Health Problems and Disability of Elderly Individuals in Two Population Groups from Same Geographical Location docx

© JAPI • VOL. 54 • JULY 2006 www.japi.org 539 Original Article Health Problems and Disability of Elderly Individuals in Two Population Groups from Same Geographical Location GK Medhi*, NC Hazarika**, PK Borah*, J Mahanta*** Abstract Objective : To compare morbidity, disability (ADL-IADL disability) along with behavioral and biological correlates of diseases and disability of two elderly population groups (tea garden workers and urban dwellers) living in same geographical location. Methods : Two hundred and ninety three and 230 elderly from urban setting and tea garden respectively aged > 60 years were included in the study. Subjects were physical examined and activity of daily living instrumental activity of daily living (ADL-IADL) was assessed. Diagnosis of diseases was made on the basis of clinical evaluation, diagnosis and/or treatment of diseases done earlier elsewhere, available investigation reports, and electrocardiography. Hypertension was defined according to JNC-VI classification. BMI (weight/height 2 ) was calculated. Logistic regression analysis was performed to see the impact of important background characteristics on non-communicable diseases (NCD) and disability. Results : Hypertension (urban - 68% and tea garden - 81.4%), musculoskeletal diseases (urban - 62.5% and teagarden - 67.5%), COPD and other respiratory problems (urban - 30.4% and tea garden - 32.2%), cataract (urban 40.3% and tea garden - 33%), gastro-intestinal problems (urban - 13% and tea garden - 6.5%) were more commonly observed health problems among community dwellings elderly across both the groups. However in contrast to urban group, serious NCDs like Ischaemic Heart Disease (IHD), diabetes were yet to emerge as health problems among tea garden dwellers. Infectious morbidities, undernutrition and disability (ADL-IADL disability) were more pronounced among tea garden dwellers. Utilization of health service by tea garden elderly was very low in comparison to the urban elderly. Both tea garden men and women had very high rates of risk factors like use of non-smoked tobacco and consumption of alcohol. On the other hand, smoking and obesity was more common in urban group. Most morbidities and disabilities were associated with identifiable risk factors, such as obesity, tobacco (smoked and non-smoked) and alcohol consumption. Educational status was also found to be an important determinant of diseases and disability of elderly population. Age showed a J-shaped relationship with disability and morbidity. Sex difference in health status was also detected. Conclusion : This study highlights the physical dimension of health problems of elderly individuals. Social circumstances and health risk behaviours play important role in the variation of health and functional status between the two groups. Life-style modification is warranted to prevent onset of chronic diseases. To improve quality of life, rectification of poor health status through affordable health service for disease screening and better management of illness, nutritional improvement and greater health awareness are necessary particularly among low socio-economic group. Low-cost intervention like cataract surgery could make a difference in the quality of life of elderly Indian. © ahead for health care in coming years is to ensure the quality of life to a large group of elderly population. However, to address the healthcare needs of this growing numbers of vulnerable and heterogeneous population, reliable information about their health problems from different social settings is still lacking in India. Functional health status greatly influences quality of life at old age. Population based data on health *Research Officer,; **Deputy Director; ***Director, Research Officer, Regional Medical Research Centre, NE Region, ICMR, Dibrugarh. Received : 19.5.2004; Accepted : 20.4.2006 INTRODUCTION P opulation around the world is growing old at high rate with increasing life-expectancy. The challenge 540 www.japi.org © JAPI • VOL. 54 • JULY 2006 problems, functional status, behavioural risk factors, healthcare utilization, social circumstances are imperative for public health intervention with elderly people. Variation may occur in the health and quality of life among different groups of elderly population even from the same geographical region due to these extrinsic factors, 1,2 which need to identify for properly addressing health needs of elderly. Tea is an important agro-industry of India. Manual workers form more than 90% of total adult population irrespective of sex. However their active life ends with superannuation at 58 years. Hence, after active manual work for long years of life, disability after 60 years should be different than those living an easy life in urban setting. The present paper compared the health problems and disability of two community dwelling elderly groups from same locality of Dibrugarh District, Assam, India in the light of behavioural risk factors, educational status and utilization of health services. MATERIAL AND METHODS A cross-sectional community based study was conducted in two different groups of elderly population (60 year and above) in Dibrugarh District of Assam, India during the study period from 2002 to 2003. The study comprised of 523 geriatric persons from both the settings. The first group consisted of 293 (male - 181 and female - 112) elderly persons from an urban setting among a population of about 1.3 lakhs. Four wards and two adjoining localities were selected randomly for the study. The second groups of 230 (male - 101 and female - 129) geriatric persons were drawn from a community predominantly engaged in tea industry mainly as manual labourer. The population of tea garden community in the district is about 2 lakhs scattered over 138 tea gardens. All these subjects were once engaged as labourer in tea industry and now retired from work due to age. Data was collected from 8 randomly selected tea gardens of the district by house-to-house visit. A total 230 geriatric persons participated in the study. The predesigned and pre-tested questionnaire was used to collect the data. The questionnaire included information on socio-demographic variables, behavioural factors (e.g. smoking, use of non-smoked tobacco, alcohol consumption), past and present illness including information on utilization of health services. Designated clinicians examined all the subjects who volunteered to participate in the study. Diagnosis of diseases was made on the basis of clinical presentation, laboratory findings consistent with the specific disease, treatment by a competent medical person. Standard definition of diseases was used for diagnosing health problems. The diagnostic criteria used for defining some health conditions frequently encountered among geriatric persons are as follows - i) Hypertension: SBP ≥ 140 or DBP ≥ 90 (JNC VI classification) or treatment with anti-hypertensive drugs, ii) Diabetes: Known diabetes (self-reported) or fasting blood sugars level ≥ 120 mg/dl 2 (blood collected after an overnight fast of ≥ 10 hours, 3 iii) Chronic obstructive airway diseases (COPD) : Respiratory symptoms of cough and expectoration of sputum with or without wheeze lasting for total duration of ≥ 3 months for 3 consecutive years or more, 4 iv) Cataract : Visible lenticular opacity or history of cataract operation, vii) Pulmonary tuberculosis : Report of sputum positivity for acid-fast bacilli or radiological evidence or treatment under DTC or garden hospital. Moreover self-reported information of diagnosis or treatment of ischaemic heart disease or anginal pain by a qualified medical practitioner was also recorded. Functional status of individuals was assessed in terms of their ability to perform seven important activities of daily living-instrumental activity of daily living (ADL- IADL) without help e.g. dressing, transferring from bed, toileting or taking bath, preparation of food, eating, shopping and walking. Height and weight of the subjects were measured using standard procedures. The weight was measured using SECA balance with minimum of cloths to the nearest of 100 gms and height was measured using an anthropometric rod to the minimum of 0.5 cm. Body mass index (BMI : weight in kg/height in meters 2 ) was calculated from heights and weights. A value ≤ 18.5 is considered as a cut-off point for chronic energy deficiency (CED) or undernutrition (thinness), while BMI ≥ 25 is considered as overweight or obese. Prevalence of diseases in both groups separately was calculated. Logistic regression [exp (b)] analysis was performed controlling the effect of other potential risk factors to detect the relationship between some background characteristics and diseases or disability (ADL-IADL disability). Statistical analysis was done suing SPSS software. Odds ratio [exp (b)] for each category of independent variable obtained from the analysis indicated the odds of having the specific disease condition or disability compared to the reference category (odds ratio one) after controlling the effect of other important variables. RESULTS AND ANALYSIS The mean age for urban group was 67.1 (SD ± 7.03) and 66.47 (SD ± 6.39) for tea garden group. Some of the important background characteristics of subjects are presented in the Table 1. Table 2 shows that prevalence of health problems including ADL-IADL disability in both groups. Chronic and non-communicable conditions like hypertension, musculoskeletal problems, cataract and respiratory conditions were commonly observed health problems among geriatric individuals of both the groups. Diabetes, ischaemic heart disease, obesity were mainly problems © JAPI • VOL. 54 • JULY 2006 www.japi.org 541 in urban geriatric population. Self reported information indicates that 5.46% (n=16) urban elderly were under treatment for ischaemic heart disease or anginal pain as against none from tea garden. Hypertension was more prevalent in tea garden group (81.4%) in comparison to urban group (68.8%). Musculoskeletal problems, respiratory problems were found to be marginally higher in tea garden group. 75.9% tea garden geriatric individuals were undernourished whereas in urban counterpart only Table 1 : Distribution of the subjects according to some important background characteristics Background Urban (N=293) Tea garden (N=230) characteristics Male (%) Female (%) Male (%) Female (%) Age 60-65 (1) 63 (34.8) 58 (51.8) 40 (39.6) 37.2 (37.2) 65-70 (2) 54 (29.8) 28 (25.0) 21 (20.8) 31.0 (31.0) 70-75 (3) 34 (18.8) 11 (9.8) 21 (20.8) 24.8 (24.8) > 75 (4) 30 (16.6) 15 (13.4) 19 (18.8) 7.0 (7.0) Sex 181 (61.8) 112 (38.2) 101 (43.9) 129 (56.1) Education Illiterate 20 (11) 34 (30.4) 89 (88.1) 123 (95.3) Primary 22 (12.2) 32 (28.6) 7 (6.9) 6 (4.7) Highschool 35 (19.3) 28 (25.0) 4 (4) Nil College 104 (57.5) 18 (16.1) 1(1) Nil Smoking Current smoker’s 43 (3.8) 2 (1.8) 20 (19.8) 6 (4.7) Non-smoker 138 (76.2) 110 (98.2) 81 (80.2) 123 (95.3) Non-smoked Tobacco use Users 38 (21) 23 (20.5) 78 (77.2) 104 (80.6) Non-user 143 (79) 89 (79.5) 23 (22.8) 25 (19.4) Alcohol consumption Current consumption 44 (24.4) 13 (11.6) 73 (72.3) 90 (69.8) Non-consumption 137 (75.7) 99 (88.4) 28 (27.7) 39 (30.2) Health service utilization Yes 72 (39.8) 42 (37.5) 12 (11.9) 7 (5.4) No 109 (60.2) 70 (62.5) 89 (88.1) 122 (94.6) Total 181 112 101 129 Table 2 : Health problems of elderly in both settings Disease conditions Urban (a=293) Tea garden (n=230) Male (%) Female (%) Total (%) Male (%) Female (%) Total (%) n=180 n=112 n=292 n=102 n=129 n=129 Hypertension 125/179 (69.8) 73/109 (67) 198/288 (68.8) 104/125 (83.2) 71/90 (78.9) 175/215 (81.4) Cataract 71 (39.2) 47 (42) 118 (40.3) 30 (29.7) 46 (35.7) 76 (33) Musculoskeletal 107 (59.1) 76 (67.9) 183 (62.5) 69 (67.6) 87 (67.4) 156 (67.53) COPD 16 (8.8) 6 (5.4) 22 (7.5) 10 (9.9) 8 (6.2) 18 (7.8) * Respiratory problems 58 (32) 31 (27.7) 89 (30.4) 40 (40) 34 (26.4) 74 (32.2) Diabetes 36 (19.9) 15 (13.4) 51 (17.4) 1 (1) 1 (0.8) 2 (9) Stroke/Paralysis 8 (4.4) 3 (2.7) 11 (3.8) 8 (7.9) 1 (0.8) 9 (3.9) **Major neurological 12 (6.6) 11 (9.8) 23 (7.8) 18 (17.8) 13 (10.1) 31 (13.5) conditions Neoplasm 1 (0.5) Nil 1 (0.34) 1 (1) 1 (0.8) 2 (0.9) Pulmonary TB Nil Nil Nil Nil 2 (1.6) 2 (0.9) Leprosy Nil Nil Nil 1 (1) 1 (0.8) 2 (0.9) Filariasis Nil Nil Nil 2 (2) Nil 2 (0.9) Diarrhea 4 (2.2) 2 (1.8) 6 (2.1) 4 (4) 6 (4.7) 10 (4.4) Skin infection/scabies 5 (2.8) 2 (1.9) 6 (2.1) 9 (9) 6 (4.7) 15 (6.5) Other GIT problems 26 (14.4) 12 (10.7) 38 (13) 4 (3.9) 11 (8.5) 15 (6.5) Injury and fall 6 (3.3) 7 (6.3) 13 (4.4) 5 (5) Nil 5 (2.2) Eye conditions 9 (5) 6 (5.4) 15 (5.1) 7 (6.9) 9 (7) 16 (7) Genito-urinary 8 (4.4) 7 (6.3) 15 (5.1) 2 (2) 8 (6.2) 10 (4.4) Undernutrition 35/178 (19.7) 32/106 (30.2) 67/284 (23.6) 57/81 (70.4) 91/114 (79.8) 148/195 (75.9) Obesity 30/178 (16.9) 25/106 (23.6) 55/284 (19.4) 1/81 (1.2) 2/114 (2.8) 3/195 (1.5) ADL-IADL disability 36 (19.9) 23 (20.5) 59 (20.1) 29 (28.7) 35 (27.1) 64 (27.8) *Also includes COPD; **Also includes paralysis/stroke 542 www.japi.org © JAPI • VOL. 54 • JULY 2006 Table 3 : Results of logistic regression analysis for determinant of diseases and health conditions Morbidities Background Hypertension Diabetes* Cataract Respiratory Locomotion Undernut- Obesity* characteristics problems problems rition (Thinness) Age 60-65 1 a 11 a 1 a 1 a 11 65-70 1.248 0.751 1.873 a 1.795 b 1.526 0.978 0.734 70-75 2.118 b 0.770 2.538 a 2.458 a 2.671 a 0.741 1.018 75 and above 3.249 a 2.128 5.243 a 6.764 a 6.808 a 0.913 0.106 b Sex Male 1111111 Female 1.242 0.729 0.983 0.792 1.382 1.231 2.909 a Place Urban 1 1111 Tea garden 1.281 0.250 1.061 0.930 5.142 a Education College 1 1 1 a 111 a 7.190 a Highschool 0.770 0.596 2.481 a 1.925 0.940 1.607 3.980 b Primary 0.997 0.4592.527 a 1.930 0.974 4.694 1.535 Illiterate 0.982 0.251 b 3.552 a 2.684 a 0.933 6.924 a 1 a Smoking Non-smoker 1111111 Current smoker 0.944 0.481 0.959 2.706 a 0.927 1.519 1.465 BMI <18.5 0.689 0.537 1.533 1.386 1.640 b 18.5-25 1 1 b 111 25> 1.739 2.353 b 0.910 0.799 1.128 * - Only urban subjects are included in the analysis; a - significant at <1% level; b - Significant at <5% level 19.4% were undernourished. Contrary to 19.4% of urban subjects only 1.5% tea garden subjects were obese. 2.6% tea garden geriatric individuals had either of the three infectious morbidities viz. tuberculosis, leprosy or filariasis. 6.5% tea garden individuals also suffered from skin sore, which was high compared to urban group (2.1%). 20.1% urban and 27.8% tea garden subjects experienced problems in self-maintenance of ADL-IADL. Table 3 and Table 4 shows the results of a logistic regression analysis to find out the impact of selected background characteristics on some of the important disease conditions and ADL-IADL disability of the geriatric population. Tea garden background was found to be an important independent predictor of hypertension. Tea garden elderly was 5.1 times more likely to be undernourished than urban elderly. In separate analysis of urban data less educational attainment was found to be an important predictor of undernutrition and ADL-IADL disability. As the age advances the odds of various diseases and ADL-IADL disability also increases significantly confirming a J-shaped relationship between age and different geriatric morbidieties. Female sex was found to be independent predictor of hypertension, locomotion problems, undernutrition and overweight. However male sex had an independent influence on IHD, respiratory diseases, and ADL-IADL disability. Cigarette smokers were 2.7 times more likely to have respiratory diseases than those of non-smokers. Similarly consumption of alcohol and use of non-smoked tobacco were found to be risk factors of hypertension. BMI more than 25 was risk factor for hypertension and diabetes. On the other hand risk of respiratory diseases and cataract increased below a BMI of 18.5. Risk for musculoskeletal problems was found to be higher in both extremes of physical status. The higher risk of diseases to the both extremes of BMI suggests a U- shaped relationship of diseases with BMI. BMI less 18.5 was also found to be a significant predictor of ADL- IADL disability among geriatric individuals. 38.9% (n=114) urban and 8.3% (n=21) tea garden elderly used health services during last one month. Use of health service was found to be significantly higher among those with a higher educational attainment than less educated. DISCUSSION If the increase in life expectancy has a downside, it is the exposure of risk to age-related chronic disorders. 5 As expected the study shows that irrespective of place of living aging is associated with higher burden of chronic and non-communicable diseases and poorer physical functioning which adversely affect the well- being of older people. The common health conditions of elderly were hypertension, musculoskeletal problems, cataract, COPD and other respiratory problems. Survey © JAPI • VOL. 54 • JULY 2006 www.japi.org 543 carried out by National Sample Survey Organization (NSSO) and some other population-based studies from different parts of the country also reported higher burden of chronic health conditions in elderly population. 6-8 Burden of hemiplegia presumed to be vascular origin was higher in both groups compared to previous statistics from India. 9 High prevalence of hypertension and low level of awareness and treatment of hypertension might have contributed in the higher prevalence of vascular complication. 10,11 Burden of non- communicable diseases like diabetes was higher in urban group and comparable to previous report. 12 The present findings show that functional dependence of geriatric individuals becomes a more important concern manly after the age of 75. However, the big difference of adjusted and unadjusted odds ratio of ADL-IADL disability in relation to age suggest that the functional status of elderly individuals can be improved to a large extent by removing those factors. Elderly women were more vulnerable to undernutrition, which could be due to their greater socio-economic marginalization. Similarly, female were more likely to Table 4 : Logistic regression analysis to show the association between some background characteristics and ADL-IADL disability* Variables Exp (B) Age (Years) 60-64 1 b (1) c 65-69 1.226 b (2.72) c 70-74 2.268 b (2.96a) c >=75 4.504 a (8.53a) c Sex Male 1 Female 0.985 Place Urban 1 Tea garden 0.859 Education College and above 1 High school 2.657 b Primary 2.583 Illiterate 3.469 a Smoking Current smoker 1 Non smoker 1.186 Non-smoked tobacco No 1 Yes 1.803 Alcohol No 1 Yes 0.674 BMI < 18.5 1.295 18-5-24.99 1 >=25 1.593 *(Also adjusted for health conditions which likely to influence ADL-IADL e.g. Cataract, Hemiplegia/other major neurological conditions, respiratory conditions, musculoskeletal conditions); a - Significant at <1% level; b - Significant at <5% level; c - Figure in the parenthesis is the unadjusted odds ratio have musculoskeletal problem than male, which perhaps reflect harder life faced by females who never retire from household work unless totally disabled. 13 Although in bi-variate analysis no gender difference was detected in disability, yet in logistic regression analysis after eliminating the influence of other factors, risk of disability increased in male sex in the present study. Independent effects of social factor like educational attainment and other well-established NCD risk factors like tobacco use (smoked and non-smoked), alcohol consumption, BMI on some selected diseases and disability was clearly visible in the study, which indicates that health at old age is modifiable in the study group. Prevalence of common risk factors of NCDs such as smoking and obesity, in urban population, was high. With urbanization, there is a marked increase in consumption of energy rich foods, a decrease in energy expenditure (through less physical activity), 14 which results in obesity. Unpublished report indicates that prevalence of physical inactivity was very high in the same urban population where study was carried out. Presence of these risk factors of NCDs seems contributed to the prevalence of ischaemic heart diseases, diabetes and hypertension. Moreover diabetes and hypertension themselves also have interactive action in IHD. Burden of undernutrition was also found to be equally important in urban population, mainly among less educated elderly. The study also provides evidence that even within urban elderly population there was striking differences in health status in terms of functional health between educated and less educated. The increased level of health awareness for remaining fit and healthy, higher utilization of health services for disease screening and treatment by higher educated probably influenced positively for their better functional health status and the reverse was probably true in case of less educated. In sharp contrast to the sedentary lifestyle in urban population, life in tea garden industry involves hard physical activity due to their job demand. Moreover, the tea garden population is characterized by very high level of illiteracy and also lagging behind rest of population of the state in other aspects of socio-economic development. The lower socio-economic condition of tea garden population was perhaps reflected in the high magnitude of preventable conditions like undernutrition and infectious morbidities like skin sores, scabies, tuberculosis, leprosy, filariasis and sequelae of these diseases. Some recent health surveys conducted in tea garden population also showed that undernutrition, infectious morbidities were high in this population. 15,16 Elderly people belonging to tea garden are of lower socio- economic status appears to be at higher risk related to poor dietary intake. Evidence suggests that loss of lean body mass predicts functional status especially in the elderly. Changes in body composition as determined anthropometrically may be extremely helpful in 544 www.japi.org © JAPI • VOL. 54 • JULY 2006 predicting the ability to live independently. 17 Undernutrition compounded with illiteracy could probably be responsible for higher prevalence of ADL- IADL disability among tea garden elderly compared to urban elderly. Further low utilization rate of health services by tea garden elderly could also adversely affect health status. Consumption of locally prepared alcohol and use of non-smoked tobacco was rampant in tea garden population. Hypertension, an important NCD in tea garden, showed association with consumption of alcohol and use of non-smoked tobacco, which was in conformity with earlier reports from tea garden. 10,11 This profile highlights the physical dimension of health of the elderly and shows evidence that socio- demographic factors and health risk behaviour accounted for much of the variation of health and functional status between two groups. Ideally, intervention at modifiable risk factors is required for keeping at bay illness of chronic nature, yet there is also need for various medical interventions for improving the health status of elderly population. Acknowledgement Authors wish to express thanks to Mr. M Chetia of this centre for his active co-operation in completing this study. REFERENCES 1. Yadava KN, Yadava SS, Vajpeyi DK. Study of aged population and associated health risks in rural India. Health Policy Plan 1994;9:331-6. 2. Kumar KV, Sivan YS, Reghu JR, Das R, Kutty VR. 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Indian J Med Sci 2001;55:609-15. 9. Dalal PM. Strokes in the elderly: prevalence, risk factors and the strategies for prevention. Indian J Med Res 1997;106: 352-32. 10. Hazarika NC, Biswas D, Narain K, Kalita HC, Mahanta J. Hypertension and its risk factors in tea garden workers of Assam. National Medical J India 2002;15:63-8. 11. Hazarika NC, Biswas D, Mahanta J. Hypertension in Elderly population of Assam. J Assoc Physicians India 2002;51:63-8. 12. Shan B, Prabhakar AK. Chronic morbidity profile among elderly. Indian J Med Res 1997;106:265-72. 13. Bali AP. Socio-economic status and its relationship to morbidity among elderly. Indian J Med Res 1997;106:349-60. 14. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases part I: General considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation 2001;104:2746-53. 15. Biswas D, Hazarika NC, Doloi P, Mahanta J. Study on nutritional status of tea garden workers of Assam with special emphasis on body mass index (BMI) and central obesity. J Hum Ecol 2002;13:299-302. 16. Morbidity profile and dimension of health problems among tea garden workers of Assam - A report of ICMR extramural project, 2004:1-37. 17. Physical status : The use and interpretation of anthropometry. WHO technical report Series 854; WHO, Geneva 1995:392. DOCTOR 2004 Medical Software DOUBLE LICENSE FOR SINGLE ORDER (offer extended till July 31 2006) CLINICAL : Case sheets, speciality sheets, Inpatient, ICU, Lab, PDR, Auto Casesummary, Certificates, letters, USS, X-ray, Pathology, Endoscopy, Echo, Proc. reports, very little typing needed. Prescription Autodose, Allergy, disease-contraindication, interaction alert, Fonts option (Hindi Tamil etc) Overdose treatment, Ther. level, dose in organ failures Store Recall at a single click. ADMINISTRATIVE : Appointment schedular; OP Card, Pt. 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