Indian Journal of Psychological Medicine

: 2019  |  Volume : 41  |  Issue : 1  |  Page : 95--96

Comments on “prevalence and predictors of abuse in elderly patients with depression at a tertiary care centre in Saurashtra, India”

Jitendra Rohilla1, Charan S Jilowa2, Akash Kumar1, Mrinal Jha1, Khwaja Khayyam1,  
1 Department of Psychiatry, All India Institute of Medical Science, Rishikesh, Uttarakhand, India
2 Department of Psychiatry, Jawaharlal Nehru Medical College, Ajmer, Rajasthan, India

Correspondence Address:
Dr. Jitendra Rohilla
Department of Psychiatry, All India Institute of Medical, Science, Rishikesh - 249 203, Uttarakhand

How to cite this article:
Rohilla J, Jilowa CS, Kumar A, Jha M, Khayyam K. Comments on “prevalence and predictors of abuse in elderly patients with depression at a tertiary care centre in Saurashtra, India”.Indian J Psychol Med 2019;41:95-96

How to cite this URL:
Rohilla J, Jilowa CS, Kumar A, Jha M, Khayyam K. Comments on “prevalence and predictors of abuse in elderly patients with depression at a tertiary care centre in Saurashtra, India”. Indian J Psychol Med [serial online] 2019 [cited 2020 Jun 4 ];41:95-96
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This correspondence is made in reference to the original article, “Prevalence and predictors of abuse in elderly patients with depression at a tertiary care centre in Saurashtra, India” by Patel et al.[1] The paper explored the prevalence of abuse in elderly patients, including its various socio-demographic variables that could predict its possibility.

The study is an important contribution to the limited data available regarding the abuse of elderly population in India. As this study has been done on a specific group of elderly people, those suffering from major depressive disorder (MDD) with exclusion of those with sensory or cognitive impairment, it would have been better if the study mentioned the need or significance of studying the problem of abuse in this group compared to the rest of the elderly patients. Moreover, excluding all patients with cognitive impairment will exclude not only patients with dementia but also those with depression whose cognitive impairment is not because of dementia but due to pseudo-dementia, a temporary condition, a part of depression itself.

We could not find in the study how many elderly depressed patients were excluded because of their score being <25 in Mini-Mental State Examination (MMSE), the tool used in this study to rule out patients with cognitive impairment. There are a few concerns about the use of MMSE and its score of 25 as the cut-off to detect and exclude patients with cognitive impairment among the elderly Indian population. MMSE cannot reliably differentiate cognitive deficits which are a part of depression from those due to dementia. In the study, a quarter of the sample belonged to either old–old (70–79 years) or the oldest–old subgroups (80 years and above), 22% and 4%, respectively, and an almost similar proportion (23%) had no formal education and was classified as illiterate. The cut-off score of 25 in MMSE may be too high for these elderly subjects who are illiterate or have a lower level of education. A recent study using receiver operating characteristic (ROC) curve analysis to find out a reliable cut-off score of MMSE to detect dementia found that cut-off scores should be different according to the level of education as follows: 22 for the low education group (sensitivity = 87%, specificity = 82%), 23 for the middle education group (sensitivity = 86%, specificity = 87%), and 24 for the high education group (sensitivity = 81%, specificity = 87%).[2] It was also suggested that if one wishes to apply a single cut-off irrespective of the level of education, the score of 23 is suitable for the whole sample. Therefore, many patients scoring between 23 and 25 may not have dementia and their performance in MMSE could be a reflection of aging and their low education level. It is possible that a study sample not including such elderly patients may not truly represent the elderly population with MDD.

An Indian study specifically comparing MMSE and Hindi Mental State Examination (HMSE) in urban Indian elderly found that illiterate elderly subjects scored lower in MMSE compared to HMSE.[3] HMSE, a Hindi adaptation of the MMSE, was developed specifically to address the limitation of MMSE for illiterate elderly Indian population, with high sensitivity (94%) and specificity (98%) at the cut-off score ≤23 and therefore is a better tool as evidenced by various studies done in Indian elderly population.[3],[4],[5]

While considering the possibility of abuse, presence of cognitive deficits in an elderly patient is important because an elderly population with cognitive deficits requires more assistance from their caregivers. Cognitive deficits also contribute to the behavior problems commonly seen in elderly patients. Both the factors (increased need for care and behavior problems due to cognitive impairment) increase the burden of the caregivers and thus increase the possibility of all types of abuse.[6],[7] Therefore, excluding such population who are at a higher risk may not give an idea about the problem seen in the society where a depressed elderly patient may have various kinds of cognitive problems due to various reasons (as a part of depression, age-related, and due to dementia).

The researchers have made a sincere effort in exploring the relatively unaddressed issue of abuse in the elderly population in India. We expect similar studies by the team in the future, covering a broader group of the elderly population in terms of both the place of selection (including patients from the community) and also other types of disorders.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Patel VK, Tiwari DS, Shah VR, Patel MG, Raja HH, Patel DS. Prevalence and predictors of abuse in elderly patients with depression at a tertiary care centre in Saurashtra, India. Indian J Psychol Med 2018;40:528-33.
2Kochhann R, Varela JS, Lisboa CSM, Chaves MLF. The mini mental state examination: Review of cutoff points adjusted for schooling in a large Southern Brazilian sample. Dement Neuropsychol 2010;4:35-41.
3Tiwari SC, Tripathi RK, Kumar A. Applicability of the Mini-Mental State Examination (MMSE) and the Hindi Mental State Examination (HMSE) to the urban elderly in India: A pilot study. Int Psychogeriatr 2009;21:123-8.
4Ganguli M, Ratcliff G, Chandra V, Sharma S, Gilby J, Pandav R, et al. A Hindi version of the MMSE: The development of a cognitive screening instrument for a largely illiterate rural elderly population in India. Int J Geriatr Psychiatry 1995;10:367-377.
5Tsolaki M, Iakovidou V, Navrozidou H, Aminta M, Pantazi T, Kazis A. Hindi mental state examination (HMSE) as a screening test for illiterate demented patients. Int J Geriatr Psychiatry 2000;15:662-4.
6Hope T, Keene J, Fairburn CJ, Jacoby R. Natural history of behavioral changes and psychiatric symptoms in Alzheimer's disease: A longitudinal study. Br J Psychiatry 1999;174:39-44.
7Vaidyanathan S, Rupesh E, Subramanyam AA, Trivedi S, Pinto C, Kamath R. Disability and caregiver burden: Relation to elder abuse. J Geriatr Ment Health 2018;5:30-4.