Morbidity profile of elderly attended / admitted in Jeddah
health facilities, Saudi Arabia
Ibrahim NK, Ghabrah TM, Qadi M
Department of Family and Community Medicine, King Abdulaziz University, Jeddah, Kingdom of
Saudi Arabia
Abstract: A cross-sectional study was conducted to determine morbidity profile and predictors of
increased number of morbidities among 2264 elderly attended / admitted in Jeddah health
facilities. Results: About one-fourth of elderly reported poor self-perceived health, 37.3 %
were dependent on others in their activities and 32.1 % utilized > 3 drugs/ day. Diminished
vision was the commonest complaint while the most prevalent diseases were diabetes
mellitus, arthritis and hypertension. The number of morbidities ranged from 1-6 with a mean
of 2.11 ± 1.16. In multivariate analysis, the predictors of increased morbidities were obesity
(OR= 1.83; 95 % CI= 1.37-2.44), feeling depressed (OR= 1.64; 95 % CI= 1.26-2.13),
advanced age, stop working and female gender. It is recommended that there is a great need
for increasing elderly medical and social care.
1
INTRODUCTION
In recent years, there has been a sharp increase in the number of older persons worldwide
more old people are alive nowadays than at any time in history.
(2)
(1)
and
The proportion of the
population aged 60 and over, is also growing each year. By the year 2025, the world will host 1.2
billion people aged 60 and over and rising to 1.9 billion in 2050.
(3)
The same trend is also
predicted in the EMR; while the proportion of the elderly population to total population was 5.8
% in 2000 it expected to reach 8.7 % by year 2025 and 15.0 % by 2050.(4)
The demographic transition with ageing of the population is a global phenomenon which
demands international, national, regional and local action. (4,5) In recent years there has been an
increasing international awareness of health issues relating to aging populations.(6) . Traditional
perceptions of old age have been challenged during the past few years and it is important that
elderly people are not taken as a burden on society, but rather as an asset.(5,6)
The health problems of the elderly are complicated by social, economic and psychological
interactions to a greater degree than younger people. Moreover, these problems are usually
multiple and are often masked by sensory and cognitive impairments so that special skills are
required to detect them. These factors contribute to a worsening of morbidity and mortality. (7)
Morbidity among elderly people has an important influence on their physical functioning and
psychological well-being. Many elderly have several disorders at the same time. The incidence
of diseases increases with age.
(8)
The importance of early surveillance of the health needs of
elderly people has been emphasized, Knowledge of the situation and circumstances of the elderly
population is essential to the provision of cost- effective services and the planning of strategies
for intervention and care. (7)
Little is known about the health needs of elderly population.
(9)
Assessment of the morbidity
profile will help in the application of interventions, to improve the health status and the quality of
life of the elderly. The objective of this study was to evaluate the morbidity profile and predictors
of increased number of morbidities among the elderly patients attended / admitted in Jeddah
health facilities.
2
MATERIAL & M ETHODS
A cross sectional study was conducted among all elderly (aged 60 years and above) attended /
admitted in health facilities which deliver health care for elderly in Jeddah governorate, during
the study period of the year 2005. All hospitals either governmental (7 hospitals) or private (25
hospitals) in addition to 17 randomly selected primary health care facilities from the total of 38
primary facilities were included in the study. The data were collected through interviewing
questionnaire, reviewing of records, and taking some measurements.
Interviewing questionnaire: All elderly attended / admitted in the selected health facilities on
the day of interview were recruited. A pre-designed questionnaire was used to collect
information about personal and socio-demographic data, presence of a caregiver, personal
habits and perceived health. Functional capacity of elderly was inquired by asking about the
ability of elderly to conduct the basic activities as walking, bathing, using the toilet, dressing,
eating, and getting in and out of home without need of help. The main physical &
psychological complaints were inquired. In addition, diagnosed chronic diseases were inquired
by asking about the presence of chronic diseases diagnosed by physicians & / diseases written
in the patients' record.
Reviewing of records: A cross-checking of medical records of interviewed patients was done.
The clinical diagnosis was taking according to physician based report. The main diagnosis,
associated diagnosis were reviewed. All investigations were also reviewed. The total numbers
of morbidities were calculated according to the main and associated diagnoses.
Measurements: The weight & height were taken. The body mass index (BMI) was calculated.
(BMI = Weight in kg/ height in meter square).
Statistical analysis: The statistical analysis was conducted using two statistical packages; SPSS
version 13 and Epi-Info version 6.04. Chi-square, independent sample t- test and ANOVA tests
were performed. Multivariate regression analysis using stepwise regression model was done for
controlling and adjusting of all confounding factors.
3
RESULTS
The total number of elderly in the study amounted to 2246 persons. Two- thirds of elderly were
recruited from governmental health facilities (hospitals and primary care facilities) while one
third of the sample was recruited from private hospitals. About one- fifth of the elderly (21.6 %)
were inpatients while the rest were recruited from outpatient clinics.
Table (1) portrays personal and socioeconomic characteristics of elderly. Males
represented 62.7 % of the sample. The age of elderly ranged from 60 - 104 years with a mean of
67.9 ± 7.71 years, about two fifths of the sample aged 70 years & above. About three- fourths
were Saudi. Widowed elderly represented about one- fifth (21.8 %) of the sample. The majority
of elderly (78.4 %) had less than secondary education. Almost all geriatric subjects in the present
study lived with their families and were cared for by family members (93.6%), while only 6.4%
lived alone
Table (2) shows that 39 .0 % of elderly perceived their health as good, while about one
fourth (23.5 %) of the sample rated their health as poor. The percentage of females who
perceived their health as poor was higher (31.2 %) than males (19.0 %). The differences between
both sexes has a highly statistical significant difference (X2 = 66.8, p=0.0000).The table also
shows that about two-fifths (37.3 %) of elderly were dependent on others in their usual daily
activities; 23.5 % were dependent in 1-3 of daily activities and 13.8 % for more than 3 of their
activities. The number of utilized drugs by elderly patients ranged from 0- 10 drugs with a mean
of 2.98 ± 2.27. About one third (32.1 %) of elderly were on more than three medications.
Females utilized excessive number of drugs compared to males with a high statistical significant
difference (X2 = 21.39, p=0.000).The number of elderly morbid conditions ranged from 1- 6
diseases with a mean of 2.11 ± 1.16. About two- fifths (39.4 %) of the elderly had one disease
while 60.6 % had two or more morbid conditions.
Table (3) demonstrates physical and psychological complaints of elderly. Diminished
vision was the most frequent physical complaint (61.5 %) while diminished hearing was
encountered among 30.6 % and 25.6 % of elderly complained from dementia. Regarding
psychological complaints; rapidly angry was the commonest one (61.4 %). The table also
4
portrays that females showed higher percentages of all physical and psychological symptoms
than males. Regarding physical complaints, they were more susceptible to repeated falling (OR=
2.10; 95% CI: 1.66-2.64), urinary incontinence (OR= 1.74; 95% CI: 1.34 -2.26). Regarding
psychological complaints females were more than two times more prone to feeling of depression
(OR= 2.31; 95% CI: 1.93-2.77) and insomnia (OR= 2.00; 95% CI: 1.67 -2.77).
Table (4) shows the morbidity profile of the elderly, it is apparent from the table that
diabetes mellitus was the commonest elderly disease (53.6 %), followed by arthritis (52.12%)
and hypertension (50.4%). Females were at higher risks of having many types elderly diseases
compared to males. The highest risk was for osteoporosis (OR= 4.82; 95 % CI= 3.93- 5.93),
followed by arthritis (OR= 2.16; 95 % CI= 1.81- 2.59) and psychological problems (OR= 2.14;
95 % CI= 1.58- 2.90). In addition, females were also at higher risks of having bronchial asthma,
cancer, COPD and eye diseases. On the other hand, they were slightly less susceptible to diabetes
mellitus and renal diseases.
Table (5) illustrates the relationship between the numbers morbidities and the studied
variable. Higher number of morbidities was observed among females compared to males with a
highly statistical significant difference (t= 5.41, p= 0.000). Age-wise, higher mean morbidities
was noticed with advancing age and a highly statistical significant difference was present (F=
12.53, p= 0.000). Lower morbid conditions were observed among married elderly compared to
others. Based on BMI, lower morbidity was found among non obese elderly. Non practicing
exercise was associated with higher numbers of morbidities compared to those who practicing
exercise. Based on psychological condition of elderly, those who were still working, those
having no family or social problems and who didn’t feel loneliness or depression encountered
less number of morbid conditions compared to others. (p<0.0000)
Multivariate regression analysis (Table 6) shows that the first predictor of increase
number of morbidity was obesity; obese elderly were at 1.83 times increased risk of multiple
morbidities compared to non-obese. The second predictor was feeling depressed; participants
who felt depressed were 1.64 times more liable to increased morbidities. The following predictor
is advanced age, elderly aged 70 years and above were 1.61 times more prone to multiple
5
morbidities compared to those aged 60- 65. (OR=1.61; 95 % CI: 1.26- 2.13). On the other hand
males, elderly who were still working were favorable of decrease morbidity number compared to
females and those who stop working.
DISCUSSION
Health status is an important factor that has a significant impact on the quality of life of
an elderly population. The major elements of health status are perceived health, especially
psychological well-being, chronic illnesses, and functional status. (8) Almost all geriatric subjects
in the present study lived with their families (93.6%) this result agrees with result of a study from
Abha city. (7)
Results of the present study revealed that poor perceived health was reported by 23.5 % of
elderly; 19.0 % by males and 31.2 % by females. These rates are much better than those reported
by Yadava et al, India, their corresponding figures were 37% and 70% among both sexes
respectively. (10) These differences may be attributed to differences in socioeconomic level and
health care delivered to elderly patients in both Saudi Arabia and India.
On the other hand, 39.0 % of elderly in the present study rated their health as good which is
lower than rates reported from a Spanish study (49.5 %) (11) and a Singaporean study (82 %). (12)
Present results showed that 37.3 % of elderly were dependent on others on conduction of their
activities. Results obtained from a study conducted in Alexandria, 2003, revealed that about one
fourth of elderly cancer patients were dependent on others on more than one of daily functions.
(13)
AL – Doghether et al , 2004, (14) reported that 19 % of 100 elderly attended one PHC
in Riyadh governorate, Saudi Arabia, were on more than three drugs, while the corresponding
figure from the current study was 32.1 %. These differences may be because elderly in the
present study were recruited from both hospitals and PHC facilities, and hospitalized elderly
(especially inpatients) usually utilize more number and have more severe form of diseases and
accordingly they consumed excessive amount of drugs than PHC attendance, or the difference
may be due to difference in sample size in both studies.
High rates of co-morbidity present a challenge in providing care to elderly. AL –
6
Doghether et al, (14) reported that 56 % of elderly had two or more diseases. A slightly higher
finding (60.4 %) was obtained from the present study.
Regarding elderly complaints, more than two- thirds of elderly in the present study
complained from diminish vision which agrees with result of Iecovich et al , 2003, (15) who found
that the majority of elderly in their study reported visual problems.
Present results show that 25.6 % of elderly complained from dementia which coincides
with the percentage reported among elderly in Hong Kong (27.0%). (16)
Results of the present study revealed that female subjects encountered more physical complaints
compared to males. Urinary incontinence was 1.74 more prevalent among females and this
coincides
with results a study reported from Alexandria, 2000. (17)
Psychological symptoms were also more encountered among females; feeling of depression
among females was 2.31 times higher than males. This goes on line with results from Abha city;
female geriatric subjects were 2.6 times more likely to suffer from depression than males. (7)
The Saudi Arabia is a rapidly developing country with changes that influence life-style of
people towards urbanization with more progression towards epidemiological transition. Diabetes
is present in epidemic proportions throughout Saudi Arabia with exceedingly high rates
concentrated in urban areas.
(18)
Results of the present study revealed that diabetes mellitus was
the most common chronic disease (53.6 %) diagnosed among elderly patients. Al- Nozha et al,
2004, (18) in a National Community Based Survey in the Saudi Arabia found that the prevalence
of diabetes among elderly population aged 60-70 years was 36.5 % and other 14.9 % showed
impaired glucose tolerance. The higher figures obtained from the present study may be because
the age of elderly in present study ranged from 60-104 years and not just elderly 60-70 and as it
is known there is an increase in the rates of diabetes with advanced age, or the difference may be
because the present study conducted among elderly patients not among the general elderly
population. The striking high figures of elderly diabetes obtained from these two studies were
7
higher than may parts of the world
(19 -21)
may indicate that there is dramatic increase in rate of
diabetes especially with advanced aging and indicates that the risk factors of increased diabetes
in increasing in Saudi Arabia. (18)
A study from the USA reported that arthritis was the most prevalent (48.9 %) chronic condition
among elderly ≥ 65 years, followed by hypertension (40.3 %).(22) In the present study, Arthritis
was the second most common disease (52.12 %) among elderly patients followed by
hypertension (50.4 %). The lower figures reported from the USA are probably the reflection of
their community based study. In Singapore study, 46 % of elderly in a population based study
had hypertension. (12)
In the present study, psychological problems were more encountered among females and this
agrees with results of Hafez et al, 2003.(23)
Results of the current study showed that IHD was more encountered among males compared to
females and 22.7 % of elderly had these diseases. Results from the National Community Based
Survey in the Saudi Arabia revealed that male gender was a risk factor of
IHD and the
prevalence among elderly aged 60-70 years was lower (9.3 %). (24) This difference may be due to
differences in the age group or the type of the target population.
The mean number of morbidities among elderly in the present study was 2.11 ±1.16, and
it was significantly higher among females (2.28 ± 1.20) compared to males (2.00 ± 1.12). These
results approach those of Fuchs et al
(25)
who found that the mean morbidity number among
females was 2.4 ±1.6 and 1.9 ±1.4 among males. On the other hand, the reported mean
morbidities from the Indian study was much higher in both males and females.(8)
It was noted from the present study that the number of morbid conditions increased
among those with poor self rated health. A study conducted in 2002 among 100 elderly in ElMinia governorate (Egypt) showed that there were positive relationship between functional
health status and perceived health status.
(26)
It is clear from the present study that morbidity
number increased among elderly experiencing family or social problems which agrees with
results of Yadava et al. (10)
In the elderly, obesity contributes to the early onset of chronic morbidity and functional
8
impairment and is related to premature mortality.
(27)
Obesity significantly increases the chance
of developing diabetes, coronary artery disease, and stroke. (28) In the present study, obesity was
the first predictor of increased morbidities among elderly.
There is an implicit assumption that disease and deterioration of ill-health are inevitably
associated with chronological ageing.
(7)
The results of the present study showed that increase
number of morbidities was associated with advanced aging which agrees with results of Sunder
et al (29) who observed that multiple morbidities were more common with advanced age. Johsi et
al (8) reported that the age was among factors which predict increased morbidity.
CONCLUSION AND RECOMMENDATIONS
About one-fourth of elderly in the present study reported poor self-perceived health and the
number of morbidities among elderly ranged from 1- 6 with mean of 2.11 ±1.16 diseases. There
is an alarming high rate of diabetes mellitus and hypertension among elderly. Obesity was the
most important modifiable risk factor for increase number of morbidity, females and those felt
depression were more susceptible. We recommend that there is a need for promotion of healthy
lifestyles and behavioral changes through conduction of community-based health education
program. The program should insist on modifying risk factors especially those causing obesity.
This in tern leads to tackling the chronic health problems among ageing population by decrease
the prevalence of many morbidities and also decreasing co- morbidities. Screening programs for
chronic diseases, especially for diabetes and hypertension, is highly recommended among elderly
population. There is also a need for satisfactory living condition for elderly; satisfy psychosocial
needs, increase recreational activities for elderly involvement of elderly in doing useful
activities.
Acknowledgment: The authors would like to thank all persons who participated and help in
accomplishing this work and also would like to thank all the elderly. Special thanks to fourth
year medical students in Family and Community medicine department , King Abdul-Aziz
University, Jeddah.
9
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