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A study of major physical disorders among the elderly depressives.

Psychiatric evaluation and assessment of common physical illnesses and disabilities was carried out in elderly depressives (aged 60 years and above). Correlation, if any, was seen between depression and physical problems. The ‘patient group’ comprised of 40 drawn from MHI, Cuttack, having a depressive disorder (ICD-10). The ‘control group’ of 20 was drawn from the general population with no psychiatric disorder. The presence of physical illness was looked for in both groups. The patient group had physical illnesses, 76% of which were previously undiagnosed. The control group had physical illnesses 71% of which were previously diagnosed. Undiagnosed physical illnesses are more common among elderly patients with depression than among matched control. The physical illnesses contributed in two thirds of the patients. So careful detection and management of physical illness is of equal importance in the management of depression.

In India, the elderly constitute 6% of the total population as perthe 1991 census and their proportion is likely to increase in coming years. It is considered that all individuals as they age, have to suffer from physical illness and depression (Rajkumar et al., 1988). Both physical and psychiatric morbidity have been reported to be high "among the elderly population (Venkoba Rao & Madhavan, 1982), depression is a common diagnosis in the geriatric population (Ramachandran et al., 1986).
Recent studies have found that depressive disorders can be caused or aggravated by the associated physical illness (Ramachandran et al., 1986;Rajkumar et al., 1988;Pitt. 1993). There is high morbidity for physical illness and disability in those who present with psychiatric disorder in late life (Pitt, 1993). It is also highly desirable to screen for depression, which may retard the patients progress, increase mortality and is often treatable (Pitt, 1993). Psychiatric assessment in the elderly needs a multidimensional approach involving medical, psychiatric and social aspects (Ramachandran et al., 1986).
In India, there is a paucity of literature concerning various aspects of aging including mental health, even though by the year 2000 A.D. a significant proportion of the aged population would be existing in not only developed but also developing countries. The present study aims to bridge this lacuna by adding information on some aspects of psychogeriatrics, especially on the nature of depressive disorders among the elderly psychiatric patients attending a hospital and the relationship, of such disorders to associated physical illnesses.
The present study was carried out with the following aims : 1. Psychiatric evaluation of depression in patients aged 60 years & above and for the presence of common physical illnesses and disabilities.
2. To determine significance, if any, between depression in these patients and the presence of physical illnesses and disabilities.

MATERIAL AND METHOD
The study material consisted of two groups, first group, hereafter referred to as the 'patient group' comprised of subjects diagnosed to have a depressive disorder, and second group referred to as the 'control group' comprised of subjects with no psychiatric disorder.
The patient group comprised of 40 subjects who were selected after screening those attending the psychiatry out patient department, using predefined selection criteria.
The inclusion criteria were that the patient should be aged 60 years and above; should have been diagnosed as having a depressive disorder as per ICD-10; should be willing to undergo the investigations and other procedures required for the study ; and the exclusion criteria were that the patients, who for any reason, were unable to undergo all the investigations and other procedures required for the study.
The control group comprised of 20 subjects, group matched with the patients group for age and sex, and were selected from the general population.
The following statistical tests have been used : 1. Chi-square test with Yate's correction.

RESULTS
The sociodemographic characteristics of  the sample were as follows: males and females were almost equally distributed. Urban dwellers were represented significantly more in the study group. It may be that the urban dwellers have greater awareness of psychiatric help and easy accessibility. Poor representation of the rural elderly does not possibly indicate the lack of psychiatric morbidity in rural areas.
The patients as a whole had greater number of systems involved. Multiple illnesses were present in 90% of the study group, whereas they were present only in 20% in the control group. The most common system involved was musculoskeletal followed by cardiovascular and ophthalmological systems.
The common diagnosis in order of frequency were osteoarthritis 77%, hypertension 55%, cataract 47%, chronic respiratory disease 25%, ischaemic heart disease 17% and diabetes mellitus 12%. Amongst these, hypertension, osteoarthritis and cataract were significantly more associated in the study group.
The physical disabilities like impairments of locomotion and vision were found in about 60% of patients and were significantly more in patient group than in controls. The hearing disabilities were not significantly different in the two groups. While having an impairment in one or more modality were significantly associated with the patients (table -1). We found that in 67% the physical illnesses and disabilities had an aggravating role in depression, while in 7% depression was possibly secondary or unrelated. Only 2% cases were not associated with any physical illness or disabilities (table 2).

DISCUSSION
This study was an attempt to examine the nature and significance of physical illnesses associated with depression in the elderly depressives. The increasing proportion of aged in the community and the higher prevalence of psychiatric and physical morbidity in this group, influenced the decision to confine the study to the elderly subjects. The findings of this study have pertinent implications for clinical practice regarding the evaluation and management of depression in the elderly patients. The high prevalence of physical morbidity point to a further need for a comprehensive evaluation of elderly depressives.
In one Indian study it was observed that physical handicaps and illnesses were encountered in 54% of the elderly depressives and they included impaired hearing & vision, hypertension, diabetes mellitus, pseudobulbar palsy, parkinsonism, ischaemic heart disease (Venkoba Rao, 1981). Observations arising from such studies would help plan the services for elderly population and in manpower development (Kumar, 1993). For obvious reasons, comparison of these studies with projects based on house to house study undertaken in rural areas will not be appropriate (Venkoba Rao, 1990).
The importance of detecting physical illnesses is even greater because medically associated depressions have a different prognosis and management implications than other kinds of depression. Adequate treatment of the physical factors would facilitate management of the psychiatric problems, while unrecognised and untreated physical factors can increase the morbidity of depression. A clear enunciation of the role of physical factors in depression is therefore important.
This study was limited by its timebound nature and the extent of resources. Further studies on similar lines but with larger samples are necessary to confirm and expand these observations. Such studies would serve the interest for optimal care of geriatric patients. Since the present study involved various measures to detect physical illnesses, it is possible that subjects who suspected themselves to be harbouring some diseases, were willing to participate. The high comorbidity for physical and psychiatric disorder in late life should always be in the minds of clinicians who work with old people.
Screening for psychiatric disorder-mainly depression improves its recognition by those who are not psychiatrists. The training of specialist psychiatrists for the elderly should include experience in geriatric medicine.