A Study of Prevalence and Factors Associated with Geriatric Impairment: Evidence from a Cross-Sectional Study in India

Background: Increasing life expectancy and declining fertility, resulting from improved healthcare systems worldwide, has resulted in a growing elderly population. The paradigm shift of the population towards the aged has tremendous health implications. Therefore, this study intends to examine the ve domains of geriatric impairment: physical, cognitive, hearing, vision, and speech impairment. Methods: The prevalence and factors associated with geriatric impairment were examined in this study by utilizing Longitudinal Ageing Study in India (LASI) wave-I data. Bivariate and binary logistic regression analyses were used as study tools. Results: The study has demonstrated that higher age had a gradient of negative impact on the older adults, although for the unadjusted model. Results found that female elderly (OR=0.81; C.I.= 0.68-0.97) and educated elderly likely (OR=0.57; C.I.= 0.32-1.02) were less likely to report geriatric impairment than their respective counterparts. Conclusion: There is a need to building partnerships to develop effective programs tackling impairment among the elderly. Launching programs that provide education for older adults to elicit potential health benets may reduce impairment progression.

Ageing is known as many physical and emotional changes that can affect the level of function and well-being of the elderly. These changes can lead to impairment among the elderly, subject to a multidimensional assessment to evaluate functional ability, physical health, cognition, mental health, hearing, visual, speech, and socioenvironmental circumstances. Physical or functional impairment includes upper or lower limb loss or impairment, manual dexterity, and impairment in coordination with different body organs. Mental and cognition impairment, also known as instinctual impairment, occurred when a person has certain cognitive functions, limitations, and skills like communication, learning, self-help, and social skills. Visual impairment can be de ned as the problems in functions of the visual system, and hearing impairment consider hearing loss that prevents an individual from partial or total receiving sounds through the ear. Speech impairment refers to an inability to produce sounds or verbal communications.
Study Variables:

Outcome variable
The study considered geriatric impairment as an outcome variable which was divided into ve categories like Physical impairment such as lower body or upper body, cognitive impairment such as intellectual, cognition, or learning impairment, Hearing impairment, Visual impairment; and Speech impairment such as speech production and language comprehension. All the impairment was self-reported as responses were observed in multiple forms. Further, geriatric impairments have been divided into the number of impairments (0, 1, 2, and ≥3) to understand the association between impairments and socio-economic and health characteristics. Further, geriatric impairment was categorized in binary form as "yes" and "no" to assess the likelihood of impairment by socio-demographic and health factors.

Predictors:
The predictors for this study are age (60-69 and 70 years and above); sex (male and female), marital status (currently married, never married, Divorced/Separated/Deserted/Widowhood), education (No education, below primary, primary, secondary, and higher); place of residence (rural and urban); living arrangements (living alone, with spouse and with others); currently working (yes and no); wealth index (poorest, poorer, middle, richer and richest); and self-rated health (poor and good). Further, activities of daily living (ADL) impairment was achieved from ve indicators, namely bathing, dressing, mobility, feeding, and toileting. The instrumental activities of daily living (IADL) impairment scale was achieved from seven instrumental activities: preparing a hot meal (cooking and serving), shopping for groceries, making telephone calls, taking medications, doing work around the house or garden, managing money, such as paying bills and keeping track of expenses and getting around or nding an address in an unfamiliar place. Both the ADL and IADL impairment was categorized into the three categories as "severe," "moderate," and "no impairment" based on the scale given in previous studies [31], [32].

Statistical analysis:
For the deceptive purpose, we have compared socio-demographic and health characteristics between elderly with physical, cognitive, hearing, visual, and speech impairment to check the proportion of geriatric impairment. Again, we have compared socio-demographic and health characteristics with 0, 1, 2, and 3 or more geriatric impairment among older persons. To assess the association between any geriatric impairment with socio-demographic and health characterizes, we used binary logistic regression with unadjusted and adjusted odds ratio as the formula is given below, Where, p is the probability of success, α is the intercept, b is the regression coe cient, and ε is the random error.
Results: Figure 1 depicts the prevalence of various geriatric impairments. Around 6.4 percent of the elderly reported physical impairment, 2.7 percent reported cognitive impairment, 0.9 percent reported hearing impairment, 0.4 percent reported visual impairment, and only 0.1 percent reported speech impairment. Table 1 depicts the prevalence of geriatric impairment by selected socioeconomic and health characteristics. Results found that the geriatric impairments were higher among elderly aged 70+ than elderly aged 60-69 years; around 7.5 percent of elderly aged 70+ reported physical impairment whereas, only 5.6 percent of elderly aged 60-69 years reported physical impairment. Physical impairments were higher among male elderly (6.8% vs. 6%) than in female elderly; however, a higher percentage of female reported cognitive impairment (2.8% vs. 2.4%), Hearing impairment (0.9% vs. 0.8%), and visual impairment (0.5% vs. 0.3%) than their male counterparts. Prevalence of all the impairment was higher among never-married elderly than their married counterparts. Furthermore, the prevalence of physical and cognitive impairment was higher among uneducated elderly, rural elderly, living alone elderly, elderly not working currently, elderly with poor self-rated health, and severe ADL and IADL.  Table 2 depicts the proportion of the number of geriatric impairment by selected socioeconomic and health characteristics. Almost 90 percent of the elderly population do not have any impairment. Around 6.4 percent of the elderly reported at least one impairment, 2.7 percent reported at least two impairment, and 1.4 percent of the elderly reported three or more than three impairment. The proportion of 3 or more than three impairment was higher among elderly aged 70+ years, female elderly, never-married elderly, rural elderly, not working elderly, and elderly who reported poor self-reported health and severe ADL and IADL impairment. Almost 7 percent of elderly who had severe ADL and IADL impairment reported three or more geriatric impairment.    Discussion: The overall prevalence of geriatric impairment estimated in the study was 10.4 percent; the speci c impairment prevalence varies from 6.4 percent in physical impairment to 0.1 percent in speech impairment. The prevalence of hearing, vision, and cognitive impairment was 0.9%, 0.4%, and 2.7%, respectively. These gures are lower than other country prevalence of estimates on hearing and vision impairment [14], [33], [34] and cognitive impairment [35], [36].
The World Health Organization (WHO) estimates that approximately 360 million, or 5% of the world's population, have at least a moderate hearing loss [37]. A study examining visual, hearing, walking, cognition, self-care, and communication impairment found an almost similar prevalence of impairment among the Malaysian elderly as in this study [38].
The study has demonstrated that higher age had a gradient of negative impact on the older adults, although for the unadjusted model. The results found that higher age is a risk factor for impairment among the elderly. Previous ndings corroborated the above nding in the Indian context [39]. Higher age is associated with several co-morbidities, which may further aggravated impairment among them [40]. Female elderly were less likely to report impairment than their male counterparts. Previous literature has found mixed evidence. Few studies noted a higher risk of impairments in the male elderly [41], and other few noted an otherwise association [42]. Lower impairments among females could be attributed to various factors, notably higher treatment-seeking [43]. Risk-taking and reluctance to seek and comply with medical treatment among men could be another explanation of higher impairments among men [43]. These gender differences appear to align with various literature, which proposes that men report fatal and functionally-related disabilities more frequently, which often warrant hospitalization, specialty care, and emergency services use than women [44], [45].
The marital status of the elderly was another signi cant predictor of impairments. The study found that the nevermarried elderly were more likely to report impairments than their married counterparts. Previous studies also noted the same association [46]. Married elderly are supposed to get support from their spouse, leading to better health and lower impairments. The pathway through which marital union explains the reduced risk of impairments among the elderly includes security and cohesion, which states that marriage may provide a sense of cohesion, security, and coping resources, leading to improved quality of life and thus reducing the risk of impairments [47]. Our study revealed that older people who were at lower risk for disabilities were those who had higher education. Previous studies agree with this nding [38], [48]. A study in rural India has noticed the same relationship between education level and impairment among the elderly [49]. Low education level is closely associated with low-income status, which might become a barrier for health services utilization, leading to geriatric impairment [38].
The results signi cantly noted that working elderly had a lower risk of impairments than non-working elderly. Previous research corroborated this nding [50]. There are several pathways explaining the reduced risk of impairments among the working elderly, including the cognitive research hypothesis. The cognitive research hypothesis suggests that occupational attainment facilitates coping mechanisms, reducing the likelihood of impairments, speci cally cognitive impairments [50]. The results found poor self-rated health as a risk factor of higher impairments among the elderly.
Previously available research noticed that good self-rated health is a strong predictor of lower disability and impairments among the elderly, speci cally cognitive and physical impairments [47]. The indication is that those who reported good self-rated health are more likely to link with better health characteristics, including reduced chances of chronic diseases and mental health, leading to less risk of impairments. The study noticed that severe ADL and IADL were associated with a higher risk of geriatric impairments among the elderly. However, the cross-sectional nature of data limits our understanding of causality appropriately. A study has noticed an inverse relationship where geriatric impairments were associated with poor ADL and IADL [51]. In line with this study nding, previous research substantiated that severe ADL and IADL affect physical and cognitive impairments among the elderly [52].

Strengths And Limitations Of The Study:
The study has potential noteworthy limitations. The prevalence of impairments might be under-estimated as they were self-reported. A study noted that more than one-third of people with impairment in vision or hearing were identi ed clinically but did not report their functional limitations [53]. Reverse causality cannot be ignored as the data is crosssectional, preventing the identi cation of causal relationships between covariates and impairment. Despite the above limitations, the study has certain strengths too. The use of a large nationally representative sample in this survey provides valid and reliable estimates of geriatric impairment in India.

Conclusion:
The LASI survey provides reliable and comparable data on geriatric impairment in India. Our ndings indicated that males, being never-married, currently working, poor self-rated health, severe ADL, and severe IADL are some of the risk factors for impairment among the elderly in India. Findings from this study accentuated the need for strengthening the health services targeting older people, speci cally those who reported poor self-rated health, severe ADL, and IADL. Also, there is a need for impairment-speci c interventions. Early identi cation of hearing and vision loss could be an effective mechanism to reduce the burden of sensory impairment among the elderly. The systematic screening for hearing and vision loss detection could be promoted in India's primary health care (PHC) centers. There is a need to building partnerships to develop effective programs tackling impairment among the elderly. Launching programs that provide education for older adults to elicit potential health bene ts may reduce impairment progression. Ethics approval and consent to participate: The authors were not involved in data collection process and therefore they did not require any ethical approval or consent to participate. The study used LASI survey data and LASI data is secondary in nature. The data is freely available on request and survey agencies that conducted the eld survey for the data collection have collected a prior consent from the respondent. The ethical clearance was provided by Indian Council of Medical Research (ICMR), India.
The survey agencies that collected data followed all the protocols. To maximize the cooperation of the sampled HHs and individuals, participants were provided with information brochures explaining the purpose of the survey, ways of protecting their privacy, and the safety of the health assessments as part of the ethics protocols. As per ethics protocols, consent forms were administered to each HH and age-eligible individual. In accordance with Human Subjects Protection, four consent forms were used in the LASI: Household Informed Consent, Individual Informed Consent, Consent for Blood Samples Collection for Storage and Future Use (DBS), and Proxy Consent. For each survey participant, the study protocol was described and the steps of each biomarker test were demonstrated by the trained health investigators. Participant's consent (signed/oral) was obtained for the interviews. Since, the survey obtained either signed or oral consent, it was feasible for each participant to provide his/her consent.

Consent for publication:
Not applicable Availability of data and materials: