Identifying elders with neuropsychiatric problems in a clinical setting

Shilpa Sadanand, Prafulla Shivakumar, N Girish, Santosh Loganathan, Bhavani Shankara Bagepally, Lakshmi Narayanan Kota, Nalini Narayana Reddy, Palanimuthu Thangaraju Sivakumar, Srikala Bharath, Mathew Varghese

Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences, Bangalore, India

Address for correspondence: Dr. Girish N Department of Epidemiology, National Institute of Mental Health and Neurosciences Bangalore - 560 029, Karnataka India girishnrao@yahoo.com

Journal of Neurosciences in Rural Practice

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Abstract

ABSTRACT

Objective: Multiple health problems among the elderly necessitate a comprehensive enquiry to detect problems early and also initiate treatment. We utilized available validated instruments to comprehensively identify older persons with neuro‑psychiatric problems including dementia and comorbid medical ailments in the screening desk of the geriatric clinic. Materials and Methods: Individuals aged 60 years and above seeking outpatient care at NIMHANS during a 2‑year period (October 2008‑September 2010) participated. We used General Health Questionnaire (12-item), AD8, questions to identify psychoses and neurological problems and a checklist of common medical ailments. A probable clinical diagnosis was made at the end by medical personnel based on ICD-10. Results: A total of 5,260 individuals were screened and more than one-third (36.7%) were women. About 50% had psychological distress (≥2 on GHQ-12), 20.1% had probable cognitive impairment (≥2 on AD8) and about 17% had symptoms suggestive of psychoses (≥1 on Psychoses screener). More than 65% had either a neurological or neurosurgical problems (≥1 on Neurological screener) and headache was the commonest complaint. At probable diagnosis, more than 50% had a neurological problem and over 30% had psychiatric disorders. Of these the most common psychiatric illnesses were psychotic disorders (22.0%), mood disorders (21.4%) and dementia (14.4%). The most common medical comorbidity included hypertension (36.4%), visual impairment (31.8%) and joint pains (30.5%). Nearly 80% had one or more medical comorbidity in addition to psychiatric illness. The overall set of instruments took about 15-20 minutes. It systematically and comprehensively guided in evaluating the elderly for neuropsychiatric problems and hence was collated to constitute the Instruments for Comprehensive Evaluation of the Elderly (ICE-E). Conclusions: ICE-E was brief, easy to administer and improved decision making even by personnel from a non-medical background. The instrument aided in systematically detecting neuro-psychiatric problems among the elderly (including psychological distress and cognitive changes) and other medical comorbidities.

Keywords

Comorbidity

Elderly

Instruments screening

Mental health

Neuro-psychiatric problems

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Conflict of Interest

None declared

References

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Brown F. W., . Late-life psychosis: Making the diagnosis and controlling symptoms. Geriatrics. 1998;53:26-8. 37-8, 41-2
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Prakash I. J., . Women and ageing. Indian J Med Res. 1997;106:396-408.
[Google Scholar]
Soares J. C., Gershon S, . Therapeutic targets in late-life psychoses: Review of concepts and critical issues. Schizophr Res. 1997;27:227-39.
[Google Scholar]
Lacro J. P., Jeste D. V., . Geriatric psychosis. Psychiatr Q. 1997;68:247-60.
[Google Scholar]
Hassett A, . A descriptive study of first presentation psychosis in old age. Aust N Z J Psychiatry. 1999;33:814-24.
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Shaji K. S., Jithu V. P., Jyothi K. S., . Indian research on aging and dementia. Indian J Psychiatry. 2010;52:148-52. Suppl 1
[Google Scholar]
Silva Pereira Y. D., Estibeiro A, Dhume R, Fernandes J, . Geriatric patients attending tertiary care psychiatric hospital. Indian J Psychiatry. 2002;44:326-31.
[Google Scholar]
Sood A, Singh P, Gargi P. D., . Psychiatric morbidity in non-psychiatric geriatric inpatients. Indian J Psychiatry. 2006;48:56-61.
[Google Scholar]
Tiwari S. C., . Geriatric psychiatric morbidity in rural northern India: Implications for the future. Int Psychogeriatr. 2000;12:35-48.
[Google Scholar]
Drayer R. A., Mulsant B. H., Lenze E. J., Rollman B. L., Dew M. A., Kelleher K, et al . Somatic symptoms of depression in elderly patients with medical comorbidities. Int J Geriatr Psychiatry. 2005;20:973-82.
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Prakash O, Gupta L. N., Singh V. B., Singhal A. K., Verma K. K., . Profile of psychiatric disorders and life events in medically ill elderly: Experiences from geriatric clinic in Northern India. Int J Geriatr Psychiatry. 2007;22:1101-5.
[Google Scholar]
Tiple P, Sharma S. N., Srivastava A. S., . Psychiatric morbidity in geriatric people. Dement Geriatr Cogn Disord. 2006;48:88-94.
[Google Scholar]
Singh G. P., Chavan B. S., Kaur P, Bhatia S, . Physical illnesses among psychiatric outpatients in a tertiary care health institution: A prospective study. Indian J Psychiatry. 2006;48:52-5.
[Google Scholar]
Shah B, Prabhakar A. K., . Chronic morbidity profile among elderly. Indian J Med Res. 1997;106:265-72.
[Google Scholar]
Purty A. J., Bazroy J, Kar M, Vasudevan K, Veliath A, Panda P, . Morbidity pattern among the elderly population in the rural area of Tamil Nadu, India. Turk J Med Sci. 2006;36:45-50.
[Google Scholar]
Krishnaswamy B, Sein U. T., Munodawafa D, Varghese C, Venkataraman K, Anand L, . Ageing in India. Ageing Int. 2008;32:258-68.
[Google Scholar]
Das S. K., Biswas A, Roy J, Bose P, Roy T, Banerjee T. K., et al . Prevalence of major neurological disorders among geriatric population in the metropolitan city of Kolkata. J Assoc Physicians India. 2008;56:175-81.
[Google Scholar]
Dhar H. L., . Gender, aging, health and society. J Assoc Physicians India. 2001;49:1012-20.
[Google Scholar]
Chaudhury S, Chakraborty R, Seby K, . Prevalence of psychiatric and physical morbidity in an urban geriatric population. Indian J Psychiatry. 2011;53:121-7.
[Google Scholar]
Singh N, Chopra H, Singh J. V., Bhatnagar M, Garg S. K., Bajpai S. K., . The psycho-social profile of the elderly people in urban area of Meerut city. J Indian Acad Geriatr. 2009;5:165-70.
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[Google Scholar]

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[1] World Health Organization , . World Population Ageing 1950-2050. Available from [Last accessed on 2011 Jan 21]
[Publisher] [Google Scholar]

[2] Chatterji S, Kowal P, Mathers C, Naidoo N, Verdes E, Smith J. P., et al . The health of aging populations in China and India. Health Aff. 2008;27:1052-63.
[Google Scholar]

[3] Sousa R. M., Ferri C. P., Acosta D, Albanese E, Guerra M, Huang Y, et al . Contribution of chronic diseases to disability in elderly people in countries with low and middle incomes: A 10/66 Dementia Research Group population-based survey. Lancet. 2009;374:1821-30.
[Google Scholar]

[4] Ministry of Health and Family Welfare , Government of India , Operational Guidelines , National Programme for the Health Care of the Elderly (NPHCE) , . Available from [Last accessed on 2012 Aug 07]
[Publisher]

[5] Joshi K, Kumar R, Avasthi A, . Morbidity profile and its relationship with disability and psychological distress among elderly people in Northern India. Int J Epidemiol. 2003;32:978-87.
[Google Scholar]

[6] Ng T. P., Feng L, Chiam P. C., Kua E. H., . Psychiatric morbidity and acute hospitalization in elderly people. Int Psychogeriatr. 2006;18:701-11.
[Google Scholar]

[7] Goldberg S. E., Whittamore K. H., Harwood R. H., Bradshaw L. E., Gladman J. R., Jones R. G., . The prevalence of mental health problems among older adults admitted as an emergency to a general hospital. Age Ageing. 2012;41:80-6.
[Google Scholar]

[8] Wray L. O., Mavandadi S, Klaus J. R., Tew J. D., Oslin D. W., Sweet R. A., . The association between mental health and cognitive screening scores in older veterans. Am J Geriatr Psychiatry.. 2012;20:215-27.
[Google Scholar]

[9] Mulrow C. D., Williams J. W., Gerety M. B., Ramirez G, Montiel O. M., Kerber C, . Case-finding instruments for depression in primary care settings. Ann Intern Med. 1995;122:913-21.
[Google Scholar]

[10] Ganguli M, Dube S, Johnston J. M., Pandav R, Chandra V, Dodge H. H., . Depressive symptoms, cognitive impairment and functional impairment in a rural elderly population in India: A Hindi version of the geriatric depression scale (GDS-H) Int J Geriatr Psychiatry. 1999;14:807-20.
[Google Scholar]

[11] Patel V, Araya R, Chowdhary N, King M, Kirkwood B, Nayak S, et al . Detecting common mental disorders in primary care in India: A comparison of five screening questionnaires. Psychol Med. 2008;38:221-8.
[Google Scholar]

[12] Ganguli M, Ratcliff G, Chandra V, Sharma S, Gilby J, Pandav R, et al . A Hindi Version of the MMSE: The Development of a cognitive screening instrument for a largely illiterate rural elderly population in india. Int J Geriatr Psychiatry. 1995;10:367-77.
[Google Scholar]

[13] Goldberg D. P., Gater R, Sartorius N, Ustun T. B., Piccinelli M, Gureje O, et al . The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med. 1997;27:191-7.
[Google Scholar]

[14] Sriram T. G., Chandrashekar C. R., Isaac M. K., Shanmugham V, . The General Health Questionnaire (GHQ) Comparison of the English version and a translated Indian version. Soc Psychiatry Psychiatr Epidemiol. 1989;24:317-20.
[Google Scholar]

[15] Kuruvilla A, Pothen M, Philip K, Braganza D, Joseph A, Jacob K. S., . The validation of the Tamil version of the 12 item general health questionnaire. Indian J Psychiatry. 1999;41:217-21.
[Google Scholar]

[16] Patel V, Pereira J, Mann A. H., . Somatic and psychological models of common mental disorder in primary care in India. Psychol Med. 1998;28:135-43.
[Google Scholar]

[17] Jacob K. S., Bhugra D, Mann A. H., . The validation of the 12-item General Health Questionnaire among ethnic Indian women living in the United Kingdom. Psychol Med. 1997;27:1215-7.
[Google Scholar]

[18] Galvin J. E., Roe C. M., Powlishta K. K., Coats M. A., Muich S. J., Grant E, et al . The AD8 A brief informant interview to detect dementia. Neurology. 2005;36:559-64.
[Google Scholar]

[19] Gourie-Devi M, Gururaj G, Satishchandra P, Subbakrishna D. K., . Prevalence of neurological disorders in Bangalore, India: A community-based study with a comparison between urban and rural areas. Neuroepidemiology. 2004;23:261-8.
[Google Scholar]

[20] Miller M. D., Paradis C. F., Houck P. R., Mazumdar S, Stack J. A., Rifai A. H., et al . Rating chronic medical illness burden in geropsychiatric practice and research: Application of the Cumulative Illness Rating Scale. Psychiatry Res. 1992;41:237-48.
[Google Scholar]

[21] World Health Organization , . The ICD-10 Classification of Mental and Behavioural Disorders. New Delhi, India: AITBS Publishers and Distributors; 2007.
[Google Scholar]

[22] Centers for Disease Control and Prevention (CDC) , . Epi Info[TM] 3.5.1.
[Google Scholar]

[23] Burns A, . Rating scales in old age psychiatry. Br J Psychiatry. 2002;180:161-7.
[Google Scholar]

[24] Cheung Y. B., . A confirmatory factor analysis of the 12-item General Health Questionnaire among older people. Int J Geriatr Psychiatry. 2002;17:739-44.
[Google Scholar]

[25] Lorentz W. J., Scanlan J. M., Borson S, . Brief screening tests for dementia. Can J Psychiatry. 2002;47:723-33.
[Google Scholar]

[26] Ganguli M, Hendrie H. C., . Screening for cognitive impairment and depression in ethnically diverse older populations. Alzheimer Dis Assoc Disord. 2005;19:275-8.
[Google Scholar]

[27] Ismail Z, Rajji T. K., Shulman K. I., . Brief cognitive screening instruments: An update. Int J Geriatr Psychiatry. 2010;25:111-20.
[Google Scholar]

[28] Galvin J. E., Roe C. M., Xiong C, Morris J. C., . Validity and reliability of the AD8 informant interview in dementia. Neurology. 2006;67:1942-8.
[Google Scholar]

[29] Mazzotti D. R., Guindalini C, Sosa A. L., Ferri C. P., Tufik S, . Prevalence and correlates for sleep complaints in older adults in low and middle income countries: A 10/66 Dementia Research Group study. Sleep Med. 2012;13:697-702.
[Google Scholar]

[30] Brown F. W., . Late-life psychosis: Making the diagnosis and controlling symptoms. Geriatrics. 1998;53:26-8. 37-8, 41-2
[Google Scholar]

[31] Prakash I. J., . Women and ageing. Indian J Med Res. 1997;106:396-408.
[Google Scholar]

[32] Soares J. C., Gershon S, . Therapeutic targets in late-life psychoses: Review of concepts and critical issues. Schizophr Res. 1997;27:227-39.
[Google Scholar]

[33] Lacro J. P., Jeste D. V., . Geriatric psychosis. Psychiatr Q. 1997;68:247-60.
[Google Scholar]

[34] Hassett A, . A descriptive study of first presentation psychosis in old age. Aust N Z J Psychiatry. 1999;33:814-24.
[Google Scholar]

[35] Shaji K. S., Jithu V. P., Jyothi K. S., . Indian research on aging and dementia. Indian J Psychiatry. 2010;52:148-52. Suppl 1
[Google Scholar]

[36] Silva Pereira Y. D., Estibeiro A, Dhume R, Fernandes J, . Geriatric patients attending tertiary care psychiatric hospital. Indian J Psychiatry. 2002;44:326-31.
[Google Scholar]

[37] Sood A, Singh P, Gargi P. D., . Psychiatric morbidity in non-psychiatric geriatric inpatients. Indian J Psychiatry. 2006;48:56-61.
[Google Scholar]

[38] Tiwari S. C., . Geriatric psychiatric morbidity in rural northern India: Implications for the future. Int Psychogeriatr. 2000;12:35-48.
[Google Scholar]

[39] Drayer R. A., Mulsant B. H., Lenze E. J., Rollman B. L., Dew M. A., Kelleher K, et al . Somatic symptoms of depression in elderly patients with medical comorbidities. Int J Geriatr Psychiatry. 2005;20:973-82.
[Google Scholar]

[40] Prakash O, Gupta L. N., Singh V. B., Singhal A. K., Verma K. K., . Profile of psychiatric disorders and life events in medically ill elderly: Experiences from geriatric clinic in Northern India. Int J Geriatr Psychiatry. 2007;22:1101-5.
[Google Scholar]

[41] Tiple P, Sharma S. N., Srivastava A. S., . Psychiatric morbidity in geriatric people. Dement Geriatr Cogn Disord. 2006;48:88-94.
[Google Scholar]

[42] Singh G. P., Chavan B. S., Kaur P, Bhatia S, . Physical illnesses among psychiatric outpatients in a tertiary care health institution: A prospective study. Indian J Psychiatry. 2006;48:52-5.
[Google Scholar]

[43] Shah B, Prabhakar A. K., . Chronic morbidity profile among elderly. Indian J Med Res. 1997;106:265-72.
[Google Scholar]

[44] Purty A. J., Bazroy J, Kar M, Vasudevan K, Veliath A, Panda P, . Morbidity pattern among the elderly population in the rural area of Tamil Nadu, India. Turk J Med Sci. 2006;36:45-50.
[Google Scholar]

[45] Krishnaswamy B, Sein U. T., Munodawafa D, Varghese C, Venkataraman K, Anand L, . Ageing in India. Ageing Int. 2008;32:258-68.
[Google Scholar]

[46] Das S. K., Biswas A, Roy J, Bose P, Roy T, Banerjee T. K., et al . Prevalence of major neurological disorders among geriatric population in the metropolitan city of Kolkata. J Assoc Physicians India. 2008;56:175-81.
[Google Scholar]

[47] Dhar H. L., . Gender, aging, health and society. J Assoc Physicians India. 2001;49:1012-20.
[Google Scholar]

[48] Chaudhury S, Chakraborty R, Seby K, . Prevalence of psychiatric and physical morbidity in an urban geriatric population. Indian J Psychiatry. 2011;53:121-7.
[Google Scholar]

[49] Singh N, Chopra H, Singh J. V., Bhatnagar M, Garg S. K., Bajpai S. K., . The psycho-social profile of the elderly people in urban area of Meerut city. J Indian Acad Geriatr. 2009;5:165-70.
[Google Scholar]

[50] Varghese M, Patel V, . The Graying of India.Mental Health: An Indian Perspective 1946-2000. In: editor New Delhi, India: Directorate General of Health Services, Ministry of Health and Family Welfare; 2004. p. p. 240-8.
[Google Scholar]