The elderly population constitutes a substantial demographic share of the total population. There are approximately 104 million elderly persons according to census 2011. ^[1] The worldwide demographic profile is aging at an accelerated and profound rate. Globally, the geriatric population is projected to exceed 2 billion by 2050, with India's elderly demographic expected to rise to over 315 million. This represents a radical demographic shift, with the elderly population projected to rise from 8.6% in 2011 to 20% by 2050 in India. ^[2]

 Ageing is a natural process associated with biological, social, and psychological changes.^[3] Thus, geriatrics population faces a triple burden of psychological, social, and physical health challenges.^[4] Psychiatric disorders are a leading cause of the global healthcare burden, responsible for 10.6% of total disability-adjusted life years (DALYs) among older adults, with depression being one of the common contributors.^[5] Geriatric depression is a major public health problem.^[6] The National Mental Health Survey of India reported the lifetime prevalence of depressive disorders as 6.93% (6.81–7.05) in the geriatric population, a rate significantly higher than that observed in other age groups.^[7]

Geriatric depression is not a natural consequence of aging, despite the common misconception. It often  has  atypical presentation.^[8] Late-onset depression presents differently than early-onset depression, as it is associated with increased somatic symptoms, psychomotor retardation, higher suicide rates and cognitive decline. ^[9] Hence, geriatric depression is often under-detected and under-diagnosed. ^[8]

Depression in elderly is associated with elevated morbidity, increased disability, higher mortality rates, suicide risk and a general decline in health status. ^[10] It impairs the quality of life and imposes economic burden on family and society. ^[6]

The risk factors for  geriatrics depression include ageing, female gender, low literacy levels,  unemployment  ,low  socio-economic status, living without spouse ,declining health, cerebral pathology, comorbidities, disabilities, family estrangement ,restricted personal autonomy , low social support , loneliness and isolation, physical  psychosocial environment, etc.^[8,11]

The physical and social environment exerts a profound influence on the mental health of the elderly. Historically, the traditional Indian joint family system managed the social challenges associated with ageing. However, industrialisation, urbanisation, and modernisation have accelerated the fragmentation of these traditional joint family structures, driving a significant rise in institutional elder care across India. ^{[8, 12]} Although institutional care provides basic necessities, instrumental care, and safety, residents often experience decreased self-confidence, loneliness, and a loss of autonomy. In contrast, community residents enjoy better emotional support, social interaction, and life satisfaction. ^[13] Hence the present study has been undertaken to determine and compare the proportion & factors associated with geriatric depression in community and old age home.

Objectives

1. To determine and compare the socio demographic profile of elderly living in old age Home and community.
2. To assess and compare the degree of depression among the study subjects.
3. To determine the relationship between socio demographic profile and depression among the study subjects.
4. To compare the relationship between socio-demographic factors and living settings among depressed older adults.

A comparative cross sectional study was conducted in community and a old age home located in urban field practice area of Gandhi Medical College from September to October 2021. Elderly individuals without severe health problems who were willing to give consent were included in the study. A total of 34 elderly inhabitants from the old age home fulfilled these inclusion criteria. For comparison, 68 community-dwelling elderly subjects were selected through simple random sampling to achieve 1:2 ratio, resulting in a total sample size of 102. The questionnaire was administered in participant’s local language after taking informed consent. It comprised two sections. Section 1: Pre tested pre designed semi structured questionnaire: It was used to collect information regarding demographic characteristics. Section 2: Geriatric Depression Scale (GDS) Short Form: It was used to assess depression among the study subjects. It is free to use, validated screening tool. [8] It evaluates psychological symptoms experienced over the past week. The questionnaire comprises 15 items scored on a dichotomous scale. Depression is indicated by a 'yes' response to 10 items (2, 3, 4, 6, 8, 9, 10, 12, 14, and 15) and a 'no' response to the remaining five items (1, 5, 7, 11, and 13)." Possible total scores ranged from 0 to 15. [6, 14] Classification of Scores [8] Score Interpretation 0–4 Normal 5–8 Mild depression 9–11 Moderate depression 12–15 Severe depression The data was compiled, tabulated & analyzed using MS excel and epi info 3.01 software. Descriptive statistics included frequency, percentage distribution, mean and standard deviation. Inferential statistics included Chi-square test. p<0.05 was considered to be statistically significant.

Socio - demographic   Characteristics

The mean age of the total study population was 72.42 ± 9.05 years. Majority of them  participants were aged 61–75 years (58%), female (60%), illiterate (60%), belonged to joint or three-generation family (59%), were financially dependent (70%)  and were married and living with their spouse (61%).

The mean age was higher for the old- age home inhabitants (78.85 ± 7.08 years). Majority of them  were in the 76–90 years  age range (71%),  female (53%),  literate (65%), formerly lived  in a joint or three-generation family (53%), financially dependent (59%) ,and only 15% were  presently married and living with their spouse.

In contrast, the community-dwelling elderly population had a lower mean age (69.20 ± 8.17 years).Majority of community participants were aged 61–75 years (72%), female (63%), illiterate (72%), belonged to a joint or three-generation family (62%), financially dependent  (91%), and were married and living with their spouse (84%).  [Table 1]

Table No: 1 Socio demographic profile

Prevalence and grades of depression (N=102)

Majority of the study subjects (63%) were found to be depressed according to   Geriatric Depression Scale. About 39% were mild depressed, 14% were moderately depressed and 10% were severely depressed.

Figure 1 : Distribution of total subjects according to prevalence and grades of depression

Comparison of prevalence and degree of depression

Depression was found to be higher in old age home inhabitants. The mean depression score of old age home inhabitants was 7.26+3.84 and community dwelling elderly was 6.176+ 3.5. The majority of the old age home subjects were mildly depressed (44%), while the majority of the community subjects had normal scores (41%). [Table 2]

Table No: 2 Distribution of subjects according to depression scale scores

Figure 2: Comparison of prevalence and degree of depression

Relationship between Socio demographic factors with Depression (Total Subjects)

Higher age, female gender, financial dependency and living without a spouse (unmarried, separated, or widowed) were significantly associated with depression among the total study subjects. [Table 3]

Table No: 1 Relationship between Socio demographic factors with Depression (N=102)

Relationship between Socio demographic factors with Depression (Old Age Home)

Depression was more common among old age home residents who previously lived in a nuclear family and those who were single. This association was statistically significant. [Table 4]

Table No: 4 Relationship between Socio demographic factors with Depression (N=34)

 Relationship between Socio demographic factors with Depression (Community dwelling elderly)

Higher age, female gender and financial dependency were significantly associated with depression among community-dwelling older adults. [Table 5]

Table No: 5 Relationship between Socio demographic factors with Depression (N=68)

Comparison of the association between socio-demographic factors and living settings among depressed older adults

In old age home, depression was significantly higher among older and single residents while, in the community setting, illiterate elderly individuals were significantly more depressed. [Table 6]

Table No: 6 Comparison of the association between socio-demographic factors and living settings among depressed older adults (N =64)

Comparison of depression among old age home residents and community-dwelling older adults

Old age home residents were more depressed than community-dwelling older adults, but this association was not statistically significant. [Table 7]

Table: 7 Comparison of depression among old age home residents and community-dwelling older adults

Factors associated with depression among old age home inhabitants

Old age home inhabitants with infrequent visits by relatives were significantly more depressed. A longer duration of stay in old age home was associated with higher depression scores, though this association was not statistically significant. [Table 8]

Table: 8 Factors associated with depression among old age home inhabitants

In the present study, it was observed that the mean age of the study population was 72.42 ± 9.05 years and majority were in the age group of 61–75 years (58%), and were females (61%). Similar findings were reported by Manandhar et al where the mean age was 70.9 ± 8.6 years and majority (54.6 %) of the subjects were females. [6] In our study, most old-age home residents were literate (65%), financially dependent (91%), and single (85%). In contrast, most community residents were illiterate (72%), married (84%), and less than half (41%) were financially independent. Comparable results were obtained by a study done by El Kady et al, in which it was reported that the majority of the institutionalized elders were literate (60.6%) and widowed (69.7%), while slightly less than half (48.5%) considered their income insufficient. Similar findings to our study were reported in relation to community resident’s marital status (84% married) and income sufficiency (67.6%). However, contrary to our findings, the majority of their community elderly were literate (82.4%). [15] Among the study subjects, overall geriatric depression was 63%, which is comparable to age-adjusted prevalence of 53.1% reported by Manandhar et al. [6] In our study, the proportion of old age home residents with depression was found to be 71%. The majority of these individuals were mildly depressed (44%), followed by those who were moderately (18%) and severely (9%) depressed. Mild depression though common, mostly tends to be overlooked and hence undetected and untreated. This contributes to increased disease burden and subsequent progression to severe forms. These findings are corroborated by Chalise et al study, in which the prevalence of depression was 57.8%, with 46.7% of participants being mildly depressed, 8.9% moderately depressed, and 2.2% severely depressed.[16] In the present study, elderly residents in old-age home were more depressed than their community-dwelling counterparts. This indicates the importance of living settings .Advancing age, female gender, financial dependency and living without spouse were significantly associated with depression. These findings are in alignment with the studies conducted by Zalavadiya et al [17], Ghimire et al [18] and Goud et al [19].

• More than half of the study population were in the age group of 61-75 years.
• Majority of the subjects were females, illiterates, belonged to three generation or joint family and were married and living with their spouse.
• Only one-third of the subjects were financially independent.
• More than two-third of the study subjects were depressed.
• Mild depression is more common than other grades of depression.
• Proportion of depression is more in elderly from old age home.
• Higher age, female gender, financial dependency and living without a spouse were significantly associated with depression among the study subjects.
• Old age home elderly with less frequent relatives visit & longer duration of stay are more depressed

 Recommendations

• Awareness activities to prevent the neglect of the mental health of older adults.
• Train frontline workers, caregivers at home and old age home staff to recognize early signs of depression.
• Ensure mental health reviews during Medical officer’s institutional visits.
• Implementation of mandatory, routine mental health screening for early detection of depressive symptoms at the Non-communicable disease (NCD) clinics and weekly geriatrics clinic at the primary care level.
• Peer support groups and professional counseling should be made accessible to the elderly.
• Prompt intervention for mild form of depression so as to prevent escalation to severe form.
• Integrate existing financial welfare schemes into institutional care protocols.
• Encourage more frequent relative’s  visits  for old age home elderly.