Assessments of functional status, comorbidities, polypharmacy, nutritional status and sarcopenia in Turkish community-dwelling male elderly

Abstract

Functionality, comorbidities, polypharmacy, nutritional status and sarcopenia affect the prognosis of elderly excessively. These parameters are influenced by the population, living settings and age. We aimed to study these parameters in Turkish community-dwelling male elderly. We studied 274 male elderly ≥60 years of age admitted to our Geriatrics outpatient clinics. Mean age was 74.4 ± 7.1 years; 47.4% of the subjects were ≥75 years, 24.1% were ≥80 years. Mean activities-of-daily-living (ADL) and instrumental ADL (IADL) scores were 9.4 and 11.1, respectively. Patients with at least one-dependence at ADL–IADL were 22.6%–47.2%, and more than half-dependence at ADL–IADL were 2.8%–17.9%, respectively. Mean number of comorbidities were 2.6. Most common diagnosis was hypertension with 65%; mean number of drugs were 4.5; 55.3% were using ≥4 chronic drugs. Prevalences of malnutrition were 3.7%–6.9%, malnutrition risk were 23.5%–26.7% by the Mini Nutritional Assessment Test - Long Form and Short Form, respectively. Calf circumference was measured <31 cm in 10.5%. Our findings suggest that Turkish community-dwelling male elderly may have greater prevalences of functional dependence, sarcopenia but lower rates of malnutrition and similar rates of polypharmacy compared with the western developing countries and developed countries. This study emphasized the geographical differences in and/or between the individual countries highlighting the need for studies both country- and world-wide.

• Comorbidity
• elderly
• functionality
• malnutrition
• polypharmacy
• sarcopenia

Introduction

There had been a dramatical increase in the proportion of aged population over the past century and this increase will continue even more in the next 50 years. This demographic transformation has an effect on a society that reverberates well beyond the increased medical care needs of the elderly. As more people live to advanced age, it is important to gain a greater understanding of more than just the individual diseases that affect them [1]. It is critical to appreciate the global needs of older persons who may have multiple chronic conditions, decrement in functional abilities, polypharmacy and nutritional status that may have an impact on many facets of their health and quality of life.

Age is an important risk factor for development of these problems but there is substantial heterogeneity in the general health of older adults. As the population ages, prognostic information is becoming increasingly important to clinicians, researchers and policy makers in making medical decisions. These data can be used to target preventive services or to decide whether to offer certain treatments to older adults, among other clinical decisions [2]. Among other geriatric problems, these parameters are influenced by the population, living settings and age group, as well. Therefore, we need data on these issues in detail from different populations, different living settings, also between different old age groups.

In this cross-sectional study, we aimed to study the functional status, comorbidities, polypharmacy, nutritional status and sarcopenia in Turkish community-dwelling male elderly.

Patients and methods

Population and setting

This study was carried out at Geriatrics outpatient clinics at Istanbul University, Istanbul Medical Faculty Hospital in Turkey. This polyclinic serves for all patients ≥60 years of age regardless of their complaints, co-morbidities and their living settings. However, due to its localization far from the nursing-homes, seldom elderly admits from institutions. In this evaluation, the patients admitting from nursing homes are excluded. Therefore all the subjects were community-dwelling elderly and all were living in one of the largest metropolis city in Turkey.

Geriatrics outpatient clinics’ patients were assessed cross-sectionally. All male patients 60 years of age or older meeting our inclusion criteria were included in the study (n = 274).

Measurements

All patients underwent a complete and standardized comprehensive geriatric assessment (CGA) on admission, including the level of functionality, chronic disease and drug use, and nutritional status. Functional status was assessed by an evaluation of activities-of-daily-living (ADL) and instrumental ADL (IADL) scales [3]. The evaluated ADL were eating, transfer to-and-out of the bed, continence, wearing and bathing, whereas IADL were cooking, cleaning, phoning, shopping, public transfer, managing finances and drug use. In these functionality assessment protocols, subjects were pointed as having 2 points if they were totally independent, 1 point if they were partially dependent and 0 point if they were totally dependent, in performing evaluated tasks individually. So, the total points were 10 and 14 points for an elderly completely independent in ADL and IADL, respectively. Accordingly, elderly were pointed as having 0 points if they were totally dependent in ADL or IADL.

Co-morbidities and drugs were defined using patients’ self-report and current medications, after the evaluation of the patient by CGA, physical examination and first-line biochemical tests including the fasting blood glucose, creatinine, electrolytes, serum lipids and TSH screening.

Nutritional assessment was performed by the full Mini Nutritional Assessment (MNA) version [4]. The MNA is an 18-item questionnaire comprising anthropometric measurements (body mass index, mid-arm and calf circumference (CC), and weight loss) combined with a questionnaire regarding dietary intake (number of meals consumed, food and fluid intake, and feeding autonomy), a global assessment (lifestyle, medication, mobility, presence of acute stress and presence of dementia or depression) and a self-assessment (self-perception of health and nutrition). It is a two-step procedure: screening with the MNA-Short Form (MNA-SF, 6 questions) followed by the assessment (9 questions and 3 anthropometric measurements), if needed, by the full MNA [4]. MNA-SF score ≥12 excludes malnutrition (MN) and malnutrition risk (MNR), which rendered further assessment unnecessary. MNF-SF score <12 indicates the full MNA test. Total score ≥24 means normal nutritional status, 17–23.5 shows MNR and <17 indicates MN. Geriatric depression was assessed by 30-item geriatric depression scale (GDS) [5] and GDS scores of 14 or above were considered as suggestive of depression. Cognitive status was assessed by the Folstein mini-mental state examination (MMSE) [6]. MMSE scores of 24 or below were considered as impaired, suggesting dementia.

Sarcopenia was evaluated indirectly by the measurement of CC. CC < 31 cm was regarded as an indirect evidence of sarcopenia as an indicator of low muscle mass.

This study was conducted according to the guidelines laid down in the Declaration of Helsinki. Informed consent was obtained from all patients and/or their related conservators.

Statistical analysis

All data were entered into a database and were verified by a second independent person. Descriptive statistics were generated for all study variables, including mean ± standard deviation for continuous variables and relative frequencies for categorical variables. The statistical analysis was performed with the statistical package SPSS version 15.0 for Windows (SPSS, Chicago, IL).

Results

A total of 274 male patients were included in this study. Mean age of patients was 74.4 ± 7.1 years. 130 (47.4%) of the study population were ≥75 years, 66 (24.1%) were ≥80 years and 24 (8.8%) were ≥85 years.

Baseline characteristics of the study population among different age groups are given in Table 1. The mean ADL and IADL scores were 9.4 and 11.1, respectively. The patients who have at least one-dependence at ADL and IADL were 22.6% and 47.2%, respectively, in the total study population. These figures rose to 28.3%, 39.6% for ADL dependence and 57.5%, 68.3% for IADL dependence in ≥75 years and ≥80 years, respectively. The patients who have more than half-dependence at ADL and IADL were only 2.8% and 17.9%. These figures again rose to 4.1%, 6.3% for ADL dependence and 25%, 31.7% for IADL dependence in ≥75 years and ≥80 years, respectively (Table 1).

Table 1. Baseline demographic and CGA characteristics of the male patients in different age groups (mean ± SD) (range) or (number and %).

	Total study population	≥75 years of age	≥80 years of age
Parameters	(n = 274) (100%)	(n = 130) (47.4%)	(n = 66) (24.1%)
Age (years)	74.4 ± 7.1 (60–95)	80.3 ± 4.4 (75–95)	84 ± 3.2 (80–95)
ADL	9.4 ± 1.6 (0–10)	9.1 ± 2.0 (0–10)	8.8 ± 2.1 (0–10)
IADL	11.1 ± 4.2 (0–14)	10.2 ± 4.6 (0–14)	9.1 ± 4.8 (0–14)
ADL<10	22.6%	28.3%	39.6%
ADL<5	2.8%	4.1%	6.3%
IADL<14	47.2%	57.5%	68.3%
IADL<7	17.9%	25%	31.7%
Number of total diseases	2.6 ± 1.5 (0–9)	2.5 ± 1.4 (0–6)	2.5 ± 1.2 (0–6)
Number of total drugs	4.5 ± 3.2 (0–19)	4.7 ± 3.2 (0–18)	4.4 ± 2.7 (0–10)
Weight (kg)	72.4 ± 12.7 (35–125)	67.9 ± 11 (40–108)	66.3 ± 10.9 (40–100)
Height (cm)	167.7 ± 7.5 (139–190)	166.9 ± 7.2 (139–185)	166.3 ± 8.5 (139–185)
Body mass index	25.8 ± 4.4 (12.1–44.4)	24.4 ± 3.8 (15.8–34.1)	24 ± 3.9 (15.8–33.7)
MNA-SF point (screening part)	11.6 ± 4.4 (1–14)	11.4 ± 2.3 (1–14)	11.1 ± 2.8 (1–14)
MNA-Evaluation point	11.9 ± 2 (7–15.5)	11.7 ± 2.3 (7–15.5)	11.5 ± 2.5 (7–15.5)
MNA total point (LF)	21 ± 3.4 (9–26.5)	20.8 ± 3.8 (9–26.5)	20.4 ± 4.4 (9–26.5)
Nutritional status (MNA-LF)
(Malnutrition/malnutrition risk/normal nutrition)
Percent	3.7/23.5/72.8%	5.8/25/69.2%	9.6/23.1/67.3%
Nutritional status (MNA-SF)
(Malnutrition/malnutrition risk/normal nutrition)
Percent	6.9/26.7/66.4%	10/33.6/56.4%	14.3/32.1/53.6
Calf circumference
<31 cm	10.5%	12.2%	24%
≥31 cm	89.5%	87.8%	76%

ADL: activities of daily living; IADL: instrumental activities of daily living; MNA-SF: Mini Nutritional Assessment Test-Short Form; LF: Long Form; MNA-LF: Mini Nutritional Assessment Test-Long Form.

The mean number of chronic diseases was 2.6. Only one patient had nine chronic diseases whereas 51.5% had ≥3 chronic diseases. There were only 5.6% male elderly with no known chronic diseases whereas 18.7% had one chronic disease on admission. The most common diagnosis was hypertension (HT) with 65%. Depression and dementia were not clinical diagnoses but suggested by GDS and MMSE with 41.1% and 32.8%, respectively. The prevalence of other diagnoses were as follows in descending order: diabetes mellitus (DM) in 24.2%, cerebrovascular accident in 14.6%, hyperlipidemia in 12.4%, ischemic heart disease in 11.3%, Parkinson’s disease in 8.8%, chronic obstructive lung disease/asthma in 7.7%, hypothyroidism in 5.1%, osteoporosis in 4.7%, congestive heart failure (CHF) in 2.9%, hyperthyroidism in 1.5%.

The mean number of drugs used chronically was 4.5; 7.9% were using ≥10 chronic drugs; 55.3% were using ≥4 chronic drugs and 40.2% were using ≥5 chronic drugs. Only 7.1% were not using any drug chronically; 8.6% were using only one drug. For the elderly ≥75 years, the mean number of; drugs used chronically were 4.7; 8.5% were using ≥10 chronic drugs; 57.9% were using ≥4 chronic drugs and 42.1% were using ≥5 chronic drugs. For the elderly ≥80 years, the mean number of chronic drugs were 4.4 while 54.5% were using ≥4 chronic drugs, 37.9% were using ≥5 chronic drugs and 6.1% were using ≥10 chronic drugs (Table 1).

Totally 217 of the study population had nutritional assessment. The prevalence of MN was 3.7% and 6.9%, and MNR was 23.5% and 26.7% by MNA-LF and MNA-SF, respectively. Overall, within the study group, 27.2% were found to have poor nutrition (either MN or MNR) with MNA-Long Form (LF) but higher percentage (33.6%) were found to have poor nutrition with MNA-SF. Therefore, only 72.8% and 66.4% were well-nourished by MNA-LF and by MNA-SF, respectively (Table 1).

There were 249 subjects ≥ 65 years of age of 199 having nutritional assessment with MNA. There were 3.5% and 6.8% MN, and 23.6% and 29% MNR, making overall prevalence of 27.1% and 35.8% poor nutrition in subjects ≥ 65 years of age via MNA-LF and MNA-SF, respectively. CC was measured <31 cm in 10.5% (Table 1).

Discussion

Our cohort was composed of the community-dwelling male elderly living in an urban area, the largest metropolis, Istanbul in Turkey. In 2011, Turkey’s population was reported as roughly 75 million of which 50.2% is composed by the males [7]. Among them ≥60, ≥75 and ≥80-year old males compose 9.6%, 2.3% and 0.9% of the male population, respectively [7]. Our cohort had a mean age of 74.4 years with almost half being ≥75 years and 1/4 being ≥80 years (Table 1). Therefore, it provides a general insight both for the relatively young-old and oldest-old elderly in Turkey. Turkey is one of the developing countries and our study results may be an indirect indicator for the other developing country male elderly.

The patients were mostly independent in most of ADLs and IADLs. The patients who have at least one-dependence at ADL and IADL were 22.6% and 47.2%, in the total study population, respectively. However, these figures rose to 28.3%, 39.6% for ADL dependence and 57.5%, 68.3% for IADL dependence in ≥75 years and ≥80 years. In a very recent population study from Mexico, at least one-dependence at ADL and IADL was reported much lower 8.2% and 12.0% in the community-dwelling males ≥60 years of age [8], while they were 10.3% and 31.5% in the female counterparts [8]. Our study results on ADL and ADL-dependence indicates even more dependence than the community-dwelling female elderly of the Mexican study. Among community-dwelling elderly women from the US, at least one-dependence at ADL and IADL was reported as 25% and 35% [9], which is again lower but a similar functional level of our study cohort.

The patients who have more than half-dependence at ADL and IADL were only 2.8% and 17.9%, respectively. More than moderate-dependence in IADL was reported 3.3% in IADL among the community-dwelling males ≥60 years of age in Mexico [8]. However, our figures again rose to 4.1%, 6.3% for ADL dependence and 25%, 31.7% for IADL dependence in ≥75 years and ≥80 years, respectively. These figures indicate the large geographic and gender effects on the functional status of the elderly signifying the need for functional assessment from different countries, for each gender, and for young-old, moderate-old and oldest-old age groups. On the other hand, our cohort was composed of the patients admitted to Geriatrics outpatient clinics. The higher prevalence of ADL and IADL dependence in our study may be partly related to this issue. However, nevertheless, these results suggest that Turkish community-dwelling male elderly may have greater prevalence of functional dependence than the Mexican and American counterparts. The future studies analyzing cohorts sampled from community-dwelling elderly is needed in our country to comment more.

The mean number of chronic diseases was 2.6. More than half had ≥3 chronic diseases. There were only 5.6% male elderly with no known chronic diseases whereas 18.7% had only one chronic disease on admission. For the elderly ≥75 years, the mean number of chronic diseases were lower, i.e. 2.5 while again almost half had ≥3 chronic diseases. There were only 3.8% male elderly with no known chronic diseases whereas 21.6% had one chronic disease on admission. In the CHAMP study of ≥70 years community-dwelling male elderly from Australia, there were 17.9% male elderly with no known chronic diseases whereas 27.5% had one chronic disease on admission [10]. Among 75–94 years old Israelien community-dwelling elderly 13.6% had no known chronic diseases, 26.8% had one chronic disease, 37.4% had ≥3 chronic diseases [11]. In the present study, the prevalence of no known chronic disease was lower and the prevalence of only one chronic disease was comparable but again somewhat lower. Our study cohort was composed of male old patients admitting to Geriatrics outpatient clinics indicating their tendency to seek medical evaluation either for a complaint and/or check-up purpose. Therefore, their chronic diseases as hypertension, diabetes, etc. may have been diagnosed earlier. We suggest that the lower prevalence of none and only one chronic disease may be related to cohort of our study.

The most common disease was hypertension with 65%. According to the results of National Health and Nutrition Examination surveys, the HT and DM prevalences were reported as 52.6% and 15.5% in community-dwelling white men ≥65 years in USA [12]. The prevalence of chronic diseases was reported from Dominican Republic in people ≥65 years were hypertension (73%) and diabetes (17.5%) [13]. These results are comparable with our data. Depression prevalence was reported to be 16% with similar GDS evaluation in community-dwelling elderly ≥70 years with a mean age of 74.8 years from randomly selected community-dwelling elderly in Turkey [14]. Dementia with similar MMSE evaluation in urban Turkish community-dwelling population ≥70 years of age with a mean age 74.9 years was reported to be 31.6% [15]. In our study, similar rates of suggested dementia (32.8% versus 31.6%) but considerably higher rates of suggested depression (41.1% versus 16%) were noted when compared with these figures although the mean ages were very similar (74.4 years versus 74.9 years versus 74.8 years). Our study may suggest that the elderly may be more influenced with hospital admission in a depressive manner.

The mean number of drugs used chronically was 4.5. Each one patient used 19, 18 and 15 drugs; 7.9% were using ≥10 chronic drugs. Polypharmacy was noted as 55.3% and 40.2% when it would be defined as use of ≥4 chronic drugs or ≥5 chronic drugs, respectively [16–18]. Only 7.1% were not using any drug chronically; 8.6% were using only one drug. For the elderly ≥75 years the mean number of drugs used chronically were higher as 4.67; 8.5% were using ≥10 chronic drugs. Polypharmacy was noted again higher as 57.9% and 42.1% [16–18]. For the elderly ≥80 years the mean number of chronic drugs was surprisingly lower than the study population: 4.4. Polypharmacy was noted again lower as 54.5% and 37.9% in this oldest-old age group.

Elderly constitute the largest portion of the population utilizing the drugs. In the US, patients aged 65 years and older reported to represent approximately 13% of the population but consume about 30% of all prescripted medications in 2002 [19]. Similarly, while 20% of the population in England was over 60 years of age, they received 52% of all prescriptions in 2000 [20]. As they use more drugs, the concept of polypharmacy is more prevalent in the elderly, the problem increasing with age. In a survey among 2590 participants in the US, the highest overall prevalence of medication use was among women aged at least 65 years, 23% taking at least five prescription drugs and 12% taking at least 10 medications [21]. The figure of using at least five prescription drugs increased to 35%–40% in 75–85 years old, as Qato et al. reported in their study of 3005 community-dwelling people aged 57–85 years in the US [22]. This frequency was the highest one at 75–85 years age group across all the studied age groups. In England, over 75 years of age, 36% were taking four or more drugs [20]. Similarly, in a study of non-institutionalized population in the US [23], the biggest consumers of medications were the elderly >65 years of age: 57%–59% taking at least five medications. Also, it has been estimated that 50% of Medicare beneficiaries receive five or more medications [24]. A study from Turkey including 1253 elderly reported the mean prescription drugs of 3.79 on admission to geriatrics outpatient clinics [25]. Our results were comparable with the data from the different western countries and our country. One important issue is that both the mean number of chronic drugs and prevalence of using ≥4–5 chronic drugs were less in the ≥80 years group. We suggest that this may be the reflection of higher prevalence of death of the male elderly at 75–80 years of age elderly due to co-morbid diseases or adverse effects of polypharmacy. In accordance with our suggestion, life expectancy at 60 years of age was found to be16.6 years in Turkish male elderly [26]. Additionally, there may be a resistance among the oldest-old elderly for use of many drugs. However, this theory lacks any evidence and needs to be studied.

The prevalence of MN and MNR in community-dwelling elderly is reported to be 2 ± 0.1% (range 0%–8%) and 24 ± 0.4% (range 8%–76%), respectively, by the literature review on MNA [27]. Prevalence of MN and MNR was reported as 3.4% and 20.8% in Spain in the community-dwelling male elderly ≥65 years-age via MNA-LF in a recent study [28]. In a more recent study, including 848 elderly male ≥65-years from our country-geriatric outpatient clinics, 24.5% overall poor nutrition via MNA-SF was reported from a different metropolis city of Ankara [29]. Our MN prevalence was similar (3.5% versus 3.4%) but MNR prevalence was higher (27.1% versus 20.8%) when compared to Spain’s community-dwelling elderly males [28]. Considering that our study cohort was composed of patients admitting to a geriatrics outpatient clinics but not sampled from the general community-dwelling elderly, this study suggests that Turkish community-dwelling male elderly may have similar or even less rates of MN than the Spanish counterparts. However, while MNR was higher in our study, it is difficult to compare the MNR since higher MNR may be due to the sampling population in our study. On the other hand, poor nutrition risk via MNA-SF was higher than Ankara’s similar sampled male elderly (35.8% versus 24.5%). These studies indicate the geographical differences in and between the individual countries highlighting the need for nutritional assessment both country- and world-wide.

The MN frequencies were more common in advanced ages (3.5%, 5.8%, 9.6% in patients ≥65, ≥75, ≥80 years of age) (Table 1). So, the MN frequency increased 1.7-fold from ≥65 to ≥75 years and 2.7-fold increased from ≥65 to ≥80 years of age. However, interestingly, the MNR frequency was not influenced by the advanced age. Nevertheless, our study stresses once again the prevalence of higher rates of MN in more advanced ages.

CCC was measured as a component of MNA. CC <31 cm is known to be a rough clinical indicator of sarcopenia with moderate sensitivity (44.3%) but high specificity (91.4%) [30]. Among the total study patients, CC < 31 cm was 10.5% (Table 1). This finding is similar to a rate of 10% of low muscle mass by CC measurement reported from 344 institutionalized elderly ≥60 years of age from both genders in Brazil [31]. Prevalence of sarcopenia is reported in different prevalences between genders. Although some studies reported higher prevalence, more studies reported lower prevalences in elderly male [32–34]. Since our study was in male community-dwelling elderly, our results may be an indirect indicator for higher rates of sarcopenia in Turkey. This finding is also in accordance with our previous data where we reported sarcopenia prevalence as very high: 85.4% by a bioimpedance analysis among male nursing home residents in Turkey [35].

Our study has some drawbacks also. First, the diagnoses were made using patients’ self-report and current medications, after the evaluation of the patient by CGA, physical examination and first-line biochemical tests. We do not have further more detailed data, such as electrocardiography, cardiac echocardiography, carotis Doppler, carotis-coronary angiography, postprandial glucose level, HbA1c measurement, central nervous system MRI, respiratory function test, bone mineral densitometry which may result in false negative or false positive diagnoses. Second, the study population was community-dwelling elderly not chosen in a randomized manner but among the ones admitted to geriatrics outpatient clinics of a university hospital. Third, sarcopenia was evaluated with only a rough estimate of muscle mass, CC. Nevertheless, it provides an insight for community-dwelling male elderly from a developing country, Turkey, where such data are scarce.

In conclusion, we reported on functional status, chronic disease-drug number, nutritional assessment and sarcopenia of community-dwelling male elderly from a developing country. Our findings suggest that Turkish community-dwelling male elderly may have greater prevalences of functional dependence, sarcopenia but lower rates of MN and similar rates of polypharmacy compared with the western developing countries and developed countries. This study also indicated the geographical differences in and/or between the individual countries highlighting the need for studies on these issues both country- and world-wide.

Declaration of interest

The authors report no conflict of interest. The authors alone are responsible for the content and writing of the article. None of the authors of this manuscript have any financial or personal relationships with other people or organizations that could inappropriately influence (bias) their work. None of the co-authors have direct or indirect conflicts of interest, financial or otherwise, relating to the subject of our report. There is role of no sponsorship.