Health problems and nutritional status of Sudanese elderly in Khartoum State Hospitals.

Eltinay, Fatima ElZara ; AbdelMagied, Ahmed ; Salih, Osama 等

Abstract

This study aims to assess the health and nutritional status and identify the major health problems and risk factors faced by the Sudanese elderly population admitted to Khartoum State Teaching Hospitals.

A Geriatric assessment to identify problems with activities of daily living, cognitive and psychological functions and senses was conducted to shed light on risk factors and heath not covered by routine medical examination that could affect health status. Nutrition was assessed using the BMI.

The commonest health problems faced by the elderly Sudanese were found to be endemic and epidemic diseases (e.g. Malaria), as well as chronic illnesses (e.g. Hypertension and Diabetes mellitus) and their complications. Activities of Daily Living revealed that a majority of the respondents were unable to care for themselves within a limited environment.

Polypharmacy was not a problem amongst Sudanese elderly. Depression, either mild or severe was found in a majority of the respondents. This was despite the strong family bonds and community socialization which is characteristic of our Sudanese society. Sensory impairments were only encountered in a few patients.

Routine medical examination to identify risk factors and health problems specific to the elderly age group is essential for providing adequate health services.

This is to allow early diagnosis and treatment of any impending illnesses. It would therefore be pertinent to emphasize the necessity for the availing comprehensive geriatric assessment in addition to the provision of adequate health care services that will provide means for proper management of the health problems of older Sudanese people.

Introduction

Aging is a normal, inevitable biological phenomenon. It is a process of gradual and spontaneous change, resulting in maturation through, childhood, puberty and young adulthood and then decline through middle and late age (1).

Theories of Aging

There are more theories on aging than facts. Aging clearly occurs at different rates for different species and even within the species; aging occurs at different rates among different individuals. The only reasonable conclusion is that aging must be genetically controlled, at least to some extent. Both within and between species, lifestyle and exposures may alter the aging process.

Some proposed theories include the Loose Cannon Theory, Weak Link Theory, Error Catastrophe Theory, Master Clock Theory (1).

World Demographics

The aging population is described by the WHO as being those individuals who are aged 60 or above. The support of this ever-expanding population has become of increasing concern. Today, the population aged 60 years and older is estimated at nearly 1 person in 10 worldwide, with a gender ratio of 302 million women to 247 million men (3).

Although ageing is not considered a priority issue in the Arab region, the absolute number of people aged 65 and above has doubled from 5.7 million in 1980 to 10.4 million in 2000 and is expected to increase to 14 million by 2010 and 21.3 million by 2020.

Physiological Aging Processes in the Body

The ageing process affects all body processes including the immune system (4), nervous systems and cardiovascular system (6) as well as individual organs such as the lungs (7), gastrointestinal tract (8), skin (9), blood (10) and kidneys (11).

Aging and Nutrition

Physiologic and functional changes during aging result in changes in nutrient needs. Research has shown that older adults do have specialized requirements for a variety of nutrients because of aging effects on absorption, utilization, and excretion (12). Common Nutritional Problems faced by the elderly include malnutrition (13), obesity (14) and vitamin and trace mineral disorders (15).

Aging and Mental Health

Aging may variably affect cognition, memory, intelligence, personality, and behavior. However, many changes are difficult to attribute to aging; they are often the result of disease (16).

Common Health Disorders affecting the Elderly

Common disorders affecting the elderly population include atherosclerosis (17), cerebrovascular disease (18), hypertension (19) and diabetes (20) and their complications. Urinary incontinence (21) and urinary tract infections (22) as well as constipation (23) pose frequent problems to the elderly population. Falls (24), fractures (25) and osteoporosis (26) and rheumatoid arthritis (27) are common afflictions preventing mobility. Chronic obstructive pulmonary disease (28) as well as lung cancer (29) and pulmonary infections (pneumonia and tuberculosis) were evident (30). Ocular disorders including glaucoma, diabetic retinopathy, and age-related maculopathy are seen (31). Sensory dysfunction (32), depression (33), and cancer (34) are also prevalent.

In Sudan, being a developing country, little emphasis was placed on the elderly. Fortunately, in the past few years more attention has been focused on this group as a result of the recent global movement towards the improvement of the elderly situation.

Different organizations have taken the responsibility of attempting to tackle the problems facing the elderly. One such organization is the Sudanese Society in Care of Older People. It was established in 1994 with the aid of Help Age International along with individual sponsors. Its goal is to help the elderly all over the country. In Khartoum State, the elderly are provided with health care in the premises of the Sudanese Society in Care of Older People and in two older people's homes in Khartoum with very modest capacities. Help Age International has targeted its activities towards the elderly in the slum areas of Al Hag Yousif, a suburb east of Khartoum city.

The government restricts its assistance to donations allocated by the Ministry of Health to the elderly occupying the elderly homes (21).

Therefore, the situation of the Sudanese elderly still receives the minimum care, especially in the field of health care. Policy arrangements and cooperation between the Government and Nongovernmental organizations are essential for achieving the desired level in accordance to International standards. It should also be pointed out that studies to actually pinpoint health problems and risk factors as well as the resultant health status of the Sudanese elderly have hardly been addressed in-depth and therefore light needs to be shed on these areas through researching before any plans can be formulated for the improvement of the elderly situation in Sudan.

Justification

Although, recently, the nutritional status and health risk factors of older people have to some extent been researched in an unpublished form, the situation of hospitalized older persons has not been investigated.

General Objective

To investigate the nutritional status and health risk factors of hospitalized older persons admitted in Khartoum State Hospitals.

Specific Objectives

--To determine the common health problems and complaints of the inpatients interviewed.

--To view the ability of the respondents in performing the Functional and Instrumental Activities of Daily Living

--To determine medication use in the sample interviewed

--To assess the mental health indicators of the sample examined

--To determine the degree of Sensory Impairment in the population studied

Methodology

Study Population and Sample Selection:

This cross sectional descriptive study was conducted on 75 elderly inpatients above 60 years, of both sexes and of different socio-economic groups admitted in Khartoum State Hospitals and were examined during May 2006-August 2006.

All respondents (75) were subjected to the different tests conducted during this investigation; this is with the exception of BMI measurements in which only 29 respondents were fit for measurement.

Data Collection:

Primary data was collected by using a questionnaire and interview with the patients. Further data was collected using Functional Geriatric Assessment. This assessment screened for problems in functional abilities. Mobility, Gait, and Balance were assessed by the Modified Romberg test, the Get Up and Go test and the Functional Reach test. Shoulder functions as well as hand functions were also evaluated (35). Mental functions were tested by the Clock Drawing test (36), Abbreviated Mental Test Score and Geriatric Depression Scale (37).

Sensory Assessment was conducted for visual acuity, hearing, taste, smell and tactile function.

To assess the nutritional status Body Mass Index (BMI) was used.

Secondary data was collected from books, specialized handbooks, researches, published articles and internet sources.

Data Analysis:

Data was analyzed using SPSS (statistical package for social search) and presented in the form of tables of frequency and percentages. This is in addition to some graphical representations.

Limitations of the Study:

--Scarcity of Sudanese literature in this age group due to minimal studies carried out.

--Difficulty of doing anthropometric measurements due to respondents being unfit.

--The changing mood and temperament of the elderly, not allowing the completion of the data collection in one session.

--Death of some of the respondents during the data collection process.

Result

Amongst the sample investigated, the majority (57%) were males while 43% were females.

According to age distribution, more than half the respondents (56%) were in the 60-69 age groups, followed by the age group 70-79 (29%). Those aged 80 years or above were found to be 15% of the respondents.

Eighty five percent (85%) of the elderly studied were married while 13% were widowed and 1% were divorced.

[FIGURE 1 OMITTED]

Figure 1 revealed that recurrent malarial attacks (45%) and constipation (45%) had the highest occurrence. Diabetes (29%), Hypertension (25%) and their complications were also present. Ophthalmic (12%), Dental diseases (12%), and Urogenital diseases followed in occurrence.

[FIGURE 2 OMITTED]

Figure 2 shows the commonest complaints of the respondents were fatigue (79%), palpitations (51%), followed by constipation (44%). Joint pain and swelling were present in 29% of the respondents.

Table 1 illustrates the functional activities of daily Living in our sample of respondents. Forty eight percent (48%) of the respondents were totally dependent on others while dressing, while 28% depended partially on others and 24% dressed independently. About 39% (38.7%) of the elderly depended totally on others for eating and 34.7% did not need help and 26.7% depended partially on others to assist them in eating.

Forty four percent (44%) of the respondents were totally dependent on others for grooming, 36% did not and 20% partially depended on others. More than half (53.3%) required total assistance in getting to and using the bathroom, while 25.3% were partially dependent on others and 21.3% were totally able to accomplish this task alone. About 53% (53.3%) of the elderly were totally in need of others in moving about, 26.7% were partially dependent on others and 20% of the respondents did not require assistance in moving around.

Table 2 revealed that 2% of the respondents drove cars, and only 1% paid bills. 14% actually shopped and 44% attended social events.

Forty seven percent (47%) of the respondents take chronic medications, 13% take recurrent medications. Of the respondents taking these types of medications, only 17% are taking them regularly. 51% of the patients only take medications prescribed by a doctor, while 3% take over the counter medications. 44% of the patients remember the timings of their drugs and 35% take their drugs alone, 21% rely on a caregiver to give them their drugs.

Of the 29 respondents fit to undergo this anthropometric measurement, the majority (76%) were found to be in the normal range. Both moderate and mild malnutrition were of the same percentage (3.4%). 17.2% were noted to be overweight. That is in total those who were malnourished constituted 24%.

Table 5 shows that 26.7% of the respondents exhibited cognitive impairment, while 73.3% had no cognitive impairment.

Table 6 revealed that 20% of the patients were normal, 60% of the patients exhibited mild depression, followed by 20% being very depressed.

Eighty four percent (84%) of the respondents enjoyed an intact sense of smell, 85% had normal sense of taste. Eighty one percent (81.4%) of the respondents had intact hearing, while 17.3% had mild deafness, and 1.3% had total deafness. Tactile function was intact in 63% of the patients and focally impaired in 14.7% and generally impaired or absent in only 1.3%.

Discussion, Conclusions and Recommendations

Among the commonest health problems (Figure 1) faced by the elderly patients was the prevalence of endemic and epidemic diseases especially Malaria (45%). This was followed by long standing chronic diseases such as diabetes and hypertension and their complications. On the other hand, the commonest complaint (Figure 2) among the respondents was constipation (54%), which is higher in prevalence (24-37%) among American elders (38).

Functional activities of Daily Living (Table 1) performed on the study group revealed that a large portion of the respondents were unable to care for themselves within a limited environment. Instrumental activities of daily living (Table 2) to function in the community by the interviewed patients were shopping and attending social events.

Regarding medication use(table 3), the majority(87%) of the respondents were found not to take chronic or recurrent medications in contrast to 90% of Americans over 65 years who take at least one prescription drug daily and the majority take two or more medications (39). Therefore, polypharmacy is not a problem in Sudanese elderly. However, only 17% of the patients take their medications regularly and this is attributed to not remembering the dose timings of the drugs, and relying on a caregiver to administer these medications. It is also important to note that the majority of patients take prescription drugs only and only 3% resort to taking over the counter drugs.

Out of the 29 patients who were in a position for BMI measurements, 24% of them were malnourished.

Depression is one of the most common psychiatric disorders in the elderly. Of the patients interviewed (table5) 20% were found to be very depressed in contrast to 12% of hospitalized elderly in the United states (40). About twenty seven percent (26.7%) of the respondents had cognitive impairment (table4).Sensory Impairments were only encountered in a minority of the patients (Table 6).About nineteen percent (18.6%) encountered hearing difficulties while 16% had diminished olfactory sense and 15% had diminished ability to taste. Impairments in tactile function needed in daily life were present only among 16% of the respondents. Therefore, the following main conclusions are here emphasized:

The commonest health problems faced by the elderly Sudanese include infectious diseases, as well as chronic illnesses (e.g. Hypertension and Diabetes mellitus) and their complications.

Depression, either mild or severe was found to be present in a majority of the respondents. This was despite the strong family bonds and community cooperation present in the Sudanese society.

Preventive measures may not benefit all the elderly population and this depends on the patient's physical health, functional ability, and cognitive status.

Accordingly, the following recommendations are suggested:

--The prevention of chronic illnesses and infectious diseases should be a priority in any health care service that targets this group.

--Recognition of the importance of availing of mental health and nutritional status on physical well being in this group.

--Recommendations should concentrate mainly on the prevention of diseases and disability in this age group as in other vulnerable groups.

--Use of the proposed Comprehensive Geriatric Assessment in addition to routine medical examination to identify" risk factors and health problems specific to the elderly age group.

--Promoting regular medical checkups at all levels of the Health Care System to allow early diagnosis and treatment of any impending illnesses.

--In those with preexisting diseases, strategies should be provided as to allay development of complications and further disability from these conditions.

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Eltinay, Fatima ElZara; AbdelMagied, Ahmed and Salih, Osama (School of Medicine and Nutrition Center for Training and Research--Ahfad University for Women

Table 1. Functional Activities of Daily Living

 Frequency Percent

Dressing Totally Dependent 36 48%
 Partially De endent 21 28%
 Inde endent 18 24%
Eating Meals Totally Dependent 29 38.6%
 Partially Dependent 20 26.7%
 Independent 26 34.7%
Grooming Totally Dependent 33 44%
 Partially Dependent 15 20%
 Independent 27 36
Going to the Totally Dependent 40 53.3%
Bathroom Partially Dependent 19 25.3%
 Independent 16 21.4%
Mobility Totally Dependent 40 53.3%
 Partially Dependent 20 26.7%
 Independent 15 20%

Table 2. Instrumental Activities of Daily Living

 Frequency Percent

Driving a Car YES 2 3%
 NO 73 97%
Payment of Bills YES 1 1%
 NO 74 99%
Shopping YES 14 19%
 NO 61 81%
Attends Social YES 44 59%
Events NO 31 41

Table 3. Use of Medications

 Frequency Percent

Uses Prescription Drugs YES 38 51%
 NO 37 49%
Over the counter Drug Use YES 2 3%
 NO 73 97%
Chronic medication Use YES 35 47%
 NO 40 53%
Recurrent Medication Use YES 10 13%
 NO 65 87%
Medication Use is Regular YES 13 17%
 NO 62 83%
Remembers timings of YES 33 44%
Drugs NO 42 56%
Relies on Caregiver to take YES 16 21%
medications NO 59 79%
Takes Medications Alone YES 26 35%
 NO 49 65%

Table 4. Body Mass Index

 Frequency Percent

Moderate Malnutrition 1 3.4%
(16.00-16.99)
Mild Malnutrition 1 3.4%
(17.00-18.49)
Normal Range 22 76%
Overweight (>25.00-24.99) 5 17.2%
Total 29 100%

Table 5. Abbreviated Mental Test Score

 Frequency Percent

Cognitive Impairment 20 26.7%
No Cognitive Impairment 55 73.3%
Total 75 100%

Table 6. Depression Assessment Score

 Frequency Percent

Normal 15 20%
Mildly Depressed 45 60%
Very Depressed 15 20%
Total 75 100%

Table 6. Senses of Smell & Taste & Hearing & Tactile function

SENSES Frequency Percent

Smell lntact 63 84%
 Diminished 12 16%
Taste Intact 64 85%
 Diminished 11 15%
Hearing Intact 61 81.4%
 Mild Deafness 13 17.3%
 Total Deafness 1 1.3%
Tactile Function Intact 63 84%
 Focal Im airment 11 14.7%
 General Impairment 1 1.3%