European Journal of Cardiovascular Medicine

Aging is a common and permanent process, which is affected by biological, psychological, social, and environmental factors. The proportion of elders above 60 years is growing more rapidly than other age groups in almost every country. People are living longer, mainly due to a decrease in fertility rates and mortality rate accompanied by increased life expectancy. Such is the rate of the demographic transition that by 2050, the older generation (aged 60 years and above) will outnumber those under 15 years of age and even make up more than one-fifth of the global population1. These demographic changes are progressing faster in the developing countries, especially in India, which will soon become home to the world’s second-largest population of over - 60s .¹

 With the surge of globalization and industrialization, there was a migration of youth to the urban areas which led to the disintegration of the age-old joint family system, thereby forcing the elderly to continue to work for their daily living. They are affected by situations of social exclusion, lack of opportunities to participate in development activities, extremely limited access to health care, non-existence or minimal development of pension systems, scarcity in the social service networks etc. These socio-economic issues are further aggravated by the lack of social security and adequate health care, rehabilitative and recreational facilities .²

Functional status decreases with the aging process, which in turn affects the health status of the elderly. The health problems and the content of health care services are different for the geriatric population. In the context of the increasing proportion of the geriatric population in India, it is essential to have an understanding of the pattern of functional capacity and related factors to provide appropriate services. The elderly person’s functional dependence is an important public health issue. Studies that address this issue are essential because they can inform and guide public health policies for the elderly.

OBJECTIVES
To estimate the prevalence of Functional dependence in elderly people

To identify the factors associated with functional dependence in elderly people

The objective was to find out the prevalence and associated risk factors for functional dependence among elderly aged 60 years and above in the study area.

Study Design: Cross sectional study

Study population: All elderly population aged 60 years and above, residing in Urban field practice area, Badi Kaman Vijayapur district.

Study period: March 2023- September 2023.

Inclusion criteria: All elderly people aged 60 years and above, who are residing in defined study area.

Exclusion criteria: Elderly people who are visitors and not residing in defined study area.

Sample size: 300 participants, when the expected prevalence of functional dependency among elderly people was 21.8% . ³This would give results at confidence level (α level) of 5%, absolute allowable error of 5% and a 10% allowance for non responders. Sample is 272(4pq/L2)

Sampling Method: A simple random sampling method was used to select the 300 Elderly people

from Urban field practice area Badi Kaman Vijayapur district.

Ethics Approval: The study was approved by the Institutional Ethics Committee (IEC) of

Al-Ameen Medical College, Vijayapur district.

Data Collection instrument

An interviewer administered a semi structured questionnaire for data collection.

The questionnaire had four parts as following:

Part 1: This part deals with socio demographic factors. This includes age, sex, education, marital status, occupation, source of income, family arrangements etc

Part 2: Functional dependency for basic activities of daily living (ADL) was assessed by Katz scale

Part 3: Functional dependency for instrumental activities of daily living (IADL) was assessed by the Lawton scale .^4,5,6

 Katz index and Lawton scale is used for measuring activities of daily living and instrumental activities of daily living. It is the most appropriate instrument to assess functional status as a measurement of the client’s ability to perform activities of daily living independently. The Katz ADL scale included the following activities: Bathing, dressing, eating, toileting and transferring from bed to chair. The ADL was assessed using the Katz Index of Independence in ADL 36. The Index ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding.

A summary score ranges from 0 (low function, dependent) to 6 (high function, independent). The responses of items in the scales were dichotomized as 0-3 score-as dependent “unable to do the activity at all/need some help” and 4-6 as independent “able to do the activity without help”.

Table .no 1, Shows that the Mean age of the participants was 68.71(SD= 7.29). Mean age of male was 69.26(SD= 7.82) and the mean age of women was 68.39 (SD= 6.96). Around 83.3% of the total study populations were in the 60-69 years age group. Only 16.7 % were in the age group 75 and above. In the present study, 36.7 % were males and 63.3 % were females. Almost 41.7% of the elderly lost their spouse. The proportion of those who have lost their spouse is much   higher among women (47.5%) compared to men (31.8). 78.3% of the elderly belong to primary schooling and above category. One fifth of elders (21.7%) were illiterates. Almost 70% of the study population belonged to the lower class. 
  
Table .no 2, shows that 53% % was living in a nuclear family. 16.7% of the elderly belongs to a joint family. Nearly 10% of elderly are living alone. 
  
Table .no 3, shows that nearly 91 % of the study population suffered from one or more chronic diseases. About 48% of the elderly had one chronic disease, while 27% and 16% elderly had two and three or more chronic diseases respectively. Majority of them suffering from Arthritis (58%), hypertension (42.6%) and diabetes (29.3%) 
  
Table .no 4 shows that among the different components in Katz scale, maximum dependency was seen in going to the toilet (46.3%) followed by dependency in Transferring (39.6%) (Moving in or out from bed/chair). Among different components in scale, Female are reported to have higher dependency when compared to male. Female (33%) were reported to have more dependency in going to the toilet as compared to Male (13.3%). This difference was found to be statistically significant (p <0.005). 
  
Table .no 5 shows results of the multivariate analysis. It was found that advanced   age, female gender, elderly living without a spouse (Widow/unmarried/ separated) had statistically significant association with functional dependence for activities of daily living (ADL). Chronic illness, Alcoholic, smoker and tobacco user associations became insignificant in multivariate analysis. Graph .no 1 , shows that the prevalence of functional dependence for basic activities of daily living among study population was 32.7% (95% CI 27.61-37.97) and for instrumental activities of daily living was 39.7% (95% CI 34.3-45.3) as shown in graph 1

 
Tables and Graphs 
Table No 1: Distribution of study subject based on socio demographic profile 

Table No 2: Distribution of the study population based on family type.

Table No 3: Distribution of the study population by co- morbidities

Table No 4: classification of functional dependence for ADL using Katz scale

Table No  5: Multivariate analysis of factors associated with functional dependency for ADL

*p value < 0.05 is significant

Graph No 1: Prevalence of functional dependence for ADL and  IADL

Similar findings were seen in a study done by Vaish, Kriti et al  and showed that the mean age of the study participants was 65.6 years  Two-thirds (66.9%) of the participants were female and housewives (66.3%). Fifteen percent of the participants were currently working. Almost half (53.9%) of the elderly were illiterate. Almost one-third (33.1%) were single. Around one-third (36.7%) of them belonged to the upper lower and lower socio-economic status. The majority (78.1%) of them lived in a joint family .⁷

Similar results   reported by study done among rural population of elderly, found that female elderly was higher in all age category as compared to male elderly people .⁸ A study done in rural area of Delhi among 350 elderly people found there were 80.7% of currently married males compared to 57.6% of currently married females and 42.4% of females were widows compared to 18.7% males who were widowers .⁸ Similar result was found in our study with a higher proportion of widows in females.

Pitchai P et al conducted a study among 2049 elderly in rural area of Maharashtra found that 26% of elderly belong to upper lower class and 4% elderly belong to lower class .⁹

 Nearly 6% were living alone, and three-fifths (60.9%) were living with a spouse .¹⁰The study done by Prithiba Bet al  showed that around 18.6% were alone and   those  who  are  staying  with  family  26.7%  are dependent .¹¹

A positive relationship between age and chronic disease suggests that chronic diseases among the elderly increase with their age .¹²

The prevalence of functional dependence was 57.1% in the study done among elderly people in rural area of South India^1. Study done by Keshari P and Shankar H showed that the Prevalence of functional disability in elderly subjects was 53.6% (95% confidence interval: 49.67 - 57.5%) .¹³ Similar findings were reported by Gupta et al¹⁴  , Paul et al¹⁵  and Gureje et al¹⁶and Aguiar et al ¹⁷  also found a significant association between increasing age and functional disability.

The prevalence of functional dependence for basic activities of daily living among the study population was 32.7% (95% CI 27.61-37.97). Among various risk factors studies, 7 factors for functional dependence for ADL. Advanced age, female gender, chronic illness, elderly who are not living with spouses (widow/unmarried/separated), tobacco user, smoker and current alcoholic had significant associations for ADL functional dependency.

These findings demonstrate the importance of Comprehensive geriatric care should be incorporated into all levels of health care and particularly in primary health care. There is a need for a new policy initiative focusing on strengthening of Community Based Rehabilitation Services (Family oriented programs, day care centers), support for family

Recommendation: 
The high prevalence of functional dependence among the study population requires suitable interventions at the community level itself. Comprehensive geriatric care should be incorporated into all levels of healthcare, particularly in primary healthcare, to provide easy access to promotive, preventive, curative, and rehabilitative services for the elderly through a community-based primary healthcare approach. Health education is needed to provide early diagnosis and treatment of geriatric disorders to the elderly and their caregivers, in order to avoid misperceptions about geriatric disorders and their signs and symptoms in the elderly.

Acknowledgements

The authors are very grateful to all the elderly population who participated in the study.

Declarations

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee. 

1. Goman M, Zaidi A. Global Age Watch Index 2015: Index Report. London: Help

Age International; 2015 November.

2. Karthikeyan S, Pedhamkar BS, Jape MR. Social Security the Global Scenario.

Indian J Occup Health 1999; 42:91-8.

3. Veerapu N, PraveenKumar BA, Subramaniyan P, Arun G. Functional dependence among elderly people in a rural community of Andhra Pradesh, South India. Int J Community Med Public Health 2016;3:1835-40.
4. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW (1963). Studies of Illness in the Aged. The Index of ADL: A Standardized Measure of Biological and Psychosocial Function. JAMA 1963 Sep 21;185:914-9.
5. Fisher T. [Internet]. Dalspace.library.dal.ca. 2008 [cited 31 July 2023].

Available from:https://dalspace.library.dal.ca/bitstream/handle/10222/14829/FisherAppendix

3.pdf sequence=4

6. Lawton, M.P., & Brody, E.M. (1969). Assessment of older people: Self Maintaining

and instrumental activities of daily living. The Gerontologist, 9(3),179-186.

7. Vaish, Kriti, Patra, Somdatta Chhabra, Pragti^. Functional disability among elderly: A community-based cross-sectional study. Journal of Family Medicine and Primary Care 9(1):p 253-258, January 2020. 
8. Devendra Kumar, Sanjeev Kumar Rasania, Ranjan Das. A Clinico -Social Study

Of  Functional Disabilities. 2018: 10.232.74.27

9. Pitchai P, Dedhia HB, Bhandari N, Krishnan D, D‟Souza NR, Bellara JM. Prevalence, risk factors, circumstances for falls and level of functional independence among geriatric population - A descriptive study. Indian J PublicHealth 2019;63:21-6.
10. Chauhan, S., Kumar, S., Bharti, R. et al. Prevalence and determinants of activity of daily living and instrumental activity of daily living among elderly in India. BMC Geriatr 22, 64 (2022).
11. Prithiba B, Baskar A, Lucas A, SuhraRS, Sobha A, Devi G, et al.Dependency and associated factors among elderly in central Kerala. Int J Community Med Public Health 2023;10:3625-30.
12. Srivastava S, Anwar T, Patel R, Chauhan S. Dynamics of chronic diseases in metro and non-metro regions of India: evidence from India human development survey I and II. Int J Sci Rep. 2020;6(8):322.
13. Keshari P, Shankar H. Prevalence and spectrum of functional disability of urban elderly subjects: A community-based study from Central India. J Fam Community Med 2017;24:86-90.
14. Gupta P, Mani K, Rai SK, Nongkynrih B, Gupta SK. Functional disability among elderly persons in a rural area of Haryana. Indian J Public Health. 2014;58:11–6.
15. Paul SS, Abraham VJ. How healthy is our geriatric population? A community based cross sectional study. J Family Med Prim Care. 2015;4:221–5. 
16. Gupta S, Yadav R, Malhotra A. Assessment of physical disability using Barthel index among elderly of rural areas of district Jhansi (UP), India. J Family Med Prim Care. 2016;5:853–7. 
17. Gureje O, Kola L, Afolabi E. Functional disability among elderly Nigerians: Results from the Ibadan study of Ageing. J Am Geriatr Soc. 2006;54:1784–9.