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w w w . r b h h . o r g

Revista

Brasileira

de

Hematologia

e

Hemoterapia

Brazilian

Journal

of

Hematology

and

Hemotherapy

Original

article

Descriptive

study

of

the

prevalence

of

anemia,

hypertension,

diabetes

and

quality

of

life

in

a

randomly

selected

population

of

elderly

subjects

from

São

Paulo

Jacqueline

Lacerda

a

,

Matheus

Rodrigues

Lopes

b

,

Douglas

Patriota

Ferreira

a

,

Fernando

Luiz

Affonso

Fonseca

a

,

Patricia

Favaro

a,∗ aUniversidadeFederaldeSãoPaulo(Unifesp),Diadema,SP,Brazil

bUniversidadeEstadualdeCampinas(Unicamp),Campinas,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received17February2016 Accepted19March2016 Availableonline14April2016

Keywords:

Anemia Elderly

Erythrocyteindices Personalfunctionalstatus Non-psychoticmentaldisorders

a

b

s

t

r

a

c

t

Background:Therapidincreaseintheagedpopulationhasresultedinagrowingnumberof casesofchronicdiseases.Thisincreaseisanimportantdemographicchangethatlow-and middle-incomecountrieshavetofaceandposesanewchallengetohealthservices.Oneof thefirststepstoformulatepublicpoliciesistounderstandtherealityofeachcountry’saging population.Thisstudydescribestheprevalenceofanemia,hypertensionanddiabetesand theoverallhealthstatusinpre-elderlyandelderlysubjectsenrolledintwoprimaryhealth careclinics,EldoradoandPiraporinha,inthecityofDiadema,SãoPaulo.

Method:Across-sectionalstudywasconductedwith373participants.Clinicaldatawere collectedfrompatientchartsandthedegreeofdisabilityandcommonmentaldisorders,as wellasdemographicdatawereobtainedbyinterviews.

Results:Theprevalenceofanemiawasapproximately11%andhypertensionwas70%and 81%inEldoradoandPiraporinha,respectively.Thefrequencyofdiabeteswas52%in Eldo-rado and30%in Piraporinha. The subjectsofboth health care clinicsreported having difficultiesinsomeoftheirdailyphysicalandinstrumentalactivities,withphysical symp-tomsandemotionaldisorders.

Conclusion: Anemia,hypertensionanddiabetesareprevalentinthestudiedpopulation,and patientsshoweddegreesofdependencyandimpairedhealthstatus.

©2016Associac¸ãoBrasileiradeHematologia,HemoterapiaeTerapiaCelular.Published byElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Correspondingauthor.

E-mails:patricia.favaro@unifesp.br,favaropb@gmail.com(P.Favaro). http://dx.doi.org/10.1016/j.bjhh.2016.03.005

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Introduction

Increasesin theproportion ofolderpeople are auniversal phenomenon.Theforecastforthisolderpopulation(>65year old)for2100,acrossthe globe, ismorethan triple the cur-rentnumber.1Thisdemographicchangeisaconsequenceof

socioeconomicgrowthandincreasingprosperity,resultingin ahigheraveragelifeexpectancy.2However,thisagingofthe

populationhasanimpactonhealthcaresystems,inpartdue totheincreaseinthenumberofpeoplewithchronicdiseases.3

Lifeexpectancyishigherindevelopedcountrieshowever theabsolutenumberofolderadultsisconcentratedin devel-opingcountries.4Inthepast50years,Brazil,thefifthlargest

country inthe world, has experienceda demographic rev-olution. Accordingto the Braziliancensusdepartment,the InstitutoBrasileiradeGeografiaeEstatística,theaveragelife expectancyinBrazilhadreached73yearsin2009(76.5and 69 years forwomenand men, respectively).5 Nevertheless,

thecorrespondingrateofsocioeconomicgrowthand improve-mentinhealthcarehasnotkeptupwiththisrapidrateof agingoftheBrazilianpopulation.6 Thus,understandingthe

Brazilianrealityofthisagingpopulationcouldhelpimplement localhealthpoliciesandinterventionsbasedondiversities.

Theaimofthisstudywastoevaluatetheprevalenceof ane-mia,hypertensionanddiabetesandtocorrelatetheseissues withtheoverallhealthstatusinpre-elderly(50–59years)and elderlypatients(age≥60years)enrolledintwoprimarycare

clinics.

Method

Studydesign

Thisisacross-sectionalobservationalstudycarriedoutattwo primaryreferralcentersforelderlycare,Eldoradoand Pira-porinha.BothclinicsareinthecityofDiadema,whichalong withother cities, belongs to theconurbation ofSãoPaulo. TheEldoradoclinicislocatedintheoutskirtsofthecityand thePiraporinhaclinicislocatedinamoreprivilegedarea,in thecitycenter,conferringdifferentgeographiccontextstothe clinics.

Participants

Thisstudyincluded373participantswithclinicaldatabeing collected between November 2012 and April 2013. All pre-elderlyandelderlymaleandfemaleindividuals(50yearsor older)ofthetwoclinicswereinvitedtoparticipateinthestudy. Subjectswho didnotliveinDiademaandindividuals who refusedtoparticipateinthestudy wereexcluded fromthe study,aswerethosewhowereunabletoanswerthequestions duetodeafness,blindness,orwithdifficultiestounderstand. Asimplerandomsamplingmethodwasused.Inorderto cal-culatethesamplesize,theelderlypopulationofDiademawas consideredtobeapproximately4%ofthetotalpopulation,5

thus using a 95% confidence level and 5%sampling error, theminimumsamplesizerequiredwas280subjects.7Allthe

individualswhoparticipatedinthestudyprovidedinformed writtenconsent.TheEthicsCommitteeoftheUniversidade

FederaldeSão Paulo(Unifesp)approvedthestudy protocol (#142.778).

Diagnosisofanemia,hypertensionanddiabetes

Diagnosesofanemia,highbloodpressureanddiabetes mel-lituswerebasedonclinicalcharts,wheneveravailable.The diagnosesforanemiaanddiabeteswerebasedontheresults from automated hematology and biochemistry analyzers, respectively.AnemiawasdefinedaccordingtoWorldHealth Organizationcriteria8asahemoglobinlevel<13g/dLinmen

or<12g/dLinwomen.Thediagnosisofdiabeteswasdefined based onthe currentAmerican DiabetesAssociation(ADA) guidelines,which includeafastingplasma glucoselevelof

≥7.0mmol/L (126mg/dL).9 Hypertension was defined as a

consistent (three or more readings by the physician dur-ing a medical appointment) systolic blood pressure (SBP)

≥140mmHgoradiastolicbloodpressure(DBP)≥90mmHg.10

Procedure

One hundred and seven subjects agreed to complete the Brazilian OlderAmericans ResourcesAnd Services Multidi-mensionalFunctionalAssessmentQuestionnaire(BOMFAQ)7,8

andtheSelf-ReportingQuestionnaire(SRQ-20)9,10;both

inter-views were carried out in person by trained students. Demographicdataregardingthenumberofyearsof school-ingandincomewerealsoobtained.TheBOMFAQconsistsof 15questionsaboutactivitiesofdailyliving(ADL),dividedinto twosub-scales;eightphysicalADL(PADL),andseven instru-mentalADL(IADL).ThePADLincludedgettingintoandoutof bed,eating,combingthehair,walkingonflatsurfaces,having abath/shower,gettingdressed,gettingtothetoiletintimeand cuttingtoenails.TheIADLincludedclimbingstairs(oneflight), takingmedicinesontime,walkingclosetohome,shopping, preparingmeals,gettingoffbusesandcleaningthehouse.11

Thesubjects’responsestotheBOMFAQwereanalyzed accord-ingtotwocriteria:withorwithoutdifficultytocompletethe task.

Statisticalanalysis

Allstatisticaldataanalyseswereperformedusingthe Statis-ticalPackagefortheSocialSciences(SPSS,version21.0;IBM Corp.,2012).TheStudent’st-test,thechi-squaretest,andthe Pearsoncorrelationcoefficientwithalevelofsignificanceof 5%anda95%confidenceinterval(95%CI)wereusedfordata analysis.Atwo-tailedp-value<0.05wasconsidered statisti-callysignificant.

Results

Studypopulation

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Table1–Clinicalcharacteristicsofsubjects.

Characteristic Eldorado Piraporinha p-Valuea

Age(years)mean(range) 61(50–93) 62(50–101) 0.377

Pre-elderlyn(%) 40(41.7) 115(41.5) –

Elderlyn(%) 56(58.3) 162(58.5) –

Gendern(%)

Male 36(37.5) 105(37.9) 0.943

Female 60(62.5) 172(62.1)

Peripheralbloodparametersmean(range)

Erythrocytes(×1012L) 4.63(2.41–5.8) 4.63(3.00–6.79 0.401

Hematocrit(%) 41.3(27.2–51.1) 41.1(25.1–60.9) 0.504

Hemoglobin(g/dL) 13.9(9.2–17.8) 13.7(8.2–20.8) 0.559

Totalleukocytes(×109/L) 6.85(2.6–11.9) 6.1(0.8–16.2) 0.460

Meancorpuscularvolume 89.4(65.6–112.9) 89.4(59.6–101.4) 0.702

MCH(pg/cell) 30.1(20.3–38.2) 30.3(18.5–36.8) 0.249

MCHC(g/dL) 33.6(30.9–36.6) 33.8(13.0–39.5) 0.461

RDW(%) 13.1(10.7–27.0) 12.8(10.1–17.9) 0.151

Platelets(×109/L) 228(130–654) 234(81–454) 0.316

Fastingplasmaglucose 117.8(67–376) 106.14(43–432) 0.06

MCH:meancorpuscularhemoglobin;MCHC:meancorpuscularhemoglobinconcentration;RDW:redcelldistributionwidth. a Student’st-testwasusedforquantitativevariablesandtheChi-squaretestforcategoricalvariables.

Prevalenceofanemia,diabetesandhypertension

The prevalence of anemia in the studied population was approximately11%formenandwomeninbothhealthcare clinics with hemoglobin <10g/dL being found in approxi-mately2%ofthesubjects(Table2).

Approximately 52% of the subjects had diabetes in the Eldoradohealthcareclinicwhichwasasignificantlyhigher frequencywhencomparedtoPiraporinha,wherenearly30% ofthesubjectswerediabetic(p-value=0.0241;Table2).

The frequencies of hypertension were similar in both clinics(70%inEldoradoand81%inPiraporinha)withno sta-tisticallysignificantdifferencebetweengenders(Table2).

Hemoglobinvaluesandage

The Pearson correlation coefficient demonstrated that hemoglobin levels were inversely associated with age

(Figure1).Inaddition,hemoglobinvaluesweresignificantly lowerintheelderlywhencomparedwiththepre-elderlygroup (Figure2).

Assessmentofthedegreeofdependencyandcommon

mentaldisorders

Onehundred andsevensubjectswere assessedusingboth the BOMFAQ and the SRQ-20 instruments to evaluate the degreeofdisability andcommon mentaldisorders, respec-tively. Table 3 shows the sociodemographic data of the sample.

Whenthesubjectswereevaluatedaccordingtotheirlevel ofindependence,thesubjectsfromtheEldoradohealthcare clinicgenerallyreportedhavingmoredifficultiesintwoPADL andtwoIADL;walkingonflatsurfaces(44.1%),gettingdressed (14.2%),gettingoffbuses(40%)andcleaningthehouse(50%) (Table4).Subjectsfrom Eldoradoalsopresentedwithmore

Table2–Prevalenceofanemia,diabetesandhypertension.

Eldorado Piraporinha p-Valuea

Anemia–n(%) 11(11.5) 32(11.6) 0.9802

Male:femaleratio 4:1 11:21 0.9050

Hemoglobin–n(%)

≥10g/dL 94(97.9) 270(97.5) 0.8071

<10g/dL 2(2.1) 7(2.5)

Diabetes–n(%) 25(52.1) 25(30.5) 0.0241

Male:femaleratio 10:15 11:14 0.7

Hypertension–n(%) 45(81.8) 55(69.6) 0.16

Male:femaleratio 14:31 23:32 0.37

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25

20

15

10

5

0

50 60 70 80

Age (years; n=373)

Hemoglobin (g/dL)

Pearson’s correlation P<.0001 r=–0.2551

90 100 110

Figure1–Correlationofhemoglobinvalues(g/dL)withage (years).

physicalsymptomsandemotionaldisorderswhencompared withPiraporinhasubjects(Table5).

Discussion

Thisstudy revealedthatapproximately 11%ofthesubjects of50yearsofageandolderpresentedanemiaaccordingto WHOcriteriainbothhealthcareclinics.Thelowprevalence ofanemiainourcohortcorroboratesotherstudiesthatalso assessedtheprevalenceofanemiaamongfree-livingelderly people;Guralniketal.presenteddataregardingaNorth Amer-icanpopulation,12Saliveetal.reportedontheEpidemiologic

StudyoftheElderly(EPESE)13andInelmenetal.describeddata

inarepresentativeItalianpopulation.14Inthecurrentstudy,

theanemiawasmildinthemajorityoftheanemicsubjects. In this cohort, normocyticanemia was the most common typeofanemia(between54.5%and70%),whichisconsistent withaBrazilianstudythatstudiedfree-livingelderly individ-ualsinsouthernBrazil.15Anemiaofinflammatoryresponseis

mostoftendescribedasanormocyticnormochromicanemia

25

20

15

10

5

0

n=155 Pre-elderly

Mann-Whitney test

Hemoglobin g/dl

P=.001

Elderly n=218

Figure2–Distributionofhemoglobinvalues(g/dL)in pre-elderlyandelderlygroups(horizontallinesindicate medians).

and isusuallymild.16 Theriskfactors linkedtothe

major-ity ofchronicdiseases,suchasdiabetes,havebeen shown toincreaseinflammation,17andinthisstudy,therewerehigh

frequenciesofbothdiabetesandhypertension.Despitehaving observed anegativecorrelationbetween hemoglobinlevels andage,withlowerhemoglobinvaluesintheelderlywhen comparedtothepre-elderlygroup,itisnotbelievedthatthese valuesareduetoage.Thereisabodyofevidencethatsuggests that mostcasesofanemia inolderpeopleare duetopoor healthandshouldpromptfurtherinvestigationsinthe clin-icalpractice,evenwhenthepersonhasnoapparentclinical disease.12,18

Withregardtothehighprevalenceofhypertensioninthe current cohort, the literatureshows that theprevalenceof hypertensionincreaseswithageinadults19andcanreacha

Table3–Sociodemographiccharacteristics.

Eldorado

n(%)

Piraporinha

n(%)

p-Valuea

Gender

Male 5(14.3) 23(31.9)

Female 30(85.7) 49(68.1) 0.05

Education(years)

None 4(11.4) 8(11.1) 0.3

1–3 25(71.4) 38(52.8)

4–7 2(5.7) 10(13.9)

8+ 4(11.5) 16(22.2)

Monthlyincome(R$)b

0–723 15(44.1) 21(30) 0.15

724–2172 19(55.9) 44(62.9)

2173+ 0 5(7.1)

a Chi-squaretest.

b DuringtheperiodofdatacollectiontheminimumBrazilianwagewasapproximatelyR$724.00,andUS$1.00wasapproximatelyequaltoR$

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Table4–Difficultyforperform15activitiesofdailylifebygroup.

Activities Withoutdifficult Withdifficult p-Valuea

Eldorado n(%)

Piraporinha n(%)

Eldorado n(%)

Piraporinha n(%)

Gettingintoandoutofbed 18(51.4) 48(66.8) 17(48.6) 24(33.3) 0.1282

Eating 32(91.4) 70(97.2) 3(8.6) 2(2.8) 0.3275

Combinghair 26(74.3) 63(88.7) 9(25.7) 8(11.3) 0.0566

Walkingonflatsurfaces 19(55.9) 6(88.9) 15(44.1) 8(11.1) 0.0001

Havingabath/shower 30(85.7) 69(95.8) 5(14.3) 3(4.2) 0.1104

Gettingdressed 30(85.7) 70(97.2) 5(14.3) 2(2.8) 0.0366

Gettingtothetoiletintime 30(85.7) 64(88.9) 5(14.3) 8(11.1) 0.754

Cuttingtoenails 18(51.4) 37(51.4) 17(48.6) 35(48.6) 0.9969

Climbingstairs(oneflight) 17(48.6) 44(61.1) 18(51.4) 28(38.9) 0.219

Takingmedicinesontime 28(80.0) 57(85.1) 7(20.0) 10(14.9) 0.5138

Walkingclosetohome 30(85.7) 61(84.7) 5(14.3) 11(15.3) 0.8926

Shopping 26(76.5) 51(89.5) 8(23.5) 6(10.5) 0.0963

Preparingmeals 32(94.1) 48(96.0) 2(5.9) 2(4.0) 1.0

Gettingoffbuses 21(60.0) 62(87.3) 14(40.0) 9(12.7) 0.0013

Cleaningthehouse 17(50.0) 39(81.3) 17(50.0) 9(18.8) 0.0027

a Chi-squaretest.Statisticallysignificancewasdefinedasp-values<0.05.

prevalenceashighas80%.20–23Itisimportanttopointoutthat

hypertensionisindependentlyassociatedwithcardiovascular diseasesintheelderly.

Thisstudyfocusedonadescriptionofthe prevalenceof diseasesrelatedtoelderlyindividualsandtheirqualityoflife. Althoughtherewerenosocialanddemographicdifferences, thestudywasperformedintwocontrastingareasofDiadema. WhilethePiraporinhaclinicislocatedinamoreprivileged area,inthecity center,theEldoradoclinicislocatedinthe pooreroutskirts.Thesubjectsthatliveintheoutskirtshad

significantlylower scoresfortwo PADLandtwo IADLthan thesubjectswholivedinthecitycenter.Subjectsfrom Eldo-radoalsopresentedasignificantlyhigherprevalenceofminor psychiatricdisorders,when comparedtothesubjectsfrom Piraporinha.Moreover,theprevalenceofdiabeteswasmuch higherintheEldoradohealthcareclinic.Theliteratureshows thattheincidenceofdepressionandimpairedcognitive func-tionincreasesinelderlyindividualswithdiabetes.24Moreover,

depressioninelderlypatientswithdiabetesisastrong predic-torofhospitalizationanddeath25;anxietyandstressinthe

Table5–ResultsoftheSRQ-20questionnairebygroup.

Yes No p-Valuea

Eldorado n(%)

Piraporinha n(%)

Eldorado n(%)

Piraporinha n(%)

1.Headaches 12(34.3) 9(12.5) 23(65.7) 63(87.5) 0.0078

2.Poorappetite 14(40.0) 13(18.1) 21(60.0) 59(81.9) 0.0142

3.Sleepingbadly 15(42.9) 29(40.3) 20(57.1) 43(59.7) 0.7992

4.Easilyfrightened 17(48.6) 18(25.0) 18(51.4) 54(75.0) 0.0148

5.Handsshake 9(25.7) 9(12.5) 26(74.3) 63(87.5) 0.0865

6.Feelingnervous,tenseorworried 26(74.3) 41(56.9) 9(25.7) 31(43.1) 0.082

7.Poordigestion 12(34.3) 17(23.6) 23(65.1) 55(76.4) 0.2438

8.Troublethinkingclearly 15(42.9) 8(11.1) 23(57.14) 64(88.9) 0.0002

9.Feelingunhappy 24(68.6) 32(44.4) 11(31.4) 40(55.6) 0.0191

10.Cryingmorethanusual 12(32.3) 19(26.4) 23(65.7) 53(73.6) 0.3982

11.Difficultyinenjoyingdailyactivities 14(40.0) 21(29.17) 21(60.0) 51(70.8) 0.2625

12.Difficultyinmakingdecisions 14(40.0) 21(38.9) 21(60.0) 51(70.8) 0.9121

13.Dailysufferingatwork 11(31.4) 15(20.8) 24(68.6) 57(79.2) 0.2306

14.Unabletoplayausefulroleinlife 14(40.0) 14(19.4) 21(60.0) 58(80.6) 0.0232

15.Lostinterestinthings 20(57.1) 26(36.1) 15(42.9) 46(63.9) 0.0392

16.Feelingthatyouareaworthlessperson 8(22.9) 6(8.3) 27(77.1) 66(91.7) 0.063 17.Thoughtsofendingyourlifehavebeenon

yourmind

6(17.1) 6(8.3) 27(77.1) 66(91.7) 0.2008

18.Feelingtiredallthetime 14(41.2) 16(22.2) 20(58.8) 56(77.8) 0.0432

19.Uncomfortablefeelingsinyourstomach 15(42.9) 23(30.6) 20(57.1) 50(69.4) 0.2094

20.Easilytired 17(48.6) 23(31.9) 18(51.4) 49(68.1) 0.0954

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elderlyareimportanthealthissuesfrequentlyassociatedwith poorerphysicalandemotionalwell-being.26

Conclusion

Regardless of the location of the health care clinic, there areprevalencesofanemia,hypertensionanddiabetesinthe populationsofpre-elderlyandelderlyindividuals.Boththese groups showed degrees ofdependency and impairment of healthstatus.Ourfindingsmightaidpublichealthcare man-agersinthetargetingofstrategiestopromotebetterhealthin theagingpopulation.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

FundingforthisworkwasprovidedbyConselhoNacionalde DesenvolvimentoCientíficoeTecnológico(CNPq).Theauthors would like to thank Raquel Susana Foglio for the English review.

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Imagem

Table 2 – Prevalence of anemia, diabetes and hypertension.
Table 3 – Sociodemographic characteristics.
Table 4 – Difficulty for perform 15 activities of daily life by group.

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