AGED SEEKING PSYCHIATRIC HELP: SOCIO-DEMOGRAPHIC CORRELATES AND ILLNESS CHARACTERISTICS

K. PRAVEENLAL, D. P. M., M.D., Dip NB1
S. DUBE, P. H. D2
D. MOHAN, M.D3
K.S. SUNDARAM4
INTRODUCTION
 Improvement in health care system, leading to declining death rates would result in a progressive rise in the aged population in the coming years. India, several years ago was a country with young population and in the years to come, would have a significant percentage of the aged population like other developing countries.
 The care of elderly persons should go beyond disease orientation and involve their total well being, taking into account the interdependence of the physical, mental, social, spiritual and environmental factors(U. N. 1982) To mach adding years to life by adding life to years is the present concern (EL - GUEBALY 1983). 
 Epidemiological studies on psychiatric illnesses in India showed a wide variation of prevalence from 2.2%(DUBE 1970) to 33.3% (NANDI et al 1975) for psychogeriatric problem. The data were not comparable as the operational definition for a case, age grouping and location varied (MOHAN & LAL 1986) and do not assist in any conclusions. VENKOBARAO et al 1972, based on out patient register in Madurai, reported that hose aged 60 years and above comprised 2.3% of the total attendance. RAMACHANDRAN et al (1982) reported that new admissions and ageing of the long stay patients accounted for nearly 25% of mental hospital beds. Community surveys in elderly above the age of 60 years showed a prevalence rate of 33.7%(RAMACHANDRAN et al 1981) and 8.9% (VENKOBARAO & MADHAVAN 1982) for psychiatric illnesses. The reason for wide difference was not clear from reports.
 Mental illness in old age is not synonymous with senile psychosis (RAMACHANDRAN et al 1982). Even though the diagnosis of psychosis has been much less reliable in aged patients (LEUCHTER and SPARRI 1985). the psychiatrically morbid can be grouped into various diagnostic categories. Results of Indian Studies showed comparable results in each category of hospital studies (VENKOBARAO 1981, PADMA RAJU 1982, ICMRI 1984) or community surveys (RAMACHANDRAN et al 1982, VENKOBARAO & MADHAVAN 1982).
 The present study attempted to study the nature of psychiatric disorders in the aged coming to a psychiatric outpatient department of the General Hospital. The study was planned with hope that the observations made and the results would be of assistance in planning better management for the aged seeking psychiatric help and a pointer for further research.
AIMS AND OBJECTIVES : To find out socio-demographic correlates of aged seeking psychiatric help and to assess the diagnostic categories of psychiatric disorders according to I. C. D.-9.
METHODOLOGY : Patients for this study were selected from the Psychiatric services of All India Institute of Medical Sciences, New Delhi. Inclusion criteria were. (i) Age 60 years and above. (ii) Case diagnosed as having a psychiatric illness by the consultant in Psychiatry. The exclusion criteria were. (i) doubtful chrmological age. (ii) absence in Psychiatric illness (iii) Unwillingness to participate in the study (iv) Continuous illness for more than 3 years of episodic illness with present episode continuously since 57 yearsor before: to exclude graduate cases (v) Non availability of an independent informant who was staying with patient for a atleast 6 months, continuously in the past, It was planned to study a minimum of 50 patients.
 Controls were selected from the relatives accompanying patients or from general public. They were group matched with the patients sample for age, sex and education status. The only inclusion criteria in them was age above 16 years and exclusion criteria were (i) suffering from a psychiatric illness or past history of it. (ii) Not a first degree relative of a patient from experimental sample. It was planned to study minimum of 30 controls. 
The data was collected by means of a semi structured interview and recorded on the proforma constructed for the purpose. Patients and controlls were explained the purpose of the study and their consent and co operation sought. The interview was conducted after establishing report, obtaining consent and ensuring confidentiality. The language used for instructions were English and Hindi , depending on the preference of the subject, which were applied uniformly. 
The data was collected under various sub heading using deferent tools described below.
1) Personal particulars - Information regarding age, sex, marital status, Number of children, and educational status was obtained from patient and / or attendant  recorded on part ( A) of the proforma.
2) Clinical variables - Information under this category was collected using part (B) of the proforma. It included - (i) presenting complaints and History (ii) Details of present illness such as mode of onset, precipitating factors and progression  (iii) Details of past illness in the past. 
3) Socio - Economic status - This was ascertained using Kuppuswamy's scale. 
4) Mental status examination - This was ascertained using the standardized psychiatric interview (GOLD BERG et al 1970). As per the liberty given by the author, the opening section was modified, because much of data was collected using part (B) of the proforma.  The interview began from page 3 of the manual. The schedule was fairly economical in time (approximately 30 Minutes for patient with functional psychiatric illness ). The schedule reliability co - efficient between interviewer , and co-rator of the interview was found to be 0.92 (GOLD BERG et al 1970). Using the schedule, 10 reported symptoms and 12 manifest abnormalities were elicited and graded on a 5 point scale (0.5) according to the severity.
5) Psychiatric diagnosis - Diagnosis of psychiatric condition was reached according to international classification of diseases 9th revision (WHO 1978).
 The patient and control samples were compared for all the variables. All the differences were further tested by chi-squaire to find cut the level of significance.
OBSERVATION AND RESULTS : For a large number of patients, socio-economic status could not be ascertained, using Kuppuswamy's scale, due to unreliability and unwillingness to disclose the exact income. Standardized Psychiatric Interview was originally meant for epidemiological studies and picks up neurotic symptoms mainly (GOLD BERG et al 1970). However it had been used for assessment of elderly demented (WINSLOW et al 1985). Selection og this tool was hence justified. In India, it was used in assessing the psychiatric morbidity in menopausal women (JAIPRAKASH & MURTHY 1981) and factory workers (STIJA et al 1984) and found satisfactory. Out of 58 patients, only 48 could be interviewed using both parts of SPI. Ten patients who could not be interviewed were four cases of acute confusional state, three manics and three withdrawn depressives. However part II of the tool could be used to carry out the mental state examination of all the patients.
 The proposed sample size in the materials had been covered as the study was done on 58 patients and 30 controls.

 Patients and controls were group matched for age, sex and educational status   (Table I) (a) and could be compared on other variables. Majority patients (87.9%) were within the age range of 60 to 74 years. The group was dominated by male to female ration being 1 : 0.7.
 Majority of patients (87.9%) belonged to Hindu religion. For a large number of patients, the socio-economic status could not be ascertained due to in adequated information. More than 2/4th of patients and alive spouse at the time of study. None in the sample were single, separated or divorced. However, on comparison with controls, on significant differences could be observed on the parameters of religion, socio-economic status and marital status (Table l b).
 Diagnostic breakup of patient group is given in Table ll. out of 58 patients; 41 were Manic Depressive Psychosis, 10 were organic brain syndrome, 3 were paraphrenics and the rest were Neurosis or adjustments disorder.
 Table lll shows Psychiatric illness characteristics. Majority of the functional psychiatric group are acute in onset, while majority of OBS were sub acute or insidious in onset. Approximately 1/4th of patients had some precipitating factor-before the onset of illness. Two organic causes-steroid in take and epilepsy-were preceding the organic brain syndrome. The rest 14 were distributed as prior to episode of effective illness (22%), 4 before the onset of Neuroses(80%) and 1 before OBS(11%). No statistical analysis was possible as the numbers in each subcategory were too small.
 Symptom profile of Manic Depressive Psychosis patients are given in        table lV a and b. Among reported symptoms, anxiety, lack of concentration and irritability. Phobia and obsessions as symptoms was reported by only one patient each and none reported depersonalization. Among manifest abnormalities, depressive thought content ranked highest. It was followed by depressed appearance, excessive concern with bodily functions, agitation, thought disorder/delusion and lacking spontaneity. None had flattened, incongruent mood or intellectual impairment. As the number of patients in other categories were a few symptom profile of them is not being presented here.
DISCUSSION : The study of Psychiatric illness of aged population is a recent phenomenon. The epidemiological studies on aged population abroad (BLAZER & WILLIAMS et al 1981; O'HARA et al 1985) and in India (RAMACHANDRAN et al 1981; VENKOBARAO & MADHAVAN 1982) showed that it is not an uncommon entity.
 The patients above 74 years of age were in small number in the present study. Same trend was observed in another hospital based study         (ICMR 1984) and may be  representative of population characteristics. 
 The present study had a male predominance over females, the male to female ratio being 1 : 0.3 (VENKOBA RAO 1981) 1: 0.8 (PADMA RAJU 1982) and 1 : 0.3 (ICMR 1984). However, the epidemiological studies on aged showed a different picture, male or female ratio being 1 : 1.2 (VENKOBA RAO et al 1982) and 1:1.7 (RAMACHANDRA et al 1982). The male predominance among the admission to hospital for psychiatric care had been explained by various authors (RAO 1967; VENKOBA RAO et al 1972, 1981) on the basis of socio- cultural and economic factors, peculiar to the Indian Society. The same may be applicable to the present observation also.
 Higher number of educated in the present study sample may be done to the location of Centre in Metropolitan city and it's status of tertiary care referral Centre. Predominance of Hindu religion may be representing the cross section of the population present in the catchment area of the Centre. However, this statistical analysis showed that educational status, religion or socio-economic status had no influence on the development of psychiatric illness in the old age.  
 78% of patients had a live spouse at the time of the study which was comparable with other hospital studies as 78% (PADMARAJU 1982 ) and 67% (ICMR 1984 ). Again, epidemiological studies on Psychiatric morbidity of the aged population in India showed a different picture, the married being lesser; 50% (RAMACHANDRAN et al 1981 ) and 49% ( VENKOBARAO & MADHAVAN 1982 ) only. This may be due to under diagnosis of psychiatric illness in the community, probably because the depression in windowed is perceived by relative as something inevitable, leading to lesser number of such patients being brought to hospital for treatment. 71% of patients were suffering from M.D.P. This figure was higher than other similar studies on aged as 40% in typical psychiatric clinic in North India (WIG 1981). However, our findings are comparable with the observation of the epidemiological which showed 62% (RAMACHANDRAN et al 1982) and 67% (VENKOBA RAO & MADHAVAN 1982 ) of Psychiatrically morbid aged was suffering frome depression. The figures are not strictly comparable as the epidemiological studies used their own definitions for diagnosis and not I.C.D. -9 as in the present study  
 5% of patients in the present study were paraphrenics, comparable to I.C.M.R. (1984) figure of 7% which also kept the critearia exclude the graduate cases and lesser than other two studies. 
 9% of patients in the present sample belonged to Nuerosis and other group, which was comparable to 9% (VENKOBA RAO 1981), 13% (PADMARAJU 1982) and 16% ICMR (1984). Lesser intencity of symptoms and lack of psychotic features may lead to relatives' missing the illness which will be reflected in lesser number of such patients being brought for treatment to hospital. However the epidemiological study also showed this small percentage as 18% (VEKOBA RAO & MADHAVAN 1982 ) and 20% (RAMACHANDRAN et al 1982) of the psychiatrically morbid aged being Neurotic. Whether lesser prevalence of Neurotic illness in the aged is real or apparent is yet unclear. The possibilities are the under diagnosis due to inefficiency of the tools used in epidemiological studies to pick up the Neurotic symptoms of the aged,or the method of diagnostic grouping as dubbing endogenous and Neurotic depressive in to one broad group of depression.
 While majority of the functional psychiatric illness were acute in onset, majority in the organic brain syndrome were sub acute or insidious in onset. This is understandable as 2/3rd of patients in that group were of senile dementia.
 Over the last 20 years, there had been a large number of research into the relationship between life events and psychiatric illness. Reported studies indicate that more life events were experienced by depressive (PAYKEL 1969, PRAKASH et al 1980); schizophrenics (BRILEY & BROWN 1970, WIG ET AL 1984) and psychiatric patients as a group (SAXENA 1981), before the onset relapse of their symptoms when compared with controls; although the view had been contradicted by others (FOREST et al 1965, JANAKI RADHAKRISHNAN 1984). The present sample 27.5% of total patient group precipitating factors. No conclusion could be drawn from these findings as number of patients in the diagnostic categories except MDP was small. It was not comparable with other published data on life events and psychiatric morbidity as only precipitating cause is considered in the study, instead of systematic search for any significant life events for any period preceding the onset of symptom.
 Among the MDP patients the predominant symptoms were depressive thought content, fatigue and depressed mood, sleep disturbance and objective depression. VENKOBARAO (1981) found similar symptoms predominating as sadness and depressed mood, somatic symptoms and signs and lack of energy; while for (PADMARAJU 1982) it were reduced sleep and appetitle, reported and apparent sdaness, pessimistic thought, lassitude and slowness of movement inner tension. The core symptoms were similar, though the findings of these three studies are not strictly comparable due to different tools need (SPI, WHO/ SADD and CP RS respectively).
    CONCLUSIONS
 While psychiatric illness of aged population is not uncommon, patients above 74 years were in smaller number. The present study showed a male predominance over female .Educational status ,religion or socio economic satus had no influence on the aged seeking psychiatric help. Contrary to epidemiological studies, hospital based studies, including present, one showed majority of patients having alive spouse at the time of consultation . Among diagnostic categories; MDP listed top followed by OBS; while neurotics were a few. The onset of illness was  acute insidious for organics brain symptoms 27% of patients had precipitating causes prior to onset of symptoms. Depressive thought content, fatigue and depressed mood, sleep disturbance and objective depression were the predominant symptoms of the MDP patients.                                
 TABLE 1(a): Sociodemographic profile of the sample and controls. Age, Sex and Educational status.
Variables      patients N=53 Control, N=30 Significant (Statistical)
   60-64 22 15    
   65-69 17 10    
   70-74 12 2 X2 = 0.03
Age in years -------------------------------------------------- DF=1
   75-79 5 1 Not significant
   80-84 1 2    
   85-89 0 0    
   90-94 1 0    
    Male 35 19 X2 = 0.80
Sex -------------------------------------------------- DF=0
    Female 23 11 Not significant
    Postgraduate 9 4    
    Graduate 6 5    
    Intermediate 3 2    
    -------------------------------------------------- X2 = 0.80
    Metriculate 4 3 DF=2
Education Middle school 13 7 not significant
    Primary 12 4    
    Illitrate 11 5    
TABLE 1 (b): Sociodemographic profile of the sample and controls. Religion, Socioeconomic status and Material status
Variables        patients N=53 Control, N=30 Significant (Statistical)
    Hindhu 51 29 X2 = 1.91
Religion Muslim 1 - D.F.=2
    Sikh 6 1 Nil significant
    l & ll 17 14 X2 = 1.72
Socio Eco- lll & lV 13 10 D.F.=2
nomic status V 14 2 not significant
    ---------------------------------------------------    
    Inadequate*    
    Information 24 4    
Merital status Married 45 26 X2 = 0.54
    Widdowed 13 4 not significant
* Not considered for statistical analysis   
TABLE ll Distribution of sample according to psychiatric Diagnostic categories.
ICD Code No. Categories Number N=58 Diagnostic group
290.0 Senile dementia, dimple type 5 OBS (15.5%)
290.2 Senile dementia, paranoid type 2    
293.0 A/C Confusional state 3    
296.1 MDP Depressed type 22    
296.2 MDP, Cirdular Currently Manic 3 MDP (70.7%)
296.3 MDP Circular Currently depressed 16    
297.2 Parapherenic 3    
300.4 Neurotic depression 3    
307.4 Specific disorder of sleep 1 Neurosis and others(8.6%)
309.4 Brief depressive reaction 1    
TABLE lll: Illness characteristic of aged seeking Psychiatric help.
      OBS MDP Parapherenia Neurosis& Other Total
Characteristic N (%) N (%) N(%) N(%) N(%)
9(100.0%) 41(100.0%) 3(100.0%) 5(100.0%) 58(100.0%)
Total                            
Mode of onset                         
Acute 4(44.4%) 27(65.9%) 3(10.0%) 3(10.0%) 36(62.1%)
Subacute 2(22.2) 8(19.5%) 1(33.1) 2(40.0) 13(22.4%)
Insidious 3(33.3%) 6(14.6%) ............ .......... 9(15.5%)
Resipitating Factor                  
Absent 6(66.7%) 32(78.0%) 3(100.0%) 1(20.0%) 42(22.4%)
Life events 1(11.1%) 9(22.0%) ........... 4(50.0%) 14(24.1%)
Organic factor 2(22.1%) ........... ........... ........... 2(3.4%)
TABLE lV(a): Symptoms profile of MDP, SPL Part l (N=35)
Report Symptoms Severity Absent Mild Moderate Morbid Severe Percentage Pathological
    0 1 2 3 4      
1. Somatic symptoms 10 - 11 11 3 71.4%
2. Fatigue 0 3 13 12 7 91.4%
3. Sleep disturbance 6 - 5 14 10 82.9%
4. Irritability 12 3 9 10 1 57.1%
5. Lack of concentration 11 2 12 7 3 62.9%
6. Anxiety 6 0 9 19 1 70.4%
7. Depression mood 3 0 3 21 8 91.4%
8. Phobia 34 0 0 0 1 2.9%
9. Obsessions and compunsions 34 0 1 0 0 2.9%
10. Depersonisation 35 0 0 0 0 0
Table lV (b): Symptoms profile of aged MDP, Patients, SPI part ll
Manifest abnormation Severity Absent Mild Moderate Morbid Severe Percentage Pathological
     0 1 2 3 4    
1.Slow, lacking spontaneity 18 9 9 5 - 31.8%
2.Suspicious, defusive 34 2 4 1 - 12.2%
3.Historic 40 - 1 - - 2.4%
4.Depressed 8 - 3 22 8 30.5%
5.Anxious, agitated 8 5 10 15 3 68.3%
6.Elated, enphoric 35 0 2 1 3 14.6%
7.Flattened, incongrous 41 - 0 - - 0%
8.Delusion, thought disorder, misinterpretation 16 1 5 12 7 58.5%
9.Hallucination 39 - - 1 1 4.9%
10.Intellectual imparement 41 - - - - 0
11.Excessive concern with   bodily function 11 - 9 12 3 68.6%
12.Depressive thought content 3 - 7 20 5 91.4%
Elicitation along with reported symptioms

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1. Assistant Professor of Psychiatry,
   Trivandrum, Medical College.
2. Additional Professor, Department of Psychiatry.
3. Professor and Head, Department of Psychiatry.
4. Additional Professor, Biostatistics unit.
2,3,4 All India Institute of Medical Sciences, New Delhi.
Address for Correspondence:
D.K. PRAVEENLAL,
Assistant Professor of Psychiatry,
Medical College Hospital,
Thiruvananthapuram, 695011