Persons aged 60 years and above are considered elderly or geriatric. Owing to increased longevity and better health care, the geriatric population is growing rapidly worldwide, and older persons are projected to constitute more than one-tenth of the global population in the coming decades (1). India is undergoing a similar demographic transition, and geriatric health has emerged as an important public health concern with unique medical and psychosocial dimensions (2).

Traditionally, the family has been the primary source of care and material support for the elderly in India, and it has been regarded as the moral and social responsibility of children to look after their ageing parents (2). However, urbanization, industrialization, migration and globalization have brought major structural and functional transformations in the Indian family. As a consequence, an increasing number of older adults are compelled to move into institutions, and old age homes have come to play an important role in the care of the elderly (2). Residents of such homes face problems of adjustment arising from rigid schedules, near-total separation from the family and familiar social milieu, anxiety over entrusting oneself to a new environment, diminished physical capacity and frequent encounters with the illness and death of fellow inmates.

The elderly are prone to both physical and mental health problems. Community-based Indian studies have reported psychiatric morbidity in about 17% to 34% of elderly persons (3,4), and an early rural survey from West Bengal found mental illness in about one-third of the aged (5). The most frequently reported diagnoses are depressive disorders, dementia, generalized anxiety disorder and substance use disorders (3,4). Importantly, comparative studies consistently show that psychiatric morbidity is higher among institutionalized elderly than among those living with their families in the community (6,7). Studies conducted specifically in Indian old age homes have documented psychiatric morbidity ranging from about 30% to more than 60%, with depression as the leading diagnosis (6-9).

Mental illness in the geriatric population often goes unnoticed and untreated because of the misperception that such symptoms are a natural part of ageing, chronic illness, bereavement and social transition. Untreated psychiatric disorders in the elderly contribute to disability, poor quality of life and mortality, particularly through suicide (3). Multiple, often overlapping, factors increase the risk of psychiatric illness in old age: ageing of the brain, fragile physical health, cerebral pathology, poor financial condition, widowhood, dependency, helplessness, low self-esteem, poor social connections and breakdown of the family support system (4,6).

Most Indian studies on institutionalized elderly have been conducted in urban old age homes (6-9), and there is a relative paucity of data from rural institutions, where residents may differ in literacy, socioeconomic status and access to health services. Considering the rise in mental illness with age and the inadequate attention given to its identification and treatment in institutional settings, the present study was undertaken to assess the pattern of psychiatric morbidity among elderly persons residing in a rural old age home, using a structured diagnostic interview, a standardized cognitive screen and ICD-10 diagnostic criteria, so that appropriate psychological and medical interventions may be planned at the earliest.

This was an observational, cross-sectional study conducted over 18 months in Shanthi Mandir, a non-governmental old age home situated at Hosakote, Bengaluru Rural, which is associated with the community psychiatry services of the Department of Psychiatry of a medical college and research hospital. The study was initiated after obtaining approval from the Institutional Ethics Committee and permission from the concerned authority of the old age home. Residents aged 60 years and above of either sex who gave informed consent were included. Residents below 60 years of age, those who did not consent, and those with severe debilitating medical or surgical comorbidities were excluded. The sample size was estimated using the formula n = 4pq/d², taking p = 50%, q = 50% and an absolute precision (d) of 13% at the 95% confidence level, which yielded 57 subjects; this was rounded to 60. Sixty residents fulfilling the selection criteria were therefore recruited by convenience sampling. The study design was explained to the residents in their vernacular language and written informed consent was obtained; for residents unable to consent, consent was obtained from the attenders after obtaining details from the in-charge of the home. Sociodemographic details (age, gender, religion, area of residence, education, occupation, marital status and socioeconomic status) were collected using a semi-structured proforma designed for the study. Socioeconomic status was assessed using the Modified Kuppuswamy socioeconomic scale (2021 revision), which classifies families into five classes on a total score of 3 to 29 (13). A detailed history was taken and clinical examination was carried out for every participant. All participants were screened for psychiatric disorders using the Mini International Neuropsychiatric Interview-Plus (MINI-Plus), a short structured diagnostic interview developed for DSM-IV and ICD-10 psychiatric disorders with an administration time of approximately 15 minutes, designed for multicentre clinical trials and epidemiological studies (10). For those who screened positive on the MINI-Plus, the final diagnosis was made according to ICD-10 diagnostic criteria for mental and behavioural disorders (12). Cognitive function was assessed in all participants using the Mini Mental State Examination (MMSE), the most widely used bedside measure of cognition, which reliably separates patients with dementia, depression or a combination of the two (11). Data were entered into a Microsoft Excel datasheet and analysed using SPSS version 22 (IBM SPSS Statistics, Somers, NY, USA). Categorical data were expressed as frequencies and proportions. The Chi-square test was used as the test of significance for qualitative data, and a p value of less than 0.05 was considered statistically significant. Bar and pie diagrams were prepared using Microsoft Excel and Word.

Table 1: Sociodemographic profile of the study subjects (n = 60)

Half of the residents (30; 50%) were aged 60–70 years, 21 (35%) were aged 70–80 years, 6 (10%) were aged 80–90 years and 3 (5%) were older than 90 years. Females (36; 60%) outnumbered males (24; 40%). Hindus (45; 75%) formed the majority, followed by Christians (9; 15%) and Muslims (6; 10%). Nearly two-thirds had little formal education, 18 (30%) being illiterate and 21 (35%) educated to primary level or below; 34 (56.7%) hailed from rural areas, and 36 (60%) were unemployed. Almost half the residents belonged to the upper-lower (Class IV, 26.7%) and lower (Class V, 21.7%) socioeconomic classes on the Modified Kuppuswamy scale.

Table 2: Result of MINI-Plus screening (n = 60)

On screening with the MINI-Plus, 45 residents (75%) screened positive for a psychiatric disorder, while 15 (25%) screened negative (Table 2).

Table 3: ICD-10 psychiatric diagnoses among the study subjects (n = 60)

Depressive disorder was by far the most frequent diagnosis, present in 24 residents (40%). Dementia and adjustment disorder were diagnosed in 5 residents each (8.3%), dysthymia and generalized anxiety disorder in 3 each (5%), insomnia in 2 (3.3%), and schizophrenia, delusional disorder and intellectual disability in one resident each (1.7%). Fifteen residents (25%) had no psychiatric illness (Table 3). No cases of organic mental disorder, substance use disorder, bipolar affective disorder, obsessive-compulsive disorder, somatization disorder or personality disorder were identified.

Table 4: MMSE severity distribution of the study subjects (n = 60)

On the MMSE, 55 residents (91.7%) had no cognitive impairment while 5 (8.3%) showed severe cognitive impairment, corresponding to the five residents diagnosed with dementia (Table 4).

Table 5: Association between MINI-Plus screener status and sociodemographic variables

None of the sociodemographic or institutional variables showed a statistically significant association with MINI-Plus screener positivity (all p > 0.05), although a trend was observed for occupation, with 30 of 45 screener-positive residents (66.7%) being unemployed compared with 6 of 15 screener-negative residents (40%) (p = 0.068) (Table 5).

In the present study, psychiatric morbidity was found in 75% of the residents of a rural old age home. This is considerably higher than the 17–34% reported in Indian community-based surveys of the elderly (3,4,5), but it is consistent with the well-replicated observation that institutionalized elderly carry a substantially greater burden of mental illness than their community-dwelling counterparts (6,7,16). Indian old age home studies have reported psychiatric morbidity ranging from about 30% to over 60% (6-9), and the still higher figure in our study may reflect the rural setting, the destitute background of many residents, limited on-site health services and the use of a sensitive structured diagnostic interview. The wide variability in reported prevalence across studies is attributable to differences in settings, sociocultural backgrounds and screening instruments, which have ranged from the Geriatric Mental State Schedule and General Health Questionnaire to the Geriatric Depression Scale; in the present study the MINI-Plus was applied, followed by ICD-10 diagnostic confirmation (10,12). Depression was the most prevalent disorder, affecting 40% of the residents. This mirrors the findings of comparative Indian studies in which depression was the leading diagnosis among old age home inmates (6,7,9) and of a large body of Indian research identifying late-life depression as the foremost geriatric mental health problem (14). Probable contributors in our setting include loss of spouse, absence of a caregiver, financial constraints, chronic physical comorbidity, restricted institutional environment and loneliness. Dysthymia (5%) and adjustment disorder (8.3%) similarly point to chronic psychosocial stressors, difficulty adjusting to institutional routines and problems cooperating with fellow inmates. Dementia was present in 8.3% of residents, which is lower than the 17–25% reported in several institutional studies (6,7). This may be explained by the sedentary, low-demand institutional life in which mild cognitive deficits go unnoticed, by limited awareness among caretakers, and by the exclusion of residents with severe debilitating illness. Generalized anxiety disorder (5%) and insomnia (3.3%) were less frequent, in keeping with hospital-based and institutional Indian reports (15). Psychotic disorders were uncommon, with one case each of schizophrenia and delusional disorder, comparable to other old age home studies (6,8), and one resident had intellectual disability, reflecting the tendency for persons with developmental disabilities to be institutionalized when family care is unavailable. No sociodemographic variable was significantly associated with screener positivity, although unemployment showed a trend towards association (p = 0.068). The small, single-institution convenience sample limits the power to detect such associations and the generalizability of the findings; the cross-sectional design also precludes causal inference. Nevertheless, the strikingly high burden of treatable disorders, particularly depression, in this rural institution underscores the need for regular psychiatric screening, liaison services between old age homes and departments of psychiatry, psychosocial interventions and staff training, so that mental illness in institutionalized elderly is identified and treated at the earliest (3,14,16).

Three-fourths of the elderly residents of the rural old age home had a diagnosable psychiatric disorder. Depressive disorder was the predominant diagnosis, followed by dementia and adjustment disorder; dysthymia, generalized anxiety disorder, insomnia, psychotic disorders and intellectual disability were also encountered. No sociodemographic factor was significantly associated with psychiatric morbidity. Routine mental health screening, early psychosocial and pharmacological intervention, and closer liaison between old age homes and mental health services are recommended to reduce psychiatric morbidity in the institutionalized elderly, and larger multicentre studies are needed to confirm these findings.

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