Dementia

Mental Health Issue

India is going through a phase of rapid demographic aging. The number of people with dementia and other late life mental health problems are expected to increase in the near future. Research and dissemination of research findings are important for service development and training. This paper aims to review the published research on people above the age of 60 years. The focus of the review was only on the articles published in Indian Journal of Psychiatry (IJP). Indian studies published elsewhere will be referred to in the discussion.
An electronic search was done to identify the articles available on the IJP website. All the issues of the journal from 1958 to the current issue in 2009 were searched. The words ‘aging’; ‘aged’; ‘ dementia’; ‘elderly’; ‘geriatric’; ‘late onset’ ‘older people’ and ‘mild cognitive’ were used to generate the potential list of articles. These articles were assessed for relevance by seeing the abstract or full text. To be included in the review, the content of the article should have addressed issues related to aging, dementia or any mental health problem in late life. The selected articles were then reviewed in detail and the findings were summarized. The articles were broadly classified as research reports, editorials and other articles. Dementia and other cognitive disorders were considered together. Other late life mental health conditions were reviewed separately.
There were nine research reports and two case reports on dementia. One of these was a study conducted in Sri Lanka. There were five other studies which looked at cognitive disturbances due to other causes. Two reports from a study on delirium examined the prevalence of delirium in elderly medical patients and the risk factors. Another study looked at cognitive decline among older people admitted to the medical and surgical wards of a general hospital. Two other studies looked at the efficacy of herbal formulations in age-associated cognitive decline.

We could only find two articles on late onset psychotic states. The first one was on late paraphrenia. The authors studied 15 cases of ‘paraphrenia’. They included cases that had onset of delusions and/or hallucinations after the age of 60 years. These patients formed about 4% of cases seen in their geropsychiatric clinic. Hallucinatory experiences were present in all cases. Delusions were seen in all cases except one. Most patients had visual or hearing impairment. Ten patients had hearing impairment in this study. Another study from Bengaluru made a comparison between early and late onset schizophrenia. We could not find any studies on delusional disorder. One study reported high prevalence of smoking and alcohol consumption from Ballabgarh in Haryana. A study from Chennai addressed the important issue of age ascertainment in geriatric research. They used a short checklist which contained multiple historical and personal events to estimate the age. They then compared it with the reported age. Under-reporting of age was common and inaccuracy was noticed even among literate subjects. A stu dy from Manipal assessed different domains of quality of life of older people using the translated Kannada version of the WHO instrument for assessment of quality of life. Erna M. Hoch described the psychosocial issues involved in the healthcare of older individuals. The article emphasized the role of culture and prevalent traditions in the expression of symptoms. Usefulness of a psychodynamic approach was illustrated by giving detailed case histories as examples. Two case reports were published during the period of review. Both were on rare conditions, namely Charles Bonnet Syndrome and dissociative fugue in the elderly.

There were five editorials on issues related to mental health in late life. The first editorial on aging was published in 1958. It referred to the challenges associated with aging in a rapidly changing world. It said “today the challenge of old age is made more serious by the increase in the pace of living and scientific advances”. The subsequent editorials also echoed similar sentiments and pointed out the urgent need for development of services and social support systems.

Dementia had not been a frequent topic for publication in IJP. However, this does not reflect the progress made in the field of dementia research. There had been many studies in India and their findings were published in other journals. The past decade witnessed active dementia research and networking of researchers. Many important epidemiological studies were done in India. Both rural and urban populations were studied. A detailed review of these studies appears in the article by Prince MJ in the dementia supplement. The reported prevalence of dementia in the community varied between 0.9-7.5% among the people above 65 years. Methodological issues and the use of different diagnostic criteria could explain the variability in the reported prevalence rates. A simple case-finding method was developed by us at Thrissur. Usefulness of a community-based intervention was reported following a randomized control trial at Goa. These studies, along with studies from other developing countries, form part of the evidence base for the development of the WHO package for management of dementia in low and middle income countries.

Psychiatric morbidity in late life, especially depression, generated lot of research interest in the late seventies and early eighties. Researchers from Madurai and Chennai published many research reports during this period. Studies have shown that 5% of people seeking help in a tertiary care or general hospital setting happen to be older than 60 years. Depression was the commonest disorder and was associated with other physical illnesses. We need more information on the incidence and prevalence of depression from large community samples. A recent study using Geriatric Depression Scale reported a prevalence of 45.9%. Similar rates were reported from West Bengal and Uttar Pradesh. A study from a rural community near Vellore in Tamil Nadu reported a prevalence of 12.7% for depression during the month preceding assessment. They used Geriatric Mental State for evaluation and found geriatric depression to be associated with low income, history of cardiac illnesses, transient ischemic attack, past head injury and diabetes. Having more confidants was a significant protective factor. We need to examine these associations in larger cohorts.