A snapshot of factual bitterness of elderly Indians: It’s time to act

Background Elderly people suffer with diverse morbidities which comes with advancement in age. There is paucity of national and regional level studies to highlight the burden of various morbidities among elderly population in a comprehensive manner, which is of paramount importance for further fine tuning of policies and strategies for geriatric people in the country. The primary objective of the study was to screen the rural elderly people for major morbidity issues, and to find out their association with sociodemographic variables. Methods This community based study was conducted in rural area of Jodhpur, India. WHO’s 10-minute comprehensive screening tool was used for screening of geriatric giants. Other tools used were; SNELLEN chart, Dementia Assessment by Rapid Test (DART), Geriatric Depression Scale (GDS), weighing machine and stadiometer for calculating BMI, glucometer for random capillary blood sugar, and digital sphygmomanometer. Data was analyzed using SPSS v.23, and inferences were drawn using chi-square & t-test. Results Depression and dementia were found in 45.4% and 36.2% of elderly people, respectively. Age was a significant predictor for both. Functional disability in any form was prevalent among 73.7% people. Eighteen participants were either had history of falls for ≥2 times in past one year or were unsteady on examination. Nearly half were having impaired hearing and/or vision. As much as 44% of the elderly were either overweight or obese. More than one third of the participants were found hypertensive. One fourth were found with >140mg/dl random capillary blood sugar. Opium addiction was quite rampant in the study area (21.1%). Conclusions This study provides a comprehensive picture of regional level estimate of major geriatric morbidities in India. These findings reinforce the need to reform the healthcare delivery for elderly people in India, and rethink in the direction of improving

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Background
It is a usual saying that age is just a number for the records. But in true sense, it is the period of life when a person experiences diverse health issues due to physiological, mental, physical and biomedical changes in the body, which are quite predictable and progressive. Socially, it is the phase of life when people start feeling neglected. Geriatric age is one of the neglected and vulnerable phase of life. Besides having noncommunicable diseases (NCDs) and age related impairments in sensory functions, elderly people also suffer from other major morbidities which comes with advancement in age like; cognitive impairment, depression, urinary incontinence, falls and physical dependence/immobility. (5)(6)(7)(8)(9) Deep routed addiction habits, which were cultivated throughout the life, are also difficult to discontinue with age and people at this age have least willingness to quit the addictions as compared to other phases of the life. (10) This also poses some physical and social burden on this age group. (11) This scenario of changing population pattern needs a completely reformed healthcare system for the welfare of elderly people in the country. Significant (12)(13)(14)(15) After literature search it was noticed that, there is paucity of sufficient national and regional level studies to highlight the burden of various morbidities among elderly population in a comprehensive manner, which is of paramount importance for further fine tuning of policies and strategies for geriatric people in the country. This is also required for customized improvements and better management of health-care services for this age group. With this background, this study was planned with the primary objective to screen and diagnose the major morbidity issues like; dementia, depression, urinary incontinence, falls, physical dependence/immobility, hearing and visual impairments, addictions and NCDs like; obesity, diabetes and hypertension in rural geriatric population. Other objective of the study was to find out the association of depression and dementia with sociodemographic variables.

Methods
This was a community based cross sectional study which was conducted from July 2018 to March 2019 in rural area of Jodhpur district of Rajasthan State, India. Geriatric people (>60 year) were included in the study. Based on literature search, it was found that the prevalence of various morbidities among geriatric people in India varies widely from 10% to 80%. (2,16) Considering the minimum prevalence as 10% and 5% absolute margin of error, the sample size was calculated by formula z 2 pq/L 2 . Assuming 10% non-responses, the final sample size came out to be 152.

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One Community Development (CD) Block was selected from ten CD Blocks of Jodhpur District by simple random sampling. The selected block (Luni) was divided into 3 strata (inner 1/3 rd , middle 1/3 rd and outer 1/3 rd ) by two arbitrary lines, which were drawn by equally dividing the distance of block headquarter to farthest point in the periphery of the block into three parts. Then from each stratum total enumeration of villages was done to prepare the individual sampling frames. There were total 61, 67 and 69 villages in inner 1/3rd, middle 1/3rd and outer 1/3 rd circles, respectively. From each sampling frame one village was selected by simple random sampling. Thus 'Feench', 'Dhawa' and 'Dhundhara' were selected for the study. Mapping and listing of households was done of all the selected villages by a rapid survey to prepare the sampling frame of households having geriatric people. Household not having any geriatric member (60+ years) were excluded from the study. Then from the sampling frame, required number of households were selected based on Probability Proportion to Size (PPS), adopting simple random sampling.
From each selected household one geriatric member was contacted for the study. The selection of participant was done by 'KISH' method where more than one geriatric people were available at home.
To find out the major morbidity issues in geriatric population, the 10-minute comprehensive screening tool from WHO's Age friendly primary health center toolkit, which is based on the principles of the active ageing policy framework was used for screening of 4 geriatric giants i.e. memory loss, depression, urinary incontinence, and falls/immobility and also for problem related to hearing and vision.(17) Risk of cognitive impairment was assessed with the help of Dementia Assessment by Rapid Test (DART).
(18) Geriatric Depression Scale (GDS) was used for assessing state of depression. (19,20) All the tools were translated into vernacular and the translation was validated after 6 retranslation with the help of language experts. To enhance the sensitivity of screening, all the tools were applied to all participants irrespective of their screening test status by 10-minute comprehensive screening tool. All those who were positive by any scale were considered positive.
Risk assessment of obesity was done by measuring weight of all the participants with the help of digital weighing machine, and height with stadiometer. Body Mass Index (BMI) was calculated and categorized as per criteria given for Asian population. (21) Screening of diabetes was done through random capillary blood sugar measurements by glucometer (Accu-check). All the participants were screened irrespective of their previous diabetic status. Those with blood glucose more than 140 mg/dl were sensitized, counselled and referred to undergo fasting blood glucose testing at nearby Primary Health Center Two measurements were taken for each patient, and average of those two readings was considered as final. As per Joint National Committee (JNC) 8 guidelines(23), those with systolic BP ≥140 millimeter of mercury (mmHg) and/or diastolic ≥90 mmHg, or history of treatment with anti-hypertensive agents, were declared to have hypertension and counselled to avoid tobacco use and high salt, to increase fruits and vegetables intake and encouraged to start moderate physical activity.(22) They were referred to nearby PHC/CHC for further medical management.
Data thus generated was analyzed using SPSS v.23. Appropriate tables and graphs were prepared and inferences were drawn using chi-square and t-test. P value <0.05 was 7 considered as statistically significant. Table 1 depicts that majority (87.5%) of the participants were in "early elderly" (>60 to <75 years) age group, while 12.5% were in "late elderly" (≥75 years) age group. As much as 61.8% were male and 13.2% were either unmarried or widow. Most of them (96.7%) were having children, and out of them 80.3% were living with their children at home, and 22.4% were living either alone or only with their spouse. Out of those who were having children, 17% were not able to meet their children on daily basis. Although 60% of elderly were not assisted by anybody for daily livings, yet majority (93%) were satisfied with the kind of assistance they were getting from their family.  unsteady (unable to rise from the chair and walk around it without holding on). Near about half of the elderly people were found with decreased hearing. Similar proportion of participants were having difficulty in reading or doing any of their daily activities because of the poor eyesight (even with wearing glasses), and out of them near about 90% were having decreased vision in any eye as per SNELLEN's chart. It is evident from table 3 that, almost one third of the elderly were found to have depression (score of ≥5) in GDS. By using DART, almost one fifth of the elderly were having higher risk of developing cognitive impairment (score of 3 or 4).  T a b l e 5 depicts that advancement in age was a significant predictor for the development of depression among elderly. Age was also significantly associated with the risk of developing cognitive impairment in elderly people. Depression and dementia were also significantly associated with each other.  Table 6 illustrates that, around 44% of the elderly people were either overweight or obese, while 14.5% were underweight. More than one third (37.5%) of the participants were found hypertensive, and 39% were pre hypertensive. Eight people reported themselves as already diagnosed diabetic patients. On screening for diabetes, 25% of participants were found with >140mg/dl random capillary blood sugar. Family history of hypertension, diabetes and heart disease was positive among 13.8%, 7.2% and 0.7% participants, respectively.

Discussion
India has already been assigned the label of "an ageing nation".(24) This is the time when

Dementia
The epidemic of dementia is going to be a highly predictable consequence of epidemiological and demographic transition in India. (26) Currently there is no recommendation for routinely screening the elderly people for cognitive impairments in India. But, it is a proven fact that this follows the iceberg phenomenon and under-detection of dementia is quite high. (27) In the present study, around one third of the elderly were found to have cognitive impairment. Wide variations in the level of dementia (0.9% to 25%) have been reported by different studies across India. (28)(29)(30) Age was found as a significant contributor in developing cognitive impairment. Effect of age on dementia has also been demonstrated by many authors. (28,29,31,32) Contrary to the findings of the present study, many authors have reported female gender as a significant predictor of memory loss. (28,29,31) A deep routed combined culture of patriarchy and hierarchy in Indian culture (especially North India) forces females into a persistent discrimination phase starting from childhood, which build up a constant stress among them, and ultimately leads to cognitive impairments. (33) In the present study, dementia was significantly associated with depression. Li Ge et.al (2011) has proved the temporal association between these two disorders and demonstrated that depression in old age may be an early manifestation of dementia rather than increasing risk for dementia. (34) Although similar kind of significant association was observed by many researchers, yet it has been declared a complex relationship due to lack of sufficient scientific evidences. (35)(36)(37)

Urinary Incontinence (UI)
Urinary incontinence is a condition which has a profound effect on wellbeing and quality of life of elderly people. (38)(39)(40) The International Continence Society has signified UI as a social problem. (41) In the present study 5.3% of the elderly people were having positive history of UI. Recent studies from India show a prevalence of 9% to 40%, which is quite contrasting from the findings of the present study. (39,(42)(43)(44)(45) These variations may be attributed to use of different definitions, diversity in screening tools, heterogeneity of study populations, and population sampling procedures.

Depression
Although old age is not a phase of life which is always filled with sadness and depression, yet there are some challenges at this age, which are difficult to cope in effective manner and play an important role in the development of depression or other mental disorders among elderly people. In the present study the self-reported depression was present among almost one fourth of the elderly people. This is in accordance to the findings reported by Bishwajit G et.al (2017). (46) As much as 45% of the elderly people were found depressed in the present study. These finding are supported by many systematic reviews of Indian studies published in previous two decades. (47)(48)(49) Age was a significant predictor of depression among elderly people. A significant positive correlation of depression with age has also been highlighted by many authors in different of depression as compared to males in this study, but this association was not significant.
Although this finding is supported by literature (50,53), yet a significant association of female gender with the risk of depression has also been emphasized by many authors.

Obesity & Underweight
Obesity and underweight are considered as two edges of a sword. Obesity can be considered as 'welcome sign' of development of NCDs, has a significant association with increasing age. (81) Although it is proven fact that obesity increases the risk of several chronic diseases (82), yet its association with increased risk of mortality among elderly people is still controversial. (83,84) Underweight, which is other edge of the sword, is 18 associated with poor self-rated health, cognition and quality of life among elderly in India. (85) In the present study, 44% of the elderly were overweight or obese and around 15% were

Conclusions
This study provides a comprehensive picture of regional level estimate of major geriatric morbidities in India. This is quite evident that, all the four geriatric giants i.e. cognitive impairment, depression, urinary incontinence, and falls/immobility were quite prevalent in the study area. Age was a significant predictor for depression and dementia. Sensory   Figure 1 CD Block