Pakistan Journal of Professional Psychologists Vol 5, No.

1, 2014

Depression, Anxiety, Coping and Quality of Life among Elderly

Living in Old Age Homes and in Family Setup

*Nadab Parshad
Kinnaird College for Women, Lahore
Amjad Tufail, Ph.D.
Govt. M.A.O College, Lahore

The present study explored differences in depression, anxiety, coping and

quality of life between elderly residing in old age homes and within
family setup. It was predicted that elderly in old age homes will have
higher depression, anxiety and poor quality of life however no difference
on coping was predicted between the two groups. A sample of 120
elderly: 60 from old age homes and 60 from family setup participated.
The measures used were: Pakistan Anxiety and Depression
Questionnaire, Brief COPE Inventory and World Health Organization
Quality of Life Questionnaire. Data was analyzed using Independent
sample t-test. Results revealed high scores on depression, anxiety and
quality of life among elderly residing in old age homes compared to
elderly living with their families. Moreover, elderly living in old age
home used more of maladaptive coping and elderly living with families
used more of adaptive coping strategies.

Keywords: Depression, Anxiety, Coping, Quality of Life, Elderly, Old

Age Homes, Family Setup

The current study was undertaken to investigate differences on

depression, anxiety, coping and quality of life between elderly living in
old age homes and within family setup. Surprisingly, there is a dearth of
literature on psychological issues faced by older people in Pakistan. As
we are aware that a silent transformation has happened in the most recent
100 years and the greatest accomplishment of the century is longevity,
globalizing and urbanization. As these changes are taking place, the
meaning of old age is changing across families, cultures and countries
(Bergeron, 2001).
Traditionally, Pakistani families have provided the older members
of family with social security. On the other hand, it has been observed
that in recent years there has been a noticeable change in the

*Correspondence concerning this article should be addressed to Nadab Parshad,

Kinnaird Collage for Women, Lahore, Pakistan. Email: nadabparshad@[Link],
Amjad Tufail, Govt, M.A.O Collage, Lahore. Pakistan
18 PARSHAD AND TUFAIL

conventional Pakistani family system. Nowadays, families are moving

from joint family system into nuclear system. Unfortunately, such
changes in family systems, have transformed position of the elderly in the
family and conventional family role is replaced by old age homes
(Kramer et al., 2005). Thus, feelings of being isolated and poor social
relationships along with decrease in physical and cognitive functioning
makes older people more venerable to psychological problems (Cano et
al., 2003; Marino, Sirey, Raue, & Alexopolous, 2008).
World Health Organization indicates that approximately 15% of
elderly people aged 60 years and more often experience mental disorders
(World Health Organization, 1999). Mental Health Foundation (2009)
statistics indicates that 20% of elderly living in community and 40%
living in old age homes suffer from depression (McEvoy, 2013).
Moreover 10 to 20% of the elderly suffer from anxiety. Generally older
population complains more about physical symptoms in depression rather
than low mood as compared to young adults suffering from depression
(Baldwin, 2002; Baldwin, 2008). Anxiety and feelings of irritability are
often reported by elderly (Shulman, 1989). Moreover they report that
they are unable to cope with such symptoms. Also, complaints of sleep
and appetite disturbance, loss of energy and lack of interest in activities
are common between elderly with depression. Often older people also
experience co-morbidity of depression and anxiety disorders. Personality
traits of a person, such as coping skills, are important resources in late
life, since they prevent the onset of psychological problems (Beekman et
al., 2000).
Coping is a progressive, dynamic and life-protecting process for
adjusting to continuous changes of life. According to Lazarus and
Folkman (1984) coping can be described as ones efforts to deliberately
reduce or manage their psychological or social demands that are
considered as difficult or demanding. When individuals are faced by a
traumatic event, they use various strategies to cope with stressful
situation. Thus, coping is classified on the bases of individual perspective
and its utilization depends on health and nature of the elderly. Elderly are
constantly faced by a number of challenges due to ageing process, loss of
loved ones, chronic illnesses, and physical disabilities. Therefore older
people utilize three most important coping styles while trying to decrease
or eliminate a stressor: problem focused coping, emotional focused
coping and avoidant coping. An adaptive form of coping is known as
problem focused coping whereas emotional focused coping and avoidant
ELDERLY DEPRESSION, ANXIETY, COPING AND QUALITY OF LIFE 19

coping is maladaptive coping. Being flexible and enhancing coping skills

can help elderly to adjust to social, physical and psychological changes in
old age (Warnick, 1995). Once elderly will learn to cope with changes of
life, they have less mental health problems and better quality of life
(Warnick, 1995).
Quality of life is an extensive concept, dynamic and continuous
process, which changes over time and with life events. WHO (1999)
describes quality of life as the perception one holds about their position
in life, their apprehensions, standards and expectation of goals are all in
accordance to the cultural values and norms in which they reside. It
encompasses ones physiological and psychological well being, social
relationships, and degree of freedom etc. Psychological approach to
quality of life is related to an individual’s life satisfaction and well-being.
Generally, quality of life for older people is beyond their physiological or
psychological health, emotional well being and social relationships.
There is a significant association between number of years of life and
quality of life which can be decreased because of mental health problems.
Therefore, coping intermediates with depression, anxiety, and quality of
life; while an individual’s psychological health depends on his/her quality
of life.
Good mental health, adaptive coping and higher quality of life are
essential for promoting good health among elderly. Therefore the current
study attempts to find difference on depression, anxiety, coping and
quality of life between elderly living in old age homes and within family
setup. The objective is to explore the psychological problems of elderly
living in the community. This study will help to assess coping
mechanisms and quality of life of elderly people living in different life
situations and the impact of such situations on their lives.
Hypotheses

 Elderly living in old age homes and in family setup are likely to differ
on depression.
 Elderly living in old age homes and in family setup are likely to differ
on anxiety.
 Elderly living in old age homes and in family setup are likely to on
differ coping.
 Elderly living in old age homes and in family setup are likely to differ
on quality of life.
20 PARSHAD AND TUFAIL

Method
Sample
Total sample consisted of 120 elderly, of which 60 elderly were
from old age homes and 60 elderly were from family set-up were
selected through purposive sampling. About 52% of elderly were aged
60-70 years whereas 47% elderly were aged 70-80 years (M=1.48, SD=
.501). Equal number of males 50% and females 50% were included in the
study. About 60% of the elderly were widow/widower, 30% were
married, 6% were unmarried and 2% were divorce or separated. Almost
40% of elderly were receiving pension, 41% were earning through other
sources (i.e. business, rent etc.) and 18% were still doing jobs. Most of
the elderly (79%) were living in nuclear family system as compared to
20% residing in joint family system.
Assessment Measures
Pakistan Anxiety and Depression Questionnaire (PADQ).
Pakistan Anxiety and Depression questionnaire (Mumford et al., 2005)
measures anxiety and depression in Pakistani population. It is a self-
report questionnaire which contains 30 items. It includes two subscales;
15 items of anxiety and depression each. All items are to be answered as
yes=1 and no=0 scores. A total score of 6 or more on anxiety or
depression subscale indicates probable anxiety or depression disorder.
Pakistan Anxiety and Depression Questionnaire has reliability with
Cronbach alpha ranging from .90 to .94 for anxiety subscale and .91 for
depression subscale.
Brief COPE Inventory (COPE). The Brief COPE Inventory
(Carver, 1997) measures individual styles of coping. In this study an
Urdu translated version (Jibeen & Khalid, 2010) was used. It is a self-
report questionnaire containing 28 items, with a four point Likert scale.
The Brief COPE determines 14 dimensions. The author has not suggested
any particular instructions for scoring but generating dominant coping
styles. For the translated version the Cronbach alpha for problem-focused
coping is .74 and for emotion-focused coping is .63.
World Health Organization Quality of Life Questionnaire
(WHO QOL-BREF). WHO Quality of Life Questionnaire (WHO,
1998) is developed by World Health Organization to measure quality of
life, which consists of 26 items. In this study an Urdu translated version
by World Health Organization was used. It measures four dimensions;
physical domain, psychological domain, social relationships and
environmental domain. Higher scores signify higher quality of life among
 ELDERLY DEPRESSION, ANXIETY, COPING AND QUALITY OF LIFE 21

individuals. The questionnaire shows discriminant validity, content

validity and test-retest reliability.
Procedure
The sample was recruited from a public and a private old age
home in Lahore. Elderly living with their families were recruited from
urban areas of Lahore; Model town, Johar town, Iqbal town and Faisal
town. Permissions were sought from the authors of the instruments and
the authorities of selected old age homes. After getting permission from
authorities, a formal consent form was taken from the participants of both
settings. The participant’s were briefed about the aim and the instructions
regarding questionnaires were explained to them. Group administrations
of the questionnaires were carried out. However participants with chronic
illnesses (heart patients, cancer etc) and with severe visual and hearing
disability were not included in the study. In case of any difficulty in
following instructions or understanding the statements, participants were
provided with assistance. There was no limitation of time for elderly.

Results
Independent sample t-test was used to compare elderly living in
old age homes and within family setup on depression, anxiety, coping
and quality of life.
Table 1
Comparison of Elderly in Old age Homes and Family Setup on Depression,
Anxiety, Coping and Quality of Life

Old age Home Family Setup

(n=60) (n=60)
Variables M SD M SD t p Cohen
’s d
Depression 5.87 1.79 3.35 .84 9.86 .00 1.81
Anxiety 6.25 1.16 3.02 .95 16.73 .00 3.08
Adaptive Coping 26.77 2.16 42.10 3.09 -31.51 .00 5.80
Maladaptive Coping 27.57 .952 17.52 1.57 31.10 .00 5.72
Quality of life 99.37 19.11 235.58 47.46 -20.62 .00 3.79
22 PARSHAD AND TUFAIL

Table 1 shows significant differences in both groups and all

proposed hypothesis are proved. Elderly living in old age homes reported
more symptoms of depression and anxiety use maladaptive coping
strategies and have poor quality of life in comparison to elderly living in
family setup.

Discussion

Present study aimed to explore differences on depression, anxiety,

coping and quality of life between elderly living in old age homes and in
family setup. The findings revealed significant differences on depression,
anxiety and quality of life between elderly residing in old age homes and
in family setup. Comparison on depression, anxiety and quality of life
revealed that there were more problems faced by elderly who were
residing in old age homes compared to the one’s residing with their
families. The findings were in agreement with the study conducted by
Agarwal and Srivastava (2002) which suggested that psychological
problems like depression, anxiety, loneliness, neglect by family
members, social isolation were more common between elderly living in
old age homes. The findings were also supported from the study by Guha
and Valdiya (2000) which suggested that psychiatric morbidity of elderly
in old age homes was 266.7% and for those living in community was
10%. Similarly, Rahman (2013) examined prevalence of anxiety (58.3%)
and depression (81%) was high among elderly in old age homes
compared to anxiety (36.6%) and depression (56.1%) among elderly
living in their homes.
In Pakistani society, the status of older people living with their
families is greater. In most families the wisdom and experience of older
people is respected and honored. Thus, elderly living with their families
experience less depression and therefore higher quality of life than
elderly living in old age homes Most elderly residing in old age homes
are widow/widower, have low or no income and also lose their influence,
their active roles in family and society also decrease (Chohan, 2007).
They therefore lose their ability to carry out activities of daily life due to
which they are faced by worries about ability to look after themselves in
future. Moreover most of the elderly in old age homes suffer from
negative life events like divorce, loss of spouse, rejection of care and
support by family members, which makes them more prone to
psychological problems than elderly living with their families (Rahman,
ELDERLY DEPRESSION, ANXIETY, COPING AND QUALITY OF LIFE 23

2013). Physical health problems are also more common among elderly in
old age homes (Rao, Chennamsetty, & Kuna, 2014). Naik (2007)
reported significant differences on quality of life with elderly living with
their families having better quality of life than those living in old age
homes. These findings were also supported by other studies (Kavitha,
2007; Mathew, George, & Paniyadi, 2009; Yadidya, 2003). Furthermore,
there is lack of privacy, restricted environment, low emotional support,
low social activity, and lack of care facilities in old age homes due to
which they have poor quality of life. Older people living in old age
homes feel negative emotions like; loneliness, social isolation, disabilities
and also suffer from prolong illnesses. All such factors either
independently or combined undermine self-respect and self-esteem of
elderly and that leads to a growing sense of sadness, anxiety and poor
quality of life (Chohan, 2007).
Also, findings revealed a significant difference on coping between
elderly living in old age homes and in family setup. It was found in
present study that elderly who were residing in old age homes used more
of maladaptive coping strategies while elderly residing with their families
used more of adaptive coping strategies to cope with different situations.
The findings were consistent with previous studies which suggested that
elderly living in old age homes use more of maladaptive coping strategies
(behavioral disengagement, denial, self-distraction, self-blame, substance
use and venting) rather than using adaptive coping strategies (active
coping, instrumental support, planning, acceptance, emotional support,
humor, positive reframing and religion) (Beena, 2006; Rohini, 2011).
Moreover, coping strategies are significantly associated with
psychological problems in late life (Beena, 2006). Elderly with
psychological problems use more of maladaptive coping strategies
(Rohini, 2011). To cope with stressors elderly living in old age homes
make more use of religious beliefs and faith. Religious beliefs can help
elderly to achieve better mental health and faith in God can provide them
strength to fight with psychological problems. Hence, frequent use of
maladaptive coping; emotion focused coping and use of less social
support as coping method makes it difficult for elderly in old age homes
to cope with mental health problems (Beena, 2006).
Conclusion

Old age had never been a problem for Pakistan because the
traditional joint family system has provided the elderly with respect,
support and social security. However, from past few years there has been
24 PARSHAD AND TUFAIL

a distinct change in the traditional Pakistani family system. Joint family

system is now revolving into nuclear family system. With the change in
family systems, the status of elderly have reformed and now the
traditional family role is being shared by institutions like old age homes.
Feelings of low social support and loneliness along with age related
decline in cognitive and physical functioning make the elderly prone to
psychological disturbances.
Thus the psychological problems are more prevalent among
elderly residing in old age homes. Moreover, the psychological problems
contribute to maladaptive coping and low quality of life among elderly
living in old age homes. On the other hand, elderly living with their
families are mostly provided with respect, emotional and social support
thus contributing to less psychological problems. Elderly with less
psychological problems use more adaptive coping strategies, and
therefore have better quality of life. Nevertheless, these issues address the
need for preserving our traditional values of joint family system and we
need to focus on the mutual support and understanding between the older
and younger generation, so that the older generation can lead a respectful
and meaningful life.

Limitations and Recommendations

 There is limitation of sample size (n=120) thus it should be increased

for future studies.
 Further investigation should include more old age homes as only two
old age homes were selected in the present study.
 Data was collected from Lahore city only, other cities of Pakistan
should be incorporated for future research.
 Data was collected using purposive sampling technique; therefore the
results of the present study cannot be generalized to larger sample.
 Moreover little research has been done on elderly especially those
living in old age homes, therefore more research should be conducted
on elderly and the issues faced by them.

Implications

Older people are a special concern group and therefore they need
special consideration. There is a need to develop programs to increase
social interaction of elderly with others (e.g. group activities).
Government and heath care services should provide more physical and
ELDERLY DEPRESSION, ANXIETY, COPING AND QUALITY OF LIFE 25

mental health care and facilities for elderly living in old age homes.
There is scope to reduce mental health problems, enhance adaptive
coping skills, and improve quality of elderly. Therefore, heath care
services and counseling programs should be organized for elderly staying
at home or living in old age homes.
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