Ageing in Puducherry, South India: An overview of morbidity profile.

BACKGROUND: The geriatric health problems are related to chronic disease as a result of increasing life expectancy.
OBJECTIVE: This study was undertaken to assess the health problems of the elderly in Puducherry.
MATERIALS AND METHODS: This cross-sectional study was carried out on 214 elderly persons from the age group of 60 years and above using a pre-designed and pre-tested questionnaire that addressed the disease magnitude in comparison with the socioeconomic variables.
RESULTS: Overall, 43% of the participants were diabetic, 47.7% hypertensive, 86% anemic and 68.2% visually impaired. All the morbidities were noted to be higher in the 70-79 years age group. Diabetes was significantly higher in participants from urban areas, with family history and increasing waist-hip ratio, but significantly lower in the below poverty line areas. Hypertension risk was significantly higher among females, among those leading sedentary life, those eating vegetarian food, those addicted to tobacco and with abdominal obesity. Anemia was significantly lower among urban vegetarians. Overweight and obese were noted in 31% of the participants, and were higher in females (87.5%). Rural residence, female sex, living in joint family, literacy, sedentary life style, decreasing per capita income and decreasing body mass index (BMI) were significantly associated with visual impairment.
CONCLUSION: This study highlights the burden of health problems of elderly individuals in South India.

The elderly population in India increased from 20 million in 1951 to 57 million in 1991, and is expected to be 198 million in 2030 and 326 million in 2050; 33% are living below the poverty line, 90% from the unorganized sector with no social security.[12] In rapidly ageing populations, we urgently need to reappraise the complex and uncomfortable relations between age discrimination, distributive justice, quality and length of life.[3] Both perceived health and chronic illness are major elements of health status in elderly and there is growing evidence that older people are at risk for manifold comorbidities.[4] Researchers examined life course social, gender and ethnic inequalities in activities of daily living (ADL) disability and opined that the decreasing social inequalities during childhood and adulthood will reduce the socioeconomic inequalities in disability in old age.[5] A thorough examination of the geriatric morbidity and Related risk factors are required to improve the delivery of health care to the elderly.[6] There is a need to highlight the medical and socioeconomic problems of elderly people in India, and strategies for bringing about an improvement in their quality of life also need.[7] This study was performed in order to assess the health problems of the elderly people and its relationship with advancement of age and other variables.

Materials and Methods

This cross-sectional study was conducted in the rural and urban field practice area of Mahatma Gandhi Medical College and Research Institute, Puducherry, from 1st December 2007 to 31st May 2008 on 214 elderly participants of age 60 years and above with no interventions. We identified 225 eligible individuals from the electoral roll and included all of them in our study. We prepared two separate lists, one for urban and another for rural area for data collection. Non-respondents (unable to respond even with the help of caregivers on three separate attempts) were 11 and 214 elderly persons finally participated.

Study instruments

The data collection tool used for the study was an interview schedule that was developed at the Institute with the assistance from the faculty members and other experts. The pre-designed and pre-tested questionnaire contained questions relating to family characteristics, residence, family history of diabetes mellitus and others chronic disease, income and personal characteristics like age, sex, education, occupation and type of food, dietary habit. By initial translation, back-translation, retranslation followed by pilot study, the questionnaire was custom-made for the study. The pilot study was carried out at the outpatients department of the Institute among comparable geriatric subjects, following which some of the questions from the interview schedule were modified.

Data collection procedure

The health workers informed and motivated the families to participate in the study along with the scope of future intervention, if necessary. All the participants were explained about the purpose of the study and were ensured strict confidentiality. Informed consent was taken from the participants and were given the options not to participate in the study if they wanted. Data regarding family and personal characteristics were recorded by interview technique by the principal investigator. On an average, three visits were repeated for those who were missed during the first contact.

Body weight was measured (to the nearest 0.5 kg) in the standing, motionless position on the Standard (Bathroom) scale with feet 15 cm apart, and weight equally distributed on each leg. Height was measured (to the nearest 0.5 cm) by a Stadeometer in the standing position with closed feet, holding their breath in full inspiration and in the Frankfurt line of vision. Waist and hip circumference was measured by a flexible, non-stretchable measuring tape in the standing position and the waist–hip ratio was calculated. The venous blood samples were taken after 10–12 h of fasting and were examined in the Department of Biochemistry of the Institute. Snellen's chart was used for the assessment of visual impairment.

Diagnostic criteria

Diagnosis of diseases was based on clinical evaluation, diagnosis and/or treatment of diseases done earlier elsewhere, available investigation reports and electrocardiography. We followed the WHO guidelines for diabetes, hypertension, anemia and visual acuity as <20/60. They were all compared with the BMI calculated as weight/height2 and used as cut-off point for normal, over weight and obesity.[8-11]

Statistical analysis

Data was analyzed using SPSS 10.0 windows version. The prevalence of diabetes mellitus, hypertension, anemia and visual impairment was presented as percentage. Categorical variables were compared using the chi-square test. Uni- and multiple logistic regression analyses were performed to evaluate associations with the prevalence of diabetes mellitus, hypertension, anemia and visual impairment. Odds ratio (OR) was calculated for each categorical and continuous variables. The 95% confidence interval (CI) was calculated for each OR. Values of P <0.05 were considered statistically significant.

Results

Of the 214 participants in the age range of 60 – 87 yrs, 43.0% were male. Majority were in the age group of 60–69 years (67.3%), from the rural area (61.7%) and belonged to nuclear families (53.3%). A greater part of them was leading a sedentary life (72.0%) and was non-vegetarian (85.0%). Only 13.1% of the study subjects belonged to the below poverty line, 48.6% were illiterate; addiction rate for alcohol and tobacco was 4.7% and 7.5%, respectively. Overweight and obese were noted in 31% of the participants; more in females (87.5%) [Table 1].

Table 1

Correlates of geriatric health problems in the univariate analysis

The prevalence ratios of diabetes mellitus, hypertension, anemia and visual impairment were 43.0% (male = 41.3% and female = 44.3%), 47.7% (male = 37.0% and female = 55.7%), 86.0% (male = 89.1% and female = 83.6%) and 68.2% (male = 60.9% and female = 73.8%), respectively. On univariate analysis, the risk of diabetes mellitus was significantly higher among elderly from urban areas than that among elderly from rural areas (OR = 2.026; 95% CI = 1.157–3.549), and significantly lower risk in elderly from below poverty line than in those belonging to normal (not below poverty line) (OR = 0.317; 95% CI = 0.123–0.818). Hypertension risk was significantly higher among female (OR = 2.148; 95% CI = 1.235–3.738), in those with a sedentary life (OR = 1.867; 95% CI = 1.012–3.447), among vegetarians (OR = 4.000; 95% CI = 1.706–9.380), among tobacco addicts (OR = 3.600; 95% CI = 1.122–11.549) and in those with abdominal obesity (OR = 2.030; 95% CI = 1.165–3.536). The risk of anemia was significantly lower among urban old (OR = 0.341; 95% CI = 0.045–0.297) and among vegetarians (OR = 0.272; 95% CI = 0.113–0.655). The risk of visual impairment was significantly higher in females (OR = 1.808; 95% CI = 1.011–3.234), in those living in joint families (OR = 2.398; 95% CI = 1.312–4.384), in those from below poverty line (OR = 7.150; 95% CI = 1.645–31.074), in elderly participants from the rural area (OR = 0.341; 95% CI = 0.188–0.617) and in the obese (OR = 0.131; 95% CI = 0.041–0.425). The proportions of diabetes mellitus, hypertension, anemia and visual impairment were higher (51.7%, 62.1%, 89.7% and 79.3%, respectively) in the 70–79 years age group. But, the difference was statistically significant only for hypertension and visual impairment. Family history of diabetes was significantly related with diabetes mellitus, hypertension, anemia and visual impairment. On the other hand, family history of hypertension was significantly related with diabetes mellitus and hypertension only [Table 1].

Overall, a BMI of <18.5 kg/m2 (thin), 25.0–29.9 kg/m2 (overweight) and ≥30.0 kg/m2 (obesity) were observed in 30 participants (14.0%), 50 participants (23.4%) and 16 participants (7.5%), respectively; the proportion of abdominal obesity was 40.2%.

Table 2 presents the proportion of hypertension in females and males. Hypertension ranging from high-normal to grade-3 hypertension was significantly higher in the females (Chi-square value = 29.996, P value ͳ 0.001).

Table 2

Distribution of the study population according to their blood pressure

In the final model, multiple logistic regression urban resident (OR = 2.773; 95% CI = 1.515–5.078), family history (OR = 4.893; 95% CI = 1.958–12.231) and increasing waist–hip ratio (OR = 35.873; 95% CI = 1.273–1011.031) were significantly associated with diabetes mellitus. Female sex (OR = 2.517; 95% CI = 1.304–4.858), sedentary life style (OR = 2.091; 95% CI = 1.041–4.202), vegetarian diet (OR = 5.918; 95% CI = 2.343–14.947) and tobacco addiction (OR = 5.081; 95% CI = 1.491–17.310) were significantly associated with hypertension.

Rural residence was significantly associated with anemia (OR = 7.787; 95% CI = 2.990–20.277). In our study participants, rural residence (OR = 6.166; 95% CI = 2.802–13.569), female sex (OR = 5.472; 95% CI = 2.232–13.412), lower literacy (OR = 3.115; 95% CI = 1.388–6.992), sedentary life style (OR = 4.480; 95% CI = 2.000–10.036), decreasing per capita income (OR = 0.999; 95% CI = 0.998–1.000) and decreasing BMI (OR = 0.877; 95% CI = 0.811–0.948) were significantly associated with visual impairment [Table 3].

Table 3

Correlates of health problems in the final model: Multivariate logistic regression by the backward LR method

Discussion

Among 214 elderly participants from 60 to 87 years, findings were 43% diabetic, 47.7% hypertensive, 86% anemic and 68.2% visually impaired; all these were higher in the 70–79 years age group. The literacy and dependency found by us was similar to by Manandhar et al.[12]

Researchers on the aged population in a rural area of Wardha district reported that the common morbidities were cataract (30%), arthritis and arthralgia (15.6%), refractory error (13.6%), anemia (13.3%), chronic bronchitis (7.3%), dental caries (7%), hypertension (5.2%), which increased with increasing age to a maximum above the age of 65 years.[13] Garg et al. held that the main cause of illness reported were anemia (39.6%), cataract (24.3%), refractory error (20.1%), hypertension (16.5%).[14] A previous Pondicherry study reported that decreased visual acuity due to cataract and refractive errors was observed in 57% of the elderly, and hypertension (14%), diabetes (8.1%).[15] Comparable observations were also noted by other researchers from India.[616]

A study from rural area of Rohtak district of Haryana , reported that the leading symptoms among the male elderly were visual impairment (65%).[17] Increasing trend of visual impairment with increasing age was also reported by other researchers in this field.[18]

In South Korea, 78.0% of the elderly people were diagnosed with disease conditions. Life style-related diseases, including hypertension, arthritis, diabetes mellitus and osteoporosis, were the most common morbidities; most prevalent was hypertension (37.5%), followed by diabetes mellitus (14.9%).[19] Wilking et al. observed that the prevalence of isolated systolic hypertension appeared to be greater for women than for men, whereas the WHO reports a common prevalence of 56%.[2021] Previous researchers in India reported a lesser magnitude of hypertension that ranged from 5.2 to 16.5%.[1314] Anil Purty et al. reported 25.9% hypertension among the geriatric population.[15] Yet, other reports were comparable with our findings.[622] Eun-kyung Woo et al. reported a prevalence of 14.9% diabetes mellitus in the people of South Korea.[18] A similar observation was reported by others.[23]

Prevalence of Type 2 diabetes was four- to five-fold higher in the urban versus rural population reported by other Indian researchers.[2425] Experiences from geriatric clinics in Northern India revealed that hypertension was the most commonly reported physical diagnosis (50%); other specific medical illnesses were osteoarthritis (15%), diabetes (13%) and constipation (8%).[26] In the rural geriatric population of Tamil Nadu, the main causes of illnesses were arthritis, cataract, bronchitis, skin diseases and malnutrition.[27]

In an Indian Council of Medical Research (ICMR) study on the urban dwellers and the tea garden workers in Dibrugarh, hypertension was the most common health problem (urban, 68% and tea garden, 81.4%).[28] In the joint ICMR/WHO initiative study at the urban slums of Faridabad, BMI was lower in men than in women. The prevalence of hypertension was 17.2% in men and 15.8% in women.[29] In a study in rural Varanasi, the most common morbidity was arthritis, with an overall prevalence of 57.08%, followed by cataract (48.33%) and hypertension (11.25%) and the prevalence of geriatric morbidities increased with advancing age.[30] Weinberger noted that almost half of the diabetics were aged 65 years or above, with an almost equal sex distribution.[31]

Hypertension as the most prevalent condition (44.9%) was noted by Kumar.[32] On the other hand, Parvan reported a 19.7% prevalence of hypertension in Shimla.[33] Bhatia et al. reported in the Chandigarh study that the main health-related problems among the aged were those of the circulatory system (51.2%), with about two-fifths (41.6%) suffering from hypertension, and this was significantly more in females (46.4%). Also, diabetes mellitus was significantly more in females (18%) than in males (6.4%). Problems in relation to the circulatory system were higher in females (56.9%) as compared with males (52.1%) in the age group of above 65 years.[34] Another Chandigarh study noted that were anemia, hypertension, cataract among the commoner morbidities. Major morbidities were more common in the rural area, except for hypertension (56%), osteoarthritis (34%), anxiety (10%), diabetes mellitus (8%), obesity (8%) and psychosis (5%), which was more common in the urban area.[6]

The ICMR report on the chronic morbidity profile in the elderly states that hearing impairment was the most common morbidity, followed by visual impairment.[5] A study on ocular morbidities among the elderly population in the district of Wardha noted that refractive errors accounted for the highest number (40.8%) among all the ocular morbidities, closely followed by cataract (40.4%).[35] In a community-based study in Delhi, the problems related to vision and hearing were the commonest.[36]

Elderly people from the middle and higher income groups are prone to develop obesity and its related complications due to a sedentary life style.[37] In a study in Delhi, 34% of the men and 40.3% of the women were obese, respectively.[38] Researchers on health and social problems of the elderly in Udupi Taluk, Karnataka, observed that all the respondents had some health problems; the most common were hypertension, osteoarthritis, diabetes or bronchial asthma, followed by cataract, anemia and skin problems.[39] The Udaipur study noted that in the morbidity profile of old age, 70% had problems related with vision (cataract 44%, refractive error 24.7%) and 48% had hypertension.[40]

Strength of the study

This study identified an increasing need for nationwide efforts to develop various intervention programs for surveillance of increasing geriatric health problems in the era demographic transition in India and other Southeast Asian countries.

Limitation of the study

We had several limitations. First, the sample was small and was drawn from one limited geographic area. So, the results cannot be generalized to national population. Second, because of the cross-sectional design, this study had a limited extrapolative value. Third, researchers in this field are troubled with age-related amnesia and other psychological problems that were not addressed. Lastly, the probability of missing data cannot be excluded as we studied only older adults.[41]

Future directions of the study

Holistic researches are needed on all dimensions of aging including the psychosocial and social security standings of morbidity. In spite of professional indifference in geriatrics, current trends point toward the foundation of sensitization of medical teachers, advance speciality of psychosocial gerontology and accessibility of some research resources.

Conclusion

The incidence of all the study parameters among the elderly population was very high in comparison with other studies from other parts of India and even previous studies of Puducherry. This highlights the increasing trend of burden of geriatric health problems in South India. For a substantial impact on this burden, unique preventive health care strategies specific to the elderly need to be clearly formulated and tested.