Risk Of Age Related Disease Health And Social Care Essay
Introduction: Ageing is a progressive, generalized impairment of functions resulting in loss of adaptive response to stress and increasing the risk of age related disease.
Methodology: A sample of 200 elderly subjects i.e. 100 from community (group A) and 100 from Old age home (group B) of sixty & above years of age were taken by convenient sampling method. The subjects were collected through various old age homes and community which includes Vaikunth Dham Old Age Home, Ishwar Prem Ashram, Swaraj Ashram, Ramkrishna Mission old age home and nearby community located in the Kanpur and Varanasi. The subjects were assigned a number to maintain the confidentiality of the subjects and then the scales were used to assess the scores i.e., Geriatric Depression Scale(GDS) and Barthel index of daily livings were used to check the level of depression & ADL’s and then scores were compared .
Results: The mean GDS scores for group A were 11.32 and for group B were 16.42 with t value of -6.981 with p value of 0.00* and mean ADL’s scores on Barthel index for group A were16.54 and 17.98 for group B with t value of -2.898 with p value of 0.004* which shows there is a significant difference.
Conclusion: Elderly subjects living in Old age home are more affected in terms of depression and ADL’s as compared to community dwelling elder subjects as old people living in their own homes were most able to cope in their homes. They received more support from relatives and friends than from health and social services16
Key words: Elderly, ADLs, depression, community, Old age home
Introduction: The ageing process is of course a biological reality which has its own dynamic, largely beyond human control. However, it is also subject to the constructions by which each society makes sense of old age.1
Although there are commonly used definitions of old age, there is no general agreement on the age at which a person becomes old. The common use of a calendar age to mark the threshold of old age assumes equivalence with biological age, yet at the same time, it is generally accepted that these two are not necessarily synonymous1
In the developed world, chronological time plays a paramount role. The age of 60 or 65, roughly equivalent to retirement ages in most developed countries is said to be the beginning of old age. In many parts of the developing world, chronological time has little or no importance in the meaning of old age. Other socially constructed meanings of age are more significant such as the roles assigned to older people; in some cases it is the loss of roles accompanying physical decline which is significant in defining old age. Thus, in contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution is no longer possible1
Age classification varied between countries and over time, reflecting in many instances the social class differences or functional ability related to the workforce, but more often than not was a reflection of the current political and economic situation. Many times the definition is linked to the retirement age, which in some instances, was lower for women than men. This transition in livelihood became the basis for the definition of old age which occurred between the ages of 45 and 55 years for women and between the ages of 55 and 75 years for men1.
Elderly people are classified into2:-
60 yrs to 70yrs young old
70 yrs to 80yrs middle old
80yrs &above old old
In old age, reduction in physical function can lead to loss of independence, the need for hospital and long-term nursing-home care, and premature death. The importance of physical functional, psychological, and social factors in realizing a healthy old age is recognized by elderly people, health-care professionals, and policy makers3
The risk factors for reduced physical function in elderly people, as identified in longitudinal studies, relate to comorbidities, physical and psychosocial health, environmental conditions, social circumstances, nutrition, and lifestyle3
As the western population is increasingly ageing, problems connected with old age will dominate healthcare. Depression, one of the most prevalent psychiatric disorders, is expected to take an even more prominent position than presently, as the risk for developing depression increases with old age. Depressive symptoms are present in almost one third of the elderly populations and major depression may be presenting up to 4% Furthermore, once present, the prognosis for elderly with depression is poor4
There have always been elderly people, but what is new today that they now form the largest sector of the population in industrialized societies. However elderly are not preparing themselves for long life, nor are we receiving any information about the aging process in home, school, community in general. Society tends to exclude the elderly. They are considered incompetent and are denied any responsibilities. This is far removed from previous societies in which, given their experience, the eldest members enjoyed a much higher status. They considered wise, the teachers, and traditions. A great number of people in this sector are slightly depressed and tend to consider themselves less productive than they really are5
Depression is recognized as a serious public health concern in developing countries. Depression is the most common psychiatric disorder among the elderly which can manifest as major depression or as minor depression characterized by a collection of depressive symptoms 6
Depression is common in medically ill elderly and associated with greater morbidity and mortality, increased health service use and medical costs. Studies have shown that antidepressant and structured psychotherapy, alone or combined, are effective in reducing depressive symptoms among older adults7
Depression and anxiety lead to a serious impairment of daily functioning and quality of life. In frail elderly, the effects of depression and anxiety are especially deep encroaching. Besides a deleterious effect on daily functioning and quality of life, a large number of studies demonstrate excess mortality, disability, handicap and service utilization .The number of elderly is rapidly growing. Almost a third of elderly subjects in the community with sub threshold depression or anxiety will develop a major depressive or anxiety disorder in three years 8
The prevalence of major depressive disorder at any given time in community samples of adults aged 65-67 older ranges from 1-5% in most large scale epidemiological investigations in the United States and internationally, with majority of studies reporting prevalence in the lower end of range. Clinically significant depressive symptoms are present in approximately 15% of the community-dwelling older adults. Rates of depression is appear to be higher in older women than in older men, but with the gender gaps somewhat narrower in this age group, particularly among the oldest old, than the two fold difference seen across the rest of adult lifes-span9
Major depressive disorder is one of the most common forms of psychopathology, one that will affect approximately one in six men and one in four women in their lifetimes. It is also usually highly recurrent, with at least 50% of those who recover from a first episode of depression having one or more additional episodes in their lifetime, and approximately 80% of those with a history of two episodes having another recurrence. Once a first episode has occurred, recurrent episodes will usually begin within five years of the initial episode, and, on average, individuals with a history of depression will have five to nine separate depressive episodes in their lifetime10
Disability in Activities of Daily Living (ADL) , which are the essential activities that a person needs to perform to be able to live independently , is an adverse outcome of frailty that places a high burden on frail individuals, health care professionals and health care systems . Frail elderly people have a higher risk of ADL disability compared to non-frail elderly people11
The model of the International Classification of Functioning, Disability and Health can describe the consequences of dementia that eventually lead to deterioration in BADL and loss of autonomy. In the context of this review, dementia (health condition) has a negative influence on mobility, endurance, lower-extremity strength and balance (body functions and body structures). Those body functions are important for BADL functioning (activity). Depending on the quality of the BADL performance, patients are less or more restricted in their participation (participation). Improvement in the other components is a prerequisite for improvement in participation. Unfortunately, dementia cannot be cured, but the consequences may be influenced. The body functions of people (e.g. mobility, lower-extremity strength, balance and walking endurance) are highly trainable in cognitively intact older adults and can lead to an improvement in ADL. By training physical components underlying ADL, or by a direct influence of exercise on ADL, healthy elderly subjects can stabilize or improve their ADL score12
A change from subthreshold to probable depression does not have significant effects on ADL disability measured either continuously or dichotomously. The estimates did not change substantively when adjusting for concomitant changes in cognitive status suggesting that the effects of depression on ADL disability are independent of cognitive functioning13
One might expect that elevated body mass index (throughout life) could also promote impairments in ADL through other mechanisms that include associations with diabetes and possibly knee joint injuries in late life or difficulties in walking around the house (more common in Hawaii but unrelated to body mass index in the current sample). It may be that impairments in ADL are more frequent in the presence of subclinical frailty where weight loss is a problem. Long-term follow-up of the effects of body mass in middle adulthood on the risk of late-life ADL impairment might reveal a clearer association. While midlife data in the sample from Japan are not available, in Hawaii, impaired ADL in later life tended to be more frequent (P = .077) in men with higher body mass index when measured more than 25 years earlier at the time of initiation of the Honolulu Heart Program14
The mechanisms by which depression has an effect on physical disability are not completely understood. Both behavioral (depressed patients may have poor lifestyle, such as nonadherence to medical and self-care regiments) and biological mechanisms (depression may worsen medical diseases through changes in hypothalamic-pituitary-adrenal axis and the sympathetic nervous and immunological system) have been proposed. Each could lead to more disability13
A difference in the correlates of ADL between communities with genetically similar backgrounds suggests that impaired ADL is not an inevitable consequence of aging but has an important and highly modifiable cultural or environmental component. It may be that the most effective countermeasures or campaigns to prevent declines in ADL are those that consider regional differences in risk factor prevalence and strengths of association14
In a study of patients with and without depression during the immediate period after stroke but with similar impairment in ADL scores, we found, 2 years later, that the depressed patients had significantly less recovery in their ADL functions than the no depressed patients. The recovery curves for ADL function were not significantly different between patients with major depression versus those with minor depression, suggesting that both moderate and severe forms of depression lead to impaired recovery in ADL functions. Morris et al who used an abbreviated version of the Barthel index, also reported that at 15 months after stroke, patients with major depression and those with minor depression had significantly greater physical disability than no depressed patients15
Between the year 2000&2050,the worldwide proportion of persons over 65 years of age is expected to more than double, from the current 6.9% to 16.4%.As healthcare facilities improve in countries, the proportion of the elderly in the population & the life expectancy after birth increase accordingly. This is the trend which has been in both developed & developing countries. It is commonly believed that the majority of the elderly population resides in developed countries. However, this is a myth, as about 60% of the 580 million older people in the world live in developing countries, and by 2020, this value will increase to 70% of the total older population 6
As in elderly people living in community & old age home depression and impairment in performing activities of daily livings are major problem therefore assessing the prevalence of depression and impairment in ADL’s forms the basis of the study.
Methodology: This study is a survey type of study which intends to find changes in level of depression and activities of daily livings scores in elderly subjects living in community and in old age home.
A sample of 200 elderly subjects i.e. 100 from community and 100 from Old age home of sixty & above years of age were taken by convenient sampling method.
The subjects were collected through various old age homes & which includes Vaikunth Dham Old Age Home, Ishwar Prem Ashram, Swaraj Ashram, Ramkrishna Mission old age home and nearby community located in the Kanpur &Varanasi.
All subjects signed consent forms & were ready to take part in the study .The subjects were given the instructions regarding the procedure & the subjects who fulfilled the inclusion criteria & were ready to actively participate, were selected.
1. Normal elderly male & female with age of ≥ 60 years.
2. Able to understand verbal instructions & completed 8-10 years of formal education.
3. Subjects with stable medications
1. Any neurological problems such as Parkinsonism, stroke, cerebellar disorders, balance disorders, myopathy, myelopathy which can influence psychological status of the subjects.
2. Any cardiovascular or orthopedic problems which affects their day to day routine activity & further may become cause of depression.
3. Significant hearing & vision impairment.
4. Uncontrolled hypertension.
5. Any speech deficit interfering the survey.
6. Unstable seizure / disorder affecting psychological status of subjects.
7. Smoking or alcohol intake.
Subjects were introduced to the study followed by the signing of consent forms ,general assessment regarding of socio-demographic data ( name, gender, age), education level, past medical history, personal history, family history were gathered in the participants assessment forms. The subjects were collected from community & various old age home & were divided into two groups a (community) and b (old age home) for comparison. Total 200 numbers of subject’s data was collected, 100 for group a (community) and group b (old age home).The subjects were assigned a number to maintain the confidentiality of the subjects and then the scale were used to assess the scores i.e., Geriatric Depression Scale (GDS) and Barthel Index (BI) was used to check the level of depression and impairment in ADL’s and then the scores were entered in data collection form.
OUTCOME MEASURES AND RESULTS
Reading on GDS and BI were taken during first interview contact with the subject and were tabulated as data.
The mean value of GDS for old age home (group b) was 16.42 with standard deviation 5.90 and mean value for subjects living in community (group a) was 11.3 with SD 4.29 and p value was 0.000 which shows there is significant difference in the score hence level of depression is more in elderly people living in old age home than community.
Table 1: Analysis of GDS score in group a and group b
Table 1: Between Group Analysis for GDS score
Fig1: Comparison of GDS score for group a and group b
The mean value of Barthel index for old age home was 16.54 with standard deviation 4.001and mean value for subjects living in community was 17.98 with SD 2.947 and p value was 0.004 which shows there is significant difference in the scores hence Activities of daily livings are more affected in elderly people living in old age home than community.
DifferTablTable:2 Analysis of Activity Of Daily Living by Barthel index between group ‘a’ & group ‘b’
Fig.4: Comparison of Barthel index scale score between group ‘a’ and group ‘b’
As results of the study shows that depression level is more in elderly living in old age home than in community. It is supported by a study which suggests that urbanization promotes nucleation of family system and a decrease in care and support for the elderly. Depression and physical illness often coexist in the elderly as they both occur commonly in old age. There is a close relation between depression and physical illness. Depression may be caused by specific physical disorder possibly as a direct consequence of the cerebral organic effect of these conditions. Therefore strategies to decrease depression should be utilized for persons living in old age home. The literature shows the institutionalized participants were more likely to report depressed mood, crime, wishing to be dead, future looking bleak and staying away from others. Therefore the persons living in old age home should be encouraged to intact with the society and family members to cope up depression.
Literature shows that old people living in their own homes were most able to cope in their homes. They received more support from relatives and friends than from health and social services3.Result of the present study also shows that elderly people living in Old age home were more affected in terms of ADLs than elderly people living in community.
Relevance to clinical practice:
This research study may serve as a basis for development and implementation of new rehabilitation program to cope up depression and to improve daily living skills for subjects living in old age home and in community by which further their level of dependency and depression can be reduced.
This study is a survey type study in which no training was given for the improvement of ADLs and to decrease the depression hence in future training program can be administered and it’s after effects may be noted down.
As sample size was small hence large sample size may be taken to generalize the results.
Task oriented goals/activities/training/may be used to improve the efficiency of subjects living in old age home and community.
Group involvement and interaction with society may be suggested for subjects living in old age home as loneliness may be the factor affecting ADLs and depression.
Functional status, that is an individual’s ability to perform daily tasks routinely, is an integral component of mental healthcare. It enters into diagnostic decision as axis V of the DSM-IV TRTM (American Psychiatric Association, 2000) and is particularly useful in gauging the severity of illness, the effectiveness of psychiatric interventions (pharmacologic, psychotherapeutic, behavioral), and need for supporting services (e.g., meals-on-wheels, chore services). From the perspective of patients, the ability to carry out daily living activities directly influences their ability to live independently in the community and their quality of life. Hence, the accurate assessment of functional status is of paramount importance because an overestimation places patients at risk, while an underestimination increases their dependency beyond that warranted by their functional status16
In summary, the evidence clearly shows that there are multiple therapeutic alternatives including somatic
And psychotherapeutic approaches each with efficacy for treating depression in later life. Because
depression in late life, even at subsyndromal levels is associated with increased physical
impairment, treatment of depression may provide an opportunity to improve physical function, clinical
trial of depression intervention for older adults have began to evaluate functioning as an outcome