RAK MEDICAL AND HEALTH SCIENCES UNIVERSITY,...

RAK MEDICAL AND HEALTH

SCIENCES UNIVERSITY,

RAK COLLEGE OF NURSING

RAS AL KHAIMAH-UAE

Dr. Faiza A. Abou El-Soud

Associate Professor

Community Health Nursing

RAK College of Nursing

Research Title

FUNCTIONAL DISABILITY AMONG SENIOR

CITIZENS EMIRATES IN HOME CARE

PROGRAM - RAS ALKHAIMAH

UAE

Background Information

Today the world is experiencing the later stages of

a longstanding demographics transition from a

predominant high mortality and high fertility pattern

to a low mortality and low fertility pattern.

Global increase in life expectancy and rapid age-

specific population growth is impressive. (Ref.:United Nations

Department of Economic and Social Affairs: Population Division : World population Ageing,2013 ; Mather et

al., 2001, United Nations, 1999, World Population Prospects: the 1998 Revision, New York)

The United Arab Emirates (UAE) like many

other countries world-wide is experiencing

demographics transition where the number of

elderly has increased threefold between 1995

to 2010 and is expected to be 20 per cent of

the population by 2040.

So a fifth of the population will be composed of

the elderly people. (Ref.: Ministry of Health - RAK Medical District -

Home care Program for Elderly - UAE, 2012).

Figure (4):

Total Fertility Rate : World & Development Regions,1950-2050

Source :United Nations Department of Economic and Social Affairs: Population Division : World population Ageing,2013

Figure:5 Extracted From World Bank Database

Figure (2):

Total Fertility Rate in the UAE,1980-2050

0

1

2

3

4

5

6

Total Fertility Rate

Total Fertility

Rate1.62

Source : United Nations, World Population Prospects: The 2012 Revision; Projections (medium variant).

5.26

Figure (3): Trends in Total Mortality Rates (Per 100,000) in USA and Hungary

Countries

(65-74 yr.)

(75--84 yr.)

Source: United Nations, World Population Prospects: The 2010 Revision* Projections (medium variant).

Table (1): Total GCC Mortality Rates,2002 -2010

Source: Extracted From World Bank Database

Rutkowsky, M. (2006, September). Demographic changes and their effects on pension funds and social security in GCC countries. Presented in

Bahrain on behalf of the World Bank.

Figure (4): Male & Female Life Expectancy at Birth and Gender Gap :World &

Development Regions,1950-2050


Figure (5): Male & Female Life Expectancy at Birth and Gender at Birth in

UAE, 1980 - 2050


0

10

20

30

40

50

60

70

80

90

Male Female

Figure (6): Speed of Population Ageing: World and Development Regions,

1980-2010 & 2010-2040


Figure (7): Speed of Population Ageing: UAE’s Elderly Population ,1950-2050


Figure (8):

Population Pyramids of the Less and More Developed Regions

:1970, 2013& 2050


Figure (9): Population Pyramid of UAE, 1950,2010 and 2050

Source for all pyramids: United Nations, World Population Prospects: The 2012 Revision; Projections (medium variant).

Significance of the Study

With ageing process, the elderly population are

characterized by an overall decline in

physiological competence and loss of functional

reserve gradually. (Ref.: Stanhope & Lancaster, 2012, Eliopoulos, 2010, Clark, 2008).

As disability increases in frequency and severity

as age increases, Therefore the current study is

undertaken to assess the functional disability

and functional limitation among Senior citizens

Emirates .

Problem Statement

Functional disability among older adults is a

precursor of a variety of negative life outcomes,

such as hospitalization, institutionalization, and

death.

Also disability in later life has even been shown to

prompt negative global psychosocial outcomes,

such as decreased quality of life, happiness,

subjective well-being, and life satisfaction.

Also disability can affect negatively on the quality

of family’s life and increase the cost burden on the

health care system. (Ref.: Wetherall et al., 2004, Lenze et al., 2001, Horowitz &

Reinhardt, 2000).

Objectives of the Study

1. Describe of socio-demographic characteristics

and health behaviors of the study participants

with functional disability .

2. Assess the proportion of functional disability

of the senior citizens emirates at their home.

3. Assess degrees of functional disability of the

senior citizens emirates at their home.

4. Assess functional limitation of the senior citizens emirates

at their home.

5. Determine the percentage and the estimated rank of the

ADL/IADL domains disability among senior citizens

emirates at their home.

6. Identify the relationship between functional limitation and

socio-demographic, health behaviors, medical condition

variables.

7. Identify the relationship between functional disability and

socio-demographic, health behaviors, medical condition

variables.

Hypothesis

H1.There is significant relationships between

functional disability and socio-demographic factors,

health behaviors, medical condition of the senior

citizens emirates.

H2. There is significant relationships between

functional limitation and socio-demographic factors,

health behaviors, and medical condition of the

senior citizens emirates .

H3. There is highly significant relationships between

functional disability and functional limitation.

Operational Definitions

of the Variables

Functional Disability

Lack of ability to perform an activity that results from impairment.

It is measured by two generic assessment instruments :

1. Activities of Daily Living (ADL) and

2. Instrumental Activities of Daily Living(IADL) . (Ref.: WHO, 1980 ; Zola, 2005).

Senior Citizens

Elderly persons, usually more than sixty or

sixty – five years of age.

According to chronological definition, it is defined as:

Young old : 60 to 74 yrs.

Old - old / Frail elderly/Aged : 75 yrs. and 84 yrs.

Oldest old or Extreme Aged: 85 yrs. and above.

Centenarians: Persons over the age of 100 years. (Ref.: Wold,2012; Eliopoulos 2010; Linton & Lach,2007).

Functional limitation

It was defined as reported by Nagi ,1965 &

Verbrugge and Jette, (1994) in the disablement

process as “a limitation in performance at the

level of the whole organism or person”.

Functional limitation was measured for both

upper & lower body functional limitation.

DISABLEMENT MODEL

Figure 10. Nagi Disablement model,1965

Socio-demographic Variables

It is a self –report used to describe an

element of a group within a society .

In this research those elements for example: age, gender, education, marital status, living

arrangement . (Ref.: http://www.ask.com / Q&A / Society / Social Science).

Activities of Daily Living (ADL)

Katz Index is the most appropriate instrument

to assess functional status as a measurement

of the client’s ability to perform activities of daily

living independently.

The Index ranks adequacy of performance in

the six functions of “Bathing, dressing, feeding,

transferring (moving out of bed), continence

and toileting”. (Ref.: Katz, 1970).

Instrumental Activities of Daily Living

(IADL)

Lawton & Brody Scale is an appropriate instrument to

assess independent living skills to identify how a

person is functioning at the present time, and to identify

improvement or deterioration over time.

It is the common used to measure the ability to use

telephone, shopping, food preparation, house-keeping,

laundry, mode of transportation, responsibility for own

medication, and ability to handle finance. (Ref.: Lawton and Brody,

1969).

Short Portable Mental Status (SPMSQ)

Questionnaire

It is a 10-item test measuring the presence and

the degree of intellectual impairment of the

elderly.

The concepts measured include: orientation,

memory function related to capacity for self-

care, remote memory, and capacity to perform

several mental operations. (Ref.: Pfeiffer, 1975).

Assumptions • Katz Index (ADL) & Lawton (IADL) scales reflect degree of

functional disability and functional limitation of the senior

citizens.

• Elderly males and females differ in their Activities of Daily

Living (ADL)& Instrumental of Activities of Daily Living (IADL).

• Socio-demographic characteristics, health behaviors, chronic

medical illness, and functional limitation have an influence the

elderly disability.

• Elderly age and history of chronic medical illness are the main

factors associated with disability among senior citizens.

Methodology

Research Design

A cross sectional descriptive design was used to assess the proportion of functional disability among senior citizens emirates who are registered in home care program – Ras Al-Khaimah.

Correlational design was used to assess the factors related to functional disability & functional limitation among senior citizens emirates.

o Setting of the Study

The study was conducted in

the community dwelling

where the senior citizens emirates

residents in their home, Ras Al-

Khaimah, UAE.

Sample Size and Sampling Technique

All the elderly people who benefited from the

home care program is 270.

The study sample size was 154 senior citizens

where selected randomly from the sampling

frame using sample criteria to define

membership to give each the opportunity for

selection and taking place in the study.

Inclusion Criteria

o Senior citizens Emirates who registered in home health care program in Ras Al-Khaimah to obtain primary care services.

o Age 60 years and above

o Both gender

o Senior citizens emirates who are living in their home.

o Senior citizens Emirates who living with proxy or family caregiver who is familiar with the patient's abilities.

o Exclusion Criteria

o Senior citizens emirates and their

caregivers who don’t willing to participate in

the study.

o Senior citizens emirates who were suffering

from severe cognitive impairment ,

psychiatric disorder or mental illness.

Data Collection Instrument

Part -1: Demographic data, health behaviors,

self-reported medical condition; function

limitation questionnaire.

Part- 2: Katz Index of Independence in Basic

Activities of Daily Living (ADL) &

Instrumental Activities of Daily Living

(IADL) .

Part -3: The Short Portable Mental Status

Questionnaire (SPMSQ) .

Part -1:

Socio-demographic data:

gender, age, marital status, education,& living arrangement.

Health behaviors factors :

Smoking status “smoked or never smoked”. Alcohol intake “ever consumed alcohol or never consumed”.

Medical conditions or diseases report:

“the presence of chronic illness or the diseases”.

Part- 2:

ADL = Katz Index

Total scores range from 0 – 6, With lower scores indicating increased disability.

The degrees of the disability categorized as follows :

Mild disabled = Unable to perform 1-2 tasks in ADL

Moderately disabled = Unable to perform 3-4 tasks in ADL

Severely disabled = Unable to perform 5-6 tasks in ADL

IADL = Lawton Instrumental Activities of

Daily Living Scale

There are eight domains of function measured with the Lawton

IADL scale.

Clients are scored according to their highest level of

functioning in that category.

for men, the areas of food preparation, housekeeping,

laundering are excluded.

0 = (low function, dependent) 5= (high function, independent)

For Women are scored on all 8 areas of function;

0 = (low function, dependent) 8= (high function, independent)

Part -3:

The Short Portable Mental Status Questionnaire (SPMSQ)

It constructed by summing up the 10 items, yielding

a range from 0 to 10.

Each item was rated as 0 = “right answer”,&

1 = wrong answer.

The total score was 10, classified as the following:

0-2 errors: Normal mental functioning

3-4 errors: Probably/mild cognitive impairment

5-7 errors: Borderline/moderate cognitive impairment

8 or more errors: Severe cognitive impairment

.

Functional limitation

There are two questions to measures

upper body functional limitations.

There are two questions to measures

lower body functional limitations.

The responses were recoded into three categories:

1. No difficulties = (Answer no) i.e., functional limitation

2. With difficulties but still able to perform = (Answer Yes)

i.e., there is functional limitation

3. With difficulties and require assistance = (Answer Yes)

i.e., there is functional limitation

Data Collection Procedure

Participants - based on the inclusion criteria and

exclusion criteria.

Data collection from 14th April, 2013 to 22nd April, 2013.

Pilot Study

10 elderly who are registered in the home care program

All the questionnaires were translated forward to Arabic and

back translated to English by two groups of independent

individuals who were well versed in both the languages.

Face to face interview.

Study was feasible within the timeframe and no further

changes were made.

Internal Reliability

Scales In the Original Scale In the Present Study

ADL No formal reliability and validity reports could

be found in the literature,

The tool is used extensively as a flag

signaling functional capabilities of older adults

in clinical and home environments.

.84 -.86

IADL .85 .83 - .85

SPMSQ .74 - .91 Not applied

Katz Index : try this: Best Practices in Nursing Care to Older Adults, The Hartford Institute for Geriatric Nursing, New York

University, College of Nursing, www.hartfordign.org. By: Meredith Wallace, PhD, APRN, BC, Fairfield University

School of Nursing, and Mary Shelkey, PhD,ARNP, Virginia Mason Medical Center. Revised 2007.

The Lawton Scale : try this: Best Practices in Nursing Care to Older Adults, The Hartford Institute for Geriatric Nursing, New

York University, College of Nursing, www.hartfordign.org. by :Carla Graf, MS, APRN, BC, University of

California, San Francisco, Revised 2007.

SPMSQ :Roccaforte, et al., Journal of Geriatric Psychiatry and Neurology, Vol 7(1), Jan-Mar 1994, 33-38.

http://www.hartfordign.org/


Protection of Human Subjects

o Written permission was obtained from RAK

College of Nursing, RAK Medical Health

Sciences University-Research and ethical

Committee to conduct the study.

o Written permission the health authorities of

Medical District – MOH and Julphar health

center director –in Ras Al-Khaimah,UAE .

Ethical Considerations

Written consent from each study participants .

The participation in the research was not

mandatory.

o Discussed the importance of the study and explain

consent form to the subjects or their caregivers.

Confidentiality of the data collected .

Results

Results

Section I:

Objective 1:

Describe of socio-demographic

characteristics and health behavior

of the study participants with

functional disability (Tab. 1 & 2).

Socio-Demographic Data

Males =66

Females =88

Total = 154

n %

n

%

n

%

Age group / years

60-74

75-84

85+

Mean + SD

35

19

12

53.0

28.8

18.2

44

29

15

50.0

33.0

17.0

79

48

27

51.3

31.2

17.5

82.71 + 9.1 83.27 + 8.9 81.96 + 9.4

Marital status

Married

Widowed

Divorced

48

18 0

72.7

27.3 0.0

32

52 4

36.4

59.1 4.5

80

70 4

51.9

45.5 2.6

Educational level

Illiterate

66

100

88

100

154

100

Living arrangement

Lives with family

Lives with home helper /caregiver

25 41

37.9 62.1

26 62

29.5 70.5

51 103

33.1 66.9

Table 1:

Description of Socio-Demographic Characteristics of the Study Participants

Health Behaviors Males =66

Females =88

Total = 154

n %

n

%

n

%

Smoking Status

Smoked Never smoked

34 32

51.5 48.5

0 88

0.0 100

34 120

22.1 77.9

Alcohol Intake

Consumed alcohol Never consumed alcohol.

13 53

19.7 80.3

0 88

0.0 100

13 141

8.5

91.5

Cognitive Status

Probably cognitive impaired

Borderline cognitive impaired Normal cognitive

4

2

60

6.0

3.0

90.9

5

18

65

5. 7

20.4

73.9

9

20

125

5.8

13.0

81.2

Self-Medical Conditions Report

Diabetes

Hypertension

18

21

27.3

31.9

23

29

26.1

33.0

41

50

26.6

32.5

Number of Chronic Diseases

Report

1-2 > 3

50

16

75.8

24.2

70

18

79.5

20.5

120

34

77.9

22.1

Table 2:

Descriptive Statistics of Health Behaviors of the Study Participants

Section II:

Objective 2:

Assess the percentage of functional

disability of the senior citizens emirates at

their home (Tab. 3).

Objective 3:

Assess degrees of the ADL disability of

the senior citizens emirates at their home

(Tab. 4).

Gender

Independent

ADL / IADL Disability

ADL IADL ADL/IADL

n % n % n % n %

Males 1 1.5

17 25.8

30 45.5

18 27.3

Females 10 11.4 26 29.5 22 25.0 30 34.0

Total 11 7.1 43 27.9 52 33.8 48 31.2

Table (3):

Percentage of ADL/IADL Disability for Males and Females (n=154)

ADL Disability Degrees

Males n = (66)

Females n = (88)

Total n = (154)

χ2

p- Value n % n % N %

No disability 1

0.6

10 6.4 11 7.0

16.62 .001***

Mild disability 17

11.0

6 3.9 23 14.9

Moderate disability 25

16.2

47 30.5 72 46.7

Severe disability 23

14.9

25 16.2 48

31.1

Table 4:

Categorization of ADL Disability Degrees for Males and Females(n=154)

*Correlation is significant at the 0.01 level ** Correlation is significant at the 0.05 level *** Correlation is significant at the 0.000 level

Objective 4:

Assess the percentage of the functional limitation

of the senior citizens emirates in the home care

program (Tab. 5).

Objective 5:

Determine the percentage and the estimated rank

of the ADL/IADL domains disability among senior

citizens emirates at their home (Tab.6 &7).

Functional Limitation

Components

Males

Females

Total

n = (154)

χ2

p-

Value n % n % n %

Upper Limbs

No Difficulty

Difficulty in putting

hand behind the neck

Difficulty in putting

hand behind lower back

0

32

34

0.0

20.8

22.08

11

60

17

7.0

39.0

11.03

11

92

51

7.0

59.7

33.1

2.50

.0 00***

Lower Limbs

No Difficulty

Difficulty in climbing the stairs

Difficulty in sitting and

standing from a chair

0

31

35

0.0

20.1

22.72

11

53

24

7.0

34.4

15.6

11

84

59

7.0

54.5

38.3

15.99

.000***

Table 5:

Percentage of Functional Limitation for Males and Females (n=154)


ADL Domains

Males Females Total

n = (154) Rank χ2

p-

Value

n % n % n %

Bathing 29 18.8 75 48.7 132 85.1 1 29.32 .000***

Dressing 43 27.9 85 55.2 128 83.1 2 26.56 .000***

Feeding 47 30.5 85 55.2 91 59.1 5 19.83 .000***

Transferring 22 14.3 69 44.8 104 67.5 4 31.69 .000***

Continence 40 25.9 71 46.1 111 72.0 3 7.55 .005***

Toileting 43 27.9 85 55.2 128 83.1 2 26.56 .000***

Table 6:

Percentage and Rank of Activities of Daily Living Domains Disability for Males

and Females


(IADL) Disability

Males =66

Females =88

Total

n = 154

χ2 p-

Value

n % n % n %

Using telephone 51 77.3 77 87.5 128 83.1 2.81 .073

Taking medication 55 88.3 84 95.4 139 88.3 6.30 .013*

Food preparation 66 100 0 100 0 100 a

Housing keeping 66 100 0 100 0 100 a

Doing laundry 66 100 0 100 0 100 a

Handle finance 66 100 0 100 0 100 a

Transportation 66 100 0 100 0 100 a

Shopping 66 100 0 100 0 100 a

Table 7:

Percentage of Instrumental Activities of Daily Living Domains Disability

for Males and Females

a. No statistics are computed because variables are constant Correlation is significant at the 0.05 level

Section III: Objective 6:

Identify the relationship between functional

limitation and socio-demographic data, health

behaviors, medical condition variables (Tab.8).

Objective 7:

Identify the relationship between functional

Disability and socio-demographic data, health

behaviors, medical condition variables (Tab.9).

.

Variables

Functional Limitation n = (154)

χ2

p-

Value

Able to

Perform

Need

Assistance

Not Able to

Perform

n % n % n %

Age group / years

60-

75-

85+

0

11

0

0.0

7.0 0.0

26

38 19

16.9

24.7 12.3

1

10 49

0.6

6.5 31.8

61.64

.000***

Gender

Male Female

1

10

0.6

6.4

47 36

30.5 23.4

18

42

11.7 27.3

19.89

.000***

Cognitive Status Probably cognitive impaired Borderline cognitive impaired

Normal cognitive status

3 2 6

1.8 1.3 3.9

4 0

79

2.6 0.0 51.3

4

16 40

2.6

10.4 26.0

31.03

.000***

Number of Medical Diseases

Report 1-2 > 3

11 0

7.0 0.0

49 34

32.0 22.0

60 0

39.0 0.0

37.32

.000***

Table 8: Univariate Analysis of Variables Association with Functional

Limitation Variables


Table 9: Univariate Analysis of Variables Association with Functional

Disability as a Dependent Variable

Socio-Demographic Data ADL Disability n = (154)

χ2

P Value

No disability Mild disability

Moderate disability

Severe disability

n

%

n

%

n

%

n

%

Age / years

60-

75- 85+

1

9

1

0.6

5.8

0.6

4

12

7

2.6

7.9

4.5

15

34

23

9.7

22.0

14.9

7

24

17

4.5

15.6

11.0

19.49

.003***

Gender

Males Females

1 10

0.6 6.4

17 6

11.0 3.9

25 47

16.2 30.5

23 25

14.9 16.3

16.62

.001***

Cognitive Status Probably cognitive impaired Borderline cognitive impaired

Normal cognitive

1 1 9

0.6 0.6 5.8

2 0

21

1.2 0.0 13.6

5

11 56

3.2 7.1 36.4

3 6 39

1.9 3.9 25.3

33.02

.000***

Number of Medical Diseases

Report 1-2 >3

11 0

7.0 0.0

12 11

7.8 7.1

11 61

7.1 39.7

11 37

7.1 24.1

17.18

.001***

Functional Limitation

Able to Perform

Need Assistance

Not Able to Perform

11

0

0

7.0

0.0

0.0

0 13 10

0.0 8.8 6.4

0 43 29

0.0 27.9 18.8

0 28 20

0.0 18.8 13.0

77.8

.000***

Limitations

Limitations Sample attrition.

The study conducted only among senior citizens emirates

who are registered in the community health care program in

RAK - UAE.

The language barrier of the caregivers .

The time consuming in the travel from home to home

because the elderly’s home allocated in different districts in

Ras Al-Khaimah.

Recommendations

Replicate the study on the others six emirates which

delivered home care services to their seniors citizens

emirates .

Conducting the same study with a large sample with

more different ethnicity, religious, spirituality to be

more representative for the risk factors and may have

a negative impact on functional disability .

Implications for Nursing Practice This research provide an evidence based that will assist the

nurse to make clinical decisions on the available evidence in

UAE.

This research study provided a clear description, and

explanation about functional disability among senior citizens

emirates in clinical practice.

This research findings identify the most modifiable and none

modifiable risk factors that may have further impact on the level

of disability among senior citizens.

Disseminating results among health care professionals in the

seminars , conferences or publication.

Conclusion Functional limitation and functional disability has a great

proportion among senior citizens emirates .

Greater emphasis to utilize ADL and IADL instruments to

assess functional disability among senior citizens emirates .

Early detection of the modifiable risk factors is needed to

identify earlier intervention that can prevent further

morbidity and postpone disability among senior citizens

emirates .

Age, gender, cognitive status and number of the chronic

disease are strongly factors associated with functional

limitation & disability among senior citizens.

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