Functional dependency among elderly population in a rural area of Ernakulam district, Kerala, India

INTRODUCTION

The geriatric population, comprising individuals aged 60 years and older, is growing at an unpredicted rate worldwide. In 2019, the number of people aged 60 years and older was 1 billion, which is expected to increase by 1.4 billion in 2030 and 2.1 billion in 2050. The rate of this increase is unpredicted and is expected to further escalate in the coming decades, especially in developing nations.¹ The old-age dependency in India has increased from 14.2% in 2011 to 15.7% in 2021. Whereas in Kerala, the old age dependency had risen to 26.1% in 2021 from 19.6% in 2021.²

Functional dependency refers to the loss or decline in the ability of older adults to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) independently. The geriatric age group being more vulnerable to health risks and morbidities are at higher risk for being functionally dependent. Age related changes, such as reduced muscle strength, joint flexibility, and sensory impairments, can contribute to difficulties in maintaining functional status. Chronic health conditions like diabetes mellitus, hypertension, cardiovascular disease, osteoporosis, chronic renal disease, osteoarthritis, obesity, asthma etc add to the challenges older adults face. The main aim of this study is to assess the functional dependency among the elderly population in rural areas of Ernakulam district and also identify the factors associated with functional dependency among them.

Objectives

Primary objective was to determine the functional dependency among the elderly population residing in rural areas of Ernakulam district.

Secondary objective was to determine the factors associated with functional dependency among the study population.

METHODS

Study design

This was a community based cross sectional study.

Study setting

Njarackal is one of the rural gram panchayats located in Vypin area of Ernakulam district, in the state of Kerala, India. The study was conducted in a rural field practice area of Amrita Institute of Medical Sciences.

Study population

The participants were chosen by a non-probability convenient sampling method. Elderly population aged 60 years and above were included in the study.

Inclusion criteria

Permanent residents among the elderly population living more than six months in Njarackal area were included in the study.

Exclusion criteria

Elderly persons who are bed ridden, physically disabled or mentally retarded were excluded from the study.

Study duration

The study duration was from April till September 2022. Data collection was carried out in May month of 2022.

Ethical consideration

The study protocol was approved and reviewed by the dissertation review committee and Institutional Ethical Committee of Amrita School of Medicine. Written informed consent was obtained from the study participants.

Sample size

The sample size was calculated based on a study done by Usha et al where the total dependency rate was 28% was 81 with a 10% absolute error.³ However, 200 participants were included in the study.

Study instruments

A semi-structured questionnaire consisting of sociodemographic details, medical history, history of comorbidities and questions on activities of daily living (ADL) was used to collect data from the study participants. Barthel’s scale was used to assess the activities of daily living (ADL) and Lawton’s scale was used to assess independent activity of daily living (IADL). ADLs include essential self-care tasks such as bathing, dressing, eating, toileting, and transferring, while IADLs encompass more complex activities like managing finances, cooking, shopping, and using transportation.^4,5 The questionnaire was prepared in English and was translated to the local language during the interview. Information was collected after obtaining written informed consent from the study participants.

Statistical analysis

The data was analysed using IBM statistical package for the social sciences (SPSS) statistics for Windows, software version 21. Categorical variables are expressed in frequency and percentage. Continuous variables are expressed as mean and SD. The chi-square test for significance was used to determine the factors associated with functional dependency. A p value <0.05 was considered statistically significant.

RESULTS

Among the 200 participants, where half of the population were females (52.2%). A majority of them belong to youngest old adult (46.7%) criteria. The mean age (SD) of the population was 68 years ±10.04 SD. Most of them (54%) belongs to APL category and half of the study population are living in joint families (50.8%). Other sociodemographic details are given in Table 1.

Among the study participants, 57.9% of females and 42.1% of males have a visual impairment, 60% of females and 40% of males have a hearing impairment, 45.5% of females and 54.5% of males have cognitive impairment (Table 2).

According to the responses obtained from study participants, scoring was done and categorized. On assessing the ADL using the Barthel’s scale, 70.1% belonged to fully independent category (90-100) and 2.5% was fully dependent (0-19).

According to the IADL assessment using Lawton’s scale, 75.1% belong to the fully independent (90-100) category and 0.5% was fully dependent (0-19). Other scoring details and categories were given in Table 3.

*Others include osteoporosis, osteoarthritis, spine derangement and renal impairments, CVD- cardiovascular disease, DM-diabetes mellitus, HTN- hypertension

In bivariate analysis, ADL is found to be significant for age (p<0.001), marital status (p<0.001) and gender (p=0.044), whereas IADL is found to be significant for marital status (p=0.023) (Table 4).

In this study, physical dependency for activities of daily living induced by comorbidities like diabetes mellitus (unadjusted OR 1.076), asthma (unadjusted OR 2.603), obesity (unadjusted OR 2.778), cardiovascular diseases (unadjusted OR 1.121) and other comorbidities (unadjusted OR 2.603) that include osteoporosis, osteoarthritis, spine derangement and chronic kidney diseases was more likely to occur as the predictor increases, whereas physical dependency induced by hypertension (unadjusted OR 0.822) is less likely to occur among the study population (Table 5).

Meanwhile, physical dependency for independent activities of daily living induced by comorbidities like diabetes mellitus (unadjusted OR 1.751), asthma (unadjusted OR 3.667), cardiovascular diseases (unadjusted OR 1.267) and other comorbidities (unadjusted OR 3.667) that include osteoporosis, osteoarthritis, spine derangement and chronic kidney diseases is more likely to occur as the predictor increases, whereas physical dependency induced by hypertension (unadjusted OR 0.877) and obesity (unadjusted OR 0.959) was less likely to occur among the study population (Table 6).

DISCUSSION

In our study, 2.5% of the elderly population were fully dependent whereas 8.5% are severely dependent for their routine activities. In a study done in Uttarakhand by Usha et al, 0.5% of the people in rural are totally dependent and 7.5% are severely dependent on their daily activities using the ADL score.⁶ In a study done in West Bengal by Dolai et al, among the age group of 60–69% and 70–79% none of the individuals have functional dependency only the elderly aged 80+ years of age were found to have a dependency of 33.3%.⁷

In our study, using the Lawton scale 0.5% were found to be functionally dependent using the IADL scale. In a study done in Jharkhand by Soren et al, ADL was found to be 39.29% for the elderly with fully dependent and the IADL score was found to be higher for the elderly with fully dependent than the ADL score.⁸ In a study done in Andhra Pradesh the prevalence of functional dependence for ADL was 21.8% and IADL was 51.7%.⁹

In this study persons with diabetes mellitus and functionally dependent was found to be 11.5% whereas in a study done in Varanasi, the elderly population in their study population with cataracts was 20.46%, COPD with 10.98%, diabetes 0.27% whereas in a study, done in Nigeria, functional dependency among diabetes patients was found to be 37.3%.^10,11 In this study, persons with cardiovascular disease and functionally dependent were found to be 11.9%.

It is observed that in our study population, 57.9% of females and 42.1% of males have a visual impairment, 60% of females and 40% of males have a hearing impairment, 45.5% of females and 54.5% of males have cognitive impairment. In a study done in Kottayam, Kerala by Bhaskar et al, functionally dependent- 30.2% depending upon the Barthel index scale, the Lawton index of the IADL scoring scale 15% of elderly people were found to be functionally dependent, the prevalence of diabetes was found to be 17.2%, 63.4% of females and 36.6% of males have a visual impairment, 65.8% of females and 34.2% of males have a hearing impairment, 64.1% of females and 35.9% of males have cognitive impairment.¹¹ The prevalence of coronary artery disease was found to be 6.6%.

Strength and limitations

The study population were mostly concerned about physical, physiological and psychological illness. Studies related to functional dependency are limited because most of the studies are focused on mental illness among the geriatric age. Limitations of this study, data collection was done around the health centre, so only a particular population was taken into consideration.

CONCLUSION

Comorbidities such as diabetes mellitus, cardiovascular diseases, osteoporosis, osteoarthritis, and cognitive impairment contribute to a decline in functional abilities among older adults. These conditions often interact and exacerbate one another, leading to a cascade of physical and cognitive impairments. The resulting functional dependency has far-reaching consequences, affecting not only the individuals themselves but also their families, caregivers and healthcare systems. Addressing functional dependency induced by comorbidities required a multifaceted approach. Prevention plays a crucial role, with emphasis on promoting healthy lifestyles, early detection and management of chronic conditions, and regular physical activity. Effective management of chronic conditions, and regular physical activity. Effective management of comorbidities through medication management, therapy and adaptive devices can help optimize functional abilities and reduce the impact on independence.

Recommendations

Strengthening geriatric healthcare services and increasing awareness for health-seeking behaviour, especially among women in the household, particularly in the rural areas will have a huge impact in decreasing the comorbidity-induced dependency among the elderly population.

ACKNOWLEDGEMENTS

The authors would like to acknowledge AMO and the Social Worker of Amrita Community Health Center, Njarackal for their full-fledged support. They thank the participants who were the great strength of this study. They also remain thankful to the authorities of Amrita Institute of Medical Sciences and special thanks to the Department of Community Medicine for their guidance throughout the study.

Funding: No funding sources

Conflict of interest: None declared

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

REFERENCES

1. 1. World Health Organization. Ageing and health. Available at: https://www.who.int/news-room/fact-sheets/detail/ageing-and-health. Accessed on 22 June 2023.
2. 2. Economic Review 2017. State Planning Board, Thiruvananthapuram, Kerala, India. Available at: https://spb.kerala.gov.in/economic-review/ER2017/web_e/ch414.php?id=41&ch=414. Accessed on 22 June 2023.
3. 3. Usha P, Kishore S, Singh M, Aggarwal P, Jain B, Gawande K. Assessment of Activities of Daily Living (ADL) in elderly population. Indian J Community Health. 2020;32(2):447-9.
4. 4. Brody L. Barthel’s scale for activities of daily living. Available at: www.ConsultGeriRN.org. Accessed on 22 June 2023.
5. 5. TOTAL (0-100). Available at: www.strokecenter.org. Accessed on 22 June 2023.
6. 6. Dolai MC, Chakrabarty F. Functional Status of the Elderly Santal People. Int J Human Soc Sci Intervent. 2013;2(1):1-6.
7. 7. Soren SK, Sunderam S, Deo M, Kujur A, Singh SB, Kachhap A. An epidemiological study on morbidity profile and predictors of health-seeking behaviour among elderly population in a tribal dominant state of India: A regression analysis. J Family Med Prim Care. 2022;11(5):2179.
8. 8. 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;1835-40.
9. 9. Patwardhan K, Tiwari S, Sinha AK, Patwardhan K, Gehlot S, Gambhir IS, et al. Prevalence of health problems among elderly: A study in a rural population of Varanasi. Prev Soc Med. 2010;41(3).
10. 10. Abdulraheem IS, Oladipo AR, Amodu MO. Prevalence and correlates of physical disability and functional limitation among elderly rural population in Nigeria. J Aging Res. 2011;369894.
11. 11. Bhaskar A, Manjula VD, Joseph J. Study on morbidities and functional disabilities of elderly in rural area of Kottayam. J Evol Med Dent Sci. 2014;3(37):9601-9.
12. 12. Sharma D, Mazta SR, Parashar A. Morbidity Pattern and Health-seeking Behavior of Aged Population residing in Shimla Hills of North India: A Cross-Sectional Study. J Fam Med Prim Care. 2013;2(2):188-93.
13. 13. Thakur R, Banerjee A, Nikumb V. Health problems among the elderly: a cross-sectional study. Ann Med Health Sci Res. 2013;3(1):19-25.
14. 14. Tiwari SC, Pandey NM. Status and requirements of geriatric mental health services in India: an evidence-based commentary. Indian J Psychiatry. 2012;54(1):8-14.
15. 15. James KS. India’s demographic change: Opportunities and challenges. Science. 2011;333(6042):576-80.