Ibrahim T Marouf (1), M.B.Ch.B., M.Sc.
Namir G. Al-Tawil (2), M.B.Ch.B., D.C.M., F.I.C.M.S.
Tariq S. Al-Hadithi (2), M.B.Ch.B., M.Sc., DTM, Ph.D.
Nazar P. Shabila (2), M.B.Ch.B., M.Sc.

(1) General Directorate of Health, Erbil, Iraq
(2) Department of Community Medicine, College of Medicine, Hawler Medical University, Erbil, Iraq

Corresponding author:
Nazar P. Shabila
Department of Community Medicine, College of Medicine, Hawler Medical University, Erbil, Iraq
Email address: nazar.shabila@hawlermu.org
Tel.: 00964-750-4450611

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INTRODUCTION AND BACKGROUND

Aging of the global population is one of the largest challenges facing the world in this century(1). In 2002, the old population represented 7% of the world population (2). Worldwide, in 2004 there were 600 million persons aged 65 years and over, which will reach virtually 2 billion by the year 2050 (1). This age has long been used to define the beginning of "old age" (3).

The vast majority of older populations are currently living in developed countries. In Sweden, as of 1995, 18% of the population are aged 65 and over. Other notably high levels are seen in Norway, the UK, Italy and Belgium with 16% for each. In the United States, older persons represent approximately 1/8th of the population (4).

In the last 2 decades significant changes have occurred in the demography and pattern of health and disease in many developing countries. With few exceptions, the elderly are the faster growing segment of the population in the developing world. By the year 2027, of the 11 largest elderly populations in the world, 8 will be in the developing world (5,6). Changes in the pattern of health and disease have resulted from improved living standards; as communicable diseases, malnutrition and problems associated with pregnancy and child care come under control, non-communicable diseases replaced them as the dominant public health problems (7).

The main predictor for the need for help and low quality of life (QOL) is a mobility problem. Other predictors for the need for help and QOL include age, sex, low education and low income factors and female gender(8,9). Performing activities of daily living (ADL) and instrumental activities of daily living (IADL) are negatively associated with increasing age, especially at ages above 75-80 years. This is a reflection not only of morbidity and multi-morbidity but also of the fact that the reverse capacity declines in old age. The prevalence of disabilities (ADL, IADL) are generally higher in old aged women than old aged men (10).

In the last two decades, there have been improvements in the health and social services in Iraq, particularly in the Kurdistan region. The age structure of the population has so evolved that the number of old people is continually on the increase (11). In 2002, 3% of the Iraqi population are aged 65 and over (2).

In Iraqi Kurdistan, no study has been published on the quality of life and morbidity pattern in this age group and there is limited data in this particular field. This study was carried out, therefore, to throw a light on the quality of life and morbidity pattern in a sample of the geriatric population in Erbil city, its association with various socio-demographic characteristics and to define the risk factors leading to increased morbidities in the elderly population.

SUBJECTS AND METHODS
This cross-sectional study was conducted on the elderly population of 65 years old and over in Erbil city, which is the central district of Erbil governorate. The population of Erbil governorate was 1,438,482 in 2006 where the geriatric population constituted 3.79% (12,13).

The study extended from mid January 2007 to the end of April 2008. A total sample of 700 subjects was selected. The sample size was calculated using 95% level significance, with 15% degree of precision and estimated prevalence of common morbidities in old ages of 20% (14). Accordingly, the size was 683 subjects; however, for convenience a sample of 700 subjects was taken.

Subjects were selected from those who receive their social benefit (financial support) from the Mala Ismail Nanacali Establishment for Zakat (MINEZ) and those who receive their pensions from the Directorate of Retirement of Erbil City. From MINEZ, all the 300 persons aged 65 years and over were included for the study out of a total of 2000 persons benefiting from the establishment. A representative random sample of 400 persons was selected from those receiving their pensions from the Directorate of Retirement of Erbil City.

The questionnaire that was used for data collection was developed through extensive literature review and expert consultation. The questionnaire was directly administered to the participants by direct interview. Data were collected about personal and behavioral aspects including age, sex, educational level, with whom he/she lives, dietary intake, smoking habit, alcohol consumption and medical problems. Part of the questionnaire included data on weight, height, blood pressure and fasting blood sugar level of the participants. Weight measurement was done by using the electronic weight measurement instrument (Home-use personal scale, KH 2003A/Taiwan). For measurement of height, the ordinary scaled tape was used. The standard mercury sphygmomanometer was used for measurement of the blood pressure. Fasting blood sugar was requested for each subject if he/she has no documentation or laboratory report. The last part of the questionnaire included data on ADL and IADL. Functional dependence in basic ADL was evaluated based on the Katz Index (15) including ability to eat, take bath, dress, use toilet and wash face. The Lawton IADL Scale was used to assess a person's ability to perform tasks such as preparing meal, using telephone, shopping and managing money and driving car (16). Data collection and measurements were made by the same person, the first author.

Statistical analysis was carried out by SPSS version 13, aided by Excel. Chi square test was used for testing association between different variables. P value <0.05 was considered as statistically significant.

The study proposal was approved by the scientific committee at the College of Medicine in Hawler Medical University that looks at the ethical aspects of the study. Due to the high illiteracy rate among the participants, no written consent was taken from the participants, however, the purpose and the importance of the study was communicated to the participants and no one disagreed to participate.

1 Less than moderately intense physical activity of 30 minutes a day, five days a week.
2 Regarded as morbidities and risk factors

Table 1. Distribution of the risk factors by gender

Table 2. ADL and IADL by gender

Figure 1. Distribution of ADL by age group

Figure 2. Distribution of IADL by age group

Table 3. Distribution of the sample morbidities by gender

RESULTS
Out of 700 elderly persons, 440 were males and 260 were females. The highest percentage of the sample was in the age group 65-69 years (37.5%). The mean age ± S.D. was 72.89 ± 6.27 years with a range of 65 to 100 years. The highest proportion of these elderly persons were living with their spouses (54.2%), 32.2% with their first degree relatives, i.e. sons, daughters, brothers, sisters. On the other hand, 9.9% of them were living alone and 3.7% were living with far relatives.

The illiteracy among the studied sample was 70.7%, which was higher among females than males, with highly significant statistical variation (95.3% versus 56.1%, p<0.001).

Around half (51.2%) of the sample subjects were of normal weight, while 31.9% were overweight (BMI=25.0-29.9 kg/m2), 12.9% obese (BMI=30.0-34.9 kg/m2), and 4% underweight (BMI <18.5 kg/m2) (17). There was no statistically significant association between gender and the BMI. The percentages of other risk factors associated with geriatric morbidities are shown in Table 1. All risk factors were more common among females than males with the exception of smoking and overweight.

The mean percent of the ADL was 92% for men and 88.7% for women while that of IADL was 59.5% for men and 39.4% for women. No statistical significant gender variation in the ability to perform ADL was demonstrated. Regarding performing IADL there was a statistical significant gender variation in the ability to use telephone, shopping and managing money, and car driving only (p<0.001), being higher in males than females as it is shown in Table 2.

All daily and instrumental daily life activities were decreasing with age with clear variation in the rates of decline of such activities (Figure 1 and Figure 2).

On average each person had 2.8 chronic diseases. The overall proportion of morbidities was 91.4% (88.6% for males and 96.2% for females). The proportion of cardiovascular diseases, sense organ disorders, oral diseases, musculoskeletal diseases, diabetes mellitus and respiratory diseases were higher among females than males, while that of other disease categories were more in males than females. The overall proportion of blindness was 10%. Diseases were categorized according to the global burden of disease cause categories and their definitions in terms of the international classification of diseases, tenth revision (ICD-10) (18). The proportions of these morbidities among the sample populations are shown in Table 3.

The diseased participants were admitted to hospitals between 1-10 times. The total number of admissions was 529. More than two thirds (68%) of admitted subjects were females, and 32% were males. One hundred and eighty five subjects (26.4%) had undergone one or more operations; 14.1% for men and 47.3% for women (i.e. more than 3 times). Cataract operation was the commonest (44.3%), followed by benign prostatic hyperplasia (10.3%), gall stone (9.2%), urinary tract stone (6.0%) and different fractures (3.6%).

DISCUSSION
The results of the current study were in agreement with the results of a study done in the Islamic Republic of Iran, in terms of age distribution, marital status, and living arrangements of the elderly. However, the proportion of illiterates was very high in comparison to that study (19). This can be due to two reasons: firstly, the majority of the participants of MINEZ were living in poor sectors of Erbil city, secondly the enrolment of females to schools was very rare in our society 60 years ago. For the same reasons large proportion of females cannot use telephones, drive cars, or use other instruments of activities of daily living.

The gender difference of the risk factors coincides with most of the results of other studies that were conducted in Iraq and Bahrain. The results of all these studies revealed that illiteracy, obesity, low physical activity, fall accident, high medication use, hypertension, and diabetes mellitus were more among females than males, while smoking and overweight were more among males than females (20,21).

Obesity was higher among females than male, while overweight was higher among males than females in studies conducted either in similar or different settings with different proportions (20-22). The overall prevalence of both overweight and obesity was very high in Western countries; 70% in UK (17) and 64% in USA (23) in comparison to this study, which could be attributed to excessive intake of food and sedentary life habits.

High medication use by elderly was seen in all communities. This consumption was higher among women than men (24), which coincide with results of the current study.

The results of other studies conducted in Bahrain, the USA and India revealed that most of the older persons are sedentary or engage only in minimal physical activity ranging between (88-90%), (21, 25, 26) which coincide with the results of the current study (88.5%).

The prevalence of ADL and IADL problems differs from country to country and differs between males and females. The explanation for such variation is more likely to be due to case definition than true variation in prevalence, although differences in the physical, environment and expectations may also play a role (27). The proportions of ADL activities were in agreement with the results of the studies that were carried out in Turkey, China, and the USA, while that of performing IADL that need some degrees of skill and concentration, such as telephone using and car driving in female populations were very low in comparison to China and developed countries (28-30). This could be attributed to illiteracy and not to disability. In all these studies disability was more frequent in women than men and in illiterates than literates. While increasing age lead to a constant decrease in both the ADL and IADL, its effect was more clear on IADL. Such findings agree with another study from China (29).

In developed countries the elderly individuals had on average 3 chronic diseases per person (1). In Iran the elderly populations had 2.18 chronic diseases per person (19). Our finding of 2.8 diseases/person coincide with the above two studies.

The proportion of some morbidities in this study such as musculoskeletal disorders, cardiovascular diseases, gastrointestinal diseases, diabetes mellitus and sense organ disorders are consistent with the results of other studies conducted in developed and developing countries with slight variations (30-32). Regarding the gender difference, the percentage of the majority of chronic diseases were higher among females than males, which coincide with other studies done in Iraq 20 and other developing countries such as the Islamic Republic of Iran (10) and India (33) and developed countries such as the USA (34) and UK (35).

Different studies have reported different prevalence rates of blindness in old aged persons ranging from 0.3 in developed countries to 18.3% in some developing countries (36-38). The upper extremes have also been reported in studies conducted on nursing home residents in the United States (39). The high percentage of blindness in the current study (10%) can be attributed to the lack of screening programs for diabetic retinopathy, delay in detecting and treating cataract and glaucoma and other causative factors, or it could be due to registration of a large number of individuals at the MINEZ as blind for financial support.

A consistent finding in the literature is that women have a significant higher health burden than men 36. In the current study, more than two thirds of admitted subjects were females who have more than 3 times proportion of operations than males. This "gender gap" can be partially explained by the greater longevity of women, with loss of spouse support, their higher prevalence of disabilities, their lower ADL scores, and their lower income (40).

CONCLUSION
A relatively high proportion of the participants of both sexes had independence in performing ADL, whereas a low proportion of them of both sexes had independence in performing of IADL in comparison to other communities. The QOL of the sample was found to be within the expected values considering the results of the studies done in nearby countries. The QOL of men was in general better than women in all age groups. The majority of the study sample had one or more chronic diseases.

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