9%. The prevalence of dementia increased with increasing age. Cognitive profile, represented by CERAD (word list), word fluency test, and delayed recall test, too showed a trend to decrease with increasing severity of dementia.

Sociodemographic factors protective against dementia were less restriction in physical mobility and having fish regularly and those considered a higher risk of dementia, were male and unmarried.

Psychiatric morbidity was higher in those with dementia with significant comorbidity of generalized anxiety disorder. There was a higher prevalence of frontal lobe dysfunctions and impairment in orientation with increasing severity of dementia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.