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Primary Care Mental Health Unit, The University of Western Australia Abstract Objective:To assess the relationship o f psychiatric morbidity, morale, physical activity and the presence o pain in older f people. Method: Older people attending senior citizensâclubs were administered the 28item General Health Questionnaire (GHQ28), the Revised Philadelphia Geriatric Centre Scale (RPGCS)and five self-report questions from the Brief Disability Questionnaire. They also rated the presence o pain on a five-point scale. f Multiple and logistic regression were used to adjust for socio-demographic factors and identify variables independently associated with psychological status and morale. Results: O 112 people approached, 86% f agreed to take part (n=96).The sample showed a wide range in total GHQ scores (mean=2.9,range=O-19)and RPGCS scores (mean=2.3, range=l.1-3.0). Twenty-one per cent had psychological distress as defined by a score o 26 on the f GHQ-28 (n=19). Fifty-four respondents (56%)reported low morale as defined by a score <2 on the RPGCS. There was a close relationship between psychological distress, low morale on the RPGCS (OR=5.5 [1.5-20.51)and moderate to severe pain (OR=5.3 [1.8-15.91).When adjusted odds ratios were calculated to control for confounding factors, moderate to severe pain remained independently associated with psychological distress ( O b l . 6 [1.3-2.41p=0.02), and limitations in daily activities with low morale (Ok3.64 (1.001-8.4)~0.05). Concluslons:There is a close relationship between physical disability, low morale and psychological distress. Implications: An increased index o f suspicion for psychological distress is warranted in all older people with physical disability, particularly in the presence o f moderate to severe pain. (Ausf N Z J Public Health 1999; 23:531-3) Peter Shannon Fremantle Hospital, Western Australia he rising proportion of older people in the population has led to a greater interest in the burden of psychological morbidity in this age group. After dementia, mood disorders are the most common disorder,l although reported prevalence depends on the setting and psychiatric instrument used. The Australian Bureau of Statisticsâ Mental Health and Wellbeing report estimated that just over 6% of Australians over the age of 65 years had anxiety disorders or depression.2This is considerably lower than rates of 20-30% reported in previous research carried out in the ~ o m m u n i t y , ârecipients ,~-~ of home help services,â nursing hornesâl0 and This may partly be exgeneral plained by the fact that although the Mental Health and Wellbeing survey sampled some 15,500 private households, it excluded residents of nursing homes, hostels, boarding houses and supported accommodation.s~â3 Women appear to have higher levels of mood d i ~ o r d e P . and married men, the lowest â~ prevalence of symptoms.14The data on age have been more e q u i v o ~ a l . ~ * ~ Less is known about the relationship between physical and social disability, and any effect on psychological status. A World Health Organization (WHO) study of under65s attending primary care in 15 countries demonstrated a clear association between these ~ariab1es.l~ community survey in A Sydney of 434 non-demented respondents over 75 years showed an association between heart disease and depression, once age, sex, education and others factors were controlled for in multiple regression anaIyses.I6 Even less is known on the relationship ~~ between pain and psychological symptoms in older people. Dworkin et al. assessed the presence of pain and psychological morbidity in patients attending a health maintenance organisation,â but not specifically older people. Two sites of pain were associated with a six-fold increase in the prevalence of depression, while three or more sites were associated with an eight-fold increase. This work studied the relationship between psychological morbidity, demoralisation, pain and disability using multivariate techniques to identify factors independently associated with psychological status and morale. For instance, older patients may be more likely to be widowed, frail or suffer from physical illness. Morale was included as an outcome measure because of its high correlation with other measures of subjective well being such as social relationships, selfesteem and self-image.lE Although depression and low morale may sometimes show a close relationship, it is possible for low morale to occur in the absence of depression.â* Method People attending senior citizensâ clubs in Fremantle were asked to complete the 28item General Health Questionnaire (GHQ28),19 the Revised Philadelphia Geriatric Centre Scale (RPGCS)*Oand five self-report questions from the Brief Disability Questionnaire (BDQ)I5derived in turn from the Medical Outcomes Survey Short Form 36.21 These settings are more representative of the community than medical centres or institutions for older people, but would not cover those still living independently in the Correspondenceto: Dr Steve Kisely, The Primary Care Mental Health Unit, 16 The Terrace, Fremantle, WA 6160. Fax: (08) 9336 5505;e-mail stephenkQcyllene.uwa.edu.au Submitted: March 1999 Revision requested: May 1999 Accepted: June 1999 1999 a. NO. 5 23 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Kisely and Shannon Brief Report community not attending clubs or associations. These instruments were selected because they could be completed by respondents themselves, had been validated in older people and were acceptable to individuals in the community who did not perceive themselves as mentally ill.'9-21 The GHQ-28 has four sub-scales covering somatic symptoms, anxiety, social dysfunction and depression. The presence of psychological distress (GHQ caseness) was defined as a score of 26 on the GHQ. This is higher than the usual threshold of 4/5 and follows work that suggests that this threshold is indicated in patients of this age with possible physical co-morbidity.22 described by Wenger et al. in their revision of the PhilaAs delphia Geriatric Centre Scale,zopatients with scores <2 were categorised as having low morale. Respondents were also asked to rate the presence of pain on a five-point scale (l=no pain; 2=very mild; 3=mild; 4=moderate; 5=severe). Variables associated with GHQ caseness and low morale on univariate analysis were entered into a logistic regression equation to calculate adjusted odds ratios for dichotomous dependent variables (GHQ caseness; low morale), and multiple regression for continuous variables (total GHQ and morale scores). (mean=2.9, range=O-19) and RPGCS scores (meanz2.3, range=l. 1-3.0).There was a close relationship between high GHQ score and low morale ( ~ 0 . 4 1 p<O.OOl), as well as with pain , (1-0.4, p<O.OOl). This relationship held true for the sub-scales, except for the anxiety sub-scale and the presence of pain ( ~ 0 . 1 5 , ~ ~ 0 . 1 4 ) . was a particularly strong association between the There somatic sub-scale of the GHQ and pain score (~0.42,p<00001), although there were also significant, but lower, levels of agreement between pain score and the GHQ social dysfunction ( ~ 0 . 3 4 , p<O.OI) and depression sub-scales ( ~ 0 . 1, p 75 Significance OR (95% CII Sex Male Female Age >75 Morale High n=41 Low n=55 1 1 (26.8%) 30 (73.2%) 2 (51.0%) 1 Significance OR (95% Cl) 19 (26.8%) 52 (73.2%) 5 (26%) 1.02 (0.3-3.3) 3.97 (1.2-13.2) 2.3 (0.8-6.7) 14 (74%) 15 (79%) 1 1 (58%) 33 (48%) 15 (25.9%) 40 (74.1%) 28 (55.0%) 36 (66.0%) 26 (49.0%) 29 (58.0%) 29 (58.0%) 23 (44.2%) 13 (26.0%) 1.0 (0.4-2.6) 1.1 (0.5-2.6) Absence of a stable relationship 26 (36.6%) BDQ self-reported disability items activity limited 25 (35.7%) walking up hill or stairs limited 3 (44.9%) 1 bending, lifting, stooping limited 27 (39.1%) walking one block limited 2 (29.6%) 1 limited self care 9 (12.9%) Moderatdsevere pain present _____ Absence of a stable relationship 2 (51.2%) 1 BDQ self-reported disability items activity limited 10 (25.0%) walking up hill or stairs limited 17 (42.0%) bending, lifting, stooping limited 13 (32.1%) walking one block limited 10 (24.4%) limited self care 3 (7.3%) 1.9 (0.8-4.4) 10 (55.6%) 2.2 (0.8-6.4) 14 (73.7%) 5.7 ( 521.7) 1 14 (73.7%) 5 4 (1.6-18.3) . 12 (36.4%) 4.8 (1.6-14.4) 7 (43.8%) 4.7 (1.4-15.6)b 13 (68.4%) 5 3 (1.8 1 . ) . -59' 16 (84.2Y0) 5.5 ( 5-20.5) 1 3.0 (1.2-7.4) 1 9 (0.8-4.3) . 3.0 (1.3-7.1) 2 4 (1.001-6.1) . 4.4 (1.2-16.9)b 20 (29.0%) RPGCS low morale 35 (49.3%) 10 (24.4%) GHQ case (5/6) case 3 (7.3%) Moderate/severe pain present 25 (48.1%) 2 8 (1.1-6.8) . 16 (31.4%) 5.5 (1.5-20.5)c Notes: (a) Final model contained limited self care and moderatdseverepain. Other variables w r e not included as these were not significant. (b) Aflusted OR=4.02(1.0-14.5)p=O.06. (c) Adjusted OR = 1.6 (1.3-2.4) p= 0.02. Notes: (a) Final model contained limited self care and GHO caseness. Other VariaMes were not included as these were not significant. (b) Aflusted OR= 5.00 (1.2-18.9)p=0.03, (C) Adjusted OR=3.64 (I.W1-8.4)p=0.05. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 5 Brief Report Demoralisation,distress and pain in older Western Australians Morale on the Revised Philadelphia Geriatric Centre Scale Low levels of activity, and problems with mobility and bending were associated with a 2-3 fold increase in low morale (Table 2).The presence of moderate to severe pain, and limitation in self care were also associated with low morale. Adjusting odds ratios to control for the possibility that patients with psychological distress were more likely to be unable to look after themselves or have limited activity or mobility, revealed that problems with self care remained independently associated with low morale (Table 2). Multiple regression confirmed the association between low morale and GHQ caseness (beta=0.41 ,p=O.OOl). Discussion To our knowledge, the present study is the first to assess the relationship of psychological distress, morale, physical activity and severity of pain. An additional strength was the use of multivariate techniques to calculate adjusted odds ratios and establish factors independently associated with outcome. As previous work has shown, it is important to control for the effect of socio-demographic variables when assessing for clinical predictors of psychological status.16 The Revised Philadelphia Geriatric Centre Scale has specifically been designed and validated for an elderly population.19Although the GHQ has also been validated in this age group, it has less specificity for the detection of psychological ill-health than structured interviews such as the comprehensive psychopathological rating scale, Geriatric Mental State/AGE-CAT diagnostic algorithm or the Psychiatric Assessment S ~ h e d u l e .However, it is ~) more suitable for community samples. The assessment of mobility and physical activity was based on self-report, so it is possible that patients with psychological distress might over-estimate concurrent disability. The present work was a small pilot study and three-quarters of the sample were women. It is possible that larger numbers would have demonstrated the associations between socio-demographic factors and psychological distress that have been reported in other literature. A larger study would also need to ensure that the preponderance of women noted in the sample was not due to some selection bias in people attending social clubs. Nevertheless, some conclusions can be drawn from this study, as the calculation of adjusted odds ratios allowed the influence of socio-demographic factors, pain, psychological illness and physical disability to be assessed independently. Levels of psychological morbidity of 21% are similar to studies in Tasmanias and o v e r ~ e a s . ~There~was a close relation~~* -'~ ship between physical disability, low morale and psychological distress, Individuals with moderate to severe pain also had high rates of psychological distress and nearly half of such individuals reported low morale. On logistic regression, the presence of pain, difficulties with the activities of daily life and frailty leading to problems with bending or lifting were independently associated with low morale or GHQ caseness. This confirms results in patients under 65 years old.I5 The association between pain, low 1999 ML. 23 NO. 5 morale and GHQ caseness was also demonstrated using multiple regression. It is anticipated that the present work will form the basis of a larger study with independent assessment of physical symptoms including pain, disability (social or physical), psychological symptoms and morale. This will reduce the possibility that self-reported physical functioning is affected by concurrent psychological status. Strategies will include the use of structured interviews, medical records and informants such as relatives and carers. For example, the Composite International Diagnostic Interview (CIDI) can be used to objectively quantify the reported number of medically explained and non-medically explained somatic symptoms, including pain.I5 However, the present findings suggest that an increased index of suspicion for psychological distress is warranted for all older people with physical disability, particularly in the presence of pain.
Australian and New Zealand Journal of Public Health – Wiley
Published: Oct 1, 1999
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