|Year : 2014 | Volume
| Issue : 3 | Page : 159-163
Functional status and its predictor among elderly population in a hilly state of North India
Deepak Sharma1, Anupam Parashar2, Salig Ram Mazta2
1 Department of Community Medicine, School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
|Date of Web Publication||13-Aug-2014|
School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Background: Functional status can be conceptualized as an individual's ability to manage activities related to personal self-care and self-maintenance. Functional status assessment is fundamental aspect of geriatric examination. This assessment helps clinicians and policymakers to design and implement interventions that help elderly to live safely and independently. Aims and Objectives: The primary aim was to assess the prevalence of limitation in activities of daily living (ADL) and instrumental ADL (IADL) among elderly population. The secondary aim was to identify the factors that predict IADL limitation among them. Materials and Methods: A total of 400 community dwelling elderly persons residing in Shimla hills of North India were interviewed using valid and reliable functional assessment scales namely Katz ADL and Lawton and Brody IADL. Statistical procedures for the analyses included descriptive statistics and logistic regression. Results: The prevalence of ADL and IADL activity limitation was 5.5% (22/400) and 21.8% (87/400), respectively. The results of logistic regression analysis revealed that advancing age (70 years and above), poor self-rated health and ailments namely musculoskeletal problems and cataract significantly predict functional limitation. Conclusions and Recommendation: Elderly having musculoskeletal problems should be provided with rehabilitative support in the community settings. Cataract surgeries patients should be identified and operated upon so as to improve visual functioning and thus their functional ability. Further, cities, towns, and rural areas should be made age-friendly.
Keywords: Activities of daily living, elderly, functional impairment, instrumental activities of daily living
|How to cite this article:|
Sharma D, Parashar A, Mazta SR. Functional status and its predictor among elderly population in a hilly state of North India. Int J Health Allied Sci 2014;3:159-63
|How to cite this URL:|
Sharma D, Parashar A, Mazta SR. Functional status and its predictor among elderly population in a hilly state of North India. Int J Health Allied Sci [serial online] 2014 [cited 2019 Nov 15];3:159-63. Available from: http://www.ijhas.in/text.asp?2014/3/3/159/138593
| Introduction|| |
The Indian population is projected to age faster than the populations of countries around the world. This is due to the combination of declining birth rates, leading to fewer young people, and increasing life expectancy and hence that more people live into old age. The Indian elderly population accounted for 7.4% of total population in 2001 census. This figure increased to 8.6% in 2011 census. It is further projected to rise to 11.1% by the year 2025. Himachal Pradesh a hilly state of North India is also experiencing an elderly population boom (10.2% elderly; census 2011). 
Threat to functional independence in elderly arises as a result of physiological changes from the ageing process. These include changes such as reduced muscle strength, bone density, bladder capacity and pulmonary ventilation.  Functional limitation lowers the older person's quality of life and predisposes him/her to hospital admissions. It also increases need for caregiver support and may cause their premature death. With the help of right policies in place, Government of India can better prepare for an ageing society. 
The aim of this study was to assess the prevalence of limitations in activities of daily living (ADL) and instrumental ADL (IADL) among elderly and identify the predictors of IADL limitation among them.
| Materials and methods|| |
This was a cross-sectional study conducted in Shimla district of Himachal Pradesh. Duration of this study was from June to December 2010. This town with a population of nearly 150,000 (census 2011) represented the urban sampling frame. There are 25 wards in the town. Mashobra primary health center area (field practice area of the Department of Community Medicine, Indira Gandhi Medical College [IGMC], Shimla) with a population of about 33,000 represented the rural sampling frame. The study participants were people aged 60 years and above.
Literature review shows that the prevalence of morbidities among geriatric population in India is 50-80%. , Taking the prevalence of morbidity as 50%, with worst possible estimate at 43% on one side and 95% confidence interval, the sample size calculated using 4 pq/L 2 formula was 200. For this study, it was assumed that the characteristics of urban and rural elderly population may differ. To elucidate the peculiarities of these areas, it was decided that 200 elderly be enrolled from urban area and 200 elderly from rural area.
The study sample was obtained using multistage simple random sampling. In urban area, five wards were selected by simple random sampling. Forty older persons were selected from each ward. Each of the selected wards was divided into four parts with equal population (approximately) so that from all the parts equal numbers of subjects were enrolled. For each part of the ward, one house was selected randomly. Starting from this house, every nearest next house was surveyed until ten subjects were enrolled for the study. A similar procedure was applied in the remaining parts of the ward.
In rural areas, out of the 15 sub-center villages, five were selected by simple random sampling. Forty older persons were selected from each selected village. With the help of key informants, sampled villages were geographically divided into four parts with equal population (approximately). For each part, one house was selected randomly. Starting from this house, every nearest next house was surveyed until 10 subjects were enrolled for the study. A similar procedure was applied in the remaining parts of the village.
Data on sociodemographic factors included age, gender, marital status, level of education, and type of family. The self-rated health (SRH) was evaluated using the response to the question, "How would you rate your health at the present time?" The possible responses were being "good," "acceptable," and "poor." To evaluate the functional ability, two self-assessment scales Katz ADL scale and Lawton and Brody IADL scale were used. The Katz ADL scale included the following activities: Bathing, dressing, eating, toileting and transferring from bed to chair.  The Lawton and Brody IADL scale included the following activities: shopping, preparing or cooking food, using the telephone, washing clothes, housekeeping, transportation, taking medication, and managing finances.  The responses of items in the scales were dichotomized as "unable to do the activity at all/need some help" and "able to do the activity without help".
Epi Info software for windows (Centers for Disease Control Atlanta, Georgia) was used for analyzing data. Logistic regression was used to list the predictors of functional impairment. Informed written consent was obtained from the study participants. Approval was obtained from the ethical committee of IGMC, Shimla, Himachal Pradesh.
| Results|| |
The mean age of the sample studied was 69.0 years (standard deviation ± 6.9), with age ranging from 60 years to 90 years. Females represented 51% of the study subjects. Nearly one-fifth (27.5%) of the study participants were widowed and nearly half (49.8%) were illiterate. A total of 359 (89.5%) study subjects were living in joint families. A total of 336 (84%) elderly were suffering from at least one medical problem. The most frequent health problem was musculoskeletal problem affecting 220 (55%) elderly, followed by hypertension in 162 (40.5%). 120 (30%) elderly were having cataract and dental problems each. 171 (46.2%) study subjects rated their health as good, 185 (42.8%) as average and the remaining 44 (11%) as poor [Table 1].
|Table 1: Distribution of study subjects according to background characteristics and study variables|
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22 (5.5%) needed one or more assistance in various ADL. 87 (21.8%) needed one or more assistance in IADL. Among the ADL tasks, bathing was the most difficult for the older persons to perform. Transportation was the most common IADL in which the 55 (63.2%) needed partial/full assistance [Figure 1] and [Figure 2].
|Figure 1: Distribution of activities of daily living among older study subjects|
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|Figure 2: Distribution of instrumental activities of daily living among older study subjects|
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In the descriptive analysis, IADL limitations were more among female elderly (26%) as compared to males (17%). Also the elderly residing in rural areas (25%) faced more functional limitation as compared to urban counterparts (19%). Similarly, widowed elderly (46%) were facing more functional impairment problems as compared to married counterparts (13%).
The results of logistic regression analysis revealed that advancing age (60-79 years adjusted odds ratio [AOR] 16.1; 80 years and above AOR = 28.9), poor SRH (AOR = 4.2) and ailments namely musculoskeletal problems (AOR = 1.3) and cataract (AOR = 1.2) significantly predicted functional limitation [Table 2].
|Table 2: Results of logistic regression analysis to show association of study variables with impaired functional ability|
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| Discussion|| |
In our study, only 5.5% study participants were categorized as dependent in carrying out ADL. Comparable prevalence was reported in a study by Swami et al. in India.  Worldwide, studies conducted by Chen in Chinese elderly and by Nugegoda and Balasuriya in Sri Lankan elderly have recorded nearly similar prevalence. , However a much higher prevalence was reported in studies done by Fuch et al. in Israel and by Graciani in Spain. ,
Our study observed that 25% of the older persons needed one or more assistance in IADL. This data is in concordance with the results of studies done among elderly in Spain  and Sri Lanka.  However, a study among elderly Zimbabweans reported higher difficulty with instrumental activities.  This difference might be due to existing differences between the study area and its elderly population.
Among the ADL tasks, bathing was found to be the most difficult task for the older persons to perform. Dressing, transferring, toileting and eating were found to be less frequent in dependency. A possible reason for this may be the cold weather conditions prevailing of the study area. The act of bathing starts right from arranging hot water in a bucket and then carrying it to appropriate place in the bathroom. Further, the process of pouring water over body might be restricted in elderly owing to stiffness and paining joints. Thus, this multiple task process might invite help from caregivers. The dependency in other activities like dressing was less frequent because for elderly it might be embarrassing to be dressed in the presence of other people, and so they do not take help in this activity. Similar might be the explanation for toileting and eating wherein elderly do not seek help until they feel that they can no longer carry on the activity.
Among the IADL tasks, transportation was the most dependent task. This might be attributed to the tough terrain of the hilly area. With limited transport facilities and crowded vehicles in the study area, it makes it difficult for the elderly to utilize these services. During the survey, it was observed that the transport system in the study area was not elderly friendly. In contrast to this, Chandigarh a nearby North Indian city has a dedicated fleet of low floor buses which makes it easy for elderly to board and get down from the bus. Another possible reason for the elderly experiencing difficulty in transportation is the observation from our study which states that most of them were suffering from some kind of morbidity, the commonest being musculoskeletal problems. This might hinder their transportation activity due to physical limitation.
The results of descriptive analysis revealed that widowed people had more functional impairment than married people. Similar observation has been reported in a study by Tang et al. in elderly Beijing Chinese and Millαn-Calenti in elderly Spanish people. , Furthermore, in our study, women showed higher functional impairment for IADL items when compared with men. Similar to our finding, previous studies have reported gender differences in functional impairment in elderly. ,
The results of logistic regression reveal that age and SRH are significant correlates of functional impairment in elderly. A possible reason may be that with advancing age the rate of physiological decline increases, which might limit the ability to perform IADL. A similar observation was made by Kelly-Hayes et al. in a study among older persons, wherein it was reported that those who perceived their health as poor were significantly more functionally impaired.  Other studies done by Rakowski and Cryan in USA elderly, Markides and Lee in Mexico elderly and Hirdes and Forbes in Canadian elderly report similar finding. ,,
Our study observed that elderly having musculoskeletal problems and cataract were at higher risk of functional impairment. It may be due to the symptoms of musculoskeletal problems such as pain, stiffness and swelling of muscles, tendons, ligaments which results in limitation of the affected elderly to perform a given task. Research suggests that exercise and optimizing pain management in elderly individuals has the potential to substantially reduce the functional impairment associated with musculoskeletal problems. ,, Cataract in very elderly can cause progressive painless vision loss. More associated disturbing features of this ophthalmological morbidity are the disabling night glare and near sightedness. Walker et al.in his interventional study about impact of cataract surgery on visual functioning reported that after cataract surgery the elderly visual disability decreased and mood improved. 
| Conclusion|| |
Older elderly (70 years +) suffering from musculoskeletal problems, having cataract and those rating their health as poor, need more focus of a caring geriatrician and policy makers in India. Regular preventive home visits need to be planned by primary health care team to identify functional decline in them. Those having musculoskeletal problems should be provided with rehabilitative support in the community settings. Cataract surgeries patients should be identified and operated so as to improve their visual functioning and in turn functional ability. Further, cities, towns, and rural areas in the study area should be made age-friendly. Geriatric friendly transport services like low floor buses will help in accommodating their functional decline.
Our study has two limitations. First is inherent to the cross-sectional design of our study which makes it difficult to establish the temporal relationship between the study variables. Second is regarding generalization of our study findings. Care must be taken not to assume that the predictors identified in our study setting will be the same for other settings across India. Hence, the authors suggest that future research should be undertaken among elderly across different states in India. This will help in generating concrete national data for enhancing geriatric services across our country.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]