IAGMH/INTAS Award-2010 Session

Predictors of Healthy and Unhealthy

Aging in North Indian Older Adults with
Reference to Mental Health
S.C. Tiwari,
Professor and Head,

*Rakesh Kumar Tripathi,

Lecturer cum Clinical Psychologist
and
Aditya Kumar
Department of Geriatric Mental Health,
CSM Medical University, UP, Lucknow
*Presenting Author
 Background
As the population of the older adults is
increasing globally, more and more interest
is being shown by the researchers to study
healthy and unhealthy aging.
Healthy aging is not only related to the advances
in medical care but is also related to interaction
of a wide range of factors such as:
– maintaining and enhancing physical and cognitive
functions,
– being fully involved in the society,
– leading a stimulating and productive life,
– living in a stable social environment and
– having meaningful personal relationships
(Archana & Mishra, 2007, IPJ).
 Background (contd.)
During the process of aging, the physical,
psychological and sociological changes take
place.
Aging can not be avoided.
But how fast we age, what factors influence
healthy and unhealthy aging, how it varies from
one person to another from region to region are
issues of great interest.
Some authors agree that, normal aging can be
divided into “successful” and “usual” aging (Jorm
et al., 1998; Rowe & Kahn, 1987; Strawbridge et
al., 1996).
 Background (contd.)
The subgroups of “successful aging” and “usual
or normal aging” have been introduced to
explain the heterogeneity of elderly populations
and there are many terms that describe
successful aging; for example:
– productive aging,
– robust aging,
– healthy aging,
– active aging, and
– aging well.
However, there is no consensus on the definition of
successful aging and on an operational criterion (Li et
al., 2006).
 Background (contd.)
The evidences in the literature regarding the
specific socio–demographic and personal
characteristics of individuals with „healthy aging‟
and „unhealthy aging due to neuropsychiatric
disorders and mental health problems‟ in their
life time are rarely reported and inconclusive.
The issue is of contemporary interest to
behavioural scientists.
Present study attempts to address these issues
from a just completed study, “An epidemiological
study of prevalence of neuropsychiatric
disorders with special reference to cognitive
disorders amongst elderly” (Tiwari & associates,
2009), funded by Indian Council of Medical
Research, New Delhi, India.
 Objectives

To study the socio-demographic profile of

healthy and unhealthy aging.
To delineate the predictors of healthy and
unhealthy aging, if any.
 Methods
Study area :
The study universe consisted of randomly
selected urban (Musahebganj & Jankipuram
municipal wards) localities of Lucknow district.

Study sample :
A total of 2283 elderly subjects aged 55 years
and above from urban areas were included
after obtaining informed consent.

Only 1368 (excluding 915 elderly with physical

illnesses only) elderly were considered for the
presentation in the study
 Methods (contd.)
Tools:
Semi-structured proforma of socio-demographic
details and personal History
Socio-economic status scale (Tiwari et al. 2005)
Initial screening to identify suspects :
– Survey Psychiatric Assessment Schedule (SPAS) (Bond
et al., 1980),
– Mini – Mental Status Examination for urban subjects
(MMSE) (Folstein et al., 1975)
– Physical and neurological examination (PNE)

Assessment schedule to identify cases :

– Schedule for Clinical Assessment in Neuropsychiatry
(SCAN) (WHO, 1996) for neuro-psychiatric disorders
– Cambridge Examination for Mental Disorders of the
Elderly -Revised (CAMDEX-R) (Roth et al., 1986) for
cognitive disorders
 Methods (contd.)
Tools (contd.)
Cut off Scores of MMSE by Age & Education*
Age in years
Education 55-69 70-74 75-79 80-84 >84

Up to 4th grade 22 22 21 20 19

Up to 8th 26 25 25 25 23
Up to High 28 27 27 25 26
School
Up to college 29 28 28 27 27
* Crum et al,1993 (http://www.minimental.com)
 Methods (contd.)
Tools (contd.)
Procedure of Translation:
Three translators well versed in English and Hindi,
translated the original English versions of MMSE, SPAS
CAMDEX-R into Hindi independently.
They discussed and compared the translation item by
item to agree upon a pre-final translated Hindi version
(PFHV) of the tools.
PFHV were administered to ten literate and ten illiterate
persons aged 60 years and above, drawn from another
community to know the comprehensibility of the items.
These people were also asked, whether the items are
clear, culture fair, simple and comprehensive.
Most of the items of PFHV were found to be
comprehensible to literate as well as illiterate persons in
respect to the nature and content of the items.
 Methods (contd.)
Tools (contd.)
Procedure of Translation (contd.):
Items that were not found to be culture and education fair,
modifications were made according to the suggestions,
given by the participants who had taken the test.
During this process the originality of the assessed domains
were conserved as much as possible. Therefore, these
versions were taken as final translated Hindi versions
(FHV) of the tools.
Two bilingual experts back translated the FHV of the tools
into English to establish meaning equivalence.
The original English, the final Hindi versions of the tools
and the back translated English versions of the final Hindi
versions of the tools were referred to three bilingual mental
health professionals to assess logical validity of the
instruments.
These mental health professionals unanimously agreed
that the three instruments of each tests had very high
balancing meaning and lingual equivalence.
 Methods (contd.)
Procedure
Socio-demographic and personal history of
subjects were recorded on a semi-structured
proforma and SES was assessed by Socio-
Economic Status Scale.
Initial screening to identify „suspects‟ for
„cognitive‟ and „neuropsychiatric disorders‟ was
done through MMSE and SPAS.
The „suspects‟ were then subjected to detailed
assessment through CAMDEX-R for „cognitive
disorders (CD)‟ and SCAN for „neuropsychiatric
disorders other than cognitive disorders‟ (NP).
The subjects grouped as neuropsychiatric
disorders are functional psychiatric disorders
and other than cognitive disorders was added to
distinguish these from cognitive disorders.
 Methods (contd.)
Procedure (contd.)
The categorization of NP and CD was done on the basis
of ICD-10 and another sub group of „sub syndromal
mental health problems (SMHP) was identified.
The recruited elderlies were also subjected to
comprehensive physical, neurological examination
(using PNE) and pathological / radiological
investigations.
Subjects without any medical / neuropsychiatric or
cognitive disorder symptomatology were categorized into
„normal aging group‟.
Subjects having only physical illnesses (n=915) were
excluded from this report so that only predictors of
healthy and unhealthy aging with special reference to
mental health problems could be studied.
 Methods (contd.)
Procedure (contd.)

Statistical analysis:
Comparisons amongst „normal aging‟ subjects
with „cognitive disorders‟, „neuropsychiatric
disorders other than cognitive disorders‟ and
„sub-syndromal mental health problem‟ groups,
were done on socio-demographic and personal
characteristics using statistical method of Chi
square test with Yate‟s correction ( wherever
applicable) . Mean, standard deviation and
percentages were also used for statistical
analyses.
 Methods (Contd.)
Operational definition of Sub-syndromal Mental Health
Problems (SMHP) in the study:
“Subjects having one or more symptoms which keep on
bothering the subject and necessitate seeking
professional help, but do not amount to any definite
diagnosis as per ICD-10”

Identification of Sub-syndromal Mental Health

Problems:
Common failure in more than 50% subjects on MMSE
items and positive symptoms on SPAS which keep on
bothering the subjects and necessitate seeking
professional help but do not amount to any definite
diagnosis as per ICD-10 were considered as
symptoms of sub-syndromal mental health problems
amongst older adults.
 Results
Table1: Age and Sex wise distribution of study sample
Area Urban (U)

Age Group Male Female Total

(1128) (1155)
Pre- 55-59 Yrs. 176 271 447
elderly (39.4%) (60.6%)
60-69 yrs. 646 617 1263

70-79 yrs. 222 176 398

Elderly
80 yrs. & above 84 91 175

Total 952 884 1836

(51.9%) (48.1%)
Grand Total 1128 1155 2283

Mean age: 66.87 ± 8.0 years

 Results (contd.)
Table 2: Comparison of Normal aging on Socio-demographic and personal
characteristics with SMHP, NP and Cog. Disorders group
Sr. No. Variables SMHP Neuro-psychiatric Cog. Dis.
other than cog. dis.
1. Age x ** ***
2. Sex x * x
3. Marital Status x ** *
4. Education * * x
5. Occupation x ** ***
6. Employment x ** **
7. Financial Dependence x ** x
8. Family type ** x x
9. Caste ** x x
10. Religion x x x
11. SES ** ** *
12. Number of Children x ** x
Note: x = Non Significant; * = p<.05; ** = p<.01; *** = p<.001
 Results (contd.)
Table 2 : Comparison of Normal aging …….(Contd.)
Sr. Variables SMHP NP other than Cog. Dis.
No. Cog. Dis.
13. Use of spare time ** ** x
14. Significant incidents in life ** * x
15. Respect in family x x x
16. Participation in decision making x ** x
17. Quality of Life ** ** x
18. Expression of feelings ** * x
19. Tobacco intake x x x
20. Frequency of tobacco intake x x x
21. Frequency of intoxicating material x * x
22. Family history of chronic illness x x x
23. Comparison of health with others x ** **
24. Health Check up ** ** x
Note: x = Non Significant; * = p<.05; ** = p<.01; *** = p<.001
 Results (contd.)
Comparison of Normal aging on Socio-demographic
and personal characteristics with SMHP, NP and Cog.
Disorders group
Age:
Cognitive disorders were found to be increasing with the
age. Those aged 80 yrs above suffered significantly
more with cognitive disorders as compared to lower age
groups (p<.001).
Sex:
Males were significantly healthier than females (p<.05).
Marital Status:
Unmarried is significantly more healthier than ever
married
 Results (contd.)
Socio-economic status (SES):
The subjects belonging to „lower SES‟ had
significantly (p<.001) higher NP, in comparison
to subjects from „upper and middle SES.
Significantly higher number of subjects
belonging to „upper SES‟ were found to have
sub-syndromal mental health problems in
comparison to subjects from „lower‟ and „middle‟
SES.
Subjects from middle and upper SES suffered
significantly more from cognitive disorders in
comparison to subjects from lower SES.
However, distribution of normal aging subjects
was almost equal in all the 3 SES (upper,
middle, lower) groups.
 Results (contd.)
Family type:
Subjects living alone suffered significantly
(p<.001) higher from sub-syndromal mental
health problems in comparison to subjects living
in joint family, and living with spouse.
Most of the subjects with neuro-psychiatric
disorders other than cognitive disorders were
living alone in comparison to those who lived in
joint family and with spouse.
Significantly higher number of subjects from joint
families had cognitive disorders in comparison to
those living with spouse and alone.
However, subjects living alone were found to be
significantly healthier than those living otherwise
(p<.001).
 Results (contd.)
Caste:
Significantly higher number of subjects suffering
from neuro-psychiatric disorders other than
cognitive disorders were from other castes
(reserved) in comparison to general castes.
However, subjects from general castes were
having significantly higher sub-syndromal mental
health problems in comparison to other castes.
Cognitive disorders were also found significantly
higher among general caste subjects in
comparison to other castes.
However, healthy aging subjects were
significantly higher in reserved castes in
comparison to general caste subjects.
 Results (contd.)
Normal aging subjects were found to be
more in families with no history of chronic
physical/mental illness though the
difference was not significant.
Neuro psychiatric disorders other than
cognitive disorder were found to be more
in those who had family history of chronic
physical & mental illnesses.
 Results (contd.)
However, there was no statistical association between
personal characteristics and groups of different
morbidities on:
– number of children,
– tobacco addiction, frequency of tobacco intake,
– frequency of use of intoxicating materials,
– respect in family and
– participation in decision making.
A number of personal characteristics were found to be
commonly associated with unhealthy aging either for
neuropsychiatric disorders without cognitive disorders or
cognitive disorders or sub-syndromal mental health
problems:
– subjects being married ever,
– age 60 years and above, unemployed,
– have faced significant life events, and
– dissatisfaction with their quality of life.
 Results (contd.)
On the other hand there are personal characteristics
which are exclusively associated with unhealthy aging of
different kinds:
– Female sex,
– lower socio-economic status and
– having no issues were associated with aging with
neuropsychiatric disorders other than cognitive disorders.
– Joint family, educated up to 10th level,
– financially self as well as totally dependent on others,
– having more than 5 children,
– involving into group activities and
– expressing their feelings were associated with aging with
cognitive disorders.
– Upper socioeconomic status, general caste categories,
education up to 12th level, self dependent and going for regular
health checkup were associated with aging with sub-syndromal
mental health problems.
 Results (contd.)
Healthy aging:
The results indicate that:
– unmarried persons with higher education,
– labourers /farmers, employed,
– financially partially dependent,
– have better perception of health than others,
– continued to go for need based health checkups,
– used spare time in group activities,
– not having significantly troublesome life events,
– highly satisfied with their quality of life, and
– always expressed their feelings were aging normally
without having mental health problems.
 Discussion
The study is an attempt to delineate socio-demographic
and personal characteristics associated with healthy
aging and aging with mental health problems (unhealthy
aging).
The study was carried out in a typical north Indian Hindi
speaking belt of India where respect and freedom to
older adults are the unwritten rules.
However, with the changing socio-demographic and
economic matrix, these traditions are gradually getting
eroded.
Today, older adults are finding it more difficult to live and
age happily and healthy.
In such a background matrix, the present study has been
able to delineate some of the factors at a preliminary
level, which could be attributed to healthy aging.
 Discussion (contd.)
There are numbers of reports about aging, healthy
aging, status of aged etc. in India.
However, similar studies in India could not be located
with best of our efforts.
Hence, the findings are not comparable.
A study from China by Li et al. in 2006 reported that
being older, female sex and lower occupational class
were negatively correlated with successful aging.
The variables identified from this study are also on
similar platform and an earlier study by Tiwari (2000).
Being older, ever married, unemployed, having faced
significant life events and dissatisfaction with quality of
life breaded unhealthy aging.
On the other hand, being younger, male, living in joint
family setup, promoted healthy aging. In addition, gainful
employment, financial independence, being able to
express feelings, going for health checkups as per need
etc. also promoted healthy aging.
 Conclusion
The study has given some leads which
need to be reconfirmed in other studies
from the same region, and different
regions of the country and perhaps in a
larger multicentric study.
The identified leads may be considered as
predictors of healthy and unhealthy (with
mental health problems) aging and
Some of these may be intervened to
promote healthy aging.
DEPARTMENT OF GERIATRIC MENTAL HEALTH,
CSM Medical University UP, Lucknow
CENTRE FOR “LUCKNOW ELDERLY STUDY”

Thank you