Abstract: This study aims at knowing old age problems especially for those living at elderly homes and extending counseling services to the vast and new field of geriatrics in Iran. In this study 120 old people who lived at governmental and private elderly homes in Tehran, Iran were randomly enrolled and studied using SCL90 and Beck Depression Inventory. The results showed that signs of depression and somatization disorders were the most common ones among the elderly in elderly homes. In all studied clinical scales, the rate of psychological symptoms was more among women than men. The most important worries of the elderly were economic status, social relations, dissatisfaction with old age, lack of favorite activities and their family members` treatment. Since living at an elderly home means staying away from family support and that it is considered reproachable, attending to psychological and emotional needs of the elderly home residents is essential.
INTRODUCTION
Old age is a period that people need physical, emotional and psychological support. The elderly have passed the time of creativity and flourishing and are evaluating and reviewing their life. An attempt to help them is actually an appreciation of their past activities and achievements. Furthermore, worrying about old age can affect many people who are not old yet. In fact, supporting and helping the elderly can relieve people who are not old yet. Research has shown that the prevalence of psychological disorders is increasing in a way that some call it a crisis. By increasing psychological disorders in the elderly, it is estimated that their prevalence will increase four folds by 2030 compared with the past 30 years (Waerna et al., 2003). In people over 65 years old, 4.9% have dementia, 2.3% have psychosis, 42.6% have non-psychotic disorders, among which 18.7% have psychosomatic disorders, 12.6% have mild depression, 5.4% have personality disorders and 5.6% have mild dementia (Trollor et al., 2007). The prevalence of cognitive impairment among the elderly of 60 years and over is 15.7%, out of which 10.2% is mild and 5.2% is medium and severe. The rate of cognitive impairment increases with age. It is also meaningfully related to factors such as race, education and hospitalization. Accordingly, medium and severe impairments are more often seen among the black and hospitalized elderly with low education (Wilson et al., 2001). In an epidemiological study on 1792 old people over 65 years of age using DSM-IV criteria, it was shown that 13% of them had some symptoms of psychological disorders in the past month and 16% of them had some symptoms in the past 12 months (Gavrilova and Kalyn, 1997).
Furthermore, research has revealed that psychological disorders occur in old men and women in different manners. Old women show more emotional disorders and general anxiety disorders while men suffer from disorders related to drug abuse withdrawal (Gavrilova and Kalyn, 1997). Except for cognitive disorders, in other disorders increasing age was related with prevalence of symptoms. Old age and no history of marriage are correlated with an increase of psychological disorders especially emotional ones. Furthermore, it was revealed that the elderly with cognitive disorders had more emotional disorders.
Cognitive disorders in the elderly have inappropriate consequences; they reduce their physical disability and are one of major reasons or maybe the only reason for suicide among the elderly. Some 97% of the suicide victims in the elderly had at least one of the symptoms of axis I, while this rate was 18% among the living elderly (non-suicidal). The highest rate of suicide was among the MDD patients and those with drug abuse (Jeste et al., 1999). Meanwhile, drug and alcohol abuse usually come along with depression and suicide (Christopher Callahan et al., 1995).
On the other hand, elderly homes are places for the elderly to reside, rest, be taken care of and live. For the elderly, living at an elderly home should mean spending time with peers, being close to medical and health services and being away from loneliness and depression. In fact, these are only a few expectations from the elderly homes. However, whether and how well elderly homes have met these needs and reduced loneliness and depression is the question of a research. Studying the psychological status of the residents of elderly homes furnishes the researchers, scientists, counselors and psychologists with the opportunity to know more about this period, its problems and the counseling services they need.
Elderly homes are not yet a place to support the elderly. On the one hand, they lack specialty services to alleviate the elderly needs and on the other hand, there is a negative attitude toward nursery homes. If they provide appropriate services for and realize the problems of the elderly, it can help extend the culture to support them.
Accordingly, the present study was designed and implemented. In this study, psychological problems of the elderly in nursery homes were investigated. One-hundred and twenty old people living in elderly homes of Tehran were randomly selected and surveyed using questionnaires to collect data.
MATERIALS AND METHODS
This is a descriptive study on the elderly living at nurseries in Tehran, Iran. Considering the extent of the studied population. The subjects that randomly selected were 120 residents of governmental and private elderly homes in Tehran. The ability to answer the questions and tests was the inclusion criteria, so the ones with brain disorders such as Alzheimer and/or speech problems were excluded.
To collect data, two tests and one researcher-made questionnaire were used. SCL90 test is used to assess the rate of psychological disorders. This is a self-assessment test and is answered by subjects themselves. It has 90 questions and 9 scales in the following aspects: Somatization (SOM), Obsessive-Compulsive (O-C), Interpersonal Sensitivity (I-S), Depression (DEP), Anxiety (ANX), Hostility (HOS), Phobic Anxiety (PHOB), Paranoid Ideation (PAR) and Psychoticism (PSY).
Beck Depression Inventory has many forms, from which the abridged one (12 question) was used. This test shows the severity of depression in sick people.
Status evaluation questionnaire has two parts; one about demographic data of the subjects and another about their opinion of themselves and their environment. The questions cover the subjects` opinions about themselves, their family, their physical environment and their social relations. To maintain harmony and integrity of the information, all questionnaires were filled by trained interviewers.
All data from SCL90 test, Beck Depression Inventory and the questionnaires were encoded and punched into the SPSS computer software for analysis. Descriptive statistical indexes such as prevalence, percentage, mean and standard deviation and t test and Man-Whitney test were used for analysis of the data.
RESULTS AND DISCUSSION
Demographic data showed that out of 120 subjects in this study, 68% were male and 32% were female. Age-wise, some 61% were between 60 and 80, 27% were under 60 and 12% were over 80 years old. Most of the men were in their 60s and most of the women were in their 70s (Table 1). Most of the subjects had elementary education (85%), which was the same among men and women. Most of them were single, whether, their spouse had died or their marriage had ended in divorce (68% versus 14%). This ratio was the same among men and women and there was no significant difference between men and women in this regard (p ≤0.5) (Table 2). Regarding their economic situation, most of them were supported by charity groups (43%) and relatives (22.5%). Pension and social security payments were two other financial sources which supported 10% of the elderly, each. This ratio was meaningfully different between men and women (p ≤ 0.1). Most of the old men were financially supported by charity volunteers while most women were supported by their relatives (Table 3). About half of the old people (52%) did not have any physical disorders, while 41% had a kind of disability or chronic diseases. This ratio was not significantly different between men and women (p ≤0.5) (Table 4).
Most of the elderly (48%) had been at the elderly home between 1 and 5 years, 24% 5-10 years, 13% more than 10 years and about 11% under 1 year. These ratios were nearly the same for men and women (Table 5). The mean age of old men was 64.89 ± 12.57 and that of old women was 68.60 ± 13.68.
About 62% of the residents of nurseries had at least one symptom of psychological disorders. The most frequent symptoms were, in decreasing order, seen in the following scales: depression 32.5%, somatization 27.5%, obsessive-compulsive 19.1%, anxiety 18.3%, interpersonal sensitivity 15.8%, hostility 12.5%, psychoticism 9.1%, paranoid ideation 8.3% and phobic anxiety 5.9% (Table 6).
Studying the prevalence of depression among the elderly living at nurseries showed that about 41% of them had depression, based on Beck Depression Inventory.
| Table 1: | The distribution of the studied elderly based on their sex and age |
| Mean age for men was 64.89 and for women, 68.60; *: p ≤ 0.05 = not sig. | |
| Table 2: | The distribution of the studied elderly based on sex, education and marital status |
| *: p ≤ 0.05 = not sig. | |
| Table 3: | Sources of financial support for the elderly |
| **: p ≤ 0.01 | |
| Table 4: | Physical health status of the elderly |
| *: p ≤ 0.05 = not sig. | |
| Table 5: | The duration of the elderly stay at the nursery |
| *: p ≤ 0.05: not sig. | |
The severity of depression was of pathological scale and needed psychological treatment (Table 7).
There is a difference in the rate of depression based on SCL90 depression subscale and that based on Beck Depression Inventory; 32.5% versus 41%. Despite this difference, the correlation between these two scales was about 78%, so we can estimate the rate of depression in the study population between 33 and 41% with more certainty. Comparing the rate of psychological symptoms between men and women living at the elderly homes using t-test showed that mean score of women in all clinical scales was significantly higher than that of men (p ≤ 0.1).
| Table 6: | Prevalence of psychological disorders in the elderly |
| Table 7: | Prevalence of depression among the elderly home residents |
| Table 8: | Comparison of prevalence of psychological disorders between men and women at elderly homes |
| Table 9: | Worries of the elderly at elderly home |
This significant difference between the two groups showed the prevalence of psychological disorders is higher among old women compared with old men (Table 8).
The most worrying issues for the elderly were economic status (55.8%), lack of social relations (55%), dissatisfaction with old age (45.8%) and lack of favorite activities (45%) (Table 9).
Based on the results of the earlier researches in this subject, it can be learned that men constitute most of the population of the elderly homes and most of them are single. In Iran, men become disabled earlier than women and usually their wives take care of them. Statistics show that men who have lost their wife`s support choose elderly homes to live more than other men.
The rate of 41% for physical disability among the residents of elderly homes includes paralysis, spinal cord injury, leg problem, back problem, heart problem and so on. The elderly receive a variety of services at the elderly homes including: routine blood tests, diabetes test, exercise test, physiotherapy and regular visits by an orthopedic surgeon and an internist. These are all essential services for the elderly, but psychological and counseling services should not be ignored. Based on the results of this study, more than half of the elderly living at the elderly homes; that is, a few more than those with physical problems, had at least one psychological symptom. Some 33% had depression and only a few of them did not have any psychological problem. That means the majority of the elderly suffer from depression or other mild to severe psychological problems.
Although anti-depressants are generally believed to be efficient for the elderly (Mulrow et al., 1999; McCusker et al., 1998; Mittmann et al., 1997; Alexopoulos et al., 2001; Mulsant et al., 2001; Lebowitz et al., 1997; Sackett et al., 1996; Jeffrey et al., 2002; Jeste et al., 1999) and that more than half of the elderly who are under treatment show reduction of depression symptoms (McCusker et al., 1998), such drugs are just 20% more effective than placebo. On the other hand, the efficacy of psychological treatments such as cognitive therapy, behavior therapy and cognitive-behavioral therapies are well known. Of course, other kinds of treatment like problem solving, interpersonal treatments and short-term psychoanalysis are common. Psychological treatments can boost medical treatments and tremendously decrease depression in the elderly (Gavrilova and Kalyn, 1997; Anderson, 2000). Disorders during old age cause more use of health care services and decrease longevity (Wilson et al., 2001). At least one fifth of the elderly over 65 suffer from psychological disorders (Jeste et al., 1999) and this rate is increasing in a way that it is estimated that the number of such old people will be equal to those of other ages (Jeste et al., 1999). Despite the increase, services to these people have not developed accordingly and do not meet their needs (Gavrilova and Kalyn, 1997; Anderson, 2000). Most probably, the elderly who suffer from psychological disorders receive unsuitable and inadequate treatments compared to other old people (Trollor et al., 2007).
The present mental health system is not ready to cope with psychological disorders of the elderly. The same is true for other health issues of the elderly (Waern et al., 2002). The costs of mental health services for the elderly are much more than those for other ages. These results have been taken from a research where even the kind of the disease was controlled as a variable (Thorpe et al., 2001). In spite of the side effects and consequences of depression in the elderly and especially their suicide and the necessity of treating depression and other psychological disorders, the elderly are less treated for psychological disorders including depression (Whelan, 2003).
In this study, it was shown that very few old people in present randomly selected population did not report any of the symptoms in the 9 studied scales. Psychological and counseling services are not considered a part of services for the elderly, though. These statistics can be disappointing for the elderly and those who are getting old. It is necessary to pay attention to this issue and improve psychological services to the elderly. Furthermore, the most common disorders at the elderly homes are depression and somatization, which usually present themselves with physical symptoms.
Incorrect diagnosis can make the elderly permanently dependent on medical treatments without helping them. Besides, providing psychological services at the elderly homes can decrease extra medical costs.
Another finding of this study was that psychological disorders were more common among women than men. According to present demographic findings, most of the women at the elderly homes have chosen the center as the last resort or they have been taken there unwillingly. Most of them are single, with economic problems, without income and dissatisfied with their life at the elderly home. These show their vulnerability and the need for a thorough investigation. Psychological support is essential for this group because they have lost most of their support.
The last point is about worries of the people at the elderly homes. They are mostly worried about their economic status, lack of social relations, dissatisfaction with old age and lack of favorite activities, in decreasing order. Except for the first one that needs governmental and charity support, the other worries need psychological support. It is noteworthy that a benefit of the elderly homes is the interaction of the old people with their peers. Their relation with their peers and the staff of the center are the only sources of social support for the elderly. If this limited relation is based on the right counseling principles, it can be more beneficial for the elderly. Therefore, based on the results of the study, it can be suggested that counseling and psychological services be a main service at all elderly homes. Each nursery should be obliged to employ psychologists and counselors and implement daily or weekly group counseling sessions for the elderly. It is recommended that attractive and beneficial programs be made for the elderly and they play important roles in designing and executing such programs so that they feel useful.
Developing the culture of living at elderly homes can increase their satisfaction. Accordingly, improving the quality and the quantity of services at elderly homes, establishing day time nurseries, providing governmental support for elderly homes, making the activities and living at nurseries more attractive can all help develop the culture of living at elderly homes. If the elderly notice that living with their peers at least during the day can make them happy and that they can use their experiences at group counseling sessions, they will be more satisfied with their old age.
Since good behavior of the staff of the elderly homes can be a strong supportive source for the residents, it is essential to pay attention to on-the-job training for the staff regarding the life of the elderly, their needs, problems and ways to approach them. It is recommended that a psychologist hold some sessions for the staff alone and some others along with the elderly.