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General & Mental Health and Life Attitude: a Comparative Study of the elderly living with Family and at Day Care Centre

Research Article Open Access
Purohit Vinay1*, Purohit Prerna2, Kumari Asha1 and Sharma Sudha2
1Department of Pharmacology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP, India
2Department of Home Science (Human Development), Mahatma Jyoti Rao Phoole University, Jaipur, Rajasthan, India
*Corresponding authors: Purohit Vinay
Department of Pharmacology
Institute of Medical Sciences
Banaras Hindu University
Varanasi, UP, India
Tel: 91-9389506450
E-mail: drvinaybikaneri@yahoo.com.
 
Received February 17, 2012; Published July 27, 2012
 
Citation: Vinay P, Prerna P, Asha K, Sudha S (2012) General & Mental Health and Life Attitude: a Comparative Study of the elderly living with Family and at Day Care Centre. 1: 214. doi:10.4172/scientificreports.214
 
Copyright: © 2012 Vinay P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
 
Abstract
 
Objective: The present study provides a comparative evaluation of general as well as mental health and life attitude status in elderly subjects living with their family and in day care centre in India.
 
Methodology: 90 male subjects (45 each from two groups living with family and in day care centre) aged 60 years or above, literate, belonging to middle class strata were selected from urban areas. Goldberg’s general health questionnaire, Geriatric Depression Scale (GDS), Abbreviated Mental Test Score (AMTS) for dementia, Beck Anxiety Inventory (BAI) and Life Attitude Profile-Revised (LAP-R) were used as tools for study. Statistical analysis was done using non parametric tests viz. Chi square and Mann-Whitney test.
 
Results: After comparing the results and applying Mann-Whitney test, depression was found more commonly among subjects of day care centre when compared to elders living with their family (p value < 0.05). General health profile was better in subjects living with their family. Interestingly, dementia and anxiety disorders were more prevalent in elders living with their family as compared to subjects living in day care centre which can be attributed to more opportunities for social interaction with peers and mental stimulation in the day care centre. No significant difference was found in Life attitude score between two groups.
 
Conclusion: Value of day care centres in policy making for better health of elderly in developing world should be actively realized. The present pilot study unveils the importance of day care centres for elderly care in developing world in general and it also guides and seeks further exploration of these comparisons in large population samples of elderly people among Indian societies in particular.
 
Keywords
 
Attitude; Mental Health; General Health Questionnaire; Geriatric Depression Scale (GDS); Abbreviated Mental Test Score (AMTS); Beck Anxiety Inventory (BAI); Life Attitude Profile-Revised (LAP-R); Depression; Anxiety; Dementia; Family; Day Care Centre
 
A man's life is usually divided into five stages namely infancy, childhood, adolescence, adulthood and old age. Of these stages an individual has to adjust himself in different situations and problems. The boundary between middle age and old age cannot be clearly defined as it does not have the same meaning in all societies. People are considered elderly because of certain changes in their activities or social roles. The ageing process is of course a biological reality which has its own dynamics, largely beyond human control. Old people have limited regenerative abilities and are more prone to disease, syndromes, and sickness than other adults. Old age is the closing period in the life span. It is a period when people move away from previous more desirable periods or times of usefulness. Though the word ‘old’ has a projective sound and people in their advanced chronological ages are now being called senior citizens, chronologically gifted, golden ages, elderly powers, person in the harvest years or twilight years or simply elders yet in our culture, ageing often gives somewhat negative implication as all of these words are perhaps perceived as euphemism. Sir James Sterling Ross commented, "You do not heal old age. You protect it, promote it, and extend it".
 
In the developed world chronological time plays a paramount role whereas in many parts of the developing world, chronological time has little or no importance in the meaning of old age. The age of 60 or 65, roughly equivalent to retirement ages in most developed countries is said to be the beginning of old age. However, it is also subject to the constructions by which each society makes sense of old age. Apart from chronological definition, Senescence or biological ageing, change in physical characteristics, social role (i.e. change in work patterns, adult status of children and menopause) and capabilities may also be used to define old age.
 
The improved standard of living and advancement of medical care has lengthened the average human life span across the world. In India the average life span has increased from 32 years in 1951 to 62 years in 1988 and expected to cross 76 years by 2031. It is expected that by 2025 nearly 71% of the world's elderly population will live in developing countries [1]. According to WHO, The proportion of older people requiring support from adults of working age will increase from 10.5% in 1955 and 12.3% in 1995 to 17.2% in 2025. In the developing world, the proportion of people aged 65 and older is still relatively small but it is expected to grow from 5.2 to 8.5 percent between 2000 and 2025, with the most rapid increases occurring in Asia and Latin America. In the developed world, the proportion of the population aged 65 and over is already at 14.4 percent, and it is expected to rise to 20.9 percent in 2025. These changes in age composition will increase the demands on health care services.
 
The world health organization (W.H.O., 1946) defines "Health as a state of complete physical, mental and social well being and not merely the absence of disease of conformity". Thus health is a positive multidimensional state that in values physical health, psychological health, social health and spiritual health each being influenced by and influencing the other. the subjective feeling of contentment, happiness, satisfaction with life's experiences and of one's role in the world of work, sense of achievement, utility, and belongingness and no distress, dissatisfaction or worry etc. These things are difficult to evaluate objectively, hence the emphasis is on the term "Subjective well-being". Physical health is defined as having a sound disease free body with good cardiovascular performance, sharp sense a vital immune system and the ability to with stand physical injury. Psychological health comprises good self-esteem, enjoying a general feeling of well-being, creativity, problems solving skills and emotional stability. Social health includes good interpersonal skills and meaningful relationships. The illness of the elderly are multiple and chronic in nature. The idea that old age is an age of ailments and physical infirmities is deeply rooted and many of the suffering and physical troubles within the curable limits are accepted as inevitable by the elderly. In old age, the major problems are those associated with physical health, cerebral pathology, socioeconomic factors such as breakdown of the family support systems and decrease in economic independence. The mental disorders that are frequently encountered include dementia, anxiety, schizophrenia and mood disorders like depression. Other disorders include neurotic and personality disorders, drug and alcohol abuse, delirium and mental psychosis. The rapid urbanization and social modernization has brought in a breakdown in family values and the framework of family support, economic insecurity, social isolation and elderly abuse leading to a last of psychological illness. Depression is the most common of these. Symptoms of depression include lack of interest in activities, sadness or unexplained crying spells, jumpiness or irritability, loss of memory, inability to concentrate, confusion or disorientation, thoughts of death or suicide, change in appetite and sleep patterns, persistent fatigue, lethargy, aches and other unexplainable physical problems. Generalized anxiety disorders may include excessive, ongoing worry and tension, restlessness or a feeling of being "edgy", difficulty in concentrating, headache, sweating, irritability, trouble falling asleep, trembling and sometimes it may be associated with panic, phobias and obsessive compulsive disorders. In old age, there are various factors that contribute to development of depression and anxieties. Biggest among them is the separation from the spouse or family. Dementia is a group of symptoms associated with a progressive loss of memory and other intellectual functions that is serious enough to interfere with performing the tasks of daily life. Apart from ageing itself many social problems may be responsible for mental illness. Old age is only factor that cause stress in the elderly person's life. Poverty inaccessible services and lack of financial support make it difficult for them to weather stresses. Every elderly population has the right to lead a healthy, active life with less suffering. For these they need clothing, housing facility, medical and social care. Many of the health problems can be overcome or delayed by changing their life style [2]. Ageing brings about a number of physiological changes. It not only affects a person's looks, but also becomes a cause of physical deterioration [3]. Late life is often seen as a time of great, often uncontrollable, stress [4]. Quality of life also is improved through participation in older adults, via increased bone health, functional capacity and independent living, as well as reduced depression anxiety and stress [5,6].
 
Psychiatric care of elderly people require more efforts than that of younger patients. Successful treatment of elderly patients requires a demanding mélange of psychological, medical, social, political, and managerial skills. An association was found between severe life events, major social difficulties, poor physical health and the onset of depression in old age. Matteson and McConnell (1988), pointed out that ageism decreases social status, and diminish contact with younger people. It affects the health care of older people by influencing the attitudes of health care professionals and policy makers towards the aggressiveness of diagnosis and treatment of the elderly. These attitudes are often based on erroneous assumptions regarding the utility of chronological age as a marker of function or ability to contribute to society. The tragedy of ageism is that it robs society of the fullest contributions of its older members, and it denies people's fulfillment of their potential as human being throughout the life course. All over the world, the family remains the cornerstone of care for older people who have lost the capacity for independent living, whether as a result of dementia or other mental disorder. For late-life depression we have antidepressants and stepped care, multidisciplinary interventions [7-10]. For dementia, psychosocial interventions for caregivers, behavioural management strategies [11,12] have all been shown to be at least moderately effective. Our limitation is more in having the resources or systems to deliver effective interventions to those who might benefit, both in the community and in care homes [13,14]. Social interaction is a major source of life satisfaction in old age and declining health is often the cause of distress in old age [15]. This is most marked in developing countries, where there are very few psychiatrists or other mental health professionals. The World Health Organization (WHO)'s Mental Health Atlas surveyed the resources available and found fewer than one psychiatrist per 100,000 population across India, China and much of the rest of South and South East Asia, and fewer than one psychiatrist per million population in most of sub- Saharan Africa. Hodgins and Sheilagh [16], reviewed research and argued that new mental health policy and programs are needed to deal with the major mental disorders (Schizophrenia, major depression, and bipolar disorder). Currently in India the advancing medical technology and health care provision has dribbled to almost everyone's reach. So it is expected that the elderly will live longer than was expected earlier. The life expectancy at age 60 has almost doubled from 1901 to 2001, 9.5 years to 16 years for man and 102 to 18.1 years for woman respectively (Government of India, 2005).
 
The traditional welfare institutions and higher socio-cultural values of Indian higher society provided respect and care for the elderly people .The aged in the families were generally taken care of by the families itself [17]. But increasing industrialization, modernization and urbanization have had negative impact on the traditional institution and socio-cultural values of the families [18].These have resulted in breaking of the joint family system and migration of children in search of jobs leading to the deterioration of the higher socio-cultural values of Indian society, and rapid transition in the structure and functioning of the family.
 
The structure in the family refers to the type of family (i.e. joint, nuclear, and extended) and functioning denotes the dynamics of interaction, interpersonal relations and communication between family members. Healthy interaction between family members leads to healthy relationship created and reinforced by positive communication. But due to structural changes in the changing the family relation and the communication pattern have inevitably changed. This transition in all the three components is a serious threat for healthy aging at the level of the family.
 
Elderly people are encountering both physical and psychological distancing in families, they feel isolated and side tracked [19]. These changes the family level and unhealthy approaches sometimes hurt them and encourage them to relocate themselves in old age homes or day care center. Some times their family members force them to shift to old age homes or day care center but elderly usually prefer to derive a sense of meaning of connectedness to their homes, their neighborhood and their natural environment [20]. For this they are usually ready to make compromises which tax their physical and mental well-being. Depression and emotional shocks are common among them. They develop negative emotion towards themselves due to lack of employment, low income and failing health, the newly added worries and feeling of neglect, loss of importance in the family, feeling of inadequacy loneliness and of being unwanted [21]. Persons who are dependent on physical appearance and youth for their identity are likely to experience loss of self esteem with age [22]. The organization of older person's lives probably exposes them to fewer stressing events than in earlier years (e.g. marriage, divorce disruptive conflict, changing or losing jobs, having children etc.). Life changes per se do not create stress; rather, adverse effects results from events that are considered unexpected or for which people are not prepared. The individual's perception of this experience has much to do with whether or how much stress accompanies his or her life events [23].
 
According to the advanced learner's dictionary of current English, "Attitude is defined as a way of looking, thinking, feeling or behaving." Therefore an attitude is defined as ones feeling or mood towards things, circumstances and people. Attitude is more important than experience or education. Attitudes of individuals affect their appraisals, their perception and their judgment and behavior in relevant situations both experimental and natural. Attitudes provide a frame of reference that helps us structure and make sense out of the world and experiences. We often use attitude as the tie breaker between two equally qualified candidates. According to Fishbein and Ajzen [24], an attitude is "a learned précis position to respond in a consistently unfavorable manner with respect to a given object. Thurstone [25] defined as "attitude is the intensity of positive or negative effect for or against a psychological object. GW Allport [26] proposed that "an attitude is a mental and neural state of readiness, organized through experience exerting a directive or dynamic influence upon the individual's response to all object and situations with which it is related". A positive attitude is therefore the inclination to generally be in an optimistic, hopeful state of mind. Generally we divided life attitude in two categories i.e. positive & negative. An example of a negative attitude towards life is being pessimistic that things will never turn out well whereas a positive attitude is characterized by high esteem, high self confidence, trustful and being optimistic [27]. Often the causes of "developing negative attitude towards life" are more mental than physical. A bad relationship, poor self image, a history of abuse, stress, frustration and many other factors can changes over all attitude towards life which may directly impede person’s overall performance. Thus elderly people are at greater risk to develop negative attitude [28]. proposed that the existential constructs of personal meaning and personal choice/irresponsibleness have value in understanding adaption to physical and mental health problems in older adults. Personal meaning is defined as having a purpose in life, having a sense of direction, a sense of order and a reason for existence, a clear sense of personal identity, and a greater social consciousness. Personal choice/irresponsibleness have been shown to be related to a number of measures of psychological, physical, and mental well-being, and are a major source for bolstering self-esteem, life satisfaction, and personal growth in the face of disability and losses that often accompany advancing age [29,30,28]. Laurent (1990) commented on attitudes to old people in Great Britain, that they are regarded as "stupid, decrepit, feeble, or unusually eccentric, wise or sweet natured, and in any event to be patronized". She then referred to a from the King's fund that claimed that " such attitudes pervade the health service and mean that services are based on deep seated stereotypes of what old people are like, rather than what they need or want". Lawton (1985) claimed that "nowhere is the attitude against ageing more manifest than among the health professionals". Collison (1992) wrote "unfortunately our society still tends to hold negative attitudes about ageing and the aged" Little research has been done on nurse's attitudes to the elderly, but Collison has suggested that nurse's attitudes toward general.
 
Reker [31], Developed Life Attitude Profile Revised (LAP-R) to measure, meaning and purpose in life and the search of meaning. These are six components of life attitude: Purpose, Coherence, Life control, Death Acceptance, Existential vacuum and Goal seeking. Purpose refers to having life goals, a sense of direction from the past in the present and towards the future. Coherence refers to having a sense and reason for existence and a clear sense of persona/ identity. Life control is an operational index of the degree to which one perceives personal agency in directing his or her life. Death acceptance refers to the absence of anxiety about death and the acceptance of death as a natural aspect of life. Existential vacuum refers to an absence of meaning in life, boredom, apathy, or feelings of indifference. Goal seeking concerns the desire to get away from the routine of life and to search for new experiences and challenges and an eagerness to get more out of life.
 
Elderly day care centers, also called Adult day care centers provide programs for adults in a community-based group setting. These programs are generally planned to provide daytime social/ health services to adults who need supervised care outside the home. Some centers may offer significantly more services. Day care centers offer seniors the chance to live with family and not be a 24 hour burden, opportunities for social interaction with peers and mental stimulation, a program of stimulating activities, meals and snacks with provisions for special dietary needs, physical, occupational or speech therapy in a non-medical environment, help with activities of daily living with dignity, transportation for daily needs. Day care center for elderly looks for round trip transportation, facilities for bathing and hair washing, licensing for administering medicine and medical procedures, professional qualifications of staff, interview the staff, the owner or sponsoring agency identity, number of years in operation, manage schedule of activities, nutritional meals prepared on site or by a qualified outside source, deal with medical conditions like Alzheimer’s disease, dementia or incontinence. A full activity schedule provides more stimuli. A good adult day care center responds quickly to changing needs.
 
Stanley and associates [32] explored change in leisure activity participation with age and health status. The mail survey consisted of both closed and open ended questionnaire that asked about their current status, attitudes concerning work, retirement, and health and leisure activity. Results indicated that age and health had a greater impact on the leisure activity participation of men than woman; however its impact varied by type of activity more for women. Men's participation in all categories of activities declined significantly over the time period, while women maintained their involvement in the activities across age and changes in health. Quackenbush and associates (1995) proposed that elderly individuals (60-75 yrs) completed a reminiscence questionnaire assessing (1) the extent to which reminiscence is motivated by a desire to enhance self-understanding (2) reminiscence affect, and (3) the preferred social modality of reminiscence .The respondents also completed questionnaires assessing existential vacuum, extraversion, and the recent experience of various life events Existential vacuum was positively associated with a tendency to engage in reminiscence in an effort to enhance self-understanding as well as a negative bias in reminiscence affect. Extraversion was positively related to a preference for interpersonal reminiscence specific life experiences (e.g. death of a spouse, retirement) were also related to reminiscence activity. Results provide support for the nation that aspects of reminiscence activity are associated with individual differences in specific psychological and situational variables, Older people who expressed good life satisfaction had better social supports, a positive life review, a fair amount of physical and mental activity, and were self confident in most of their affairs [33].
 
The severity of elderly abuse is increasing day by day, the worst sufferers of abuse in the society are elderly people. There is a large gap between the problems of the aged and the available resources. Although voluntary organizations such as day care centre are engaged in taking care of elderly, their limitations disable them from addressing the magnitude of the problem. Day care centres provide seniors with the best of opportunities for a productive living. They support them by attending to the issues like taking them to banks and hospitals, attending to their needs during emergency, providing them companionship by meeting them often and discussing their problems. Also the centre works towards getting jobs to retired employees. Most of the government or NGO facilities like day care centers are urban based. Since 75% of the elderly reside in rural areas, it is mandatory that geriatric health care services be made a part of the primary health care services.
 
The demographic picture of every country keeps changing rapidly and constantly.We need to study ageing because of the rapidly increasing population of elderly and their age related problems pertaining to their health, attitude etc. As the elders are the better assets for any country and they have rich experiences and wisdom, they may contribute in the progress of any nation but due to diminished physical and mental abilities and depending on their psychological situation, they are somehow discarded from the normal working population. It is believed that now only 60% of senior citizens live in joint families in India, rest of them live alone with their spouse or in day care centre or in old age homes. Hence an understanding of the situation of the elderly is necessary to avert catastrophic consequences. Keeping them busy in social and productive activities can change their attitude towards life. Day care centres provide aged with the best of opportunities for a productive living. It is presumed that elderly having positive attitude towards life must have good general health. So we decided to carry out a pilot study where life attitude, general and mental health were assessed and compared in elderly living with their family and in day care centre.
 
Materials and Methods
 
Objective
 
To assess and compare the level of general health, life attitude and mental health parameters (depression, anxiety and dementia) in elderly living with their family (n=45) and at day care centre (n=45).
 
Sample selection
 
The subjects aged 60 years or above, literate, belonging to middle class strata were selected randomly from their family and Day care centre (Anubhav day care center, Helpage India, Jaipur, Rajasthan, India). Demographic characteristics of samples are given in Table 1.
 
Table 1: Demographic characteristics of study sample.
 
Description of the tool
 
Following standardized tools were used to conduct the study:
 
General health questionnaire- General Health Indian adoption of Goldberg's general health questionnaire by Dr. Shiv Gautam Madan, Nijhawan and Preet Kama (1987) was used.
 
Life attitude questionnaire- The life Attitude profile (LAP) developed by Reker [31] was used. 6 variables of this questionnaire are Purpose, Coherence, Choice/ Irresponsibleness, Death Acceptance, Existential vacuum and Goal seeking.
 
Depression- 30 question Geriatric depression scale was used [34].
 
Anxiety- Beck anxiety inventory (1988) was used to assess anxiety in subjects.
 
Dementia- Abbreviated mental score developed by Hodkinson (1972) was used for assessment of mental impairment in the elderly.
 
Procedure for data collection
 
After the sample selection, our attempt was made to establish rapport with the subjects. The purpose of the research was explained to them. The subjects were also informed that the data obtained will be kept strictly confidential and will not be missed and will be used only for research purpose. All the questionnaires were administered personally by the researcher. Instructions for each questionnaire were given on the basis of the information provided in the manual. Special care was taken in administering tests properly, if necessary, translated and described in their local language giving them fatigueless environment.
 
Statistical analysis
 
Statistical comparison was performed using Mann-Whitney test and Chi-square test for all qualitative data. All statistical analyses were performed using SPSS statistical version 16.0 software package (SPSS® Inc., USA) at Department of statistics, CIMS (Centre for interdisciplinary mathematical sciences), Banaras Hindu University, Varanasi. P value <0.05 were considered statistically significant.
 
Results
 
The results of this observational study indicated that Geriatric depression scale score was significantly higher in elderly living in day care centre (7.51 ± 4.49) when compared with elderly living with their family (5.62 ± 2.29) after applying Mann-Whitney test. When Chi square test was used for categorical comparisons, significant difference was found (P=0.044, df = 1) between elderly living with family & living in day care center (Table 2 and 7, Figure 1). Similarly, General health parameters were found to be better (score 9.96 ± 4.57) in elderly living with their family than subjects living in day care centre (6.24 ± 1.85) when compared using General Health Indian adoption of Goldberg's general health questionnaire (Table 5,10, Figure 4).
 
Figure 1: Showing comparison of number of subjects in different categories of Geriatric depression scale.
 
Table 2: Comparison of group I and group II scores on the Geriatric Depression Scale. (Group I: Elderly living with family, Group II: Elderly living at day care centre).
 
Table 3: Comparison of group I and group II scores on the Abbreviated mental test score for dementia. (Group I: Elderly living with family, Group II: Elderly living at day care centre).
 
Table 4: Comparison of group I and group II scores on the Beck anxiety inventory. (Group I: Elderly living with family, Group II: Elderly living at day care centre).
 
Table 5: Comparison of group I and group II scores on the General health questionnaire. (Group I: Elderly living with family, Group II: Elderly living at day care centre).
 
Table 6: Comparison of group I and group II scores on the Life attitude profile-revised. (Group I: Elderly living with family, Group II: Elderly living at day care centre).
 
Table 7: Geriatric depression scale score (0-30).
 
Abbreviated mental test score was found to be 5.42 ± 2.26 in group of elderly living with their family whereas it was 6.98 ± 1.70 in elderly living in day care centre. It clearly showed that prevalence of dementia was significantly higher among elderly living with their family. Significant difference was also obtained in Chi square test (Table 3 and 8, Figure 2). Similarly, results of Beck anxiety inventory also showed higher prevalence of anxiety disorders among subjects living with their family (score 19.51±9.14) than those living in the day care centre (12.96 ± 5.73; Table 4 and 9, Figure 3).
 
Figure 2: Showing comparison of number of subjects in different categories of Abbreviated mental test for dementia.
 
Figure 3: Showing comparison of number of subjects in different categories of Beck anxiety inventory.
 
Figure 4: Showing comparison of number of subjects in different categories describing general health level according to Goldberg’s general health score.
 
Table 8: Abbreviated Mental test Score (0-10).
 
Table 9: Beck Anxiety Inventory score (0-63).
 
There was no significant difference in level of Attitude among subjects living with their family and in day care centre when compared using Life attitude profile-revised score (Table 6 and 11, Figure 5).
 
 
Table 10: Goldberg’s general health score (0-60) and Level of General Health.
 
Table 11: Life attitude profile-revised score (48-336) and level of Life attitude.
 
Figure 5: Showing comparison of number of subjects in different categories describing level of attitude according to Life attitude profile-revised score.
 
Discussion
 
Ageing is an inescapable reality of the human existence. Fall in birth rate and rise in availability of better medical facilities will result in rapid graying of the population and add to the proportion of the geriatric population. According to some, changing balance between the age groups would make the aged more of a burden on society. A rapid spread of modernization, growing urbanization and crumbling of joint family system all have conspired to increase insecurity and loneliness among the geriatric population. Deteriorating health and economic insecurity are the most pressing problems facing the elderly population in the villages. Lack of family support, poor financial status, physical and mental disorders and guilt of being dependent on others are problems nagging the elderly population in India and other countries around the world. An increasing demand for geriatricians with knowledge and expertise are required to handle and treat the elderly population. From the family side, the elderly population looks forward to emotional support, love and affection. The biggest enemies of the geriatric population include solitude, loneliness, isolation, neglect and a sense of not being wanted that can lead to many mental and impending medical disorders even in apparently healthy elders. In order to combat loneliness, the elderly population should interact with their friends, families and neighbors. Very little attention has been focused on the pitiable plight of the elderly population especially in developing countries. It is suggested that the aged should be made to involve themselves in creative and developmental programmes. Care giving certainly involves a significant expenditure of time, energy and money over potentially long periods of time; it involves tasks that may be unpleasant and uncomfortable and are psychologically stressful and physically exhausting. Care giving is a lifespan experience. The process of care giving and its public health importance is needed to be understood.
 
Family caregivers are valuable to our economy but they often need additional help in caring for the beloved old people. Providing proper care to the older persons is an enormous task both physically and mentally. So for care of elderly people many day care centres and old age homes are being run by NGOs. According to the national portal of India there are more than a thousand old age homes in India. Many of them are charitable organizations which offer free shelter. Others charge according to the services and facilities they provide. Yet others act as day care centers. Adult day care centers can be public or private, non-profit or for-profit. They provide older adults an opportunity to get out of the house and receive both mental and social stimulation. Basically the services provided are a decent place to live among other elderly citizens, food and medical facilities. Some offer yoga classes, telephone and Internet access, weekly movies etc. By staying active during the day and returning home in the evening, elderly keep a sense of independence and remain close to their families.
 
In developing countries like India, there is hardly any social, health related and psychological study depicting comparison of level of health and attitude between elderly living in day care centres and those living at their home. To evaluate importance of day care centres and to know if they aid in improving mental health and attitude, we selected various parameters like general health questionnaire, Life attitude profile revised, depression scale, anxiety inventory and dementia scale for comparing health and attitude status among these elderly people. In a study on Chinese elderly in Singapore by Low and associates [35], it was felt that there is a need for closer communication between older persons and their carers with regard to end-of-life care. Need of day care centres has been experienced because of the fact that for working caregivers (family members), greater conflict on the job was associated with higher role overload in care of cognitively impaired elderly [36]. According to Martin and associates [37], who conducted a study in low income countries, the most cost-effective way to manage people with cognitive impairment will be through supporting, educating and advising family caregivers. The next level of care to be prioritized would be respite care, both in day centres and in residential or nursing homes. Importance of family in mental health care is well known. Our results showed decreased prevalence of depression in elderly living with their family. General health status was significantly better in elderly living with their family.
 
Anxiety disorders and dementia were found to be more prevalent among elderly living with their families than those living in day care centre. In a study by Dennis and Jim [38], measures of social contacts and instrumental support exerted small to moderate effects on life satisfaction, psychosomatic distress, and emotional distress. Day care centres provide excellent opportunities for recreational activities and to interact with peers which continuously stimulate mind of elderly. This may be an explanation for lower anxiety score and lesser chances of dementia in subjects living in day care centres. No two single elderly care centers are exactly alike. Each might have a different set of services they cater to their residents nonetheless they often involve elderly people in diverse activities as well as relaxing techniques which may contribute to relieve their anxiety. Wang and associates (2002) also found that late life engagement in social and leisure activities was associated with a decreased risk of Dementia.
 
Difference in Life attitude profile score between two groups remained insignificant and inconclusive in our study and no correlational hypotheses were thus made. So the present pilot study can be regarded as a preliminary approach towards seeking valued status of day care centres in policy making in developing countries particularly in Indian perspective. Comparisons may be more conclusive and revealing with additional medical and psychological findings if replicated on large and multicentric samples.
 
Acknowledgement
 
We are heartily thankful to all elderly subjects participating in this study and Anubhav day care center, Helpage India, Jaipur for their valuable and consistent support in our study.
 
 
References