THESIS

IDENTIFICATION OF COGNITIVE IMPAIRMENT AND
PSYCHIATRIC ILLNESS AMONG INHABITANTS OF OLD AGE

HOMES IN MYSURU – A COMMUNITY SURVEY
By,
Mr. VAISHAK BHARADWAJ K (17Q2127)
Mr. DEVENDRA SANJOY G (17Q2106)
Mr. BETTASWAMY H V (16Q2109)
Dissertation submitted to,

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BENGALURU, KARNATAKA
In partial fulfilment of the requirements for the degree of

DOCTOR OF PHARMACY
Under the guidance of
MR.CHARAN C S
Associate Professor
Department of Pharmacology
SVCP, Mysuru
SARADA VILAS COLLEGE OF PHARMACY

KRISHNAMURTHYPURAM, MYSURU –570004
2021-2022
This is to certify that this dissertation work entitled “Identification of cognitive

impairment and psychiatric illness among inhabitants of old age homes in Mysuru
- A community survey” has been submitted by Mr.Vaishak Bharadwaj K, Mr.
Devendra Sanjoy G, Mr.Bettaswamy H V to the university.
Date: Registrar
(Evaluation)
EVALUATION CERTIFICATE
This is to certify that this Dissertation has been evaluated.
Internal Examiner External Examiner
Signature
Name
College
Date
DECLARATION BY THE CANDIDATES

We hereby declare that the Dissertation entitled “Identification of cognitive impairment and
psychiatric illness among inhabitants of old age homes in Mysuru - A community survey”
has been submitted by Mr.Vaishak Bharadwaj k, Mr.Devendra Sanjoy G, Mr.Bettaswamy
H V, is a bonafide and genuine research work carried out in partial fulfilment of the
requirement for the degree of Doctor of Pharmacy under the guidance and supervision of
Mr.Charan C S, Associate Professor, Department of Pharmacology, SVCP Mysuru.
The contents of this Dissertation, in full or in parts, have not been submitted to any other
institute of university for the award of any degree or diploma.
Signature of the candidates,
(Vaishak Bharadwaj K)
Date:
(Devendra Sanjoy G)
Place: Mysuru
(Bettaswamy H V)
d
CERTIFICATE BY THE INSTITUTIONAL GUIDE

This is to certify that the Dissertation entitled “Identification of cognitive impairment
and psychiatric illness among inhabitants of old age homes in Mysuru - A
community survey” has been submitted by Mr.Vaishak Bharadwaj K, Mr.Devendra
Sanjoy G, Mr.Bettaswamy H V is a bonafide research work carried out in partial fulfilment
of the requirements for the degree of Doctor of Pharmacy under my supervision and guidance.
The contents of this Dissertation, is in full or in parts, have not been submitted to any other
institute or university for the award of any degree or diploma.
Signature of the Institutional Guide,
Date: Mr. Charan C S
Associate Professor
Place: Mysuru Department of Pharmacology
, Sarada Vilas College of Pharmacy
Mysuru
CERTIFICATE BY THE INSTITUTIONAL CO-GUIDE

and psychiatric illness among inhabitants of old age homes in Mysuru - A community
survey” has been submitted by Mr.Vaishak Bharadwaj K, Mr.Devendra Sanjoy G,
Mr.Bettaswamy H V is a bonafide research work carried out in partial fulfilment of the
requirements for the degree of Doctor of Pharmacy under my supervision and guidance. The
contents of this Dissertation, is in full or in parts, have not been submitted to any other institute
or university for the award of any degree or diploma.
Signature of the Institutional Co-Guide
Date : Dr.Ravindra P Choudhary

Assistant Professor
Department of Pharmacy Practice,
Place: Mysuru Sarada Vilas College of Pharmacy,
Mysuru
ENDORSEMENT BY THE PRINCIPAL

and psychiatric illness among inhabitants of old age homes in Mysuru - A community
survey” has been submitted by Mr.Vaishak Bharadwaj K, Mr.Devendra Sanjoy G,
Mr.Bettaswamy H V is a bonafide research work carried out in partial fulfilment of the
requirements for the degree of Doctor of Pharmacy under my supervision and guidance. The
contents of this Dissertation, is in full or in parts, have not been submitted to any other institute
or university for the award of any degree or diploma.
Date: Signature of the Principal
Place: Mysuru
Dr.Hanumanthachar Joshi
Principal
Sarada Vilas College of Pharmacy
Mysuru
ENDORSEMENT BY THE HOD

This is to certify that the Dissertation “Identification of cognitive impairment and
psychiatric illness among inhabitants of old age homes in Mysuru - A community survey”
has been submitted by Mr.Vaishak Bharadwaj K, Mr.Devendra Sanjoy G, Mr.Bettaswamy
H V is a bonafide research work carried out in partial fulfillment of the requirements for the
degree of Doctor of Pharmacy under my supervision and guidance. The contents of this
Dissertation, is in full or in parts, have not been submitted to any other institute or university
for the award of any degree or diploma.
Date:
Place: Mysuru Signature of the HOD
Dr.Davan B Bevoor,
Head and Assistant Professor,
Department of Pharmacy Practice
Sarada Vilas College of Pharmacy
Mysuru
DECLARATION BY THE CANDIDATES
COPYRIGHT
We hereby declare that Rajiv Gandhi University of Health Sciences, Bengaluru,
Karnataka, shall have the rights to preserve, use and disseminate the Dissertation in print
or electronic format for academic/ research purpose.
Signature of the candidates,
(Vaishak Bharadwaj K)
Date:
(Devendra Sanjoy G)
Place:
(Bettaswamy H V)
© Rajiv Gandhi University of Health Sciences, Karnataka
Identification of cognitive impairment on psychiatric illness among inhabitants of old age home in mysuru Page 8
ACKNOWLEDGEMENT
Firstly, thank god for giving us the strength, ability and opportunity to undertake this study and
to preserve and complete it satisfactorily.
We respect and thank Dr.Hanumanthachar Joshi, Principal, Sarada Vilas College of

Pharmacy, for giving us an opportunity to do our project and providing us all guidance and
support to complete this project work in time.
Our sincere gratitude to Dr.Davan B Bevoor, Head of Department of Pharmacy Practice,

Sarada Vilas College of Pharmacy, for their constant encouragement and timely guidance
which paved the path towards the successful completion of our project work.
Oursincere gratitude to our guide Mr.Charan C S Associate professor, Department of

Pharmacology, Sarada Vilas College of Pharmacy, for his prompt inspiration, timely
suggestions with kindness and enthusiasm have enabled us to complete our project
We owe a deep sense of gratitude to our co-guide Dr.Ravindra P Choudhary, Assistant

Professor, Department of Pharmacy Practice, Sarada Vilas College of Pharmacy for his
constant encouragement and timely guidance with kindness and enthusiasm have enabled us to
complete our project work.
Our special thanks to Dr.Aravinda Kumar S Psychologist Viveka Hospital, Vajamangala,

Mysuru, for his advice and encouragement to choose right way to do project work.
Our special thanks to Dr.Srinivas B Prasad Belavadi, Associate Clinical Psychologist Viveka
Hospital, Vajamangala, Mysuru, for his advice and encouragement to choose right way to do
project work.
Our special thanks to Dr.Saraswathi K N Assistant Professor, JSS Nursing College Mysuru,
for her advice and encouragement to choose right way to do the project work.
It’s our privilege to thank all teaching and non-teaching staff of our institution for their support
and encouragement.
CONTENTS
SL NO TITLE PAGE NO
1 INTODUCTION 23-53
1.1 NEUROLOGICAL DISORDER 24
1.1.1 Prevalence
1.1.1 Aetiology
1.1.2 Types
1.2 PSYCHOLOGICAL DISORDER 25
1.2.1 Types
1.2.2 Aetiology
1.2.3 Prevalence
1.3 DEMENTIA 26
1.3.1 Prevalence
1.3.2 Stages
1.3.3 Aetiology
1.3.4 Types
1.3.5 Diagnosis
1.3.6 Treatment
1.3.7 Non-Pharmacological Therapy
1.4 DEPRESSION 34
1.4.1 Prevalence
1.4.2 Signs And Symptoms
1.4.3 Pathophysiology
1.4.4 Causes And Contributing Factors
1.4.5Diagnosis
1.4.6 Treatment
1.5 SLEEP DISORDERS 42
1.5.1 Prevalence
1.5.2 Types
1.5.3 Signs And Symptoms
1.5.4 Causes
1.5.5 Diagnosis
1.5.6. Treatment
1.5.7 Life Style Modification
1.6 NEED OF THE STUDY 53
2 AIM AND OBJECTIVE 54-55
2.1 AIM
2.2 OBJECTIVES
3 LITERATURE REVIEW 56-67
4 METERIALS AND METHODS 68-73
4.1 Study Design
4.2 Source Of Data
4.3 Study Population
4.4 Study Period
4.5 Inclusion Criteria
4.6 Exclusion Criteria
4.7 Site Of Study
4.8 Study Tools
4.9 Methods
4.10 Statistical Analysis
5 RESULTS 74-94
5.1 GENERAL DEMOGRAPHICS OF STUDY SUBJECTS 75
5.2 DEMENTIA 76
5.2.1 Demographics Of Subjects With Dementia
5.2.2 Risk Factor Analysis Of Dementia
5.3 DEMENTIA AND DEPENDENCY 83
5.4 DEPRESSION 83
5.4.1 Demographics Of Depressive Patients
5.4.2 Risk Factor Analysis Of Depression
5.5 PROPORTION OF POPULATION WITH DEMENTIA AND 88

DEPRESSION
5.6 SLEEP DISORDER 89
5.6.1 Demographics
5.6.2 Proportion Of Population With Depression And
Abnormal Sleep
5.6.3 Risk Factor Analysis Of Sleep Disorder
5.7 DEPENDENCY 94
6 DISCUSSION 95-96
7 CONCLUSION 98-99
8 LIMITATIONS 100-101
9 FUTURE DIRECTION 102-103
10 SUMMARY 104-106
11 REFERENCE 107-113
12 ANNEXURES 114-120
LIST OF FIGURES
FIG PAGE
TITLE
NO. NO.
01 STAGES OF DEMENTIA 28
02 PROGRESSION OF DEMENTIA 30
03 PATHOGENESIS OF DEMENTIA 31
04 VARIOUS WAYS TO PREVENT THE DEMENTIA 34
05 PATHOLOGY OF DEPRESSIVE DISORDER 36
06 DISTRIBURTION OF SEVEARITY OF DEMENTIA WITHIN 77

STUDY POPULATION
07 AGE DISTRIBUTION WITHIN STUDY POPULATION OF 78

DEMENTIA
08 LITERACY DISTRIBUTION WITHIN STUDY POPULATION 79

OF DEMENTIA
09 DISTRIBUTION OF STUDY POPULATION WITHIN 80

DEMENTIA WITH HTN AND DM
10 GENDER DISTRIBUTION OF STUDY POPULATION WITHIN 80

DEMENTIA
11 DISTRUIBUTION OF STUDY POPULATION OF DEMENTIA 83

WITH RESPECT TO DEPENDENCY
12 DETAILS OF SEVEARITY OF DEPRESSION WITH IN 84

STUDY POPULATION
13 AGE DISTRIBUTION WITHIN STUDYPOPULARTION OF 85

DEPREPRESSION
14 DISTRIBUTION OF DEPRESSION WITHIN GENDER 86
15 DIETARY DISTRIBUTION WITHIN STUDY POPULATION 86

OF DEPRESSION
16 DISTRIBUTION OF HTN AND DM WITHIN DEPRESSIVE 87

STUDY POPULATION
17 PROPORTION OF POPULATION WITH DEMENTIA AND 88

DEPRESSION
18 LITERACY DISTRIBUTION OF STUDY POPULATION WITH 90

DEPRESSION
19 GENDER DISTRIBUTION OF STUDY POPULATION WITH 91

DISTRUBED SLEEP
20 DISTRIBUTION OF HTN AND DM WITHIN STUDY 92

POPULATION WITH DISTURBED SLEEP
21 PROPORTION OF POPULATION WITH DEPRESSION AND 93

ABNORMAL SLEEP
22 DIETRIBUTION OF SEVERITY IN DEPENDENCY WITHIN 94

STUDY POPULATION
LIST OF TABLES
TABLE TITLE PAGE
NO NO
01 DRUGS USED IN TREATMENT OF DEMENTIA 32
02 LIST OF SELECTIVE REPTAKE INHIBITORS 39
03 LIST OF TRICYCLIC ANTIDIPRESENTS 40
04 LIST OF MAOI SNRI DRUGS 41
05 BENZODIAZEPINES DRUGS USED IN SLEEP 50

DISORDERS
06 DEMOGRAPHIC DISTRIBUTION OF STUDY 75

POPULATION
07 DISTRIBUTION OF DEMENTIA PATIENTS BASED ON 77

SEVIARITY
08 DETAILS OF AGE DISTRIBUTION WITHIN STUDY 77

POPULATION OF DEMENTIA
09 DETAILS OF LITERACY DISTRIBUTION WITHIN 78

STUDY
10 DISTRIBUTION OF HTN AND DM WITHIN STUDY 79

11 80
DETAILS OF GENDER DISTRIBUTION WITHIN STUDY
12 DETAILS OF STUDY POPULATION OF DEMENTIA 81

CONSIDERING TREATMENT
81
13 DETAILS OF DISTRIBUTION OF STUDY POPULATION

WITHIN DEMENTIA BASED ON OCCUPATION
14 DETAILS OF DIET DISTRIBUTION WITHIN STUDY 82

15 DETAILS OF VARIOUS FACTORS INFLUENCING 82

PROGRESSION OF DEMENTIA
16 DETAILS OF STUDY POPULATION OF DEMENTIA 83

WITH RESPECT TO DEPENDANCY
17
DISTRIBUTION OF DEPRESSIVE PATIENTS BASED ON 84
SEVERITY
18 DETAILS OF CATEGORIZATION OF STUDY 85

POPULATION WITHIN DEPRESSION BASED ON AGE
19 DETAILS OF GENDER DISTRIBUTION OF DPRESSIVE 85

SUBJECTS
20 DETAILS OF DIETARY DISTRIBUTION WITHIN 86

DEPRESSIVE SUBJECTS
21 DETAILS OF VARIOUS FACTOR INFLUNCIG
DEPRESSION 87
22 PROPOTION OF POPULATION WITH DEMENTIA AND 88
DEPRESSION
23 DETAILS OF AGE DISTRIBUTION OF STUDY 89

24 DETAILS OF DIETARY DISTRIBUTION OF STUDY 89

25 DETAILS OF LITERACY DISTRIBUTION OF STUDY 90

26 GENDER DISTRIBUTION OF STUDY POPULATION 91

WITH DISTURBED SLEEP
27 DETAILS OF DISTRIBUTION OF HTN AND DM WITHIN 92

STUDY POPULATION OF DISTURBED SLEEP
28 PROPOTION OF POPULATION WITH DEPRESSION 92

AND ABNORMAL SLEEP
29 DETAILS OF VARIOUS FACTOR INFLUENCING SLEEP 93

DISTURBANCE
30 DETAILS OF OVERALL DEPENDENCY OF STUDY 94

POPULATION
ABBREVIATIONS
SL ABBREVIATIONS EXPANSIONS
NO
1 WHO WORLD HEALTH ORGANIZATION
2 AD ALZHEIMERS DISEASE
3 PTSD POST TRAUMATIC STRESS DISORDER
4 CT COMPUTERIZED TOMOGRAPHY
5 MRI MAGNETIC RESONANCE IMAGING
6 PET POSITRON EMMISION TOMOGRAPHY
7 NE NEUROTRANSMITTERS NOREPINEPHRINE
8 5-HT SEROTONIN
9 DA DOPAMINE
9 DSM-V DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDER
10 BDI BECKS DEPRESION INVENTORS
11 HDRS HAMILTON DEPRESSION RATING SCALE
12 SSRI SELECTIVE SEROTONIN RECEPTOR INHIBITORS
13 TCA TRICYCLIC ANTI DEPRESANTS
14 H1 HISTAMINERGIC RECEPTORS
15 MAOI MONOAMINE OXIDASE INHIBITORS
16 CBT COGNITIVE BEHAVIOR THERAPY
17 ECT ELECRO CONVULSIVE THERAPY
18 RTS RESTLESS LEG SYNDROME
19 NSAIDs NONSTEROIDAL ANTI INFLAMMATORY DRUGS
20 ESS EPWORTH SLEEPINESS SCALE
21 COPD CHRONIC OBSTRUCTIVE PULMONARY DISEASE
22 OSA OBSTRUCTIVE SLEEP APNEA
23 GABA GAMMA AMINO BUTYRIC ACID
24 DZP DIAZEPAM
25 SCN SUPRACHIASMETIC NUCLEUS
26 OTC OVER THE COUNTER
27 MMSE MINI MENTAL SCALE EXAMIANTION
28 BPRS BRIEF PSYCHIATRIC RATING SCALE
29 IQ CODE INFORMANTS QUESTIONNAIRE ON COGNITIVE DECLINE IN
ELDERS
30 GDS GERIATRIC DEPRESSION SCALE
31 SPAS SURVEY PSYCHIATRIC ASSESSMENT SCHEDULE
32 MDQ MOOD DISORDER QUESTIONNAIRE
33 SCAN SCHEDULE FOR CLINICAL ASSESSMENT IN
NEUROPSYCHIATRIC
34 VaD VASCULAR DEMENTIA
35 MCI MILD COGNITIVE IMPAIRMENT
36 DLB LEWY BODY DEMENTIA
37 PDD PARKINSON DISEASE DEMENTIA
38 FTLD FRONTOTEMPORAL LOBAR DEGENERATION
39 EDS EXCESSIVE DAYTIME SLEEPINESS
40 RBD REM BEHAVIOR DISORDER
41 OAHs OLD AGE HOMES
42 MDI MAJOR DEPRESSION INVENTORY
43 PSQI PITTSBURGH SLEEP QUALITY INDEX
44 SPSS STATISTICAL PACKAGE FOR THE SOCIAL SERVICE
45 CAMDEX CAMBRIDGE MENTAL DISORDER OF ELDERLY
EXAMINATION
46 NINC-ARDRA NATIONAL INSTITUTE OF NEUROLOGICAL AND COMMOM
DISORDER AND STROKE/ALZEIMERS DISEASE
47 NINDS-AIREN NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND
STROKE AND THE ASSOCIATION INERNATIONALE POUR LA
RECHERCHE ET I’ENSCIGNMENT EN NAUEOSCIENCE
48 LOR LORAZEPAM
49 MT MELATONIN
ABSTRACT
BACKGROUND: The phenomenon of population aging is a major social and health
problem in developing countries, India ranks 4th in terms of the size of the elderly
population. An exceptional increase in the number and proportion of older adults in the
country, contemporary changes in psychosocial values, and modern strategies of increase in
nuclear families often compel this segment of society to live alone or in old age homes. As
this group of people is more vulnerable to mental health issues, a cross-sectional study was
carried out with following aim.
OBJECTIVES : Aims to assess the prevalence and risk factor of mental illness, sleep
disturbance and depression by using MMSE,PSQI,MDI scale respectively.
METHODOLOGY : An observational cross-sectional study, carried out at 10 randomly

selected old age homes in Mysuru. The inhabitants who are willing to participate, above 50
years of age were included and the survey was conducted using MMSE, MDI and PSQI
questionnaires and scores were allotted and analysed.
RESULT : Out of 187 subjects, the age groups of people 71-80 yrs are found to be more
prone to the neurological and psychological disorder and also the study finds out that females
are more prevalent. 39.57%(n=74) of study subjects found to be with dementia and it is more
prevalent in gender (p value : 0.03477525), education(p value: 0.0019773). 27.50%(n=52) of
study subjects were found to be with depression and it is more prevalent in diet (p value:
0.0026217). 34022%(n=64) of study subjects found to be with sleep disturbence and it is
more prevalent in gender (p value: 0.0214832).
CONCLUSION : The study shows that about 40% of the inhabitants are suffering from
neurological disorder and more than 75% of the same are unaware of the situation. Only 23%
of population are taking medication hence, health camp need to be conducted at sufficient
times. Hence, more schemes and awareness programmes and sufficient prophylactic measure
to be brought in no time, or the consequences would be a generation of elderly people filled
mostly with mental disorders.
KEYWORDS : Dementia, Depression, Sleep Disorder, Elderly population, Risk factors,

MMSE, MDI, PSQI.
INTRODUCTION
1.0 INTRODUCTION
1.1 NEUROLOGICAL DISORDER
A neurological disorder is any disorder of the body nervous system. The abnormalities like
structural, biomedical or electrical conduction in the brain, spinal cord or other nerves can
result in various symptoms that include
• Paralysis
• Muscle weakness
• Poor coordination
• Loss of sensation
• Seizures
• Confusion
• Pain
• Altered level of consciousness,
More than 600 neurological disorder and conditions were found which impacts the human
nervous system, out of which many conditions still lacks a standard treatment [1].
As per WHO, millions of people are affected from neurological disorder including 24million
affected from Alzheimer’s disease and 326 million experiencing migraine [2]
1.1.1 PREVALENCE
In India, as per 2019 reports, 3.0 to 11.9 per 1000 of the population were found to be affected
from one or more neurological disorder. The incidence of the same was found to be 0.2-0.6 per
1000 population per year [3]
1.1.2 ETIOLOGY
• Physical injury to the brain, spinal cord or nerves.
• Biochemical causes like imbalances in neurotransmitters.
• Idiopathic[1]
1.1.3 TYPES
As already mentioned, there are more than 600 known neurological disorders, but most
commonly occurring of them are:
• Epilepsy
• Dementia (Alzheimer’s disease)
• Migraine and other headaches
• Multiple sclerosis
• Parkinsonism[2]
1.2 PSYCHOLOGICAL DISORDER

Psychological or mental disorders are the conditions that affect the thinking, mood and
behaviour of an individual. They may be occasional or long lasting which affects daily
functioning.
1.2.1 TYPES
• Anxiety disorders
• Depression
• Personality disorders
• Post-traumatic stress disorder
• Psychotic disorder
• Eating disorder
• Mood disorders
1.2.2 ETIOLOGY
There is no any single cause for Psychological disorder. Various factors can influence the
psychological disorder. Some of them are:
• Family history of genetic

• History of abuse
• Biological factors
• Trauma to the brain
• Substance abuse
• Isolated behaviour or social isolation
• Viral or toxic chemical exposure in mother during pregnancy
• Stress(4)
1.2.3 PREVALENCE
According to the studies of 2017, in India 197.3 million people were suffering from the mental
disorders in which 45.7 million were suffering from depressive disorders, 44.9 million were
suffering from anxiety disorders [3]
1.3. DEMENTIA
Dementia is currently the seventh leading cause of the death among all other disease and one
of the major causes of disability and dependency among elderly people in world wide.
Currently more than 55 million people live with dementia worldwide, and there are nearly 10
million new cases every year.
Dementia is a syndrome usually of chronic or progressive in nature that leads to deterioration

in cognitive function beyond what might be expected from the usual consequence of biological
aging. It affects memory, thinking, orientation, comprehensive, calculation, learning capacity,
language, and judgement. Consciousness is not affected.
Dementia is usually results from various diseases and injuries that are primarily / secondarily
affects the brain such as Alzheimer’s diseases / stroke.
Dementia has physical, psychological, social and economical impacts, not only on people
living with dementia but also for their care givers, families and society [5]
1.3.1PREVALENCE
WHO estimates that the number of people living with dementia will be all most double every
20 years to 42.3 million in 2020 and 81.1 million in 2040.it also says that growth rate will be
highest in India, China, South Asia and western pacific regions, and lower in developed
countries.
In India there are few urban studies from various regions of India showing similar varying
rates from 2.44 – 4.1% in western India, 1.83% in north India, 0.8-1.28% in east India, and
3.6% in south India. [7]
1.3.2STAGES
Early stage
The early stage of dementia is often overlooked because the onset is gradual.
Common symptoms are
➢ Forgetfulness
➢ Losing track of the time
➢ Becoming lost in familiar places
Middle stage
As dementia progress to the middle stage, the signs and symptom becomes clearer and may
include
➢ Becoming forgetful of recent events and people’s names

➢ Becoming confused while at home
➢ Having increasing difficulty with communication
➢ Need help with personal care
➢ Experiencing behaviour changes, including
➢ Wandering and repeated questioning
Late stage
The late stage of dementia is one of near total dependence and inactivity. Memory disturbance
are serious and the physical signs and symptoms become more obvious and may includes
➢ Becoming unaware of the time and place

➢ Having difficulty in recognizing relatives and friends
➢ Having an increase need for assisted self-care
➢ Having difficulty in walking
➢ Experiencing behaviour changes that may escalate and include aggression.(5)
8)
FIG 1: STAGES OF DEMENTIA(
1.3.3. ETIOLOGY
The underlying causes of the dementia, remains unknown in most of the cases. Some
researchers found that some changes in the brain are linked to certain form of dementia. Rare
genetic mutations may cause dementia in a relatively small number of people.[3]
1.3.4. TYPES
Neurodegenerative disorders results in a progressive and irreversible loss of neurons and brain
functioning and currently, there are no cures for these diseases.
There are five most common forms of dementia, these are:
Alzheimer’s disease
This is the most common form of dementia diagnosis among elderly people. It is believed that
Alzheimer’s caused by changes in brain, including abnormal building up of proteins, known as
amyloid plaques and tau tangles.
Fronto-temporal dementia
A rare form of dementia, that tends to occur in people younger than the age of 60. It is caused
by abnormal amounts or forms of the proteins (tau) and TDP-3.
Lewy body dementia
This is a type of dementia, caused by abnormal deposits of the alpha synuclein protein, known
as lewy bodies.
Vascular dementia
This form of dementia is caused by conditions that damages blood vessels in the brain /
interrupt the blood flow and oxygen to the brain.
Mixed dementia
Two / more types of dementia are found in single dementia patients.
E.g.: many people with dementia have both Alzheimer’s disease and vascular dementia.
Researchers found that many medical conditions occurs as the side effect of certain medication
that can cause the serious memory problems includes stress, anxiety, depression, and delirium.
Other conditions which leads to dementia /dementia like symptoms are
➢ Argyrophilic grain disease, a common, late onset degenerative disease

➢ Creutzfeldt- jakob disease, a rare brain disorder
➢ Huntington’s disease, an inherited progressive brain disease
➢ Chromic traumatic encephalopathy, caused by repeated traumatic brain injury
➢ HIV associated dementia, a rare condition, occurs when HIV virus spreads to the brain.
The overlap in symptoms of various Dementia can make it difficult to get an accurate diagnosis.
1.3.5. DIAGNOSIS
To diagnose dementia, doctors will check whether the patient has an underlying, potentially
treatable, conditions that may relate to cognitive difficulties by using different procedures that
are:
Cognitive and neurological tests
A type of test used to find the thinking and physical functioning. The assessment includes
memory, problems solving, language skills, and maths skill and also balance, sensory response
and reflexes
Brain scans
It is used to identify stroke, tumours, and other problems that can cause dementia. Scans also
hep to find the changes in structure and functioning of the brain
Commonly using scans are
Computed tomography(CT)
It uses the x-rays to produce the brain’s images
Magnetic resonance imaging (MRI)
This scan uses the magnetic fields and radio waves to produce the detailed images of body
structure, including tissues, organs, bones, and nerves
Positron emission tomography (PET)
It uses radiations to provide the images of brain activity.
Psychiatric evaluation
This test helps to evaluate whether the

depression or other mental health condition
is causing or contributing the person’s
symptoms.
Genetic tests
It helps to find the people with higher risk of

FIG 2: PROGRESSION OF DEMENTIA
dementia as dementia is also caused by
person’s genetics. FIG 2: PRORESSION OF DEMENIA
Blood tests
It helps to measure the level of beta-amyloid, a protein that accumulates abnormally in the
Alzheimer’s patient.
Some of the blood tests are still in development stages, at the same time, the blood tests for
diagnosis of Alzheimer’s is limited.(6)
1.3.6. TREATMENT
Dementia is the disease for which there is no complete cure, but some of the symptoms of the
disease can treated with medications.
FIG 3 : PATHOGENESIS OF DEMENTIA(9)
Cholinesterase inhibitors
The medications of this class include -Donepezil, Rivastigmine and Galantamine
These drugs shows the action by boosting the levels of a chemical messenger involved in
memory and judgement
These medications are commonly used for the treatment of Alzheimer’s disease but it is also
used for the other types like vascular dementia, Parkinson’s disease dementia and lewy body
dementia
Side effects – Nausea, vomiting, and diarrhoea. Other possible effects are slowed heart rate,
fainting and sleep disturbances.
Memantine
These medications act by regulating the activity of glutamate and other chemical messenger
involved in the brain functions like learning and memory.
It is given along with cholinesterase inhibitor.
Dizziness is the common side effect.
Miscellaneous
Some other medications used in treatment are anti-depressive andanti-anxiety medications.
COST OF THERAPY: Cost for treating dementia or caring dementia patients in India may
vary between 45,600-2,02,450 per annum.(10)
Table 1: List of drugs used in Dementia[13]
DRUGS
Donezepil 5mg 5-10mg
Rivastigmine 4.6mg 3-6mg
Galantamine 8mg 8-12mg
Antipsychotics
Haloperidol 0.25 1-3
Olanzapine 2.5 5-10
Risperidone 0.25 0.75-2
Antidepressants
Citalopram 10 10-20
Escitalopram 5 20-40
Fluoxetine 5 10-40
Anticonvulsant
Carbamazepine 100 200-600
Valproic acid 125 500-1000
1.3.7. NON PHARMACOLOGICAL THERAPIES

Some symptoms and the behaviours are initially treated with non- pharmacological approaches,
which are
Occupational therapy
The occupational therapist will guide the patient, how to be safe at home and preventing the
accidents, such as falls.
Modifying the environment
Reducing clutter and noise can make easier for the patients with the dementia for focusing and
functioning and making fearless and safe environment.
Simplifying the tasks
Make easier steps for the activities and focus on only the success. The routine of activities also
helps to reduce confusion in the dementia patients
Other therapies like
➢ Music therapy, which involve in improving the listening capacity

➢ Light exercises helps to maintain the body coordination
➢ Watching videos of family members helps to maintain the memory and concentration
➢ Pet therapy, which involves animals like dogs, or cats which will help to improve the
mood of the patients
➢ Art therapy, which involves creating art, as it helps to improve the concentration [4]
[8]
FIG 4 : VARIOUS WAYS TO PREVENT DEMENTIA
1.4. DEPRESSION
Depression is a common but serious mood disorder that causes persistent feeling of sadness
and loss of interest in daily functioning. It can lead to a variety of emotional and physical
problems and can decrease the ability to function.
Depression is ranked as the single largest contributor leading to global disability. Although the
known effective treatments for mental disorders are available, more than 75% people of middle
and low income countries receive no treatments. (11)
1.4.1 PREVALENCE
WHO estimates depression to be affecting 3.8% of the world’s population, including 5% in
adults and 5.7% among elderly population of age 60 and above.
Approximately, around 280 millions are said to be living with depression. Suicidal death tolls
over 700000 every year and is fourth leading cause of death in 15-30 years old.
In India, as per National Mental Health Survey 2015-16, nearly one in 20 suffers from
depression and 15% of the Indian population is suffering from one or more mental disorder
which needs an intervention. As of 2017 45.7 million Indians were suffering from depressive
disorder.(12)
1.4.2 SIGNS and SYMPTOMS

• Feeling of sad or on low spirits
• Loss of interest in daily activities
• Lack of energy and strength
• Feeling of less confidence
• Feeling of guilt or helplessness or hopeless
• Difficulty in concentrating
• Feeling of restless
• Trouble sleeping or lack of sleep
• Persistent feeling worthlessness
• Suicidal thoughts
• Changes in appetite (increased or decreased appetite)
• Irritability
• Pain, fatigue or Weakness without physical cause.
Not everyone with depression experiences every symptom; some may experience few
symptoms while others may experience many. To be diagnosed with depression the symptoms
must be present for at least 2 weeks (11)
1.4.3 PATHOPHYSIOLOGY
• Biogenic amine hypothesis – Depression may be caused by decreased brain levels of
neurotransmitters norepinephrine (NE), serotonin (5-HT) and dopamine (DA)
• Postsynaptic changes in receptor sensitivity
• Dysregulation hypothesis – this states that depression is caused due to dysregulation in
homeostasis in neurotransmitter system.
• 5-HT/NE link hypothesis – this theory suggests some link between 5HT and NE activity
and both the noradrenergic and serotonergic system are involved in antidepressant
activity.
• DA – several studies suggest that increased DA neurotransmission in the mesolimbic
(13)
pathways may be related to the antidepressant activity
16]
FIG 5 :PATHOPHYSIOLOGY OF DEPRESSIVE DISORDER[
1.4.4. CAUSES AND CONTRIBUTING FACTORS

Depression results from complex interaction of social, psychological and biological factors. It
can be seen in any age group but is seen more in adults and older adults.
Depression can be due to:
• History of depression.
• Family history of depression
• Major life instances or life changes.
• Major trauma or stress.
• Certain medication and or physical illness
In older adults (elderly) the depression can co-occur with other serious illness like heart disease,
diabetes, cancer, dementia or other illness. These illnesses even become worse when depression
is present. In some cases medications taken for these illnesses may cause side effects that may
contribute to depression.
Factors that may contribute to depression include:
• Biochemistry – Chemical imbalance in brain may contribute to the symptoms of

depression.
• Genetics – association of depression within families have been stated by some studies.
• Hormones – changes in levels of certain hormones can cause or trigger depression.
• Environmental factors – continuous exposure to violence, neglect, family situations,
substance abuse and poverty can also trigger depression.
• Personality – person with low self-confident, dependent, can’t handle situation and
workload easily can be more prone to depression.(11)
1.4.5. DIAGNOSIS
There is no universally accepted biochemical or genetic tests o confirm the presence of
depression. Various rating scales have been developed to help demonstrate the severity of
depressive disorder.
Major depression is characterized by one or more episodes of major depression as defined by

the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revised (DSM-V).
Symptoms must be present for at least 2 weeks.
Depressed patients should have a medication review, physical examination, mental status
examination, a complete blood count with differential, thyroid function tests and electrolyte
determinations.
Rating Scale
Various scales have been used to assist the assessment of severity of depression. Two of the
most commonly used are the Becks Depression Inventory and Hamilton Depression Rating
Scale
Beck Depression Inventory

This is a self reporting scale looking at 21 depressive symptoms. The subject is asked to read
a series of statements and mark on a scale of 1-4 how severe their symptoms are. The higher
the score, more severe is the depression.
Hamilton Depression Rating Scale

This scale is used in the clinical setup by the health care professionals to rate the severity of
depression.
1.4.6. TREATMENT
Depression can be treated most effectively than most of the mental illness. Earlier the treatment
begins more is the effectiveness. Based on its severity, certain medications, psychotherapy or
combination of both may be used. If these interventions do not respond, electroconvulsive
therapy or other brain stimulation therapy may be used.
Pharmacotherapy
Antidepressants are the medications used in the treatment of depression. These medications
alter levels of chemicals in the body that control mood or stress. Selective Serotonine Reuptake
Inhibitors (SSRI) and Tricyclic Antidepressants (TCA) are most prescribed drug for
depression. Antidepressants take around 2weeks to show its effects and may take upto 6months
to show its full effect. Hence a course of 6-12 months are recommended to be prescribed.
The acute phase of treatment may lasts for 6-10 weeks aimed for remission or absence of
symptoms, while continuation phase lasts 4-9 months. The maintenance phase aims at
prevention of relapse and may last for at least 12-36 months.
Longer terms maintenance therapy is recommended for people with high risk to prevent
reoccurrence of depression.
The SSRI are often selected as first choice antidepressants in elderly patients.
In healthy elderly, cautious use of Secondary Amine TCA (desipramine or nortriptyline) may
be used because of their efficacy and lower ADR.
Bupropion and Venlafaxine may also be chosen because of their milder Anticholinergic and
less frequent cardiovascular effect.
DRUGS
The Selective Serotonin Reuptake Inhibitors
• These drugs inhibit the reuptake of 5-HT into presynaptic neuron. They are generally
chosen as first line antidepressants because of their safety in overdose and improved
tolerability.
Table 2: List of Selective Serotonin Reuptake Inhibitors
Generic Name Initial dose (mg/day) Usual dose range (mg/day)
Citalopram 20 20-60
Escitalopram 10 10-20
Fluoxetine 20 20-60
Fluvoxamine 50 50-300
Paroxetine 20 20-60
Sertraline 50 50-200
Tricylic Antidepressants (TCA)
• These drugs block the reuptake of serotonin and norepinephrine in presynaptic

terminals, thereby increasing its concentration in synaptic cleft and contribute to anti-
depressive effect. In addition they act as competitive antagonists on post-synaptic
alpha1 and alpha2, muscarinic and histaminergic receptors (H1).
• They are effective for all subtypes of depression but availability of equally effective
therapies with higher safety profiles have diminished their usage.
• The drug Clomipramine was one of the first antidepressant found to be potent 5-HT
reuptake inhibitor.
Table 3 : List of Tricyclic Antidepessants
Generic Name Initial dose (mg/day) Usual dose range (mg/day)
Tertiary amines
✓ Amitriptyline 25 100-300
✓ Clomipramine 25 100-250
✓ Doxepin 25 100-300
✓ Imipramine 25 100-300
Secondary amines
✓ Desipramine 25 100-300
✓ Nortriptyline 25 50-200
The Monoamine Oxidase Inhibitors (MAOI)
• As the name suggests, these drugs inhibits the Monoamine Oxidase Enzyme system
and increases the concentration of NE, 5-HT and DA.
• The Selegiline is available as transdermal patch, inhibits both MAO-A and MAO-B in
the brain, but has reduced effect on MAO-A in the gut.
• Phenelzine and Tranylcypromine are the two nonselective inhibitors of MAO-A and
MAO-B available as oral drug.
The Serotonin-Norepinephrine Reuptake Inhibitors
• These include Venlafaxine and Duloxetine.

• Venlafaxine is an inhibitor of 5-HT and NE reuptake and a weak inhibitor of DA
reuptake.
• Duloxetine weakly inhibits dopamine reuptake and may be less tolerated than SSRI.
Given the relative risk-benefit ratio, this drug is considered as second-line treatment
option.
Table 4 : List of MAOI and SNRI Drugs
Generic Name Initial dose (mg/day) Usual dose range

(mg/day)
Monoamine Oxidase Inhibitors
✓ Phenelzine 15 30-90
✓ Selegiline(transdermal) 6 6-12
✓ Tranylcypromine 10 20-60
Serotonine/norepinephrine
reuptake inhibitors
✓ Venlafaxine 37.5-75 75-225
✓ Duloxetine 30 30-90
Mirtazapine
• It enhances central noradrenergic and serotonergic activity through the antagonism of

central presynaptic alpha-2 adrenergic autoreceptors and heteroreceptors. It also
antagonizes 5-HT2 and 5-HT3 receptors. In addition it also blocks histamine receptors.
• Dose range – 15-45mg/day
St. John’s wort
• An herbal non prescription medication containing hypericum, may be effective for both
mild and moderate depression, but is associated with several drug-drug interactions.
• It shouldn’t be taken with other anti-depressive drugs.(13,14)
Psychotherapy
Psychotherapy is also called talk therapy or in other words is counselling. It is seen to be
effective in some cases of mild depression without the need to antidepressants, in moderate to
severe cases psychotherapies are used along with the medications. This therapy includes
Cognitive behaviour therapy (CBT), Interpersonal therapy and Problem solving therapy.
Cognitive behavioural therapy is most effective in treating depression. The CBT helps a person
to recognize distorted/negative thinking with the goal of changing thoughts and behaviour to
respond to challenges in a more positive manner.
The psychotherapy may include only the individual or in some cases the family members or
other relevant person. It can take weeks to months or much longer to show the complete effect
depending on the severity. Usually, improvement can be made in 10-15 sessions.
Brain Stimulation Therapy

Electroconvulsive therapy is the medical treatment given to severely depressed individual who
do not respond to medication or other treatments. It involves brief electric stimulation of brain
while being on anaesthesia. It is handled by trained professionals and the patient may receive
2-3 ECT per week as required.
Others – Self help and coping

• Regular exercise
• Try being active
• Socializing oneself
• Spending time with loved ones and trusted friends and relatives
• Expect to improve the mood gradually not immediately
• Try not to isolate (11)
1.5. SLEEP DISORDERS

Sleep disorders are group of various conditions that disturbs the sleep on a regular basis. Sleep
disorder may be caused by any health conditions or by increase in stress level. Modern times
have seen sleep disorder to be more common than the olden times.
Most of the people commonly experience the sleep disorders due to stress, hectic schedules
and other outside influences. These factors may interfere with daily life that might cause a
sleeping problem.
Based on types of sleep disorders, people might feel difficulty in falling asleep and may feel
extremely tired throughout the day. The lack of sleep can cause a negative effect on mental
health, concentration, mood and energy of the patient. In some conditions sleep disorders may
be the symptoms of the other medical health condition and the sleep problem may go away
once treatment is obtained for the underlying cause.
1.5.1 PREVALENCE
As per National Study of 2007[42], the prevalence of sleep disorder was found to be 15% among
50 years age group and 37.7% in 65years and above age group in Indian population.
1.5.2 TYPES
There are various types of sleep disorders they are
Insomnia
Insomnia refers to the inability to fall asleep or to remain asleep. It can be caused by jet lag,
stress and anxiety, hormones, or digestive problems. It may also be the symptom of other
medical condition. Insomnia is a common type of sleep disorders, it might leads to the other
medical conditions like
Depression
Difficulty in concentrating
Irritability
Weight gain
Impaired work or school performance
Insomnia is commonly found in older adult and women
Insomnia is classified as
❖ Chronic- insomnia occurs on regular basis for minimum of 1 month
❖ Intermittent –insomnia occurs periodically
❖ Transient – when insomnia lasts for just a few nights at a time
Sleep Apnea
Sleep apnea is the condition characterised by pause in breathing during the sleep. It is the
serious medical condition that causes the body to take in less amount of oxygen. It also cause
you to wake up during the night
Two types of sleep apnea
❖ Obstructive sleep apnea –in this type the flow of air stops because of obstruction in
airway space or narrow
❖ Central sleep apnea - it is the loos of connection between brain and the muscle that
controls your breath
Parasomnias
Parasomnias is the a type of sleep disorder that causes abnormal movements and behaviours
during sleep, this includes
• Sleep walking
• Sleep talking
• Groaning
• Nightmares
• Bedwetting
• Teeth grinding or jaw clenching
Restless Leg Syndrome [RLS]

RLS is an overwhelming need to move the legs. This urge is sometimes accompanied by a
tingling sensation in the leg.
These symptoms are more prevalent in night, but the symptoms also occurs in day time.
The exact cause of the disease is unknown, but it is associated with certain diseases like Deficit
hyperactivity disorder and Parkinson’s diseases.
Narcolepsy
Narcolepsy is characterised by sleep attack that occur while awake. This is characterised by,
sudden feel of extreme tiredness and fall asleep without warning.
Narcolepsy can occur by its own and also can associate with certain neurological disorders,
such as multiple sclerosis.
Narcolepsy can also lead to sleep paralysis, which may make you physically unable to move
right after waking up.
1.5.3 SIGNS and SYMPTOMS

General symptoms includes
1. Day time fatigue

2. Difficulty falling or staying asleep
3. Unusual breathing patterns
4. Unusual movement or other experiences while asleep
5. Unintentional changes to your sleep/ wake schedule
6. Irritability or anxiety
7. Impaired performance at work or school
8. Lack of concentration
9. Depression
1.5.4 CAUSES
Allergies and respiratory problems
Allergies, colds, and upper respiratory infections may causes the breathing problems this might
leads to the inability of breath through nose can cause sleep problems.
Frequent urination
Nocturia, or frequent urination may cause disturbance in the sleep cycle. The hormonal
imbalance and disease of urinary tract infection may cause this problem.
Chronic pain
Constant or chronic pain leads to difficulty in falling asleep. It may also disturb the sleep cycle.
Causes of chronic pains are
➢ Arthritis
➢ Chronic fatigue syndrome
➢ Fibromyalgia
➢ Inflammatory bowel disease
➢ Persistent headaches
➢ Continuous lower back pain
Stress and anxiety

Stress and anxiety has a negative impact on sleep cycle, it causes difficulty in fall asleep or to
stay asleep. It may lead to the nightmares, sleep talking or sleep walking that may cause
disturbance in sleep(17)
1.5.5. DIAGNOSIS
Many patients complaining of insomnia overestimate their sleep requirements. The hours of
sleep requirements may vary within the individuals, some may sleep for 6-7 hours but some
healthy individuals may require as little as 3hours of sleep and sleep requirements decline with
increasing age.
Diagnosis of sleep is done basically by comparing the symptoms in individuals. In patients

with chronic disturbances, a diagnostic evaluation includes physical and mental status
examinations, routine laboratory tests, medications and substance abuse histories.
DSM -V criteria
The following criteria are used to diagnose the depression; here the individual should
experience the five or more symptoms during a period of 2 weeks. The individual must
experience at least one of the symptoms which is either depressed mood or loss of interest or
pleasure.
1. Depressed mood most of the day

2. Markedly diminished interest or pleasure
3. Significant weight loss when not dieting or weight gain
4. A slowing down of thoughts and reduction of physical movement
5. Fatigue or loss of energy nearly every day
6. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
7. Diminished ability to think or concentrate
8. Recurrent thoughts of death (17)
Sleep History
Sleep history is the first step in evaluation of primary insomnia, which provides the clinician
with a structured approach to diagnose. The sleep history requires some of the details like its
duration, variation, severity and daytime consequences.
The physician may ask some of the common questions relating to sleep hygiene to identify the
nature and severity of the problem, patients sleep environment, sleeping routine and to identify
maladaptive behaviour (if any).
Use of medication
Various drugs may be the reason for sleep disorder. Some of the drugs that may be responsible
are anticonvulsants (phenytoin, lamotrigine), beta blockers (atenolol, metoprolol, sotalol),
selective serotonin reuptake inhibitors (SSRI), antipsychotics and NSAIDs.
Sleep Dairy
A sleep diary helps in specifically estimating the severity of the condition. The sleep diary
helps in finding night to night variability, sleep hygiene, presence of maladaptive habits like
spending long time in bed (more than 8 hours), taking naps, drinking coffee during night. It
also helps in follow up during treatment.
Rating scale
Epworth sleepiness scale (ESS)
This scale rates the chance of dozing in the situation like sitting, reading, watching television,
talking to someone, waiting at a traffic signal in a car, being a passenger in a car for an hour,
lying down to rest in the afternoon, sitting inactively in a public place.
ESS is rated on a 4-point scale for each of the above factors based on following scores
0- No chances of dosing
1- Slight chances of dozing
2- Moderate chances of dozing
3- High chances of dozing
A score of more than 16 indicates daytime somnolence, a score of more than 11
indicates a possible disorder associated with excessive sleepiness.
PSQI
It is also a sleep rating scale with cut-off score of 5. The detail of this scale is described in
methodology.
Focused physical examination.
A physical examination can assess different health condition that may influence
insomnia such as chronic obstructive sleep disorder (COPD), asthma, restless leg
syndrome.
Blood tests
It is used to access thyroid disease, anemia and vitamin b12 deficiency

It can also access other pathologic factors like infections.
Polysomnography
It is the gold standard test to access sleep pattern. A polysomnogram utilizes

electroencephalogram, electro-oculogram, electromyogram, electrocardiogram and
pulse Oximetry as well as the airflow and respiratory effort to evaluate the underlying
causes of sleep disturbances. It is considered as gold standard for accessing breathing
related sleep disorder like Obstructive Sleep Apnea (OSA), Central Sleep Apnea and
Sleep related hypoventilation or hypoxia. It can also be used to access other sleep
disorder like REM sleep disorder, narcolepsy, nocturnal seizure and periodic limb
movement disorder.
Actigraphy
It measures the physical activity using a device usually accelerometer. The data can be
stores on the portable device for weeks and later be transferred to the computer to
analyse the result. The sleep and wake time can be analyzed by accessing the movement
data.
1.5.6. TREATMENT
NON PHARMACOLOGICAL TREATMENT
A non pharmacological intervention consists primarily of short term behavioural changes.
Explanation of sleep requirement, attention to sleep hygiene, reduction in caffeine or alcohol
intake may reduce the need of hypnotics. Behavioural and educational interventions include
short term cognitive behaviour therapy, relaxation therapy, stimulus control therapy, cognitive
therapy, sleep restriction, paradoxical intention and sleep hygiene education.
Stimulus control therapy
It is based on the objective that the patient is trained to “re-associate the bed and bedroom with
rapid sleep onset by curtailing sleep-incompatible activities that serve as cues for staying awake
and by enforcing a consistent sleep-wake schedule.” Here the patient is instructed to go for
sleep only on bed and only when felt sleepy. One is not allowed to watch television on bed,
avoid daytime napping and maintaining a regular rising time in the morning.
Relaxation therapy
Relaxation therapy uses interventions to reduce the high levels of arousals which are usually
observed in insomnia. Progressive muscle relaxation and biofeedback techniques seek to
reduce somatic arousal, while imaginary training and thought stopping seek to reduce pre-sleep
cognitive arousal. These interventions need regular practice over a period of several weeks.
During initial stage of training a professional guidance may often be required.
Cognitive therapy
It mainly consists of identifying the patient specific problems in sleep, addressing the same and
replacing it with more adaptive substitute through use of techniques like reattribution training,
reappraisal and attention shifting. It seeks to address the misconceptions about the cause of
insomnia, unrealistic sleep expectations and reducing performance anxiety resulting from
excessive attempts at controlling the sleep process.
Paradoxical intention
It is a method where patient is persuaded to engage in his or her most feared behaviour which
is staying awake. If a patient stops trying to sleep and contrarily try to stay awake, performance
anxiety will be reduced and sleep may come more easily.
Sleep hygiene education
It educates the patient about the environmental factors (light, noise, mattress) and social and
life style factors like exercise, diet, substance abuse which may either beneficial or can lead to
insomnia. The patients are also informed about the importance of maintaining sleep cycle and
additional recommendations to improve sleep behaviour.
Behavioural intervention
Having the patient to keep a sleep dairy for 2 weeks may be helpful. Depending on the findings
in the sleep diary, recommendations on the sleep hygiene may be beneficial to the patient.
Adopting the practices of good sleep hygiene is helpful to the patient regardless of the severity
of the illness, whether it is primary insomnia or something related to the medical condition.
PHARMACOLOGICAL TREATMENT.
Benzodiazepines
By far the most commonly prescribed hypnotics are benzodiazepines.
Table 5: Benzodiazepine Drugs Used in Sleep Disorders
DRUG USUAL DOSE AT NIGHT HALF LIFE IN ADULT (h)

(mg)
Diazepam 2-5 24-36
Loprazolam 1 11
Lorazepam 1 12-16
Lormetazepam 0.5-1.5 10
Nitrazepam 5-10 18-36
Temazepam 10-20 5-11
Mechanism of action
Most of its effect is from the interaction with specific binding sites associated with postsynaptic
GABA-a receptor. The benzodiazepines reduce latency to sleep onset and total awakening by
increasing total sleep duration. Benzodiazepines enhances the effect of inhibitory
neurotransmitter, gamma-amino butyric acid by increasing the affinity of GABA for its
receptors. They have sedative, anxiolytic, muscle relaxant and anticonvulsant activities.
GABAa receptors are a multi-molecular complex that control a chloride ion channel and
contains specific binding sites for GABA. The various effects or properties of benzodiazepines
result from GABA potentiationin specific brain sites and at different types of GABAa receptor.
There are multiple subtypes of GABAa receptor and benzodiazepines binds to three or more
subtypes.
Benzodiazepines binding to alpha-2 subtypes results in its anxiolytic effect, while alpha-1 gives
sedative and amnesic effect. The alpha-1, alpha-2, alpha-5 is responsible for its anticonvulsant
effect.
The benzodiazepines act by increasing stage 2 sleep while decreasing REM and delta sleep.
Pharmacokinetics
Most benzodiazepines are well absorbed and rapidly penetrate the brain, producing hypnotic
effects within half an hour after oral administration. These undergo hepatic metabolism via
oxidation or conjugation. It has elimination half life of 6-100h.
Adverse effects
Side effects include drowsiness, psychomotor incoordination, decreased concentration and

cognitive deficits. Tolerance to daytime CNS effects may be seen in some.
Tolerance to hypnotic effect develops after 2weeks of continuous use of Triazolam.
Anterograde amnesia has been reported with most benzodiazepines. Using the lowest dose
possible reduces the amnesia.
Rebound insomnia occurs frequently with high doses of triazolam and it can be reduced by
using lowest dose possible and tapering the dose upon discontinuation.
Non benzodiazepine drugs

Non benzodiazepine hypnotics include zopiclone, zolpidem and zaleplon.
Zopiclone
Zopiclone belongs to class cyclopyrrolone, was the first non-benzodiazepine hypnotics to be

approved for insomnia in Europe. It reduces sleep latency and nocturnal awakening and
increases total sleep time. Side effects including psychiatric reactions such as hallucinations,
behavioural disturbances and nightmares have been reported to occur shortly after the first
dose.
Zolpidem
It is a hypnotic drug of imidazopyridine class. It binds preferentially to the alpha-1 receptor

subunit and exhibit hypnotic effect with minimal anticonvulsant and muscle relaxant
properties. It is effective for reducing sleep latency and nocturnal awakening and increases total
sleep time. Side effects like drowsiness, dizziness and headache may be seen.
Zaleplon
It is a Pyrazolopyrimidine class of drug which selectively binds to the alpha-1 benzodiazepine

receptors. It reduces time for sleep onset but has no effect on nocturnal awakening or total sleep
time. It has a very short elimination half life of 1 hour and has minimal residual effect on
psychomotor and cognitive functions after 5hours.
Melatonin
It is a naturally occurring hormone, produced by pineal gland, which regulates the circadian
rhythm of sleep. Melatonin release decreases with age and supplementation with Melatonin
can restore the sleep cycle and even increases next day functioning. Unlike other hypnotics,
melatonin doesn’t show any dependency or abuse and even dizziness on next day.
Ramelton
It is a melatonin agonist and acts by selectively binding to the melatonin receptors (MT1, MT2)
in the suprachiasmaticnucleus (SCN). It is the only non-scheduled prescription drug available
in the United States.
Antidepressants
Tricyclic antidepressants such as amitryptiline, doxepine and nortryptiline are effective for
inducing sleep. These are used as second line treatment when other drugs seem to be less
effective in the individual. Side effects may include adrenergic blockade, anticholinergic
effects and cardiac conduction prolongation.
Trazadone
It is often used for insomnia under the class selective serotonin reuptake inhibitors. Side effects
may include oversedation, serotonin syndrome, dizziness and rarely priapism.
Antihistamines
Antihistamines are used by many as OTC sleep aids. These agents are effective for mild
insomnia. These drugs can cause psychomotor impairments and anticholinergic effects.
Tolerance may also develop with repeated use and evidence for their efficacy and safety is very
limited. (13 & 14)
1.5.7. LIFE STYLE MODIFICATION
➢ Maintain the scheduled timings for going bed and waking up

➢ Avoid caffeine containing drinks
➢ Avoid alcohol and nicotine at bed time
➢ Don’t use mobiles or any other electronics at night
➢ Make the room dark and quiet.
➢ Avoid heavy meals before going to bed
➢ Maintain regular exercise
➢ Doing yoga and meditations regularly will help to get good sleep
➢ Maintain
1.6. NEED OF THE STUDY
• Aging is a part of natural development processes in the life of any living being. As
for a social organism like Humans, aging is not just about physical, but has social and
psychological implications
• According to research mental illness is one of the major issues found in the elderly
population. India been the second most popular country in the world with around
1,27billion people, approx 20.5% of senior population are said to be suffering from
one or other the mental health problems, which means 17.13 million older adults are
suffering from mental health problems
• Demographics have presumed that by the year of 2050 more than 40% of people
would be elders in India, referring to the current scenario of the incidence rate by
2050, India will be dominated with mental illness
• Most of the elderly symptoms of mental illness are never been could and is considered
to be a common prospective seen in geriatric populations
• This study aims to find the mental health issues in society and their association with
socio demographic. The study further elucidates the need of education and early
monitoring of mental health to prevent further complications
AIMS AND OBJECTIVES
2.1 AIM
To identify the prevalence of the disease like dementia , depression and sleep disturbance
2.2 OBJECTIVES
Primary Objectives:
• To assess the mental illness by using MMSE scale and find its prevalence in the elder
population.
• To assess the depression by using MDI scale and find its prevalence in the elder
population
Secondary objectives:
• To assess the sleep disorder in the elderly population by using PSQI
• Dependency of elderly population in old age homes for daily activities.
REVIEW OF LITERATURE
3.0 REVIEW OF LITERATURE
1. A. Purna Singh, K Lokesh Kumar, C M Pavan Kumar Reddy conducted a study titled
‘Psychiatric morbidity in geriatric population in old age homes and community: a
comparative study’. The study was aimed at studying the association between
sociodemographics and psychiatric disorders and also to find its prevalence in geriatric
population. A total of 120 elderly people over 60 years were included among which 60
were from general population while other 60 were the one residing in old age homes of
khammam town, Andrapradesh. Out of 120 selected population 53 were males and 67
peoples were females. The study was conducted for a period of one month from June 1 to
June 30, 2011. Standard questionnaires including Mini Mental Status Examination
(MMSE), BPRS and ICD-10 diagnostic criteria were used to measure the severity and
prognosis of mental illness. The result showed that, in the age group of >80 44% were
found to be having one or more psychiatric disorders followed by 28.9% in 70-79 years
and 33.3% in 60-69 years. Among all these 18 out of 53 (33.9%) males and 23 of 67
(34.3%) females had one or the other psychiatric disorders. The prevalence of psychiatric
illness was found to be 38.3% and 30% in those living in community and in old age homes
respectively. Thus the prevalence of psychiatric illness was comparatively more among
the elderly population living in old age homes than in community. Among other
psychiatric disorder depression was found to be more common in people living in old age
homes with 25% prevalence than in general population with a percentage of 21.7%,
followed by anxiety (5.8%), substance abuse (4.2%) and organic disorder (0.9%) which is
dementia. This study emphasized the importance of care that has to be given to the geriatric
population.[19]
2. G Livingston, B Blizard Et al conducted a study to find the association between sleep

disturbance and depression in elderly people in London. People of age 65 years and above
were selected who were residing in London electoral ward (Gospal Oak) in the year 1987.
A shortened version of comprehensive assessment and referral evaluation schedule were
used. The shortened schedule is semi structured interview containing homogenous scales
which assess the organic brain syndrome, depression, subjects memory impairment,
somatic symptoms, activity limitations and sleep disturbances. The interview was
conducted in the year 1987-88 and again in 1990 by experienced clinicians using the
preselected scales. In 1987-88, 705 people aged 65years and over were interviewed and in
1990, 524 out of 705 were re-interviewed. In 1988, 33.3% (235) were reported with sleep
disturbances while in 1990 the number turned to be 43.1% (226). Out of all people with
sleep disorder, 35.7% in 1988 and 30.1% in 1990 were depressed. In addition, 24.7% and
26.9% in 1988 and 1990 respectively, were classified to be having subjective memory
impairment. The study found no association or relation between depressed sleep and
dementia; however it could elucidate the association between sleep and depression. The
sleep disturbances were seemed to lead to depression and thus sleep disturbance was best
predictor of new depression. Insomnia in elderly requires assessment and must be
accompanied by treatment of underlying disorder.[20]
3. Anil Kumar Mysore Nagaraj Et al conducted a cross sectional study titled ‘Psychiatric
morbidity among elderly people living in old age home and in the community: a
comparative study.’ A total of 100 subjects were included among which 50 were from
community and 50 from old age homes and each group included 25 male and 25 female
participants. Mini Mental Status Examination (MMSE) and Informants Questionnaire on
Cognitive Decline in Elderly (IQCODE) for cognitive deficits,Brief Psychiatric Rating
Scale (BPRS) for psychiatric morbidity and a Quality of life visual analogue scale for
satisfaction on elderly subject reports in his life were used. The study found that persons
in old age homes (38%) suffered depression more commonly than those in communityor
their homes(22%). Female sex, medical commodity, poor social economics status,
widowed state, other disabilities seemed to be risk factor for depression.Overall mental
illness is high in elderly irrespective of the setting in which they live. Moreover literacy
and living with life partner is associated with better mental health. However overall results
showed that staying in old age homes is as good asking in own homes.[21]
4. S Ranjan, A Bhattarai, M Dutta conducted a study on Prevalence of depression among

elderly people living in old age home in the capital city Kathmandu.The study included 150
elderly individuals and were interviewed who were residing in an old age home in
Kathmandu, Nepal. The study was conducted at Social Welfare Centre Elderly’s Home,
Pashupatinath at Gaushala, Kathmandu, which is the only elderly home run by government
of Nepal. Self designed questionnaire with 12 items was implemented to collect details on
socio demographic variables including age, sex, education, address, religion, marital
status, past occupation, reason for admission in old age homes, duration of stay,
psychological and financial support. Standard 30 items questionnaire, Modified Geriatric
Depression Scale (GDS) was administrator to access the prevalence and severity of
depression. Out of total population, 47.33% were accessed to be with depression, among
which 70.42% had mild depression, 29.58% with severe depressive disorder. Relating to
the socio-demographic variables an association between depression and history of
physical illness was found, while no significant association was found with other variables
like age, gender, education level, marital status, etc. thus depressive disorder was found to
be highly prevalent among the elderly population in the city of Kathmandu, Nepal.[22]
5. ArunaDubey, SeemaBhasin et al conducted a study in April and May 2008, titled ‘A study
of elderly living in old age home and within family setup in Jammu’. The study used 60
individuals aged 60 years and above of urban area of Jammu City out of which 30 were
from old age homes and other 30 from general community. The data was collected using
specially designed interview schedule and observation technique through house to house
survey for those residing in the family and data on institutionalized one were collected
from ‘Home for the Aged’, Amphala, Jammu. The study divided the interview into four
sections. The first section included the questions regarding General information of the
respondents, while second section includes question relating to general feelings of elderly
to happiness, loneliness, depression, security, insecurity and different moods. The third
section included questions regarding social relations of old age people with friends,
relatives and family members and 4th section regarding the personal interest and hobbies
of old age people. 63.3% of elderly women living in families were dependent upon their
family for support, 16.6% felt economically insecure 20%felt loneliness. In case of
institutionalized inmates 40% stated economic insecurity and loneliness as the reason for
negative perception. 13.3% of elderly women of both family and institutionalized wishes
to leave alone and independent. The study concluded that the general feeling of elderly
women living in the family had better position in scoring than those living in old age
homes.Study related this cause due to the fact that there is less social interaction with
family to express feeling in old age home that could lead to a life of loneliness, depressive
and a lover level of satisfaction with life. Further, certain efforts of government and
nongovernment organizations, religious institutions and individuals must be made to solve
for at least mitigate the problems being faced by aged people so that they can lead a
dignified and meaningful life.[23]
6. AnantlaxmiAnantaramGoud,NitinSuhasNikhade conducted a cross sectional study on

Prevalence of depression in older adults living in old age homes. The study was carried
out in two old age homes in Ahmednagar District, Maharashtra and 80 participants were
included in the age group of 60-85 years. Suitable data collection from was designed and
demographics were collected. Geriatric Depression Scale(GDS) questionnaires in the local
language (Marathi) were used to access the depressive state of the participants. Out of 80
participants, 29 were men and 59 were women. The prevalence of depression in older
adults living in THE old age home was found to be 53.75% among which, 27.5% cases
was mild depression followed by 21.25% moderate depression and 5% severe depression.
There was an increase in percentage of depression in women (58.82%) than in males
(44.83%). The study further divided the old age participants into young-old, mid-old and
old-old, where the prevalence of depression was found to be 47.92%, 57.69% and 83.33%
respectively. Further, significantly high depression was found in widow and
divorcee/separated old adults compared to the older adults living with spouse and never
married. The depression was seen to be gradually increasing with increasing age. All the
factors should be addressed properly to improve the quality of life of all older adults and
decrease burden on family, society and the nation.[24]
7. Dipesh Kumar D, Zalavaditya Et al conducted a cross sectional study titled‘Comparative

study of depression and associated risk factors among elderly inmates of of old age homes
and community of Rajhot: A Gujarati version of Geriatric Depression Scale- Short Form
(GDS-G). The study was carried out in 6 old age homes of Rajkot city and included all
residents of age 60 and above. A total of 88 to president were included from old age home
while twice the number was included from the community. Thus, a total of 176 elderly
residence where studied. A pretested semi structured interview schedule was used. Sleep
duration less than 7 hours a day was considered to be ‘Impaired sleep’. A 7 point Likert’s
scale was used to check the stage at which people would likely visit Hospital. A 15 item
GDS short form (GDS 15/GDS SF) was used to screen depression in elderly. Blood
Pressure classification was done according to JNC 7 criteria.A Gujarati version of GDS
15 was developed and validated before its application. The result of the study shows that,
the prevalence of depression is 46.6% among elderly of old age homes compared to the
32.2% in community. 46.7% of males and 46.6% of females were depressed in adult
elderly of old age homes, while in community the number was 24.7% in males and 37.9%
in females. In community, females where more depressed than the males, while in old age
home the number remains almost equal. The greater proportion of those having impaired
sleep was found to be depressed (62.9% in old age home and 81.1% in community). Thus
a direct proportionality between impaired sleep and depression was found. The presence
and severity of physical illness has also been played a major role in depression. The study
shows that level of depression increases with age in both setting. Feeling of loneliness,
being neglected by family members and financial abuse, have all being factors influencing
depression.[25]
8. SC Tiwari et al conducted a study on ‘Mental health problems among inhabitants of old

age homes: A preliminary study’. It was an exploratory study carried out in the old age
homes of Lucknow city. The study used Mini mental status examination (MMSE), Survey
psychiatric assessment schedule (SPAS), Mood disorder questionnaire (MDQ), Schedule
for clinical assessment in neuropsychiatry (SCAN) as the screening and assessment tool.
The study included 45 inhabitants and were categorized into three groups: young-old (60-
69 years), old-old (70 to 79 years) and oldest old (80 years and above). Further,
categorization based on sex was also made. A total of 20 males and 25 females were
participated in the study wherein, old-old and oldest old groups had females outnumbering
males but in young old group 35% were men while 20% were women. The study shows
that, overall prevalence of Mental Health illness is more in males (85%) than in females
(48%). 50% of the males were suffering from depression, while female had prevalence of
28%. In males subsequent disorder was found to be dementia (28%) followed by anxiety
(10%) and schizophrenia (5%), whereas, in females dementia was 4% and anxiety disorder
was 16%. Thus from the study, they have concluded that more than half of the inhabitants
were suffering from one or other mental health problems and the depression was the most
common among them.[26]
9. Michele Pistacchi et al conducted a study on ‘Sleep disturbance and cognitive disorder’.

The study aimed at describing the frequency and characteristics of sleep disorder in
persons with different types and degrees of dementia. The type of dementia that is
considered in the study was Alzheimer's disease (AD), vascular dementia (VaD), mixed
dementia, mild cognitive impairment (MCI), dementia with Lewy body (DLB),
Parkinson’s disease dementia (PDD) and frontotemporallobar degeneration (FTLD). The
types of sleep disturbance considered in the study was insomnia, excessive daytime
sleepiness (EDS), REM behaviour disorder (RBD), Restless leg syndrome (RLS) and
Nightmares.A total of 236 patients were enrolled in the study with different sub types of
dementia among which 78 were men and 158 were women and were followed up for a
period of 3 years. The subject or the caregivers were interviewed to obtain social
demographics of the participants including age, daily alcohol and coffee consumption,
current or former use of tobacco, marital status and education level. The diagnosis of
dementia was made using DSM-IV- TR criteria, while Alzheimer’s disease according to
National Institute of Neurological and Common Disorder and Stroke/Alzheimer’s Disease
and Related Disorder Association (NINC-ARDRA) and vascular dimension according to
National Institute of Neurological Disorder and Stroke and the Association Internationale
pour la Recherche et I’Enseignment en Neuroscience (NINDS-AIREN) criteria. Other
types were diagnosed according to the specific consensus guidelines. MMSE and GDS
scales where implemented to diagnose the severity of dementia and depression
respectively. The study found that 48% weere suffering from Alzheimer's disease followed
by 8.5% with vascular dementia and 9.7% with mixed dimension, and 11.4%MCI, 5.1%
DLB, 8.1% PDD and 4.2% FTLD. The prevalence of anxiety was 82.4% ,insomnia 76.5%
and depression found to be 64.7%. The anxiety and depression were often associated with
insomnia and pathologic conditions. A high prevalence of depressive symptoms was found
to be common in pre-clinical phases of dementia. All the 236 patients complained one or
more sleep disturbance and thus could state that the sleep disorder might represent a
causative factor of cognitive decline in older adults. AD and MCI had almost same
frequency of geriatric sleep disturbance. LBD and PDD had highest frequency of EDS,
RLS and Nightmares. Study reported that the sleep disturbance can precede for many years
the onset of PDD and LBD. Thus the study concluded that the sleep disturbance was
related to dementia and hence careful clinical evaluation of sleep disorders should be
performed routinely in clinical setting of patients with cognitive decline.[27]
10. Kamlesh Sharma, Anmol Gupta, Ravi C Sharma et al conducted a cross sectional study
on Prevalence and risk factors for depression in elderly North Indians. The study was
conducted from July 2014 to June 2015 and included 800 subjects of elderly population
aged 60 years and above residing in Shimla, the capital city of Himachal Pradesh. Among
the 800 subjects selected, 400 were enrolled from urban areas while the rest 400 from rural
areas. Pretested standard questionnaire called Geriatric Depression Scale-30 (GDS-30)
was administered to evaluate the depression. Those who were screened positive using
GDS 30 scale were further evaluated using Hamilton Depression Rating Scale (HDRS) to
validate the diagnosis. Further, the modified BG Prasad’s classification was used to access
the social economic status of the subject. Data Collection form was designed to collect the
social demographic details. Behavioral factors accessed were alcohol consumption,
tobacco usage, smoking and activities of daily life. Based on preliminary screening by
GDS, prevalence of depression was found to be 10.3% and finally based on Hamilton
rating scale 76 (9.5%) were found to be suffering from depression in which 6.4% had mild
depression followed by 2% and 1.1% of moderate and severe depression respectively.
Associating with socio-demographics, elderly of urban areas (7.3%) and people with low
income (17.9%) were significantly more depressed. Elderly tobacco users had more
depression of 19.2 percent compared to their counterparts. Thus the study found that the
tobacco use can be a risk factor for depression, Nicotine present in the tobacco usage
damages certain pathways in the brain that regulate mood. Hence this study shows that
one tenth of elderly residing in Shimla district of Himachal Pradesh are suffering from
depression. Trained geriatric care professionals should be appointed who can regularly
screen for depression and offer free counseling.[28]
11. David P Joyce, Marjolane Limbos conducted a study on conducted a study on

Identification of cognitive impairment and mental illness in elderly homeless men. The
object of the study was to describe the occurrence of mental health problem and cognitive
impairment in a group of elderly homeless men and to demonstrate how can you can
examination and screening base used in the center might be a full form in identifying
mental illness and are beginning to the study was conducted in a community. The Study
was conducted in a community based shelter in Tornotp, Ont between September 2002
and August 2004. The 15 item Geriatric Depression Scale (GDS-15) and Folstein Mini
mental status examination (MMSE) was administered to the participants. A total of 49
male participants of 55 years of age or older were included and the data was collected by
face to face interview and from the medical records if available.The average period of
homelessness of the participants was 8.8 years. By using GDS 15 scale the prevalence of
depression was found to be 31.0% among which 20.7% had Mild depression and 10.3%
had severe depression. Evaluating the cognitive impairment one participant had a
diagnosis of dementia before admission to old age home, while in 6 months of admission
additional seven participants (14.3%) had been diagnosed with dementia. Using MMSE
scale 37.9% with cognitive impairment among which 20.7% had mild cognitive
impairment and 17.2% has dementia. Thus the study had found that a large proportion of
participants with mental illness were unrecognized. 37% of participants had previously
unrecognised mental illness. Hence use of simple screening tests must be made so that
most of the mental illness would be uncovered or can be recognised prior to its severity.[29]
12. Juliana Dias de Lima et al conducted a cross sectional study on ‘The co-morbidity
conditions and poly pharmacy in elderly patients with mental illness in a middle income
country’. In the study, cognitively healthy elders from community and patients with the
diagnosis of major depressive disorder, Mild cognitive impairment and Alzheimer's
disease from the Centre of Alzheimer's Disease of the Psychiatry Institute of Federal
University of Rio de Janeiro were recruited. The screening for mental disorder was done
according to the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV) and
Peterson Criteria for Dementia. The study included the total of 212 subjects who had given
the consent to be included in the study. All the democracy details where collected and the
number of daily medications used and cardio metabolic diseases such as hypertension,
diabetes and dislipedimia were assessed. The Charlson Comorbidity Index was calculated
according to reported commodities. Polypharmacy is considered only upon usage of 4 or
more medications after excluding supplements and vitamins. Out of all 212 subjects
included, 102 were cognitively healthy individuals, followed by 30 MDD, 26 MCI and 54
AD. After statistical analysis the study found that dementia and MCI patients had higher
number of co-morbidities compared to one with depressive disorder and cognitively
healthy people. The study found that older people who live in MIC(middle income
countries) are more vulnerable to developing chronic mental condition even with no pre
existing mental illness. Additionally ADDand MDD patients were more susceptible to
poly pharmacy, multi morbidity and poly pharmacy conditions are commonly observed in
the general elderly population and found 22 times risk of polypharmacy in dementia
patient 10 times for mild cognitive impairment (MCI) and 14 times for elderly with
depression.[30]
13.
KhadervaliNagoor, SurendraBabuDarivemala et al conducted a community based study
on ‘Prevalence of mental illness and their association with socio demographic factors in
the rural geriatric population in Chittoor, Andhra Pradesh, India’. A pre designed semi
structure question was used to collect data including social demographics and
psychological factors. Folsteinsmini mental status examination (MMSE) scale was
implemented in the study to assess dementia or cognitive impairment and geriatric
depression scale (GDS 15) to accessdepressive state additionally Barathel index was used
to access the activities of daily living.A total of 415 elderly persons where included in the
study among which199 were males and 216 females. The subjects were further group
based on age, education, marital status, type of family, financial status and religion 55.6%
(266) of the participants had normal sleep while 45.5% (189) of them had disturbed sleep.
The prevalence of mental illness suffering with one or other type was 52.2% (212) of
which males was 19.5% (81) and female 32.7% (136). The prevalence of depression was
27.7% (115) among which 17.8% (74) were female and 9.8% (41) males, followed by
7.2% anxietydisorder and 14.9% dementia, with respect to cognitive impairment 27.2%
mild impaired, 12.6% with moderate impairment and 7.9% severely impaired as per
MMSE. Thus from the result the study concluded that the participants with the age more
than 70, female, illiterate, poverty, living in joint family, poor and with unfair relationship
with family members, financially dependent were majorly affected with mental illness.[31]
14. Shammi Akbar, S.C Tiwari et al conducted a study on the prevalence of ‘Psychiatric illness
among residence of old age homes in Northern India’. The study included a total of 306
patients participants who are the residents of oldage home in the district of
Bhuville,Lucknow, Varanasi, Dehradun and Haridwar among which 98 were males and
208 were females of age 60 years and above.A predesigned semi structured data collection
form was used Hindi Mental Status Examination (HMSE) was administered to screen
cognitive impairment, Survey Psychiatric Assessment Schedule (SPAS) for psychiatric
illness and the participant screen ‘in’ on SPAS were further evaluated through Schedules
for Clinical Assessment in Neuro-psychiatry (SCAN) based clinical interview for specific
diagnosis as per International Classification of Disease (ICD 10) Diagnostic criteria for
Research. The participants were group based on sex, education, age, occupation for
comparison between the results. It was shown that overall prevalence of PI is 43%, among
which female were at 51% and males at 21%. Depression was the most common disorder
with their prevalence of 53.7% followed by dementia (21.6%) and least prevalent being
BDHD (0.7%). The prevalence of anxiety in the study was 94.6% among institutionalised
elderly persons when compared with 92.6% among those living in the community. Thus
56% of the inmates of old age home had no PI, while inmates suffering from PI were 43%.
Depression was the most common disorder in older adults and female had more prevalence
than male in elderly adults[32]
15. S Shaji, Srija Bose et al conducted a study on,‘Prevalence of dementia in Urban population
in Kerala, India’. The study was conducted in Ernakulam constituency part of the city of
Cochin. The study was conducted by door to door survey to identify residence of 65 years
and above. The study administered MSE screening test for Cognitive Impairment,
CAMDEX Section B(section B of Cambridge Mental Disorder of the Elderly
Examination) was used for cognitive examination, Section H of CAMDEX was used
through which individual’s history and fundamental ability is obtained from a relative or
caregiver. Socio Economics Status Scale- Urban was used to categorise the population in
to different social economic groups. The study was conducted in 3 phases, during Phase 1
all the participants were screen with MMSE and those who scored 23 or above on MMSE
Phase 2 evaluation with CAMDEX Section B was done to confirm the impairment. For
each individual or relative, interview with CAMDEX Section H was done to confirm the
history of deterioration on social and occupation functioning or activities of daily living.
In Phase 3, impairments were confirmed by CAMDEX Section B and H for evaluation
according to DSM-IV Criteria. The Phase 3 also included detailed medical history,
physical and neurological examination. The survey identified 2031 elderly people aged 65
years and above of which, 1934 people were screened with Vernacular Adaptation of
MMSE. Out of 1934 subjects included, 327 scored at or above cut off score of 23. After
different phases of evaluation prevalence rate of dementia was found to be 33.6 per 1000.
Categorization of 56 cases of dementia by ICD-10 showed that 30 (54%) were due to
alzheimers disease 22 (39%)due to vascular disease and 4 (7%) due to other causes
including tuberculous infection, head trauma and cerebrltumors. Thus AD was found to
have a prevalence rate of 15.5 per 1000 and ratio of 1:13 (male to female). One of the
findings in the study is that prevalence of dementia increases proportionately with age.
Family history of dementia was a risk factor for Alzheimer's disease and history of
hypertension is risk factor for VaD. AD was the most common cause of dementia followed
by VaD. Identification of risk factors such as hypertension can be done as the intervention
to reduce the total prevalence of dementia disorder in the community.[33]
MATERIALS AND METHODS
4.0. MATERIALS AND METHODS
4.1. Study design: It is a cross sectional observational study.
4.2. Study period: This study was conducted over a period of six months from March 2022 to
August 2022.
4.3. Site of study: Old age homes of urban areas of Mysore.
4.4. Study population: About 187 subjects were included in this study
4.5. Sources of data: All the relevant and necessary data were collected by interviewing the
participants. Additionally data will be collected from medical and medication records.
4.6. Inclusion Criteria:

• older adults aged 50 years and above of both gender residing in OAHs and able to
communicate
• Staying in OAHs for 6 months or more
• Able to understand comprehends and reply to questions
• Giving written informed consent
4.7. Exclusion Criteria:
• Residents who decline/not interested to participate in the study

• People who are not cooperative
• People who are not able to talk or respond (even caretaker do not respond )
4.8. Study tools: The study procedure involves the use of some forms for data collection,
documentation, and analysis of the data.
Informed Consent Form [Annexure 12.1]: An informed consent form was designed
incorporating all the vital information about the study. The information consent form was
prepared in English and the same was also translated into the local language (Kannada) and
the participant was explained clearly about the study. The consent was obtained from
patients who volunteered for the study and those who fulfilled the study criteria. The
prepared information consent form consists of study objectives and advantages for the
patient being a part of the study, with a provision for obtaining the patients’ signature. Those
who were illiterate, the study was discussed with them, and in case of those who cannot give
the consent, the study was discussed with caretaker and consent was obtained from them.
Patient Data collection Form [Annexure 12.2]: It includes the demographics of the
patients such as age, literacy, occupation, socio-economic status and also consists of past
medical history, past medication history, current medication, relevant laboratory details.
MMSE Questionnaire [Annexure 12.3]: It is a 30-point questionnaire that consists of 11

questions that is used to estimate the severity of cognitive impairment for dementia. It
assesses the different subset of cognitive status including attention, language, memory,
orientation. This questionnaire is converted to the local language (Kannada) and attested
by the reliable authority.
MDI Questionnaire [Annexure 12.4]: Major depression inventory (MDI) is a self-report

mood questionnaire developed by WHO. Instrument was conducted by prof. per bach, a
psychiatrist in Denmark.
The MDI differs from other self-report inventories, such as Beck Depression Inventory, as
it is able to generate an ICD-10 (or) DSM-IV diagnosis of clinical depression in addition to
an estimate of symptom severity.
PSQI Questionnaire [Annexure 12.5]: The Pittsburgh sleep quality index is an effective
instrument used to measure the quality and pattern of sleep-in adults. The question is related
to the usual sleep habits during past month only.
It differentiates ‘poor’ and ‘good’ sleep quality by measuring several areas like Subjective
sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use
of sleep medication, daytime dysfunction over the last month.
Barthel Index [Annexure 12.6]: It is an ordinal scale used to measure the performance in
daily living activities. 10 HDL and mobility related characteristics are rated, with a higher
score indicating a greater capacity for independence.
4.9. Methods:
Study Procedure: The study procedures were conducted according to the following steps:
STEP 1: All the documents which used in the study were translated to the local language
(kannada).
STEP2: Consent was obtained from the patient through informed consent form in English
and Kannada language.
STEP 3: Collected data regarding the demographics of the patient (Name, Age, Sex etc.)
and the data regarding prescribed drugs, indication and their route of administration.
STEP 4: Assessed the mental status of the participants by asking questionnaires.
STEP 5: Analysed the data to assess the mental illness including dementia, depressive state,
sleep behaviour among participants.
STEP 6: Analysed the extent of dependency among elderly by using Barthel index.
STEP 7: The obtained data was subjected for suitable statistical method.
Collection of demographics: The Informed Consent Form and the Information to participant
sheet (annexure 11.1.A, 11.1.B, 11.2.A, 11.2.B) were initially given to the patient and our
objective was explained to the patient prior to each interview with a patient. After approval and
signature from the patient, the study was proceeded to collect the demographic details of the
patient (Name, Age, Sex, occupation, etc.) and data regarding past and present medical history
are collected according to the questionnaire and data entry forms.
Scoring of MMSE questionnaire:

The MMSE questionnaire consist of 11 questions which was divided into different parts,
Orientation – ask the patient for Date, month and year specifically. Participant will receive
1 point for each correct response.
Registration– 3 unrelated objects will be named clearly and slowly. After all objects been
named, ask the person to repeat or name the objects. A score will be given on the basis of
identification.
Attention and Calculation – person will be asked to begin with 100 and count backwards by
subtracting 3 and stopped after 5 subtractions. One score for a correct answer is given. If he
cannot calculate ask him to spell any word backward.
Recall – Ask the participant to recall the 3 objects previously asked and score accordingly.
Language – for testing skills in naming objects. Some objects will be slowed and asked them
to name.
Repetition – he/she will be asked to repeat a sentence.
Complex and stage demand – a piece of paper will be given to the participant and asked him
to drop and pick up the same.
Reading – a large letter of command will be printed on paper and he/she will be asked to
read and do it as it says.
Writing – blank paper will be provided to participant to write sentence of his/her own.
Copying – on a paper, he/she will be asked to draw a pentagon that is showed to him/her.
The total overall score is given as follows:
<10 – Severe
10-20 – moderate
20-25 – mild
>25 – normal
MDI questionnaire scoring:
The major depression inventory is used to assess the depressive state of a person. The items
1-10 are summed up to give a total score for depression severity. The theoretical score range
is from 0 to 50.
No or doubtful depression: 0-20
Mild depression: 21-25
Moderate depression: 26-30
Severe depression: 31-50
PSQI Scoring:
It contains 19 self-rated questions and 5 questions rated by bed partner or roommate. Only
self-rated questions are included in the scoring. The 19 self-rated questions are combined to
form seen ‘component’ scores, each of which has a range of 0-3 points. In all cases, a score
of 0 indicates no difficulty, while a score of 3 indicates severe difficulty. The seven
component scores are then added to yield one ‘global’ score, with a range of 0-21 points, 0
indicating no difficulty and 21 indicating severe difficulty in all areas.
Barthel Index Scoring:
The scale contains 10 daily activities and scoring is made according to the capability of an
individual to conduct activities oneself. The scores of all activities are summed to get total
score. Total possible score is 0-100.
Highly Dependent: 0-25
Partially Dependent – 26-50
Minimally Dependent – 51-75
Independent – 76-100
4.10. Statistical Analysis:

Statistical Package for the Social Sciences (SPSS) version 25.0 for Windows was used
in the data analysis for this study. The quantitative variables were described using
their number, mean. Microsoft Word and Excel have been used to generate Graphs,
Table, Chi Square Test, Mean and P-value were used in our study.
RESULTS
5.0.RESULT
5.1 GENERAL DEMOGRAPHICS OF STUDY SUBJECTS
The study examined a total of 187subjects among which 45.99% are Males (n=86) and 54.01%
females (n=101). All the subjects are aged 50 years and above while majority of them are from
age group of 71-80years [n=50, 26.73%], followed by age groups 61-70 years [n=42, 22.45%],
81-90 years [n=41, 21.92%], 50-60 years [n=41, 21.92%] and the least >91 years [n=13,
6.95%]. 64.7% [n=121] are literate among which 32.23% [n=39] are primary, 31.4% [n=38]
high school, 7.4% [n=9] PUC, 17.35% [n=21] Degree and 11.57% [n=14] had Master degree.
Data suggested that 53.47% [n=100] subjects are Non Vegetarians or had mixed diet and
46.52% [n=87] are Vegetarians. A total of 166 subjects are married while 21 are unmarried.
Data shows that 132 subjects had a past medical history of one or more co morbidities that
includes Hypertension [n=43], Diabetes [n=22], Diabetes and hypertension [n=42] and others
[n=61]. 55 from the total subjects are free from co morbidities. The data also shows that 16.04%
had history of smoking and 12.83% with history of alcoholism.
Table 6 : Demographic Distribution of Study Population

DEMOGRAPHICS NUMBER OF SUBJECTS (%)
Age Group 50-60 years 41 (21.92%)
61-70 years 42 (22.42%)
71-80 years 50 (26.73%)
81-90 years 41 (21.73%)
> 91 years 13 (6.95%)
Gender Male 86 (45.99%)
Female 101 (54.01%)
Literacy Illiterate 121 (64.7%)
Primary 39 (20.85%)
High School 38 (20.32%)
PUC 9 (4.81%)
Degree 21 (11.22%)
Master Degree 14 (7.48%)
Diet Vegetarians 87 (46.52%)
Non- Vegetarians (Mixed) 100 (53.47%)
Marital Status Married 166 (88.77%)
Unmarried 21 (11.23%)
Occupation Tailoring 8 (4.27%)
Farmer 13 (6.95%)
Teaching 14 (7.48%)
Office 18 (9.62%)
Daily Labourer 35 (18.71%)
House Wife 71 (37.96%)
Others 18 (9.62%)
Unemployment 10 (5.34%)
Smoking History Present 30 (16.04%)
Absent 157 (83.95%)
Alcoholic History Present 24 (12.83%)
Absent 163 (87.16%)
Co morbidities Present 132 (70.58%)
Absent 55 (29.41%)
5.2. DEMENTIA
5.2.1DEMOGRAPHICS OF SUBJECTS WITH DEMENTIA
In our study out of 187 people we found that 74 [39.57%] peoples are having the symptoms of
the Dementia, in which majority are females [n=47, 63.51%] than males [n=27, 36.48%]. In
this study we found that the age group of the people between 71-80years were majorly affected
from Dementia [n=25, 33.78%] than 50-60 years [n=12, 16.21%], 61-70 years [n=15, 20.27%],
81-90 years [n=16, 21.62%] and >91 years [n=6, 8.10%]. We categorized the people with the
symptoms of dementia into three categories, mild [n=23, 31.08%], moderate [n=27, 36.48%]
and severe [n=24, 36.48%].
SEVERITY
Out of 74 subjects, based on severity we classified dementia in 3 categories that is mild,

moderate and severe. The people with mild is about 23 [31.08%], moderate 27 [36.48%] and
severe 24 [32.43%].
Table 7 : Distribution of Dementia Patients based on Severity
Severity Number of Subjects (%)
Mild Cognitive Impairment 23 (31.08%)
Moderate Cognitive Impairment 27 (36.48%)
Severe Cognitive Impairment 24 (32.43%)
Severity of Dementia
27
26
25
27
24
23 24
23
22
21
mild moderate sever
Fig 6 : DISTRIBUTION OF SEVERITY OF DEMENTIA WITHIN STUDY POPULATION
AGE GROUP
The elderly people majorly affected are seen in the age group of 71-80y (n =25, 33.78%) when
compared to the other age groups in our study, followed by the group 81-90y (n=16, 33.78%),
61-70y (n= 15, 20.27%) and 50-60y (n =12, 16.21%). The least affected people are seen in age
group of above 91y (n=6, 8.10%).
Table 8 : Details of Age Distribution within Study Population of Dementia
Age Group Number of Subjects (%)
50-60 Years 12 (16.21%)
61-70 years 15 (20.27%)
71-80 years 25(33.78%)
81-90 years 16 (21.62%)
91-100 years 6 (8.10%)
Dementia Among Age Groups
25
20
15
25
10 16
15
12
5 6
0
50-60 61-70 71-80 81-90 91-100
Fig 7 : AGE DISTRIBUTION WITHIN STUDY POPULATION OF DEMENTIA
EDUCATION
Our study recognized that literates are more prone to the dementia than the literate. Out of 74
people, we have seen that illiterates are majorly affected (n=36, 46.64 %), when compared to
literates including Primary Education (n=11, 14.86%), High school (n=16, 21.62%), Degree
(n=5, 6.75 %) and Masters (n=5, 6.75%).
Table 9: Details of Literacy Distribution Within the Study Population of Dementia
Education Number of Subjects (%)
Illiterate 36(48.64%)
Primary 11 (14.86%)
High school 16(21.62%)
PUC 1(1.35%)
Degree 1(6.75%)
Master degree 5 (6.75%)
Literacy Distribution Within
Dementia
0
primary
11
High school
36 Degree
16
masters
illiterate
5
5
Fig 8 : LITERACY DISTRIBUTION WITHIN STUDY POPULATION OF DEMENTIA
COMORBIDITIES
The people who are presented with complaints of Hypertension (n=34, 45.94%) are majorly
seen to be having symptoms of Dementia than the people affected with type -2 diabetic mellitus
(n=22, 29.72%) and other comorbidities 37.83% (n=28).
Table 10: Distribution of HTN and DM within Study Population of Dementia
Comorbidities Number of Subjects (%)
HTN 34(40.94%)
DM 22(29.72%)
Others 28(37.83%)
Comorbidities and Dementia
35
30
25
20 34
15 28
22
10
5
0
Hypertension Diabetis Others
Fig 9 :DISTRIBUTION OF STUDY POPULATION WITHIN DEMENTIA WITH HTN AND DM
GENDER
The study shows that females are majorly affected than the males. Females are about 63.51%
(n=47) affected than males (n=27, 36.48%).
Table 11: Details of Gender Distribution within Study Population of Dementia
Gender Number of Subjects (%)
Male 27(36.48%)
Female 47(63.51%)
Dementia within Gender
45
40
35
30
25 42
20
15 22
10
5
0
male female
Fig 10 : GENDER DITRIBUTION WITHIN STUDY POPULATION OF DEMNTIA
MEDICATION
Outof 74 subject with dementia, we found that around 22% subjects were taking medication
while the rest 77% of subjects were not on medication
Table 12 : Details of Study Population of Dementia Considering Treatment
Subject – Treatment Number of Subjects (%)
On medication 17(22.97%)
Off medication 57 (77.02%)
OCCUPATION
The study population with dementia are categorized on the basis of occupation in which,
47.29% were House wife, 12.16% were Daily Workers, 6.75% were Farmers, Teaching and
Tailoring are found to be 4.05%, around 14.86% subjects were working in Other Department
and 10.81% were Unemployed.
Table 13 : Details of Distribution of Study Population within Dementia Based on

Occupation
Details Number of Subjects (%)
House wife- 35(47.29%)
Daily workers 9(12.16%)
Teaching 3(4.05%)
Tailoring 3(4.05%)
Farmer 5(6.75%)
Others 11(14.86%)
Unemployment 8(10.81%)
DIET
The study states that both mixed and vegetarians are equally affected with the dementia, found
to be 50%which shows that diet is not an major risk factors for developing dementia.
Table 14 : Details of Diet Distribution within Study Population of Dementia
Diet Number of Subjects (%)
Mixed 37(50.00%)
Vegetarians 37(50.00%)
5.2.2. RISK FACTOR ANALYSIS OF DEMENTIA
The probable risk factors for dementia such as Gender, Age, education and comorbidities were
considered for analysis, the following results were found
Table 15 : Details of Various Factors Influencing Progression of Dementia

Factors Chi-square value p-value
Gender Female(n=47)
Male (n=27) 4.4559 0.03477525*
Age Above 70 (n=27)

Below 70 (n=47) 3.0947 0.078517
Education Educated (n=38)

Uneducated (n=36) 9.5584 0.0019773*
Comorbidities Present (n=42 )
Absent (n= 32) 0.0102 0.916899
Note:-statistically significance level: p value ≤ 0.05

(*) indicates results are significant
5.3. DEMENTIA AND DEPENDENCY
The study population with Dementia and Dependency were compared and the results were
shown in the following table
Table 16 : Details of Study Population of Dementia with respect to Dependency

Dependency Status Total number of people (%)
Highly dependent (0-25) 13(17.56%)
Partially dependent (26-50) 12(16.21%)
Minimally dependent (51-75) 5(6.75%)
Independent (76-100) 44(59.45%)
Dementia and Dependency
76-100 44
51-75 5
26-50 12
0-25 13
0 10 20 30 40 50
Fig 11 : DISTRIBUTION OF STUDY POPULATION OF DEMENTIA WITH RESPECT TO DEPENDENCY
5.4. DEPRESSION
5.4.1.DEMOGRAPHICS OF DEPRESSIVE POPULATION
Out of 187 subjects, n=52 [27.80%] are affected with depressive disorder, out of which
majority [n=27, 51.92%] are affected with mild depression followed by moderate [n=19,
36.53%] and severe depressive disorder [n=6, 11.53%]. Females are predominantly affected
[57.69%, n=30] than males [42.30%,n=22]. Data shows that n=13 [25%] of the depressive
subjects are from age group of 50-60y, n=12 [23.07%] from 61-70 years, n=19 [36.53%] from
71-80years, n=7 [13.46%] from 81-90 years and n=1 [1.92%] from >91 years. The data shows
that 50% [n=26] of the patients are literate having acquired with minimum of primary
education. Further data shows that majority [n=38, 73.07%] subjects are having history of one
or more co-morbidities while rest [n=14, 26.07%] are free from co-morbidities. Majority of
subjects [n=41, 78.84%] are married and are following a mixed diet [n=37, 71.15%]. 7 out of
52 subjects [13.46%] had a history of alcoholism and 6 [11.53%] had history of smoking. No
subjects had present habit of smoking and alcoholism.
Table 17 : Distribution of Depressive Patients Based on Severity
Severity Number Of Subjects (%)
Mild 27 (51.92%)
Moderate 19(36.53%)
Severe 6,(11.53%)
Severity of Depression
Severe
11%
Mild
Mild Moderate
52%
Moderate Severe
37%
Fig 12 : DETAILS OF SEVERITY OF DEPRESSION WITHIN STUDY POPULATION
AGE DISTRIBUTION
We have seen that age group of 71-80 years are majorly affected with depression [n=19,
36.53%], followed by 50-60 years [n=13, 25%], 61-70 years [n=12, 23.07%,], 81-90 years
[n=7, 13.46%] and >91 years [n=1, 1.92%].
Table 18 : Details of Categorization of Study Population within Depression Based on Age
Age Group Number of Subjects (%)
50-60y 13 (25%)
61-70y 12 (23.07%)
71-80y 19 (36.53%)
81-90y 7 (13.46%)
>91y 1 (1.92%)
Depression among age groups
20
18
16
14
12
10 19
8
13 12
6
4 7
2
1
0
50-60 61-70 71-80 81-90 >91
Fig 13 : AGE DISTRIBUTION WITHIN STUDY POPULATION OF DEPRESSION
GENDER
Out of 52 subjects Females are seen to be majorly [n=30, 57.69%] affected with depression
when compared to males [n=22, 42.30%].
Table 19 : Details of Gender Distribution of Depressive Subjects
Gender Number of Subjects (%)
Male 22 (42.30%)
Female 30 (57.69%)
Depression within Gender
30
25
20
30
15 22
10
5
0
Male Female
Fig 14 : DISTRIBUTION OF DEPRESSION WITHIN GENDER
DIET
Out of 52subjects, the data shows that people with mixed diet had significantly higher
proportion [n=37, 71.15%] of depressive disorder than vegetarians [n=15, 28.84%].
Table 20 – Details of Dietary Distribution Within Depressive Subjects
Diet Number of Subjects (%)
Vegetarians 15 (28.84%)
Mixed diet 37 (71.15%)
Depression and Diet
80.00%
70.00%
60.00%
50.00%
40.00% 71.15%
30.00%
20.00% 28.84%
10.00%
0.00%
Veg Non veg
Fig 15 : DIETARY DISTRIBUTION WITHIN STUDY POPULATION OF DEPRESSION
COMORBIDITIES
The study has shown that 46.15% [n=24] of the depressive subjects had HTN while
42.30%[n=22] are affected with DM.
Deoression with Comorbidities
24
23.5
23
24
22.5
22
22
21.5
21
HTN DM
Fig 16 : DISTRIBUTION OF HTN AND DM WITHIN DEPRSSIVE STUDY POPULATION
5.4.2.RISK FACTOR ANALYSIS OF DEPRESSION
The probable risk factor for developing depression such Gender, Diet, Age were considered
for the risk factor analysis and results are shown in following table
Table 21 : Details of Various Factors Influencing Depression.

Factors Chi-square value P value
Gender
Male (n=30) 0.3914 0.53058267
Female (n=22)
Diet
Mixed (n=37) 9.0532 0.0026217*
Veg (n=15)
Age
Below 70 (n=25) 0.395 0.52921248
Above 70 (n=27)
Note:- statistically significance level P ≤ 0.05
5.5. PROPORTION OF POPULATION WITH DEMENTIA AND DEPRESSION
Out of 74 dementia subjects, 37 [n=37, 71.15%] are suffering from depression among which
females are majorly affected [n=25,67.57%] than males [n=12,32.43%]. The data shows that
17.30% [n=9, 17.30%] of the depressive patients had Mild cognitive impairment, 21.15%
[n=11, 21.15%] moderate impairment and 32.69% [n=17, 32.69%] are with severe cognitive
impairment.
Table 22 : Proportion of Population with Dementia and Depression

FACTORS Number (%)
Severity Mild Impairment 9 (17.30%)
Moderate Impairment 11 (21.15%)
Severe Impairment 17 (32.69%)
No Impairment 15 (28.84%)
Gender Male 12 (32.43%)
Female 25 (67.57%)
Dementia and Depression
17.30%
28.84%
Mild Impairment
21.15% Moderate Impairment
Severe Impairment
32.69%
No Impairment
Fig 17 : PROPORTION OF POPULATION WITH DEMENTIA AND DEPRESSION
5.6. SLEEP DISORDER
5.6.1 DEMOGRAPHICS
We have checked the quality of the sleep by using the PSQI scale in around 187 subjects, out
of this we found that, n=64 [34.22%] has disturbed sleep. We found that the educated has
major sleep disturbance 60.31% (n=38, 60.31%) than the uneducated 41.26% (n=26, 41.26%).
AGE DISTRIBUTION
The study population with disturbed sleep are categorized on age groups like 50-60y (17.18%),
61-70y (29.68%), 71-80y (28.12%), 81-90y (21.87%) and 91-100y (3.12%)
Table 23 : Details of Age Distribution of Study Population with Disturbed Sleep
Age Grops Number of Subjects (%)
50-60 Years 11 (17.18%)
61-70 years 19 (29.68%)
71-80 years 18 (28.12%)
81-90 years 14(21.87%)
91-100 years 2 (3.12%)
DIET
The subjects with 51.56% of veg diet and 48.43% of mixed diet were having the disturbed
sleep out of 64 study population
Table 24 : Details of Dietary Distribution of Study Population with Disturbed Sleep
Diet Number
Mixed 31 (48.43%)
Only Veg 33 (51.56%)
EDUCATION
Out of 64 subjects who had disturbed sleep, educated are seen to be having more sleep
disturbance than the uneducated. The educated includes, primary [n=11, 12 .69%], high school
[n=11, 17.46%], puc [n=3, 4.76%], degree [n=7, 11.11%] and master degree [n=9, 14.28%],
while uneducated is seen to be n=26 [41.26%].
Table 25 : Details of Literacy Distribution of Study Population With Disturbed Sleep
Education Number of subjects (%)
Illiterate 26 (40.62%)
Primary 8 (12.5%)
High school 11 (17.18%)
PUC 3 (4.68%)
Degree 7 (10.93%)
Master degree 9 (14.06%)
Education
12.5%
primary
40.62% 17.18% high school
puc
degree
4.68% master degree

illiterate
10.93%
14.06%
Fig 18 : LITERACY DISTRIBUTION OF STUDY POPULATION WITH DISTURBED SLEEP
GENDER
The study finds that the females have much disturbed sleep pattern [n=64, 65.62%], when
compared to males [n=22, 34.37%]
Table 26 – Gender Distribution of Study Population with Disturbed Sleep
GENDER Number Of Subjects (%)
Females 42 (65.62%)
Males 22 (34.37%)
Sleep Disturbance Among Gender
45
40
35
30
25 42
20
15 22
10
5
0
male female
Fig 19 : GENDER DISTRIBUTION OF STUDY POPULATION WITH DISTURBED SLEEP
COMORBIDITIES
About 54.68% of hypertensive and 31.25% of diabetic subjects are having disturbed sleep out
of 64 study population
Table 27 : Details of Distribution of HTN and DM within Study Population with Disturbed
Sleep
Comorbidities Number of Subjects (%)
HTN 35 (54.68%)
DM 20 (31.25%)
Sleep Disturbance and Comorbidities
absent
23%
present
present absent
77%
Fig 20 : DISTRIBUTION OF HTN AND DM WITHIN STUDY POPULATION WITH DISTURBED SLEEP
5.6.2 PROPORTION OF POPULATION WITH ABNORMAL SLEEP PATTERN AND

DEPRESSION
The data shows that 29 out of 64 subjects disturbed depression [45.31%]. Data shows that out
of 29 subjects, majority are females [n=18, 62.06%] than males [n=11, 37.93%].
Table 28 : Proportion of Population with Abnormal Sleep and Depression

Variables Number of subjects with both
depression and disturbed sleep(%)
Depression Present 29(45.31%)
Absent 35(54.68%)
Gender Male 11(37.93%)
Female 18(62.06%)
Disturbed sleep with and without depression
30
25
20
35
15
23
10
Fig21 : PROPORTION OF POPULATION WITH ABNORMAL SLEEP AND DEPRESSION
5.6.3. RISK FACTOR ANALYSIS OF SLEEP DISORDER
The probable risk factor such as Education, Gender, Comorbidities, Depression are considered
for risk factor analysis and results are given below
Table 29 : Details of Various Factors Influencing Sleep Disorder

Factor Chi-square value P value
Education
Uneducated (n=26) 1.2127 0.2706113
Educated (n=38)
Gender
Male (n=22) 1.2127 0.0214832*
Female (n=42)
Comorbidities
Present (n=40) 1.1046 0.293082
Absent (n=24)
Depression
Present (n=29) 14.3 0.000114*
Absent (n=35)
Note:-Statistically significance level P ≤ 0.05
5.7 DEPENDANCY
The subjects with dependency and their severity in the overall study population are given in
below table
Table 30 : Details of Overall Dependency of Study Population

Dependency Total number of people (%)
Highly dependent (0-25) 15(8.02%)
Probably dependent (26-50) 19(10.16%)
Minimally dependent (51-75) 13(6.95%)
Independent (76-100) 140(74.86%)
Severity of Dependency
75%
0-25
8%
26-50
10% 51-75
76-100
7%
FIG 22 : DISTRIBUTION OF SEVERITY IN DEPENDENCY WITHIN STUDY POPULATION
DISCUSSION
6.0. DISCUSSION
This study had included 187 subjects from 10 old age homes from urban areas of Mysuru. Data
shows that majority of the inhabitants are females (54.01%) than males (45.99%). While
looking at the literacy rates females are maximally illiterate (68.18%) than males (31.81%)
which is in accordance to the Census of India 2001 report.[34] There is high prevalence of
hypertension which affects around 50% of the elderly population which relates to the study of
Prince et al[35] in the year 2015.
The study have found the prevalence of dementia to be 39.57% and this result is similar to the
findings of the study conducted by J.D de Lima et al[30] but is in contrast to the study conducted
by Sharma et al[28] who had found the prevalence to be 9.5%. In an East Asian study, ShanhuXu
and Xiaoging Tin et al[36] reported the prevalence of dementia to be 44.5% in residents of China.
The females had higher risk of dementia than men at a ratio of 1:1.74 which is in accordance
to the survey reports of Alzheimer’s Society[37]. Choudhary A et al[38]reported similar
prevalence in males and females while Saldanha D et al[39] reported males to be at high risk of
acquiring dementia than females which is in contrast to the current study, but studies by Jishnu
et al[40],Vas C J et al,[41]Hasselgreen C et al[42], Chih-Ching Liu et al[43] all reported higher
prevalence in females which is in accordance to our study.
The data shows that the literates are more affected with dementia than the illiterate which is
contrast to the reports published by Singh et al[19] in 2012.
There was statistically significant association shown with different socio demographic
variables like age, gender and literacy states. Moreover, 39.57% of subjects had signs of
dementia, more than 70% of these were not on any medications.
The study shows that the risk of dementia increases with age which is in accordance to the
study by Saldanha D et al[39]it has also found that subjects with co-morbidities like DM and
HTN had most prevalence of dementia which is in accordance to the studies conducted by
Vassilaki et a44], Ganguli et al[45], Luck et al.[46]and Bunn et al [47]
Looking at the dependency or restriction in physical activities, the study has clearly shown that
high dependency and dementia is co-related to each other, similar results were given by
Saldanha D et al[39]who reported that dementia is protective with less restriction.
While looking at the depression the prevalence among elderly in old age homes were found to
be 27.80% which is similar to the study conducted by Nagoor et al[31] who reported the
prevalence to be 27.7%. Similar results were shown by a study conducted by Singh et al[19]with
the prevalence of 29%, while the study conducted by Nagaraj AKM[21] et al shows prevalence
of 29%. Ritchie et al reported 26.5% depression in elderly. The study conducted by Zalavadiya
et al[25] shows the prevalence of 46.6% of depressive rate which is in contrast to our findings.
There are other studies conducted in india which is in accordance with the prevalence of
depression of our studies. In Karnataka, a study by Barua and Kar[48] showed the prevalence of
depression to be 21.7%. Comparatively similar results were also found by Nandi et al[49] (22%)
in West Bengal among elderly inhabitants. In Chennai, a study by Ramachandran et al[50] found
that 24 in 100 elderly populations (24%) were suffering with depression. Moreover the
prevalence of depression in our study is also comparable to that reported in WHO report
2001[51] on estimation of depression in geriatric population (10-20%)
Socio demographics data of depressive individuals that females are more affected with 57.69%
than the males with 42.30% affected which is accordance to the findings of the study conducted
at Maharashtra by Gaud AA and Nikhale NS[24] on Prevalence of depression in older adults
living in old age homes reporting 58.82% of depression in females and 44.11% in males.
Significantly similar results were also found by Nagoor et al[31] with 64.34% in females and
35.65% depression in males. The study by Soni S et al 2016 also reported similarly that females
are more prone to depression than the males.
The present study shows that 34.22% of the study population has disturbed sleep which is
significant to the study of Nagoor et al[31] reporting 45.5% of disturbed sleep. The increase in
the percentage could be due to the different settings and life style in old age homes. The Jain
and Aras[54] reported a prevalence of 43.9% disturbed sleep among elderly population.
However the present study differs from the findings of Singh et al[52] (3.5%) and Goswami et
al[53] (58.36%). Moreover most of the subjects with disturbed sleep were depressive.
The study shows that 55.76% of the people with disturbed sleep pattern had depression which
is in accordance to the study conducted by Zalavadiya et al[25] (62.9%)
The study had further found that 71.15% of the depressive individuals had symptoms of
dementia which is similar to the study conducted by Nagaraj AKM et al[21].
CONCLUSION
7.0. CONCLUSION
In this study, we found that 39.57% of elderly inhabitants of old age homes are having the signs
of dementia. We have seen that there is no significance of age with dementia after crossing 50
years of age. The data shows that the literates are at high risk of developing dementia than the
illiterates and it seems to be that the diet doesn’t have any significance for developing of
dementia
We have seen that approx. 23% of the subjects with dementia as per MMSE were on the
medication while the rest 77% of the subjects were not on any type of psychiatric medications.
This elucidates the fact that there is a need of proper medical care and education for the elderly
population.
Findings show that approx. 50% of subjects with dementia were dependent on their caretakers
for their daily activities.
The 27.80% of the study population were in depressed state in whichfemales and the subjects
with mixed diet are majorly affected. More than half of the depressed population were seemed
to be having disturbances in their sleep.
Data shows that 34.22% of subjects have disturbed sleep. The disturbed sleep may be related
with dementia and depression and female in gender are having significant risk of developing
the disturbed sleep and other factors like diet and educations are not shown an remarkable
changes in sleep.
LIMITATIONS
7.0. LIMITATIONS
The study was conducted only for a period of 6 months

Hindrance of the individual to share medical and social history
The research could have carried out throughout the various cities of Karnataka.
The research can be focussed on rural population also.
FUTURE DIRECTIONS
8.0. FUTURE DIRECTIONS
The study serves as a basis for the further study conducted on the mental illness.
The study helpful for developing mental health guidelines for elderly.
The study elucidates the importance of neurological disorders like dementia and helps
to do further research works
It provides the prior awareness about the progression of the mental disorders.
SUMMARY
9.0. SUMMARY
WHO states that there are millions of people suffering from one or more neurological disorder
and some of them remains undetected. Approximately 600 neurological disorders and
conditions are found around the world. In India, 3-11.9 per 1000 (as per 2019 report) are
affected by one or more neurological disorder, while 197.3 million (as per 2017 report) Indians
are affected by psychological disorders.
According to WHO, dementia is found to be 7th leading cause of death among all the diseases
and remains one of the major cause of disability and dependency among the elderly population.
In India the prevalence of dementia was found to be 2.7% as per the 2011 census. There are
different types of dementia among which Alzheimer’s disease remains to be the most common
and has no cure.
The psychological disorder which is seen common among the general population is depression.
As per WHO, 3.8% of the world’s population is affected by depression. National Health Survey
2015-16 states that, in India nearly 1 in 20 of the population suffers from depression and 2017
study says that 45.7 million Indians were suffering from depressive disorder. The depression
can be caused by many factors but stress plays a major role.
Sleep disorders are group of various conditions that disturbs the sleep on a regular basis. Sleep
disorders are commonly experienced due to stress and busy schedules.
The study is a cross sectional study carried out in the old age homes of Mysuru over a period
of 6 months. The study subjects were of elderly age group above 50years of age. No individuals
below 50 years and not giving consent were included in the study. The examinations of the
subjects were made according to MMSE, MDI and PSQI scale for dementia, depression and
sleep disorders respectively. Additionally, the patient demographics, social history, past and
present medical and medication history were taken into considerations. Results were
statistically analysed using mean, chi square test, p-value along with risk factor analysis.
Out of 187 study population, 101 were females while the rest 86 were males. The majority of
the inhabitants were aged between 71-80 years (50) and majority were following mixed diet.
In the study out of 187 subjects, 74 were having signs of dementia out of which 47 were females
and 27 males. The study found that females are majorly affected than males with the ratio of
approx 1:2. The people with age group of 71-80years are majorly affected by dementia and
majority of the subjects had moderate cognitive impairment. Approximately 50% of the
subjects were dependent on third person for their daily activities, which was examined using
Barthel index. Further, 37 out of 74 subjects were suffering from depressive disorder.
The study further finds the prevalence of depression to be 27.80% among the inhabitants of old
age homes. Data shows that majority were affected with mild depression (27), followed by
moderate (19) and severe depressive disorder (6). Further the study had found that the females
are predominantly affected with depression (57.69%) than the males (42.30%). The subjects
with mixed diet (37) were majorly affected with depression when compared to vegetarians
(15), hence leaving the population with mixed diet at higher risk of acquiring depression.
The study further shows that 34.22% of the subjects were having sleep disturbances according
to PSQI scale. The data shows that literates (38) are majorly affected with sleep disturbance
than the illiterates (26). The socio demographics show that females are majorly affected than
the males.
REFERENCES
10.0.REFERENCES
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ANNEXURES
ANNEXURE 12.1
ANNEXURE 12.2
ANNEXURE 12.3
ANNEXURE 12.4
ANNEXURE 12.5
ANNEXURE 12.6

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IDENTIFICATION OF COGNITIVE IMPAIRMENT AND

PSYCHIATRIC ILLNESS AMONG INHABITANTS OF OLD AGE

Dissertation submitted to,

In partial fulfilment of the requirements for the degree of

SARADA VILAS COLLEGE OF PHARMACY

This is to certify that this dissertation work entitled “Identification of cognitive

Internal Examiner External Examiner

DECLARATION BY THE CANDIDATES

Signature of the candidates,

CERTIFICATE BY THE INSTITUTIONAL GUIDE

Signature of the Institutional Guide,

Date: Mr. Charan C S

CERTIFICATE BY THE INSTITUTIONAL CO-GUIDE

Signature of the Institutional Co-Guide

Date : Dr.Ravindra P Choudhary

Place: Mysuru Sarada Vilas College of Pharmacy,

ENDORSEMENT BY THE PRINCIPAL

Date: Signature of the Principal

ENDORSEMENT BY THE HOD

Place: Mysuru Signature of the HOD

DECLARATION BY THE CANDIDATES

Signature of the candidates,

© Rajiv Gandhi University of Health Sciences, Karnataka

We respect and thank Dr.Hanumanthachar Joshi, Principal, Sarada Vilas College of

Our sincere gratitude to Dr.Davan B Bevoor, Head of Department of Pharmacy Practice,

Oursincere gratitude to our guide Mr.Charan C S Associate professor, Department of

We owe a deep sense of gratitude to our co-guide Dr.Ravindra P Choudhary, Assistant

Our special thanks to Dr.Aravinda Kumar S Psychologist Viveka Hospital, Vajamangala,

1.1 NEUROLOGICAL DISORDER 24

1.2 PSYCHOLOGICAL DISORDER 25

1.3.7 Non-Pharmacological Therapy

1.4.2 Signs And Symptoms

1.4.4 Causes And Contributing Factors

1.5 SLEEP DISORDERS 42

1.5.3 Signs And Symptoms

1.5.7 Life Style Modification

2 AIM AND OBJECTIVE 54-55

3 LITERATURE REVIEW 56-67

4 METERIALS AND METHODS 68-73

4.1 Study Design

4.2 Source Of Data

4.3 Study Population

4.4 Study Period

4.5 Inclusion Criteria

4.6 Exclusion Criteria

4.7 Site Of Study

4.8 Study Tools

4.10 Statistical Analysis

5.1 GENERAL DEMOGRAPHICS OF STUDY SUBJECTS 75

5.2.1 Demographics Of Subjects With Dementia

5.2.2 Risk Factor Analysis Of Dementia

5.3 DEMENTIA AND DEPENDENCY 83

5.4.1 Demographics Of Depressive Patients

5.4.2 Risk Factor Analysis Of Depression

5.5 PROPORTION OF POPULATION WITH DEMENTIA AND 88

5.6 SLEEP DISORDER 89

9 FUTURE DIRECTION 102-103

04 VARIOUS WAYS TO PREVENT THE DEMENTIA 34

05 PATHOLOGY OF DEPRESSIVE DISORDER 36

06 DISTRIBURTION OF SEVEARITY OF DEMENTIA WITHIN 77

07 AGE DISTRIBUTION WITHIN STUDY POPULATION OF 78

08 LITERACY DISTRIBUTION WITHIN STUDY POPULATION 79

09 DISTRIBUTION OF STUDY POPULATION WITHIN 80