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 Table of Contents  
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 95-100

Assessment of psychiatric variables in geriatric patients diagnosed with different types of osteoarthritis: Radiographic-based evidences

1 Student, Department of Clinical Pharmacy and PharmD, Vaagdevi College of Pharmacy, Warangal, Telangana, India
2 Professor, Department of Orthopedics, Kakatiya Medical College, Mahatma Gandhi Memorial Hospital, Warangal, Telangana, India
3 Associate Professor, Department of Clinical Pharmacy and Pharm D, Vaagdevi College of Pharmacy, Warangal, Telangana, India
4 Principal, Department of Clinical Pharmacy, Jayamukhi College of Pharmacy, Kakatiya University, Warangal, Telangana, India
5 Head, Department of Clinical Pharmacy and Pharm D, Vaagdevi College of Pharmacy, Kakatiya University, Mahatma Gandhi Memorial Hospital, Warangal, Telangana, India

Date of Submission31-Jul-2020
Date of Acceptance30-Oct-2020
Date of Web Publication14-Jan-2021

Correspondence Address:
Dr. Venkateshwarlu Eggadi
9-1-175/1, Vishwakarma Street, Warangal - 506 002, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AMH.AMH_35_20

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Context: Osteoarthritis (OA) is the most prevalent musculoskeletal condition in the world and is the most common cause of joint disability in approximately 15% of the total world population. The severity of the disease increases with age. It can have adverse effects on mental stability and is associated with poor clinical prognosis.
Aim: The aim of the study is to assess psychiatric variables (depression, anxiety, and perceived stress) in geriatric patients diagnosed with OA based on radiographic evidence and the item(s)/question(s) from questionnaires influencing their emotional instability.
Settings and Design: The prospective observational study was conducted in a tertiary care Mahatma Gandhi Memorial Hospital, Warangal.
Subjects and Methods: The study conducted for a period of 6 months and encompasses 158 elders with different types of OA. Standardized questionnaires were used to assess psychiatric variables.
Statistical Analysis Used: Statistical analysis was conducted using Microsoft Excel 2019 and IBM SPSS Statistics for Windows, Version 22.0. (IBM Corp, Armonk, NY, USA).
Results: The results of Pillai's trace revealed the scores of depression and anxiety as severe and perceived stress as moderate. Linear logistic regression stepwise disclosed the order of included variables affecting depression, anxiety, and perceived stress based on their level of significance (P < 0.05).
Conclusion: The findings in our study exemplify a strong correlation between psychiatric variables and OA.

Keywords: Anxiety, depression, geriatric patients, osteoarthritis, perceived stress

How to cite this article:
Komuravelly S, Chevireddy SR, Katam RR, Bandaru S, Sindgi V, Eggadi V. Assessment of psychiatric variables in geriatric patients diagnosed with different types of osteoarthritis: Radiographic-based evidences. Arch Ment Health 2020;21:95-100

How to cite this URL:
Komuravelly S, Chevireddy SR, Katam RR, Bandaru S, Sindgi V, Eggadi V. Assessment of psychiatric variables in geriatric patients diagnosed with different types of osteoarthritis: Radiographic-based evidences. Arch Ment Health [serial online] 2020 [cited 2023 Jun 5];21:95-100. Available from: https://www.amhonline.org/text.asp?2020/21/2/95/306866

  Introduction Top

Osteoarthritis (OA) is the most prevailing polymorphic whole-organ disease with a variety of clinical presentations, primarily characterized by defective integrity of articular cartilage due to pathologic changes between synthesis and degradation of cartilage.[1],[2],[3] It is also accompanied by underlying bone changes such as thinning of joint space, subchondral sclerosis, osteophytes formation at the joint margin, and synovial inflammation in many affected joints.[4] These processes often result in joint pain, loss of mobility, stiffness of joint, painful range of motion, and cracking of joints (crepitus), leading to long-term disability.[3] The pathophysiology involves a complex interplay among various mechanisms that include chondrocyte regulation, proteolytic degradation of cartilage components, and phenotypic changes.[5] The utmost important aspect responsible for the disease is increasing age. However, aging solely does not cause OA, yet it stimulates the progression of OA in association with other risk factors. Globally, OA is one of the fifty most prevailing diseases. Of the global burden of disease, knee OA constitutes 83%. Epidemiological data disclose more than one-third of the population over 65 years and the younger population outline radiographic confirmation and injury-induced OA, respectively. Based on radiographic criteria for OA, the European League against Rheumatism committee reports 30% of knee OA over 65 years of age[6] and other types of OA with lesser predominance. The preponderance of OA is higher in women than in men in individuals older than 55 years.[7] Nearly 18% of women and 9.6% of men reported symptomatic OA in 60 years and a higher age group.[8] A plain radiograph is the current gold standard for the morphological assessment of OA. The Kellgren and Lawrence grading system (K/L grade) is the most acknowledged and widely used clinical tool for radiographic diagnosis and aids in clinical decision-making through an evidence-based approach.[9] Patients suffering from chronic disabling conditions report anxiety, depression, and psychosocial factors particularly stress as comorbidities. OA can have emotional outcomes, leading to poor clinical prognosis. This can alter pain threshold levels and vice-versa.[10] The occurrence of OA has been affiliated with aberrant emotional well-being. Researchers surmise that there is an association between dysphoric effect and OA. Adjustment disorders escorted with delirium, depression, and anxiety are seen in more than half of the patients experiencing psychological distress. Besides, these disorders are aggravated by the illness. OA persuades psychological attributes that become a mark for melancholy and pain. Psychological distress may interrupt a patient's quality of life (QOL). Severe immobility, arduousness in sleeping, and experiencing ache or strain are the adverse impacts on QOL and are escalated by depression associated with OA.[11]

Diagnostic Statistical Manual-5 denotes depression as the prevalence of sad, empty, or irritable mood. The main factors responsible for depression in the elderly are chronic pain associated with arthritis, social isolation, and loneliness. Researchers suppose that there is a circumscribed relationship amidst depression, symptoms of depression, and disabling conditions of the disease. OA who suffer from depression expresses the pain more compared to normal patients.[12],[13],[14] Anxiety is characterized by the presence of fearfulness and jitters about what is going to happen, and this uneasiness leads to changes in physiology and behavior. This may affect the patient more often to experience pain and adversely affect psychological health in patients with OA.[13],[15] Stress involves an interpersonal event such as trauma or response to a situation such as stress perception are considered as a risk factor. Concerning symptom expression and the onset of arthritis perceived stress may play a relevant role and the perception of stress evokes negative emotional states that in turn trigger behavioral and/or physiological responses that may have harmful health effects. Perceiving life chronically as stressful is an influential factor in the stress-chronic disease mechanism.[15] To correct the condition precisely, it is fundamental to obtain perception into predominance, the direction of the psychological anomaly, and the cause influencing them. Management strategies for patients experiencing psychological comorbidities need self-care, telephone support, audio/video education programs, social support, and coping strategies to a stressful event that reduces psychological distress such as anxiety and depression during times of stress. Recent evidence suggests that exercise programs (minute walks, minute march, aerobic, and balance training) and physical activity helps improve the strength of muscle, relieve pain, ameliorate physical function, enhances mood, decreases depression and stress, improves cognitive function, and increases the QOL.[10],[12],[13],[14],[15],[16],[17]

  Subjects and Methods Top

This prospective observational is a study conducted in the Orthopedic Department of Mahatma Gandhi Memorial Hospital, Warangal, with approval from the Institutional Review Board, Ethics committee (approval no: IHEC/VCOP.PHARM.D/2019-20/NCT04). A total of 158 subjects with OA of age above 65 years were included in the study. The subjects were selected based on the following inclusion and exclusion criteria before the initiation of the study: (1) patients diagnosed with an unreformable diagnosis of different types of OA; (2) patients of age above 65 years; (3) no previous history of psychiatric conditions; and (4) no history of psychotropic or psychoactive drug use. Exclusion criteria include: (1) patients below 65 years of age; (2) patients presenting with comorbidity of chronic diseases such as cancer, thyroid diseases, multiple sclerosis, asthma, renal failure, heart failure, and neurologic diseases (cerebral palsy and  Parkinsonism More Details) and psychiatric illness (depression, anxiety, and perceived stress) before developing arthritis. Data collection tools were standardized questionnaires to assess the psychiatric variables. First, a demographic dataset was used to record the personal characteristics such as height, weight, gender, diagnosed disease, K/L grade and duration, educational level, occupation, social history, family history, and comorbidities.

The Geriatric Depression Scale (GDS) is a 30-item self-reporting questionnaire used for the interpretation and evaluation of elder's depression. This generic scale shows strong internal consistency with favorable reliability and validity. To accomplish the GDS, the individual is required to mention the presence of the symptom present over the past week. The result is obtained by adding the scores of all responses in terms of severity the cutoff range includes 0–9 score means normal, 10–19 moderate depression, and 20–30 severe depression.[18] The Geriatric Anxiety Scale (GAS) is a quantitative self-reporting measure for the assessment of anxiety symptoms over the past week designed for use in the elder population, which includes ten items, and each item is scored from 0 to 3. There are four possible responses in terms of severity and the items from 1 to 10 are summed to provide a total score. Scores 1–6 indicate minimal anxiety, 7–9 indicate mild anxiety, 10 indicate moderate anxiety, the scores 12, 14, 16, 18, 24, and 30 indicate severe anxiety.[19] The Perceived Stress Scale appraises the extent of perception of the situation in an individual's life over the past 4 weeks. It is a 10-item questionnaire, each item is scored from 0 to 4, and scores for four items are obtained by reversing the scores 0 = 4, 1 = 3, 2 = 2, 3 = 1, and 4 = 0. The result is obtained by summing the scores of all responses. Scores ranging from 0 to 13 are considered as low perceived stress, 14–26 is considered as moderate perceived stress, and 27–40 is considered as high perceived stress.[20] Statistical analysis was conducted using software (Microsoft excel 2019 and SPSS 22.0). Descriptive analysis of the data was provided in terms of mean and standard deviation. Multivariate analysis of variance, Pillai's trace (P < 0.0001), and Linear logistic regression (P < 0.05) was calculated.

  Results Top

All the eligible subjects participated in the study. The mean age of OA patients was (72.2 ± 6.7), the majority of patients were females (70.8%), and the most common age group being 65–74 years (58.2%). Considering the body mass index (BMI), the preponderance of subjects was preobese (89.7%), of which maximum were females. Nearly 20.7% of patients presented with a family history. Out of 158 OA patients, 1.8% had foot OA, 3.1% shoulder, 6.2% hand, 15% spine, 15.7% hip, and 57.8% knee. Scrutinizing various history of occupations majority were farmers and daily labor with 33.5% and 31%, respectively. After being adjusted for K/L grade, a higher proportion was Grade I and Grade II with 46.8% and 34.8%, respectively [Figure 1]. Moderate correlation between disease duration and psychiatric variables was observed, with R2 value 0.6014 for depression and duration of illness, 0.1562 for anxiety and duration of illness, and 0.4512 for perceived stress and duration of illness [Figure 2].
Figure 1: Distribution of grades of osteoarthritis among subjects

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Figure 2: Correlation between duration of illness and psychiatric variables

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This study involved the assessment of psychiatric variables (depression, anxiety, and perceived stress) in OA patients. In general, depression, anxiety, and perceived stress were seen in almost all patients, but the severities varied. Among 158 subjects, severe depression and anxiety were observed and perceived stress was moderate [Table 1].
Table 1: Psychiatric variables in osteoarthritic patient's

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Linear logistic regression stepwise is carried out to assess majorly influencing item(s)/question(s) affecting geriatric psychiatric variables in OA. This analysis revealed the order of inclusion of items affecting based on the level of significance and are mentioned below [Table 2].
Table 2: Inclusion of the items based on their order of influence

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  Discussion Top

This research work was established for the assessment of psychiatric variables in geriatric patients with OA. Our results suggest that age, sex, family history, occupation, BMI, disease duration, and severity contribute to the changes in patient outcome variables.

In this study, among 158 subjects, 46 subjects were males (29.1%) and 112 were females (70.8%), which was juxtaposed to Nageshwaran and Suresh[21] reported that 67 (33.5%) patients were males and 133 (66.5%) patients were females.

The mean age of our study was 72.2 ± 6.7. The maximum number of OA patients belonged to the age group of 65–74 years with a percentage of 58.2% (n = 92), followed by the age group of 75–85 years 31% (n = 49). The least number of patients belonged to the age group of above 85 years, with a percentage of 10.7% (n = 17). A study by Shams et al.,[11] reported that the prevalence of OA is most common in the geriatric age group of 60–74 years.

A family history of OA was present in 20.7% of patients in our study. A study by Mangat et al.[22] reported similar observations with a family history of 13.7%.

Data from various research studies show occupation as a positive risk factor in patients with OA. Occupations involving knee bending, squatting, and straining activities were affected more than the other ones. This research work shows that farmers 33.5% (n = 53) followed by daily labors with a percentage of 31% (n = 49) were at higher risk. This relationship between OA and occupation was found significant, which can be compared to a study report by Cooper.[23]

In our study, BMI is higher in females than in males, which is a main modifiable trait in OA. The WHO classification of BMI includes six categories and are: under weight, normal weight, preobesity, obesity Class I, obesity Class II, and obesity Class III off which most of the female patients pertained to the categories preobesity and obesity Class I with a proportion of 89.7% (n = 36) and 81.8% (n = 9), respectively. According to the data from the National Health and Nutrition Examination Survey, the probability of developing OA is four times more common in obese women than in nonobese women.

The diagnostic distribution of the study shows that knee OA is the most common type, accounting with a percentage of 57.8% (n = 91), followed by hip OA 15.7% (n = 25) and spine OA 15% (n = 24). A minimum number of patients were affected with other types such as hand OA, shoulder OA, and foot OA with a percentage of <12%. A study by Litwic et al.[24] reported analogous observations that hips and knees tend to cause the greatest burden to the population and often lead to significant disability.

The duration of illness when correlated with the association of mental health, a significant result was obtained with an R2 value of 0.601 for depression, 0.156 for anxiety, and 0.451 for perceived stress. However, this observation differs from that made in a study by Weiss.[25] This study observed that poor clinical outcomes do not correlate with the graded severity of the disease. The maximum number of patients with Grade I severity with 46.8% (n = 74), followed by Grade II severity with 34.5% (n = 55) were at higher risk of disease impact according to K/L grading system which defines Grade 0 (no abnormality), Grade 1 (incipient OA, beginning of osteophyte formation on eminences), Grade 2 (no abnormality, moderate joint space narrowing, and moderate subchondral sclerosis), Grade 3 (>50% joint space narrowing, rounded femoral condyle, extensive subchondral sclerosis, and extensive osteophyte formation), Grade 4 (joint destruction, obliterated joint space, subchondral cysts in tibial head and femoral condyle, and subluxed position).

When geriatrics were examined for the severity of depression, anxiety, and perceived stress, the results demonstrated that middle old (75–85 years) with 18.9% (n = 30) followed by old old (>85 years) with 10.1% (n = 16) accounted for a higher risk of depression and young old (65–74 years) reporting moderate risk with 24.6% (n = 39). The results were found significant with a study conducted by Nageshwaran and Suresh.[21] Interestingly, anxiety was found higher in young old reporting severe anxiety with 32.9% (n = 52), followed by middle old and old old at high risk of anxiety with 14.5% (n = 23) and 6.3% (n = 10), respectively. All three age groups reported moderate levels of perceived stress with 36% (n = 57), 17.7% (n = 28), and 5.6% (n = 9) in the order of young old, middle old, and old old. The illustrations of stress were similar to the study reported by Nageshwaran and Suresh.[21] All the scales were used to define the intent and absolute criteria to find out the influence of psychiatric variables on the disease (P < 0.05). Our results demonstrated a solid correlation of psychiatric variables with the disease accounting with a greater significance (P < 0.0001).

Besides these, the post hoc tests (Tukey HSD) are performed for each psychiatric variable (GDS,GAS, PSS) and the results can be seen from [Supplementary Table 1-3][Additional file 1].

  Conclusion Top

OA can flare up negative effects on physical and mental health. The outcomes of the disease such as restriction of movement and increased depression can have a negative impact, especially in elders. This study assessed psychiatric variables in elders with OA. The findings proved a significant relationship between psychiatric variables (depression, anxiety, and perceived stress) and OA. Therefore, personality traits and emotional states predict clinical outcomes. Our results strongly show a need for psychological intervention and evaluation when these psychological factors lead to poor clinical prognosis. In addition, the close association between orthopedists and psychologists helps to reform patient outcomes and QOL.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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