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ASSESSMENT OF DEMENTIA AMONG RURAL ELDERLY OF MIRJAPUR DISTRICT, U

ASSESSMENT OF DEMENTIA AMONG RURAL ELDERLY OF MIRJAPUR DISTRICT, U.P., INDIA

Poddar K.1, Singh A.1 , Kant S.1, Singh T.B.2, Seth N.3

1Neurology Centre, Varanasi, U.P., India,  2Professor, Division of Biostatistics, Department of Community Medicine, IMS, BHU, Varanasi, U.P., India  3Research scholar, Division of Biostatistics, Department of Community Medicine, IMS, BHU, Varanasi, U.P., India.

 

 

Abstract

One out of ten persons is now 60 years and above; by 2050, one out of five will be 60 years or above, and by 2150, one out of three persons will be 60 years or above-Worldwide.1 So for a developing country like India this segment of population poses mounting pressures because they face multiple medical and psychological problems like dementia. Dementia is a major health problem among elderly. Dementia is an umbrella term for a variety of brain disorders. Loss of memory, confusion in taking judgment and making sequencing of reasoning, and changes in mood and behaviour etc. are the symptoms of dementia. Though some attempts have been made to understand its pattern and to examine the significant risk factors for dementia for developed and developing countries, there is no authentic study for this specific region. Using the primary data taken in this region, this paper examines the significant risk factors for dementia and its distribution among rural inhabitants in Fahari Tahasil of Mirzapur district U.P. This study is based on 1562 rural inhabitants aged 60 or above. To screen the dementia Hindi Mental State Examination (HMSE) was used as the instrumental tool to find out the score of the individual and a cut off score of ≤ 23 was considered as prevalence of dementia among the study subject. X2 test was used to find significant positive association of risk factors with dementia. 

Results show that the overall prevalence of dementia was observed 8.2% ranging from 7.5% to 16% in the age group of 60-69 and ≥ 80 years respectively. This shows that the prevalence of dementia increases as age increases. More than two times risk was observed among female (14.8%) as compared to male (5.1%). The findings also suggest that as the educational status increases the dementia case decreases. Thus it is that the educational level is highly associated negatively with disease prevalence. The presence of personal habitual variable such as tobacco chewing and smoking had no significant association (p> 0.05) for this morbidity. The associated co-morbidities, e.g., hypertension, diabetes and IHD had no significant association for dementia (P>0.05). The results of binary logistic regression analysis showed that education, occupation and earning members were found significant independent variables with odds ratio were 4.68 (95% C.I. 2.94-7.43), 1.97 (95% C.I. 1.05-3.67), 2.24 and 1.67 (95% C.I. 1.13-4.41 and 1.09-2.56) respectively. The stepwise binary logistic regression analysis depicts that education was found most significant variable followed by earning members and occupation. The value of LR test used at stepwise also showed the significant effect of these variables.

Our findings suggest that during the last two decades, though India has experienced improvement in health and health care utilization, the elderly health outcome is not satisfied. So there is an emerging need to pay magnanimous attention to ageing related issues and to promote holistic policies and programmes for the well being of ageing society.

 

Key Words Dementia, Hindi Mental State Examination (HMSE), Prevalence.

 

Introduction

The older population has been growing at an unprecedented rate. In 1980, just prior to the convening of the First World Assembly on Ageing, there were 378 million people in the world aged 60 years or above. That figure has risen to 759 million over the past three decades and is projected to jump up to 2 billion by 2050.2 

Population ageing is the most significant result of the process known as demographic transition. Population ageing involves a shift from high mortality/high fertility to low mortality/low fertility and better health care have increased the proportion of older people in the total population. India is undergoing such a demographic transition. The exact definition of ageing or elderly age group is controversial. In most gerontological literature, people above 60 years of age are considered as ‘old’ and as constituting the ‘elderly’ segment of the population. In India the proportion of aged 60 years and above was 8.65 percent in 2011 census and it is projected to be 20 percent by the year 2050.3 With the rising of old population, the burden of disability is expected to increase as the prevalence of disability among the older cohorts.4  

People living in developing countries not only have lower life expectancies but also live with greater proportion of their lives in poor health as compared to developed countries. The average global prevalence of moderate to severe impairment is about three times higher among persons aged 60 years and over than among those aged 15-59 years. Hearing loss, vision problems and mental disorders are the most common causes of overall impairment. Persistent conditions such as dementias, chronic obstructive pulmonary disease and cerebrovascular disease are especially common at higher ages. Depression is known to be common among older persons, though in developing countries precise data are scarce. Country studies show that a high proportion of older people suffer from depression, loneliness and anxiety.5 Depression often occurs together with other co-morbidities such as dementia, heart disease, stroke, diabetes or cancer, further degrading the quality of life among afflicted older persons. Although depression often improves with treatment, the condition is frequently overlooked among the old because of a lack of knowledge among caregivers and health professionals and the widespread belief that it constitutes a normal part of ageing.

Especially when we talk about the condition of elderly in India, it is true that we are now facing a demographic transition, where the fertility rate has declined and the life expectancy of individuals has increased; this refers to the decrease in relative and absolute numbers of the younger population, in contrast to an increase in aged 60 years and over; this has in turn established an epidemiological transition that entails chronic degenerative diseases, including dementia. Dementia is a clinical syndrome caused by neurodegeneration and is characterized by a progressive decline in brain function manifested by intellectual deterioration, especially the capabilities to process (abstract thinking) and to remember new episodic and semantic events. Furthermore, mood disorder, personality, and behaviour changes can impinge significantly on social and occupational functioning. In some cases it may be associated with psychotic and motor symptoms. However consciousness remains essentially intact. In 2010 an estimated 36 million people worldwide were living with dementia, and the number is projected to nearly double every 20 years.6 Much of the increase will occur in low- and middle-income countries. People with dementia are often specifically excluded from residential care and are sometimes denied admission to hospitals. Awareness of the signs of dementia is limited in many countries, and the signs are often dismissed as a normal part of ageing. One study in the United Kingdom, for example, found that 70 per cent of caregivers were unaware of the symptoms of dementia before diagnosis, and 58 per cent of caregivers believed the symptoms were a natural consequence of ageing. In developed countries an estimated 1-3 per cent of those over the age of 65 suffer from severe depression, and an additional 10-15 percent suffers from milder forms.7

Mental health is also essential to overall health and well-being.  Mental illness constitutes one of the world's most critical and social health problems8 and unfortunately mental health is not regarded same importance as physical health in most of the world. Currently more than 450 million people are suffering from mental illness and few of them will get treatment. Apart from this more than 40 percent countries have no mental health policy and over 30% of countries don’t have mental health program.9 Mental health is a leading cause of disability and it is estimated that 12 percent of global burden of disease. There are strong indications that depression substantially increases the risk of death in adults, mostly by unnatural causes and cardiovascular disease.10 The number of older people is increasing throughout the world. As individuals grow older, they are faced with numerous physical, psychological and social role changes that challenge their sense of self and capacity to live happily. With this backdrop this study aims to assessment of dementia among elderly.

 

Objectives

(1)    To determine the burden of dementia among various socio demographic & personal variables.

(2)    To find out the significant risk factors for dementia.

 

Material and Methods

This Study was based on 1562 subjects of aged 60 years and above residing in the rural communities Fahari Tahasil of Mirjapur District of Uttar Pradesh. The data was collected in two phases on the same day. In first phase, a door to door survey was conducted to identify aged ≥60 years and to collect the information regarding socio demographic personal variables using cluster sampling on pre-designed and pre-tested schedule. In second phase, Hindi version of Mini Mental State Examination was administered to know the cognitive decline.11 Chi-square and student t – test were used at 5% level of significance at two tailed test as per their suitability.

 

Assessment Tool

The study area is Hindi speaking belt and the mostly used common language among the subjects was Hindi and, therefore, the Hindi version of the Mini Mental State Examination (MMSE) developed by the Ganguli et al 199511 was used and their standard was maintained. This Hindi Mental State Examination (HMSE) consists of 22 items which includes different components of intellectual capability. The examination covers several areas of cognitive functioning, such as orientation to time and space, attention and concentration, recognition of objects, language, function, both comprehensive and expressive speech, motor functioning and praxis. It is relatively simple to administer and provides a quick, brief index of the subject's current level of mental functioning. It is a modified version of the MMSE.12 Here, a cut-off score of ≤23 was taken to screen the dementia cases, with a sensitivity of 88%, specificity of 82% and with an interrater reliability coefficient of 0.9 as per reported by Shaji et al.13

 

Study design

By applying the cross-sectional/ design, the data were collected in two phases on the same day. During the first phase, all the subjects were thoroughly interviewed by a psychologist and the background information like age, gender, education, marital status, dietary habits, number of family members, number of earning family members, addiction (tobacco and alcohol) and associated co-morbidities were noted. In the second phase, the HMSE was administered to determine the cognitive decline.

 

Statistical analysis

The data were entered in the MS Excel software after completion of data collection and scrutiny. The qualitative data was presented in the form of number and percentage. The significant association of dementia with socio-demographic, behavioural and co-morbidity variables was tested by the X2 test at a 5% level of significance and at the two-tailed test. The relative risk (RR) and 95% CI were calculated for each study variable. The statistical calculation was performed using the Statistical Package of Social Sciences (SPSS), version 20.0.

 

Results

The result of this study was based on 1562 subjects. The overall prevalence of dementia was observed to be 8.2%. Further analysis has been performed on all subjects. The distribution of the subjects in the age group 60-69, 70-79 and 80 years and above was 66.4, 27.6, and 6%, with a prevalence of dementia of 7.5, 8.8, and 16%, respectively, which shows that the prevalence increases with age (P<0.05, Table 1). The percentage gender distribution was 68.1 for males and 31.9 for females, and the prevalence of dementia in males and females was 5.1% and 14.8%, respectively, and there was a significant association between dementia and gender(P<0.05, Table 1). 21.4% of the subjects were widows/widower/unmarried and, among them, 11.9% were suffering from dementia as compared with 7.2% among the married subjects, i.e. more cases of dementia has been seen in widows/ widower/unmarried (P<0.05, Table 1). This result highlights that persons living without life partner had higher prevalence than the married life. Thus, living with spouse was a preventive measure of dementia.

A continuous pattern of decrease in the prevalence of dementia was observed with increase in the educational level. The prevalence of dementia in the uneducated was 20.7%, which decreased to a significant level of 4.1% for subjects educated up to class 5th, then further reduced to 1.9% for high school and onwards [P<0.05, Table 1]. The prevalence of dementia in the unemployed subjects was 3.3% as compared with 14.9% in the self-employed, 8.0% in

 

 

 

Table.1. Association of Socio-Demographic and Socio-Economic Variables with Dementia

SOCIO-DEMOGRAPHIC

HMSE SCORE

HMSE SCORE

TOTAL

CHI-

p-VALUE

VARIABLES

<=23

>23

No (%)

 SQUARE

 

 

No (%)

No (%)

 

 

 

AGE-GROUP (Yrs)

 

 

 

 

 

60-69

75(7.5)

962(92.8)

1037(66.4)

 

 

70-79

38(8.8)

393(91.2)

431(27.6)

9.028

0.011

80 & ABOVE

15(16)

79(84.0)

94(6.0)

 

 

 

 

 

 

 

 

SEX

 

 

 

 

 

MALE

54(5.1)

1009(94.9)

1063(68.1)

42.908

0.00

FEMALE

74(14.8)

425(85.2)

499(31.9)

 

 

 

 

 

 

 

 

MARITAL STATUS

 

 

 

 

 

MARRIED

88(7.2)

1139(92.8)

1227(78.6)

7.953

0.005

WIDOW/WIDOWER/ UNMARRIED

40(11.9)

295(88.1)

335(21.4)

 

 

 

 

 

 

 

 

SOCIO-ECONOMIC

 

 

 

 

 

VARIABLES

 

 

 

 

 

EDUCATION

 

 

 

 

 

EDUCATED

42(3.7)

330(79.3)

1146(73.4)

117.36

0.00

UNEDUCATED

86(20.7)

899(95.9)

416(26.6)

 

 

 

 

 

 

 

 

OCCUPATION

 

 

 

 

 

UNEMPLOYED

16(2.7)

568(97.3)

584(37.4)

36.892

0.00

EMPLOYED

112(11.5)

866(88.5)

978(62.6)

 

 

 

 

 

 

 

 

FAMILY MEMBER

 

 

 

 

 

<=5

29(8.5)

314(91.5)

343(22.0)

 

 

 6-10

72(8.7)

754(91.3)

826(52.9)

1.246

0.536

>10

27(6.9)

366(93.1)

393(25.2)

 

 

 

 

 

 

 

 

EARNING MEMBERS

 

 

 

 

 

>=5

13(6.3)

195(93.8)

208(13.3)

 

 

2-4

73(7.4)

915(92.6)

988(63.3)

7.135 0

0.028

1

42(11.5)

324(88.5)

366(23.4)

 

 

 

employed and 2.6% in retired subjects [P<0.05, Table 1]. The total number of members in the

family had  significant association with the prevalence of the disease (P<0.05, Table1),

subjects living with family members less than 5, 6-7, 8-10, 11-15 and 16 and more   had a prevalence of  dementia 8.5, 6.9, 10.1, 9.5 and 1.5%, respectively. The total number of earning members in the family had no significant association with the prevalence (p>0.05,

Table1).

 

Table.2. Association of Personal habit and Co-Morbidity with Dementia

PERSONAL HABITS AND

HMSE SCORE

HMSE SCORE

TOTAL

CHI-

p-VALUE

CO-MORBIDITIES

<=23

>23

No (%)

 SQUARE

 

 

No (%)

No (%)

 

 

 

DIET

 

 

 

 

 

VEGETARIAN

77(8.4)

842(91.6)

919(58.8)

0.101

0.751

NON-VEGETARIAN

51(7.9)

592(92.1)

643(41.2)

 

 

 

 

 

 

 

 

ADDICTION TOBACCO

 

 

 

 

 

YES

49(7.4)

617(92.6)

666(42.6)

1.082

0.298

NO

79(8.8)

817(91.2)

896(57.4)

 

 

SMOKING

 

 

 

 

 

YES

8(5.6)

134(94.4)

142(9.1)

1.362

0.243

NO

120(8.5)

1300(91.5)

1420(90.9)

 

 

 

 

 

 

 

 

HYPERTENTION

 

 

 

 

 

YES

47(8.4)

510(91.6)

557(35.7)

0.068

0.794

NO

81(8.1)

924(91.9)

1005(64.3)

 

 

DIABETIES

 

 

 

 

 

YES

15(6.2)

226(93.8)

241(15.4)

1.471

0.225

NO

113(8.6)

1208(91.4)

1321(84.6)

 

 

.

The type of diet had no significant association (P>0.05), as Table 2 shows that the prevalence of dementia among vegetarians was 8.4% as compared with 7.9% among non-vegetarians. Tobacco chewing and smoking had no significant association (p>0.05, Table2). The proportion of subjects with co-morbidities of hypertension and diabetes was 35.7 and 15.4, with prevalence of dementia of 8.4 and 6.2, respectively. These disease had no significant association (P>0.05) [Table2].

The findings of multiple binary logistic regression analysis have been shown in Table 3 in which only those variables were included which was found statistically significant at univariate analysis. The above table depicts that age, sex, marital status, education, occupation and number of earning member in the family were found significant independent variables for dementia with odds ratio 1.42, 1.23, 1.34, 4.68, 1.97, 2.24 and 1.67 respectively. Among these variables education status and occupation and earning member were observed statistically significant.

 

 

Table.3. Multiple binary logistic regression analysis

 

Independent Variable

-2LOG

Sig.

Odds Ratio

95% C.I for Odds Ratio

 

 

LIKELIHOOD

 

 

lower

upper

Age

 

 

 

 

 

60-69

 

 

Ref.

 

 

70 & Above

 

0.10

1.419

0.955

2.107

 

 

 

 

 

 

Sex

 

 

 

 

 

Male

 

 

Ref.

 

 

Female

 

0.361

1.232

0.788

1.928

 

 

 

 

 

 

Marital Status

 

 

 

 

 

Married

 

 

Ref.

 

 

Widow/Widower/Unmarried

 

0.178

1.340

0.876

2.051

 

763.898

 

 

 

 

Education

 

 

 

 

 

Educated

 

 

Ref.

 

 

Uneducated

 

0

4.677

2.943

7.432

 

 

 

 

 

 

Occupation

 

 

 

 

 

Unemployed

 

 

Ref.

 

 

Employed

 

0.034

1.966

1.053

3.669

 

 

 

 

 

 

Earning members

 

 

 

 

 

>=5

 

 

Ref.

 

 

2-4

 

0.019

2.241

1.139

4.411

1

 

0.018

1.673

1.094

2.558

 

 

Table.4. Stepwise Binary Logistic Regression Analysis

 

Step

Independent

-2 Log

Sig.

Odds Ratio

95% C.I for Odds Ratio

 

 

Variables

Likelihood

 

 

lower

upper

1

Education

784.157

0.00

6.85

4.643

10.107

2

Education

776.399

0.00

 

 

 

 

Earning Members

 

 

 

 

 

 

>=5

 

 

Ref.

 

 

 

2-4

 

0.026

2.144

1.096

4.197

 

1

 

0.012

1.712

1.125

2.607

3

Education

770.133

0.00

5.284

3.430

8.140

 

Earning Members

 

 

 

 

 

 

>=5

 

 

Ref.

 

 

 

2-4

 

0.021

2.204

1.126

4.315

 

1

 

0.011

1.721

1.130

2.623

 

Occupation

 

0.016

2.080

1.145

3.779

 

The results of stepwise binary logistic regression analysis are shown in Table 4. In the first step the education status of the subjects was observed the most significant variable with odds ratio 6.85 and 95% C.I. (4.643-10.107). In the second step number of earning member was found significant variable and in the last step occupation was included as significant variable. The values of LR tests observed at stepwise also showed the significant effect of these variables on dementia.

 

Discussion

The broad studies from developed countries have provided a range of prevalence of dementia between 3.8 to 10% in the age- group of above 65 years of age.14,15 Very few studies are available from developing countries. Several community based urban and rural studies have been reported on dementia from different part of India, with a varying range of prevalence from 1.02% to 4.86% in the age-group 55-65 years and above. 13,16-22 The findings of our study show that the prevalence of dementia was 8.2%, which was higher in comparison with other Indian studies, but is consistent with other studies of Asian and western countries. Raina et al. 21 reported a higher prevalence of dementia of 6.5% among the Kashmiri migrants of age groups 65 years and above. It was ranging between 8 and 15% in the age-group of 70 years and above. In our study, the prevalence of dementia in female was 14.8 and in male it was 5.1, i.e. prevalence was more than double in female than that of male, which is comparable with other studies.21 This may be due to better care given to males as compared with females, as the study area was predominantly a male-dominant society. The marital status also had a significant impact on the prevalence of dementia. Widows/Widower/Unmarried showed more prevalence of dementia as compared with married life living subjects. This may be due to a better social life in married subjects, although this has not been reported in other studies and needs more evaluation. The prevalence rates among uneducated and educated up to class 5th were 10.0 and 4.1%, respectively in our study. This shows that education, even of primary level, may reduce the prevalence of dementia at a later age. In a pilot study conducted by Shaji et al.20 with a Malayalam adaptation of the MMSE, there was no significant difference in the total MMSE scores between the literate and the illiterate. Mathuranath et al.22 also reported the association of low education with dementia. In our study, we also tried to find out an association between dementia and occupation. The prevalence of dementia in unemployed subjects was 3.3% in comparison of 8.0% in the employed. This needs further evaluation. Similarly, an association between types of family and status of dementia showed a lower prevalence in joint families. This is possibly because of a healthier atmosphere and number of helping members in the family, which strengthens the relevance of Indian culture in the study. This has not been reported in any other study from developing or developed nations. Diet, tobacco chewing, smoking and concomitant diseases had no significant association with dementia.

 

Conclusions  

The elderly population is the foundation of the intellectual wealth of any of the nation, as no family grows without parents like no country develops without its leader. In India, traditionally elderly persons live with their children especially with sons. Their physical and financial needs are generally covered by the children with whom they are co-residing and elderly people's accumulated income. In joint family, the aid of each member specially seniors in the family was better as compared to nuclear family because work sharing concept was present among family members, thus they had time to spent leisure time with other family members. But the living arrangements and support system of elderly in India both has undergone a transition due to increase of urbanization, industrialization, rural-urban migration pattern coupled with increase of modern nuclear families in urban areas makes the elderly severely isolated and depressed, which has become universal phenomenon. According to the current study by Holwerda and colleagues, there is an increasing prevalence of Alzheimer's disease and other dementias, and multiple factors have been found to predispose to dementia. Emerging evidence suggests that depression and social isolation are associated with late-onset dementia. In India the size of the elderly population is fast growing. In 2010, there are 3.7 million Indians with dementia and this is expected to double by 2030 (Alzheimer’s & Related Disorder Society of India, 2010). For a developing country like India, this may pose mounting pressures on various socio economic fronts including old age pension outlays, health care expenditures, social discipline, saving levels etc. Again this segment of population faces multiple medical and psychological problems. There is an egressing need to pay greater attention to ageing related issues and to promote holistic policies and programs for well basing dealing with the ageing society.

 

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