Psychiatric Morbidities of Elderly Out-patients Attending Various Outreach Clinics in Gandaki Province of Nepal: A Descriptive Cross-sectional Study

ABSTRACT Introduction: Dramatic growth of the aging population resulted in an increased number of mental disorders and such data are limited in Nepal. The objective is to find out the psychiatric morbidities of elderly out-patients attending Baglung, Kusma, Walling, and Dumre out-reach clinics in Gandaki Province of Nepal. Methods: This was a descriptive cross-sectional study conducted in 392 patients attending out-reach clinics of Baglung, Kusma, Walling, and Dumre of Gandaki Province for one year with the convenient sampling method. Ethical approval was taken from the Institutional Review Committee of Manipal College of Medical Sciences, Pokhara. The diagnosis was done according to the International Classification of Disease-10 guidelines. Epi-info 7 was used and point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data and the analysis was done. Results: The prevalence of neurotic, stress-related, and somatoform disorders 145 (37.0%) was maximum followed by mood disorders 111 (28.3%). Maximum cases were in between 66 and 75 years, Brahmin and Chhetri caste, females, married, and from an extended nuclear family. There is more prevalence of female gender in all psychiatric diagnoses except in mental and behavioral disorders due to psychoactive substance use. There is more prevalence of age groups of patients less than or equal to 75 years in all the psychiatric diagnosis. Conclusions: Neurotic, stress-related, and somatoform disorders were the most common diagnosis. The risk of development of certain disorders based on gender and age group of the patients would be helpful for case identification.


INTRODUCTION
The aging of the populations has become a worldwide phenomenon. 1 This phenomenon has extensive consequences. 2 Population aging is producing changes to the demographics of the developing countries like Nepal. 3 The people aged above 65 years in Nepal comprises 5.42% in 2011 which is projected to increase to 6.79% of the total population in 2031. 4 This phenomenon has dramatic consequences for public health, health care financing, and delivery systems in the whole world. Mental disorders are common chronic conditions among elderly people, and the absolute number of subjects with psychiatric disorders will increase dramatically soon worldwide. 5 A plan is needed for provisions of services to elderly persons with mental disorders. 6 The objective is to find out the psychiatric morbidities of elderly out-patients attending Baglung, Kusma, Walling, and Dumre outreach clinics of the Gandaki Province of Nepal.

METHODS
This descriptive cross-sectional study was conducted in all the elderly patients of above 65 years who attended the psychiatry out-patients department (OPD) of outreach clinics of Baglung, Kusma By adding 32 more samples (9% as non-response rate), the final sample size was calculated to be 392.
The written informed consent was taken from the patients. The consent was taken from the relatives of the patients in case if the patient was unable to give consent because of an unstable mental state. The confidentiality of the participants was maintained.
The convenience sampling method was used. Selection and information bias has been minimized as possible. Data entry and analysis was done in Epi-info version 7. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data and analysis was done.
A self-designed proforma was used to record the sociodemographic profile of the patients. The diagnosis of the elderly patients was based on International Classification of Disease-10 guidelines. 8

RESULTS
A total of 392 consecutive elderly patients was selected for the study. The prevalence of neurotic, stress-related, and somatoform disorders 145 (37.0%) was maximum followed by mood disorders 111 (28.3%).
The sociodemographic profile of the patients is shown (Table 1). was followed by a mood disorder 111 (28.3%). The distribution of the psychiatric diagnosis according to the gender of the patients is shown (Table 3). All the psychiatric diagnosis was prevalent among female gender except in mental and behavioral disorders due to psychoactive substance use. The distribution of the psychiatric diagnosis as per the age groups is shown ( Table 4). All psychiatric illness is prevalent among patients less than or equal to 75 years. There are more females as compared to males in the current study. This finding was following the studies done both in Nepal and India. 15,16,19,21 However, the different studies found more male respondents in their sample of the population. [10][11][12]14,17,20 Majority of the respondents were Brahmins & Chhetri 239 (61.0%) followed by Mongolians 93 (23.7%), others (Dalits) 47 (12.0%) and Newars 13 (3.3%) in the current study. A similar trend has been found in the different studies conducted in Nepal. 14,16,17,20 According to one study, the Brahmins and Chhetri are more aware of psychiatric illness and their treatment due to the privilege of higher education/ socio-economic status. 20 There is a higher proportion of the distribution of Brahmin and Chhetri caste in the total national census of Nepal as well. 4 Maximum cases in the out-reach clinics were married in the present study. The different studies also found the maximum number from the married group. 9,15,17,19,20 Better support system of the married patients can explain this finding. 20 However, a well-designed populationbased case-control study is needed to establish this finding.
In the present study, about 55.9% and 33.9% of the cases come from extended nuclear and joint family respectively. This finding also consistent with the one study conducted in Nepal. 17 The study conducted in India concluded that family setting continues to be available for the elderly in the developing country. 9 This study found that the maximum proportions of elderly citizens are suffering from neurotic, stressrelated, and somatoform disorders (37.0%). One study was done in a rural setting inside Nepal also found maximum respondents to be suffering from somatization and generalized anxiety. 22 However, the different studies found maximum senior citizens to be suffering from mood disorders. 13,15,16,18,23 One study conducted in Nepal found maximum patients to be suffering from psychosis. 14 These overall findings reflect that if the study is conducted in the rural area 22 or close to the rural area (like in this study), there is a high prevalence of neurotic disorders. This is just the possible hypothesis which needs to confirm/reject with large scale comparative studies. This could be due to the fact that long standing somatic symptoms of neurotic disorders make the patient to visit multiple hospitals to relieve their distress immediately. 24 The prevalence of organic, including symptomatic, mental disorders was 7.7% in the present study. The different studies found prevalence of 11.9%, 18 12%, 16 15%, 17,23 and 15.9%. 13 The diagnosis of mental and behavioral disorders due to psychoactive substance use constitutes 3.8% of the total sample in the current sample. This patient was diagnosed to be suffering from alcohol dependence syndrome. Other studies done previously in Nepal found prevalence of 5%, 25 10.5%, 14 12.9%, 15 14%, 23 18.1% 13 and 19%. 16 The prevalence of schizophrenia, schizotypal, and delusional disorders was 3.1% in the current sample. The prevalence of schizophrenia ranges from 6% to 33.3% according to different studies have done both inside Nepal and India. [13][14][15][16]18,23 The prevalence of mood disorder (which includes both depressive episodes and bipolar disorders) in the current study was 28.3%. The prevalence found in other studies were 19.5%, 14 32.5%, 23 39.1, 13 44.0%, 18 44.8% 15 and 46%. 16 The study conducted in tertiary care hospital in Nepal found a prevalence of depression of 53.2% according to the Geriatric Depression Scale. 26 The proportion of elderly patients to be suffering from neurotic, stress-related, and somatoform disorders was 37.0% in this study. The other study done in Nepal found a prevalence of 23.3% and 2.5% of anxiety disorder and somatoform disorder respectively. 23 Two studies done in the Eastern region of Nepal found a prevalence of 22% 16 and 13.8%. 15 In the gender distribution of the current study samples, the psychiatric diagnosis was more prevalent in females as compared to males except in mental and behavioral disorders due to psychoactive substance use. One study conducted in the same Province area as the current study also found more elderly males to be suffering from alcohol dependence syndrome. 25 One study done in Nepal found more prevalence of alcohol dependence and dementia in the male population. 13 There is more prevalence of all psychiatric diagnoses in the patients less than or equal to 75 in this study. One study found that except for dementia, there is more prevalence of psychiatric diagnosis at the age of less than or equal to  23 This overall finding might just be due to the small sample size of patients above 75 years in the current study.
The reasons for the study findings of the different studies might be due to the difference in the sample characteristics of the study populations. The different study design and confounding factors in various studies may lead to different findings. The use of different assessment tools and study settings (out-patient, inpatient, and rural setting) might be the other reason for the difference in the study findings.
There are limitations to this study. The use of ICD for diagnosis of psychiatric disorder in an elderly sample may underestimate its true prevalence. Also, as this study was conducted in the outpatient department settings, the finding cannot be generalized to the entire population.

CONCLUSIONS
The study found that the majority of the elderly patients who visited the out-reach clinics were from the age groups between 66 and 75 years, Brahmin and Chhetri caste, females, married, and living in the extended nuclear family. The maximum patients were also found to be suffering from the neurotic, stressrelated, and somatoform disorder which is followed by a mood disorder. This study finding would be helpful in the identification and holistic management of elderly patients. Further large scale, case-control, and analytical design studies in the community setting in a different region of Nepal are required before generalizing the result of this study.
Conflict of Interest: None.