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

Original ArticleHealth Problems and Disability of Elderly Individuals in Two Population Groups from Same Geographical Location GK Medhi*, NC Hazarika**, PK Borah*, J Mahanta*** Abstract

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/height2) 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

Population around the world is growing old at high

rate with increasing life-expectancy The challenge

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/dl2 (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 meters2) 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

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

Age

Education

Smoking

Non-smoked Tobacco use

Alcohol consumption

Health service utilization

Table 2 : Health problems of elderly in both settings

Male (%) Female (%) Total (%) Male (%) Female (%) Total (%)

Hypertension 125/179 (69.8) 73/109 (67) 198/288 (68.8) 104/125 (83.2) 71/90 (78.9) 175/215 (81.4)

Musculoskeletal 107 (59.1) 76 (67.9) 183 (62.5) 69 (67.6) 87 (67.4) 156 (67.53)

* Respiratory problems 58 (32) 31 (27.7) 89 (30.4) 40 (40) 34 (26.4) 74 (32.2)

**Major neurological 12 (6.6) 11 (9.8) 23 (7.8) 18 (17.8) 13 (10.1) 31 (13.5) conditions

Other GIT problems 26 (14.4) 12 (10.7) 38 (13) 4 (3.9) 11 (8.5) 15 (6.5)

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

Table 3 : Results of logistic regression analysis for determinant of diseases and health conditions

Morbidities Background Hypertension Diabetes* Cataract Respiratory Locomotion Undernut- Obesity*

(Thinness)

Age

Sex

Place

Education

Smoking

BMI

* - 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

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

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*

Age (Years)

Sex

Place

Education

Smoking

Non-smoked tobacco

Alcohol

BMI

*(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

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

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