Ageing is universal and occurs naturally as a part of the developmental process in life of all living beings. [1] Relationships and career are the major midlife preoccupations whereas the aging body becomes a central concern in the late adulthood and in old age. The reasons for this are increased incidence of physical illness, decrease in normal functioning, changes in the physical appearance. [2] The process of aging known as senescence is defined as gradual deterioration in functioning of all the systems of body- immune system, respiratory, cardiovascular, endocrine and genitourinary system etc. [2] As a part of ageing, along with biological changes occurring in the body, psychological and social implications are also accounted for. [4]

There has been a considerable rise in the number of people with age more than 60 years due to availability of better health care facilities. [1] Various authors have defined old age as the stage of life cycle that begins at age of 65 years and has divided older adults into two groups: young- old in the age group of 65-74 and old- old, ages 75 and beyond. [2] There has been increase in average life expectancy at birth from 63.4 years in 1993-2003 to 69.4 years in 2014-2018. [3]

In old age, a person becomes more dependent on others due to physical illness or financial issues. Along with physical support they also need psychological and social support. [2] Even the thought of being old and dependent on others is very distressing for people who are not old yet.

Traditionally, family accounted for the main support system and source of care for older adults especially in Indian family system. The system of joint families was a symbol of family unity and elderly were held with respect and regard and were consulted in all important matters such as marriage, property dispute. [5]

But major structural and functional changes have been brought in the family system by modernization, urbanization, industrialization. [6] The family structure has been shifted from joint families to nuclear families. Due to the changes in socio-demographic variables, people in old age have no option but to leave their homes and shift themselves to some institutions/old age homes. [6,7,8,9] People in old age are extra vulnerable to mental health problems along with other health problems. [4] Lack of social and psychological support can make them more prone to mental health problems. [1]

Shifting to old age home in itself is a very traumatising experience because of the negative attitude towards them. Highly institutionalized atmosphere in old age institutions is one of the main concerns of the residents there. [1] Old age people face adjustment problems as adjusting to new place or environment is challenging and the inflexible schedules of old age home also adds to it1. Studying about the mental health problems faced by the residents of old age home will help to know more about this period, their problems and the counselling and treatment services they need.

Therefore, this study was planned to study about the mental health problems and the associated co-morbidities in residents of old age home of North Western Rajasthan.

Aim of study: To study about the mental health problems and the associated co-morbidities in residents of old age home of North Western Rajasthan.

Methodology: The study was Descriptive Cross-sectional Observational type of study conducted on 209 residents of an old age home, Bikaner, Rajasthan after taking permission from the ethical committee of the institution and the authorities of old age home.

Inclusion criteria- All the persons residing at old age home for at least 6 months.

Tools- 1. Semi-structured Proforma for collecting data regarding Sociodemographic Profile and clinical variables.

2. Diagnostic criteria of The ICD-10 Classification of Mental and Behavioural Disorders (ICD-10).

3. Hindi Mental Status Examination (HMSE)- for screening of Dementia and maximum score in HMSE is 30. Score less than

24 indicates cognitive decline and needs further assessment.

Procedure- After taking permission from the authority of old age home, socio-demographic data and clinical details of the residents were collected from their records and from the caretakers of the old age home. Their nutritional status was studied by calculating their Body Mass Index (BMI). Hindi Mental Status Examination (HMSE) was applied on participants after taking consent to screen for cognitive impairment excluding the ones already diagnosed as suffering from Mentally Retardation and Psychotic Disorders. Diagnosis was made during mental status examination based on diagnostic criteria of ICD-10. Data was analysed using descriptive statistics.

Total 209 male destitute are residing currently in old age home from at least 6 months. Table 1: Socio- demographic details of the subjects- Socio-demographic Variables N = 209 n (%) Age (Years) 55- 60 years 60 (28.70%) 61-65 86(41.15%) 66-70 32 (15.31%) 71-75 20(9.57%) 76-80 9(4.31%) >80 2(0.96%) Duration of stay <3 years 88 (42.10%) 4-6 years 91 (43.55%) >6 years 30 (14.35%) Residence Rajasthan 48 (22.97%) Other states 76 (36.36%) Not known 85 (40.67%) Religion Hindu 184 (88.04%) Sikh 15 (7.18%) Muslim 7 (3.35%) Christian 3 (1.43%) Table 1 reveals that majority (41.15%) of subjects belonged to age group of 61-65 years followed by age group- 55-60 years and then 66-70 years. All the residents were males. Majority of them (43.55%) were residing there from past 4-6 years. The residence of 40.67% of the residents could not have been traced till date. 36.36% of the residents were from other states- Kerala, Punjab, Gujarat and Madhya Pradesh etc. whereas 22.97% belongs to Rajasthan. Majority of the participants were Hindu by religion followed by Sikhs. Figure 1: Distribution of the subjects as per BMI Figure 1 depicts the BMI of the subjects indicating their nutritional status. 60% of the residents were underweight which means their BMI was <18.5 followed by normal weight. Only 3% of the residents were overweight. Table 2: Prevalence of Mental Health problems among subjects who were not reported to be suffering from any mental illness. Mental Health Problems N= 98 n (%) Mood Disorders 35 (35.7%) Dementia 15 (15.3%) Anxiety Disorders 10 (10.2%) Psychoactive substance use 0 No psychiatric illness 38 (38.8%) Table 2 shows the prevalence of mental health problems in subjects who were not reported to be suffering from any mental illness with depression being the most common followed by dementia followed by anxiety disorders.

All the residents were male and destitute. Most of them belonged to age group of 61-65 years, were Hindus and were staying for 4-6 years duration.

The nutritional status of the inhabitants was studied by calculating their BMI from their height and weight and was found that majority of them were poorly to averagely nourished given their long time spent away from their families.

The medical records maintained by the authorities of old age home revealed that out of 209 residents, approximately 75(36%) were Mentally Retarded and 36(17%) were suffering from Psychotic Disorders and were on treatment and follow ups for the same and 21% of them were staying there because of their old age with either no family member available or not willing to take care of them. 8% were Physically handicapped, 5.2% were having seizure disorder, 7% were deaf and dumb, 2% were blind and remaining 3.8% had other physical morbidities.

Excluding the ones as already diagnosed as MR (36%) and suffering from Psychotic Disorders (17%) and on treatment, HMSE was applied on the remaining 98 residents (47%). On the basis of mental status examination and as per diagnostic criteria of ICD-10; 60 of the 98 residents (61.2%) were suffering from mental illness with Depression (35.7%) being the most common in the residents who were not reported to be suffering from any mental illness followed by dementia (15.3%) and then anxiety disorders (10.2%). The results were concomitant with the findings of study by SC Tiwari et al. [4] Similar results have also been obtained in the study of Singh et al [10] which showed that the most common mental illness in persons staying in old age home as well as in general population was depression followed by the anxiety disorder.

In our study, among mental illnesses, most common were mood disorders with no patient of Mania or Bipolar Affective Disorder. All of the patients in the category of mood disorders were diagnosed with Depression with a prevalence of 35.7%. Dalia A et al [15] also reported similar results with prevalence of depression in geriatric homes as 37.5% whereas the prevalence of depression in study conducted by Barua and Kar [14] in the rural region of south India was found to be 21.7%. The findings are also supported by various earlier prevalence studies. [11,18,19,20,21] The higher preponderance of the depression in residents of old age home could be because of various stressors such as the death of partner, financial constraints, presence of physical morbidities, impending death, lack of social and familial support.

15.3% of residents scored less than 24 in HMSE, on further evaluation, fulfilled the ICD-10 diagnostic criteria for dementia. This finding was in accordance with results of study by Seby et al [12] where 14.9% was the prevalence of dementia.  

10.2% of the residents were diagnosed with anxiety disorder with no case of specific phobias which is closer to that reported by Praveen Kumar [17], Richie et al [16] and Dalia A et al [15] in their studies with prevalence rate of 8.5%, 14.6% and 14% respectively.

Residents of old age homes did not consume any psychoactive substance during the study duration, however a few of them had alcohol use or smoking history before becoming a part of old age home. This could be explained by the disciplinary conditions imposed on them, engagement in regular activities as scheduled- like spiritual activities, or due to the better care facilities.

Almost all the residents had one or more physical illness ranging from weakness and fatigue, Diabetes Mellitus, hypertension, having respiratory problems to being handicapped, deaf, dumb, blind, etc, no one reported themselves healthy. This finding supported the findings of earlier studies which stated that mental health morbidity is rarely an isolated event in elderly. [4,22]

The high prevalence of both physical and mental illness in inhabitants of old age homes can be explained by presence of more psychological stressors, restricted environment and lack of family support.

The fact that all the residents were diagnosed and were on treatment and regular follow ups, resulted in a positive outcome in form of a number of destitute reuniting with their families after years of being lost and separated.

In last three years, 148 destitute became a member of this old age home and 33 were reunited with their families. 

More than one-half of the residents of old age home were suffering from atleast one or more mental health problems.

Apart from the ones already diagnosed as MR and suffering from Psychotic Disorders, the most common mental illness was depression followed by dementia and then anxiety disorder in the remaining ones.

More than half of the subjects were having one or more physical and medical co-morbidities.

Limitations:

The study cannot be generalised to general population as it was conducted in old age home and sample size of the study was small.  

The residents labelled as MR and Psychotic were not reassessed.

Residents < 60 years were also included.

Conflicts of interest: Nil.