PREVALENCE AND PREDICTORS OF GERIATRIC SYNDROMES IN AN OUTPATIENT CLINIC AT A TERTIARY CARE HOSPITAL OF INDIA

Abstract

Background: The precise prevalence of "Geriatric syndromes" among older patients in India is uncertain both in community or hospital setting. We examine the prevalence of geriatric syndromes in a dedicated outpatient clinic of a tertiary care hospital and to correlate their association with commonly encountered co-morbidities. Methods: OPD records of 343 older patients of the Geriatric Clinic of All India Institute of Medical Sciences, New Delhi, India, between August 2010 and January 2011 were reviewed. Data on prevalence of geriatric syndromes and the co morbidities were collected and the significance of their association was analyzed with appropriate statistical methods. Results: The mean age of presentation was 70.19(±5.6) years. The top five commonly associated comorbidities were hypertension (39.4%), diabetes (21.6%), cataract (12.5%), COPD (10.5%) and osteoarthritis (OA) (8.2%). Comprehensive geriatric assessment of these patients showed the prevalence of geriatric syndromes were depression 28(8.2%), cognitive impairment5 (1.5%), falls 26(7.6%), incontinence 15(4.4%) and functional dependency 37(10.9%). In our study CAD and osteoarthritis were strongly associated with cognitive impairment ( p=0.000) and falls (p=0.004) respectively. Old CVA was found to be significantly associated with depression (p=0.010) and falls ( p=0.007). Conclusions: Prevalence of Geriatric syndrome in outpatient settings was high. Under- recognition of these syndromes with routine medical assessments was common. Co- morbidities are very often independently associated with these geriatric syndromes. Therefore, routine screening by comprehensive geriatric assessment can prevent future disability.

Full text

Journal of Aging Research & Clinical Practice©
Volume 2, Number 1, 2013
PREVALENCE AND PREDICTORS OF GERIATRIC SYNDROMES
IN AN OUTPATIENT CLINIC AT A TERTIARY CARE HOSPITAL
OF INDIA
P. C . D a s 1, P. Chatterjee2, P. Kumar3, G. Kumar4, A.B. Dey5
Background
India has seen rapid demographic transition for last
few years with almost tripling of population over the age
of 60yrs (i.e. the elderly) (1). Life expectancy at birth in
1990 was 58 yrs and has been increased to 66.6 by
2010.Increase in literacy rate, better health care and
improved awareness on health gave rise to increase in
longevity and survival of elderly population (2). In older
patients association of multiple comorbidities is very
common, which very often result in atypical symptoms
(e.g. Immobility, instability, impaired cognition,
incontinence and depression), not directly related to a
particular disease process. They are referred to as
“geriatric syndromes”, leads to significant morbidity, and
future disability (3). These syndromes may have a
common pathophysiology despite their different
presentations, and require interventions and strategies
targeted towards the etiological factors (4). Elderly
patients usually present with certain symptoms of a
particular disease on the background of multiple co
morbidities and geriatric syndromes. Health
professionals underestimate the prevalence of these
conditions, as they routinely don’t look for these
conditions (5). Under-recognition or suboptimal
assessment of these syndromes in general medical
outpatient clinic is common (6). A comprehensive
geriatric assessment is very much needed for ideal
management of elderly patients both in OPD and acute
care settings. In Indian context there is no large scale
study on this issue. Moreover there is no special or
separate geriatric set up in most of the tertiary care
centres of this country and hence the exact prevalence of
geriatric syndromes in hospital settings is not known.
A third of the patients receiving care at All India
Institute of Medical Sciences, New Delhi, India are
1. MD, Assistant professor ,Department of Geriatric Medicine, All India Institute
of Medical Science (AIIMS), New Delhi, India; 2. MD, Senior Resident,
Department of Geriatric Medicine, AIIMS, New Delhi, India; 3. PhD Scholar,
(KGMU, Lucknow), Senior Research Fellow (ICMR), Department of Geriatric
Medicine, (AIIMS, New Delhi, India; 4. PHD (Statistics), Scientist, Department of
Biostatistics, AIIMS, New Delhi, India; 5. MD, Professor and Head, Department of
Geriatric Medicine ,AIIMS, New Delhi, India.
Corresponding Author: Dr A B Dey, HOD Geriatrics, Room No- 3091, Teaching
block, Email-abdey@hotmail.com
117
Abstract: Background: The precise prevalence of "Geriatric syndromes" among older patients in India is uncertain both in
community or hospital setting. We examine the prevalence of geriatric syndromes in a dedicated outpatient clinic of a tertiary care
hospital and to correlate their association with commonly encountered co-morbidities. Methods: OPD records of 343 older patients
of the Geriatric Clinic of All India Institute of Medical Sciences, New Delhi, India, between August 2010 and January 2011 were
reviewed. Data on prevalence of geriatric syndromes and the co morbidities were collected and the significance of their association
was analyzed with appropriate statistical methods. Results: The mean age of presentation was 70.19(±5.6) years. The top five
commonly associated comorbidities were hypertension (39.4%), diabetes (21.6%), cataract (12.5%), COPD (10.5%) and osteoarthritis
(OA) (8.2%). Comprehensive geriatric assessment of these patients showed the prevalence of geriatric syndromes were depression
28(8.2%), cognitive impairment5 (1.5%), falls 26(7.6%), incontinence 15(4.4%) and functional dependency 37(10.9%). In our study
CAD and osteoarthritis were strongly associated with cognitive impairment ( p=0.000) and falls (p=0.004) respectively. Old CVA
was found to be significantly associated with depression (p=0.010) and falls ( p=0.007). Conclusions: Prevalence of Geriatric
syndrome in outpatient settings was high. Under- recognition of these syndromes with routine medical assessments was common.
Co- morbidities are very often independently associated with these geriatric syndromes. Therefore, routine screening by
comprehensive geriatric assessment can prevent future disability.
Key words: Geriatric syndromes, co-morbidities, prevalence.
Received September 3, 2012
Accepted for publication September 27, 2012
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elderly. Unfortunately, the prevalence of geriatric
syndromes in this apex institute is not known. The
Geriatric Medicine unit (Which runs daily outpatient
services since August 2010), which uses the
comprehensive geriatric assessment tool, may highlight
the exact prevalence of geriatric syndrome and associated
co morbidities.
The primary objective of this study is to determine the
prevalence of the geriatric syndromes (cognitive
impairment, depression, functional limitation, urinary
incontinence, and falls) in Geriatric outpatient clinic of All
India Institute of Medical Sciences, New Delhi, India. The
secondary objective is to assess the significant association
of particular comorbidity with these commonly
encountered geriatric syndromes.
Materials and Method
Study participants
A retrospective study was carried out from geriatric
assessment records of patients, 60 years of age or older,
who attended the Geriatric Outpatient Clinic of All India
Institute of Medical Sciences between August 2010 and
January 2011. The comprehensive geriatric assessments
were carried out in these patients, which includes, in
addition to the usual assessment, a detailed functional,
social, and environmental assessment. As part of the
assessment, patients were screened for cognitive
impairment, depression, functional dependency, urinary
Incontinence, and falls. The diagnosis of cognitive
impairment was based on the Folstein MMSE (score<24)
was used as diagnostic criteria. Depression was
determined with the help of Yesavage Geriatric
Depression Scale-Short form (score ≥5). The BARTHEL
ADL INDEX (BADL) was used to determine the
functional dependency of the participants. Functional
dependency was defined as,participant having
dependency in any one domain of BADL (score<20 ).
Urinary incontinence was defined as a self-reported
presence of involuntary urine loss. A fall, defined as
inadvertently coming to rest on the ground, floor or other
lower level (excluding intentional change in position to
rest),were taken into consideration only if there were at
least one fall in last six months. All subjects (or their
proxies) gave informed written consent. Baseline
characteristics such as age, sex, marital status, and living
environment, as well as data on comorbidities, including
vision, hearing impairment was collected. Data on the
geriatric syndromes was also collected. Based on this, the
association of each comorbiditiy with the geriatric
syndrome was statistically analyzed to predict for their
significance of association (p<0.05).
Statistical analysis
The prevalence of the geriatric syndromes and
comorbidities were analyzed using descriptive statistics.
The results were expressed both as percentages and
frequencies. Odd Ratio with 95% confidence intervals
using the Chi-square test was used for analyzing the
significance of association between comorbidities and
geriatric syndromes. The continuous data was compared
by t-test .Univariate and multivariate logistic regression
was used find out the predictor for Geriatric syndrome.
We regarded a two sided p-value less than 0.05 as
significant. All analyses were undertaken using SPSS
version 19 (IBM, USA).
Results
There were 343 patients, mean age was 70.19 (± 5.602).
Females were 110(32.1%) and male 233(67.9%).The
number of patients as per their age distribution 60 to
69,70 to 79 and 80 yrs or more were 144(42%),172(50%)
and 27(8%) respectively (Figure 1).
Figure 1
Percentage of patients in different age group
Figure 2
Association of co-morbidities
The associated comorbidities in our patients were
shown in (Figure 2). The top five common underlying
PREVALENCE AND PREDICTORS OF GERIATRIC SYNDROMES IN AN OUTPATIENT CLINIC AT A TERTIARY CARE HOSPITAL OF INDIA
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119
diseases were hypertension (39.4%), diabetes (21.6%),
cataract (12.5%), COPD (10.5%) and OA (8.2%).
After comprehensive geriatric assessment with
different assessment tools, the prevalence of common
geriatric syndromes were determined as shown in figure
3. In our study depression 28(8.2%), cognitive
impairment 5(1.5%), falls 26(7.6%), incontinence 15(4.4%)
and functional dependency 37(10.9%) were found. We
analyzed the association of top seven important (HT,
DM, Cataract, COPD, OA, CAD and old CVA)
comorbidities with each of the geriatric syndromes
separately to find out the significance of their association,
which are enumerated in Table-1. CAD was strongly
associated with Cognitive decline [odd ratio(OR)=25.02,
95% confidence interval (CI)=3.94,158.86), p=0.000] and
Osteoarthritis(OA) was significantly associated with falls
[OR=3.995, CI=1.455,10.970, p=0.004] .Old CVA was
found to have significant association with Depression
[OR=4.377, CI= 1.307, 14.65, p=0.010] and Falls
[OR=4.591, CI=1.367, 15.419, p=0.007].
Figure 3
The prevelance of geriatric syndromes
All these variables with p<0.25 were enter in
multivariate logistic regression and it shows none of the
variable were significant. The possibility of this results
may be due to less number of observation in the
parameter.
Table 1
Sociodemogarphic profile of elders attending geriatric
OPD
Male (%) Female (%) Total (%)
Educational Status Illiterate 15.1 33.9 24.8
Primary 57.3 57.3 53.4
Class12 and above 27.6 8.8 21.8
Occupational Status Unemployment 63.2 90.3 72.47
Employment 8.1 3.5 5.7
Retired 28.7 6.1 21.83
Living Status Spouse 5.1 6.4 5.3
Spouse & Children 73.3 52.7 63.71
Children 16.3 37.5 26.12
Old Age Home 1.8 1.1 2.7
Alone 3.5 2.3 2.1
Marital Status Married 88.7 72.2 78.8
Single 2.5 0.2 1.54
Divorced 0.4 0.5 0.3
Widowed 8.4 27.1 19.36
Discussion
This study provides the prevalence of the geriatric
syndromes such as falls, cognitive impairment, functional
dependency, urinary incontinence and depression in the
geriatric outpatient clinic of the All India Institute of
Medical Sciences, New Delhi. Most of the elderly patients
(about 90%) were between the age group of 60 -79 yrs.
Male outnumbers the female patients. Illiteracy was
almost double in female compare to male and most of
people have primary education only. Though maximum
number of patients were unemployed, they live in joint
family, signifies strong social system of Indian culture.
Hypertension was the most commonly associated
comorbidity in our patients followed by DM, cataract,
COPD, OA, CAD and old CVA. It is obvious that most of
these comorbidities are preventable or treatable.
Functional dependency was the most prevalent
geriatric syndrome in our patients, which is consistent
with the Thailand study by Panita Limpawattana et al (6).
This findings, is alarming, as this would increase the
financial and social burden. Other important Geriatric
syndromes were depression, fall, incontinence and
cognitive impairment. These syndromes are very much
underreported and neglected in Indian Geriatric
population.
Table 2
Significance of association between comorbidities and Geriatric syndromes
Depression Cognitive impairment Falls Incontinence Functional dependence
HT *n(%) +p 7(2.1%) 0.130 1(0.3%) 0.367 10(.9%) 0.903 3 (0.9%) 0.113 17(5.0%) 0.402
DM n(%) p 2(0.6%) 0.065 1(0.3%) 0.938 9(2.6%) 0.088 3(0.9%) 0.892 12(3.5%) 0.083
CAD n(%) p 1(0.3%) 0.545 3(0.9%) 0.000 4(1.2%) 0.054 2(0.6%) 0.267 5(1.5%) 0.064
COPD n(%) p 0(0.0%) 0.063 0(0.0%) 0.439 1(0.3%) 0.247 2(0.6%) 0.720 3(0.9%) 0.608
OA n(%) p 0(0.0%) 0.105 0(0.0%) 0.500 6(1.8%) 0.004 2(0.6%) 0.460 5(1.5%) 0.213
Cataract n(%) p 2(0.6%) 0.375 0(0.0%) 0.386 3(0.9%) 0.829 1(0.3%) 0.461 3(0.9%) 0.357
Old CVA n(%) p 4(1.2%) 0.010 0(0.0%) 0.617 4(1.2%) 0.007 2(0.6%) 0.106 4(1.2%) 0.062
*Number of cases in percentage of total (343) with the corresponding comorbidities and geriatric syndromes; +p values showing significance of association between the
corresponding comorbidities and geriatric syndromes.
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Prevalence of depression is slightly lower in our study
population than that of community prevalence (13 to
25%) as reported in various community based studies
from different parts of India (7-9). This is because
depressive behavior in elderly is very often regarded as
old age phenomenon rather than a treatable medical
problem and hence remains unreported in the
community without seeking specialized service in tertiary
care.
Older patients may assume that urinary incontinence is
a normal consequence of aging. Some patients do not
disclose the incontinence because of fear of invasive
testing and females are hesitant to disclose due to social
reason. Incontinence does not lead to death but it causes
substantial debility. In India the overall prevalence of
urinary incontinence is about 12% in all age groups (10),
but practically there in no knowledge of its prevalence in
geriatric population. In our outpatients the prevalence of
urinary incontinence was 15%, which is although
comparable to the prevalence of the all age groups, but
gives an idea of urinary incontinence in geriatric
population.
Falls in the elderly are a major health problem with
medical and economic consequences to the individual,
families, and society. The prevalence of falls increases
with age (11). About 10% will suffer a serious injury (12).
In our study we found out 7.6% had history of fall.
Because of the scarcity of the elderly specific study on
falls in tertiary care hospitals it is not very clear what’s
the exact incidence and impact of falls in elderly.
Cognitive impairment is one of the most common
underestimated and under diagnosed geriatric syndrome
in India. In our study prevalence of cognitive impairment
was 1.2% which is lesser than industrialized western
countries (5-10%) and among Japanese, the prevalence is
around 7% in those aged >65yrs. It may be due to less
awareness in common people about the disease and
many patients might be attending to neurology and
psychiatry OPD (as it is a tertiary care hospital) for the
same disease.
Comorbidities such as CAD, osteoarthritis, and Old
CVA were significantly associated with one or more of
the geriatric syndromes individually, supported by other
study (13) Explanation could be as there is reduction of
mobility and impaired quality of life with the patient
with CAD, OA knee or Old CVA, these can increase.
But none of the co- morbidity was significantly
associated with Geriatric syndrome when we consider all
the variable (comorbidities) together.
Study limitations
As it was a cross-sectional study for small duration
with small sample size, it has its own limitation to
conclude.
Conclusion
Our study shows the importance of comprehensive
geriatric assessment, and there by analyzing the
prevalence and predictors (comorbidities) of geriatric
syndromes. Early diagnosis of Geriatric syndromes,
proper prevention and ideal management of
comorbidities is a must in Geriatric OPD services to
reduce morbidity, mortality and disability in this
population.
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