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A study of the morbidity pattern among the elderly population in Vadodara, Gujarat

A man’s life is normally divided into five main stages namely infancy, childhood, adolescence adulthood and old age. In each of the stages, an individual has to face different situations and different problems. The old age is also not without the problems. Aging is an integral part of the growth and development which is terminated by death. The elderly people are the precious asset for any country. With their rich experience and wisdom, they contribute their strength for the substance and the progress of the nation. 1 Their special health and economic issues differ from those of the general population. Improvements in health care facilities have brought about longevity, which is considered to be one of the greatest achievements of the 20th century. The ratio of older persons has changed dramatically from approximately one in fourteen in the fifties to about one in four at present. 3 In India, the elderly population is 10 crore forming 10% of total population and it is estimated to reach up to 15 crores by the year 2020 and it is projected to rise to 12.4% of the population by the year 2026. 2 The demographic population is rising due to better health control of communicable diseases resulting in increased longetivity 3 . From the morbidity point of view, almost 50% of the Indian elderly have chronic diseases and 5% suffer from the immobility which poses a greater responsibility on the health services especially in developing countries like India where there is a greater strain on available health infrastructure. 4


INTRODUCTION
A man's life is normally divided into five main stages namely infancy, childhood, adolescence adulthood and old age. In each of the stages, an individual has to face different situations and different problems. The old age is also not without the problems. Aging is an integral part of the growth and development which is terminated by death. The elderly people are the precious asset for any country. With their rich experience and wisdom, they contribute their strength for the substance and the progress of the nation. 1 Their special health and economic issues differ from those of the general population. Improvements in health care facilities have brought about longevity, which is considered to be one of the greatest achievements of the 20th century. The ratio of older persons has changed dramatically from approximately one in fourteen in the fifties to about one in four at present. 3 In India, the elderly population is 10 crore forming 10% of total population and it is estimated to reach up to 15 crores by the year 2020 and it is projected to rise to 12.4% of the population by the year 2026. 2 The demographic population is rising due to better health control of communicable diseases resulting in increased longetivity 3 . From the morbidity point of view, almost 50% of the Indian elderly have chronic diseases and 5% suffer from the immobility which poses a greater responsibility on the health services especially in developing countries like India where there is a greater strain on available health infrastructure. 4 double burden of communicable and non-communicable diseases. For the substantial impact of this burden, preventive health care strategies specific to the elderly need to be clearly formulated and tested. Old age is not a disease in itself, but the elderly are vulnerable to longterm diseases of insidious onset such as cardiovascular illness, CVA, cancers, diabetes, musculoskeletal and mental illnesses. 5 There is a need to highlight the health problems that are being faced by the elderly people in India and strategies for bringing about an improvement in their quality of life also need to be explored. So the present study was carried out to know the morbidity pattern of geriatric people in rural area.

METHODS
A cross-sectional (observational) study was carried out in the villages of Vadodara district among geriatric population-person having age 60 years or more. Noncooperative persons were excluded from the study.

Sample Size and sampling
Sample size of 600 was calculated on hypothesis testing methods based on the following assumption: 95% confidence interval, assuming 50% of prevalence for the morbidity for maximum sample size (The literature review revealed that the prevalence of various health problems in elderly varies from 8% to 80%) and 4% margin of error. Six talukas out of twelve of the Vadodara district were selected by simple random sampling. From each of these selected 6 talukas, 4 villages were selected by simple random technique. From each of the selected village, 25 study participants were selected conveniently by the house to house survey. The survey was started on the right-hand side of the village panchayat office. The village next to that in the random list was selected to fulfill the study subjects if study participants were not enough in a selected village.

Data collection
House to house survey was done to find the study subjects from the selected villages. After acquiring the study subject the details regarding the study viz. purpose of the study, method of the study was explained in the vernacular language to each participant and head of the family. Written consent was taken from the each subject with assuring that their name was not be disclosed other than the person concern with the study. The questionnaire was filled by personal interview. Questionnaires were of two parts. The first part included socio-demographic details regarding age, sex, religion, marital status, education, occupation, income, addiction (tobacco and alcohol), drug using for any chronic illness etc. The second part of the questionnaire was about morbidities they suffer at the time of the survey. Blood pressure was measured by random zero mercury sphygmomanometer and stethoscope in sitting position in right brachial artery after 5 minute rest. Korotkoff sound 1 and 5 were considered as systolic and diastolic blood pressure respectively. Pulse pressure was calculated as the difference between systolic and diastolic blood pressure. Mean arterial blood pressure was calculated by using following formula: DBP+1/3 pulse pressure. Measurement of blood pressure of all participants was done by a single investigator. The Folstein Mini-Mental State Exam (MMSE) and its Hindi and Guajarati version of MMSE were used to measure cognition among study participants. [6][7][8] The MMSE that was used for the study purpose is described below. Geriatric depression scale short form (GDS-15) was used to measure depression. 9 Self-reported morbidities were noted for vision problems, hearing problems, musculoskeletal problems, respiratory problems, cardiovascular problems, gastrointestinal problems, genitourinary problems.

Statistical methods
Data were entered and analyzed on the Epi info 7. Chisquare test was applied for proportions. A p<0.05 was considered as statistically significant.

RESULTS
The present cross-sectional study was carried out in villages of Vadodara district during January 2011 to January 2012. A total of 600 participants above the age of 60 years were included in the study. Prevalence of various other morbidities among study participants according to their history and records is described in Table 2. Prevalence of musculoskeletal problems, vision problems, gastrointestinal problems, depression is significantly higher among female than males (p<0.05). Prevalence of respiratory problems, genitourinary problems, polypharmacy is significantly higher among male than in the female (p<0.05). The majority of elderly were found living with their spouse and other members. Study of Srivastava and Mishra's supported the same finding. 13 Living with family can improve their quality of life and uncertainties while physical or mental breakdown. Here depression is present in around half of the population suggests some or other differences in the families and lack of understanding in the families even though they are present.
The proportion of current smokers was 16.7%, currently; smokeless tobacco was used by 14.1%. Bala et al in their study of tobacco use in Gujarat state found in the age group of 65 years or older 10.68% were tobacco chewer, 20.36% wire snuffing and 2% were using more than one form of tobacco and 64.73% were smokers. 14 This study again observed that snuffing was more common in elderly above 65 years age group especially in women, illiterate & in household occupation.
Morbidity profile of our surveyed elderly had the maximum problem of musculoskeletal disorder (64.9%), followed by depression (54.2%) and obesity (46.2%).
Another study done in Ahmedabad revealed that Morbidity profile of our surveyed elderly had maximum problem of locomotors (48.6%), followed by vision (42.7%) and hypertension (34.4%) and only 3.7% of elderly had psychosocial problems. 4 Jacob et al (Tamil Nadu), Gaur et al (North India) and Padda et al (Amritsar) observed in their respective studies that the most common morbidity was joint pain/ joint stiffness (43.4%, 46%, and 60.6%), cataract (68%, 45.3%, and 54.01%) and dental problems (45.3%, and 21.9%) respectively. [15][16][17] In our study vision, problems and dental problems are somewhat lower than these studies. Decreasing prevalence clearly suggests improvement in health care system even at primary level.
Rahul et al found that 44.2% of male and 54.5% of the female were having hypertension in an urban area. In our study both the prevalences are comparatively low correspondingly 31.5% and 28.5%. 18 As per Swami et al, 53.59% of male and 61.24% of female had hypertension. 19 There is no significant difference between hypertensive male and female in both the studies. As both the studies done in an urban area has a higher prevalence of hypertension than in this study which is done in a rural setting.
Rahul et al found that 44% of elderly were having a musculoskeletal problem as compared to 64.9% in this study. 18 Here in rural are it is possible that people are more engaged in the laborious job than urban area so the musculoskeletal problems are more in a rural area of Vadodara. Female are having more musculoskeletal problems than male in both the studies.
Psychosocial problems were also found among 42% in the urban area of Udaipur Rajasthan whereas 54.2% depression is found in this study. It is possible that in a rural area the person is not having various kind of diversions to engage their minds to leave other psychosocial problems are that's why the amount of depression is more whereas in urban areas there more ways of entertainments to divert the mind.
Gaurav and Kartikeyan found 7.92% of the asthmatics elders whereas in this study 26.3% were having respiratory complaints including asthma. 20 Diabetes was seen in 18.7% of the aged which was observed in the present study. 33.25% and 30% prevalence of diabetes mellitus was reported by Sithara et al and Joshi et al respectively. 21,22 Diseases of the circulatory system were reported lower than another study done in an urban population of Karnataka. Prevalence of diseases of the digestive system and respiratory diseases were noted higher among villagers of Vadodara than the urban population of Karnataka. 23 The possible reason might be the difference in nutritional pattern, environment conditions, and lifestyle differences.
Rural-urban differences in health and of older particularly in Indian traditional societies are due to the majority of older population lives in rural India (75%). Secondly, elderly from rural areas tend to be the highly marginalized person in terms of socioeconomic conditions due to various patriarchal norms such as patriarchal inheritance and division of labor by gender coupled with the lack of social reforms for older widows in rural India. Third, better quality health care services are more concentrated in urban areas and, still to achieve in rural areas even for the general population. Fourth, due to long period social negligence, older widows are most likely to perceive their ill health condition as godgifted. [24][25][26]

CONCLUSION
The study among the elderly in the rural area of Vadodara has highlighted a high prevalence of morbidity and identified common existing medical problems such as like musculoskeletal disorder, depression, vision and dental problems, hypertension and diabetes mellitus. Therefore, the facilities providing geriatric health care services should be strengthened to provide comprehensive services at every level to address the health care needs of the vulnerable elderly population.