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Yousefi M, Papi S, Abolfathi Momtaz Y, Akbari Kamrani A A, Yousefi M, Fadayevatan R. Non-Communicable Disease Mortality among a Sample of Older People in Iran from 2007 to 2018. Elderly Health Journal. 2021; 7 (1) :45-51
URL: http://ehj.ssu.ac.ir/article-1-228-en.html
Clinical Gerontologist, Vice-Chancellor of Azad University in Oxford (GB) and Dubai (UAE) , reza1092@yahoo.com
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Non-Communicable Disease Mortality among a Sample of Older People in Iran from 2007 to 2018
 
Masood Yousefi 1, Shahab Papi 2, Yadollah Abolfathi Momtaz 1, 3, Ahmad Ali Akbari Kamrani 1, Mahdi Yousefi 4, Reza Fadayevatan *1,5
 
  1. Iranian Research Center on Aging, University of Social Welfare & Rehabilitation Science, Tehran, Iran
  2. Department of Public Health, Faculty of Health, Social Determinant of Health Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
  3. Malaysian Research Institute on Ageing (My Ageing), University Putra Malaysia
  4. Department of Biomedical Engineering, Home Care Research Center, Dezful Branch, Dezful, Iran
  5. Clinical Gerontologist, Vice-Chancellor of Azad University in Oxford (GB) and Dubai (UAE)
Article history
Received 11 Apr 2021
Accepted 31 May 2021 

Introduction:
Increasing age is one of the most important predictors of mortality among aged population. Therefore, determining the causes of death among older people could be imperative. The purpose of this study was to investigate non-communicable disease mortality among a sample of older people in Iran from 2007 to 2018.
 
Methods: This was a retrospective descriptive study that applied census sampling technique to investigate 1202 Medical Records of older adults (60 ≤ years old) died during 2007-2018 at three hospitals of Khuzestan province, Iran. Data analysis was conducted using SPSS version 24 software.
 
Results: The mean age of participants was 77.4 ± 8.38. Of whom 50.7 % were male. The highest number of deaths were related to the internal ward (41.4%), CCU (29.3%) and ICU (25.6%), respectively. In addition, Angina pectoris, Respiratory disease and Cerebrovascular Accident were the most important cause of death among aged population. Also, the history of hospitalization (87.1%) and cardiovascular disease (82.2%), and hypertension (67.8%) were the prominent risk factors for mortality among aged population. According to chi-squared, there was a significant relationship between smoking and death attributed to cardiovascular diseases among older adults.
 
Conclusion: Angina pectoris, Respiratory disease and Cerebrovascular accident diseases are the most important cause of death among older adults. Prevention and screening programs should be implemented to discern and screen these chronic diseases at the early stage among older people.
 
Keywords: Non-Communicable Disease, Mortality, Aged
 
Copyright © 2021 Elderly Health Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cite.
Introduction
 
    Epidemiological transition in developing countries  result in changing the cause of death from infectious to some non-communicable diseases (NCDs), including heart disease, cancer, diabetes, and respiratory disease (1, 2). This shift can be attributed to some achievements in health improvements, such as high rate of vaccination coverage, improved sanitation, access to medical care, and attainment of higher life standards. Furthermore, since the rate of fertility and mortality have been decreasing, the proportion of older people is increasing (3), which can be result in increasing prevalence of chronic NCDs for aging population because the health condition of people would be deteriorated as they get older (4).
    In the definition  of  chronic NCDs, it can be said that any non-communicable condition that is persistent for one year or more and need constant medical care services and/or bring about a huge limitation in activities of daily living (5). In 2016, NCDs were responsible for 73% leading cause of death across the world, and the disability adjusted life year (DALYs) due to NCDs was 59.7 (61.7-7.7%) (6). The percentage of deaths associated with NCDs in low and middle income countries was approximately 80%, which have indicated that mortality distribution is not equally worldwide (6). Also, In Iran, 287000 individuals were killed because of NCDs in 2016 (7). Furthermore, 6.5 million years of life loss (YLLs) and 8.5 million years of DALYs were related to NCDs (7). In Iran, the burden of NCDs among aged population (70+ years old) was account for 90-92% from 1990-2015, which was higher than EMRO region and world estimations (8). According a study in China, the cardiovascular disease will more likely to increase account for 50% between 2010 and 2030 due to aged population growth (9). Recent work by Cheng et al. has examined that deaths attributed to population aging were related to ischemic heart disease and stroke (10). It should be noted that high prevalence of NCDs among aged population may be associated with the existence of known risk factors among this group (11).   
    Although aging can have the predominant role in increasing prevalence of NCDs, the number of risk factors consist unhealthy life style such as tobacco use, excessive use of alcohol, unhealthy diet, and physical inactivity and increased blood pressure (12, 13). The interaction of known risk factors could result in occurrence of NCDs including cancer and cardiovascular disease (14). According to an Iranian national survey in 2014, 7.9% of older adults smoked cigarette, the prevalence of diabetes was 20.5% for men and 23.5% for women, the prevalence of hypertension was reported 47.6% and 52% for men and women, respectively. In terms of nutrition status, 5.5% of older adults were affected by malnutrition and 41.3 % were at the risk of malnutrition and the prevalence of obesity was reported 89.2% and 65.9% for men and women, respectively. Also, 22.5% of older adults did not take part in physical activity (15, 16). Although several previous community-based studies about mortality rate among all age groups (17, 18), were conducted in Iran, none of them have particularly focused on older adult's mortality. Then, development of a national mortality and its related risk factor profile for NCDs among aged population not only could provide predominant information for planning prevention and control activity but also it could predict the burden of disease in future. Therefore, the present study aimed at investigating the trend of NCDS mortality among a sample of older people in Iran from 2007 to 2018.
Methods
Research design
    This study was a retrospective descriptive.  The raw data was obtained from three Hospitals in Khuzestan Province (Shahid Mostafa Khomeini, 17 Shahrivar, and Amiralmomenin) since 2007-2018. This province is located in southwest of Iran and its area is 63,238 km in a subtropical zone (19), and according to last census in 2016, the population of older adults aged 60 and over was 257290 (20). For this survey, 1202 Medical Records (MR) of older adults (60 ≤ years old) who died during 2007-2018 through census sampling technique were retrospectively  reviewed.
Instrumentation
    A researcher-made checklist was used to extract required information from MR, which were including, demographic information, characteristics in relation to death occurrence among older adults in three hospitals (cause of death, time of death, issuance of death certificate, period of hospitalization, death occurrence in hospital wards), and risk factors related to NCDs among older adults (smoking, substance abuse, history of hypertension, diabetes, hyperlipidemia, cardiovascular disease, Pulmonary disease, and history of hospitalization).
Ethical considerations
    Ethical approval was obtained from university of social welfare and rehabilitation sciences, Tehran, Iran (IR.USWR.REC.1398.105). Since the current study was retrospective design, the researcher was cautious to maintain the principals of confidentially and anonymity.
Data analysis
    Descriptive data were generated in the format of percentages for categorical variables, and mean with standard deviation for all variables. Chie-squared was conducted to determine significant relationship among cigarette smoking and all-cause mortality attributed to cardiovascular disease. Data management and analysis were performed using IBM SPSS (2010). 
 
Results
    In the present study, 1202 medical records (men = 603, women = 586) were assessed, the mean age of older adults was 77.42 ± 8.38. In total, 547 of older adults were at the age of 75-84 (old-old). From aspect of marital status, the majority of older people were married (99.1 %, n = 1185). Fifty percent of older adults were retired. Nearly, three in fourth of older adults (70.6%) had no formal education. The majority of our aged population resided at own house (81.5%, n = 887), nine hundred fifty five older people lived in urban region. Fifty percent of the participants had 5-8 children. Table 1 indicates socio-demographic characteristics of subjects in three hospitals.
    In total, a large percentage of deaths were due to Angina pectoris (22.2%, n = 261), Respiratory disease (20.1%, n = 236), Cerebrovascular accident (CVA) (16.3%, n = 192), and Cardiovascular disease (15%, n = 176), respectively. Nearly half of deaths (42.3%, n = 484) were occurred at night. More than half of death certificates (76.8%) were issued at the hospital. In term of period of hospitalization, the longer length of stay in hospital was 3-7 days; the median length of hospital stay was 6.85 ± 7.99.  The percent of mortality at three hospital wards, including internal medicine, coronary care unit (CCU), and intensive care unit (ICU) was high, which were 41.4%, 29.3%, and %25.6 respectively. Table 2 shows characteristics in relation to death occurrence among older adults in three hospitals. Figure 1 shows the cause of death due to non-communicable diseases in aged population.
    Approximately one-fourth of older adults (26.7%, n = 315) smoked. The rate of substance abuse was 3.4% older adults. In total, history of some NCDs, including hypertension, diabetes, hyperlipidemia, cardiovascular disease, and pulmonary disease were 67.8%, 59.5%, 26.3%, 82.2%, and 44.9%, respectively. Eighty-seven percent of older adults with NCDs had history of hospitalization. Table 3 highlights risk factors related to Non-communicable disease among older adults.
 
Discussion
    This retrospective descriptive study was about mortality among a sample of older people in Iran from 2007 to 2018. The mean age of study population was 77.42 ± 8.38, and the majority of deaths occurred in age group of 60-84, which is reflected the prior survey that in late-middle and early-old age pattern of mortality increase (21). A possible explanation for this might be that in early-age the rate of physiological deterioration will be increased because the rate of damage repair declines (21). On the other hand, the mortality rate tend to decreased among oldest ages, this discrepancy may be due to the predominant role of genetic, environmental, and behavioral characteristics among this age group (22). Furthermore, there is less evidence of mortality due to chronic conditions among oldest-old. In fact,  functional limitations are the predominant predictor of mortality at advanced age (23).  
 
Table 1. Socio-demographic characteristics of subjects in three hospitals
% N Variable
35.4 424 Young old Age
45 547 Old-old
19.6 234 Oldest-old
50.7 603 Male Sex
49.3 586 Female
0.4 2 Never married Marital status
99.1 1185 Married
0.5 9 Widow/widower
9.9 112 employed Job
17.8 202 Self-employment
22.2 252 Housekeeper
50.1 568 Retired
70.6 699 No formal education Education
27.1 268 Under diploma
2.37 23 Diploma
81.5 887 Own house Living arrangement
17.9 195 With children
0.6 7 Nursing home
80.3 955 Urban The place of living
19.7 235 Rural
26.4 100 4 ≥ The number of children
50.1 190 5-8
23.5 89 9 ≤
 
 
 
 























 
Table 2. Characteristics in relation to death occurrence among older adults in three hospitals
% N Variable
22.2 261 Angina pectoris Cause of death
20.1 236 Respiratory disease
16.3 192 Cerebrovascular accident
15 176 Cardiovascular disease
10 119 Septicemia
7.63 89 Cancer
3 35 Chronic Kidney Disease
1.7 20 Heart Valve Problem
1 12 Hepatic
1 12 Gastrointestinal Bleeding
0.9 10 Diabetes
0.7 8 Digestive problems
0.2 3 Accident
0.09 1 Alzheimer
0.09 1 Seizure
0.09 1 Hypovolemic Shock
33.6 384 Morning Time of death
24.1 275 Afternoon
42.3 484 Night
23.2 266 Forensic Medicine Center Issuance of death certificate
76.8 882 Hospital
34.2 247 2 ≥ Period  of hospitalization
37.3 269 3-7
28.5 206 8 ≤
0.3 3 Infection Hospital's ward
0.3 4 emergency
3.1 37 Surgery
41.4 494 Internal medicine
29.3 349 CCU
25.6 306 ICU
 
Table 3. Risk factors related to non-communicable disease among older adults
% N Variable
26.7 315 Yes Smoking
73.3 866 No
3.4 36 Yes Substance abuse
96.6 1140 No
67.8 813 Yes History of hypertension
32.2 386 No
59.5 713 Yes History of diabetes
40.5 486 No
26.3 315 Yes History of hyperlipidemia
73.3 884 No
82.2 986 Yes History of cardiovascular disease
17.8 213 No
44.9 538 Yes History of pulmonary disease
55.1 661 No
19 228 Yes History of other non-communicable  disease
81 971 No
87.1 1004 Yes History of hospitalization
12.9 149 No
 
 






















Figure 1. Cause of death due to non-communicable diseases in aged population
 
    Overall, the majority of death caused by NCDs across the world, which is about more than 73% of global death (24). Based on Global Burden of Disease report  in 2017, cardiovascular disease, cancers, respiratory disease are third leading of death among 50-69 and over year-old (24). In contrast, in the current study, Angina pectoris, Respiratory disease, and CVA were the predominate cause of death among aged population. This result may be explained by the fact that racial differences and its attributed risk factors including socioeconomic status, health behavior, health insurance, and health status could have an important role in all-cause of death among older people around the world (25). In the present study, the majority of deaths occurred at night and morning. According to current evidence, 60 percent of deaths occurred between 2 A.M and 8 A.M, it is therefore likely that such connections exist between the time interval between the time of death and find the body the next day, providing uneven health care services between 2 A.M and 8 A.M ,and the influences of circadian rhythms, sleep, and disease processes that may increase the probability of death (26). In our study, the median length of hospital stay was 8 days (range, 0-60), which was consistent with Oruç et al. survey (27, 28).
    The mortality rate among CCU, and ICU wards were high in comparison with other wards of hospital. Within our sample, 41.4% of older patients admitted in internal medicine ward died, we found that much higher values with respect those reported by Simon et al. (29). The mortality rate in ICU was 25.6%, which was lower than 42% total mortality rate indicated in the study conducted by Daubin et al. (30). Nearly 30% of death occurred in coronary care unit that was relatively high as compared to 13% mortality among patient in Canada (31), 7-8% mortality in United States (32). This difference can be


explained in part by the proximity of high rate of mortality due to Angina pectoris and hospitalization in CCU in the current study. One unanticipated finding was that despite cognitive impairment has already been determined as a predictor of mortality among older patients (33), the cause-specific share of deaths caused by it was very low in our study.  
    In addition to NCD smortality, different risk factors for mortality among our sample population were reported, history of hospitalization was a crucial risk factor among older adults, which was consistent with Obiora's study (34). In accordance with previous study, the frailty of hospitalized older individuals could lead to higher mortality rate among this group because these patients have chronic comorbidity and functional disability (35). Furthermore, the History of cardiovascular disease, hypertension, and diabetes could have pivotal risk factors for mortality among older population. High blood pressure  is considered as main risk factor for cardiovascular morbidity and mortality among older population (36), which is in accordance with the result of prior study (37). Hypertension may have relatively impact on mortality among patients with two various chronic diseases (37). In this study, there was a significant relationship among cigarette smoking and all-cause mortality related to cardiovascular disease among our population, which was consistent with other studies in this filed (38-40).
 
Conclusion
    Angina pectoris, Respiratory disease, and CVA diseases were the most important cause of death among older adults. Prevention and screening programs should be implemented to detect and screen these chronic diseases at the early stage among older people.
 
Study limitations
    It is plausible that a number of limitations may have influenced the results obtained. The first is a retrospective design and the fact that all cases were recruited from one single province and related laboratory variables were not taken into account. The second is a real trend of disease- related death and its risk factors were not particularly determined for each year. Therefore, it is recommended that future research should be undertaken in the following areas: 1) the further studies should be validated by a larger sample size among all provinces across the country so that provide vital information to compare the all- cause of death among older adults based on diverse cultural and ethnicity background. 2) The future prospective cohort studies are needed to estimate social and health determinants related to all- cause of death in older people.    
 
Acknowledgement
    We would like to thank the managements of three hospitals in Khuzestan province without whose help this work would never have been possible.    
 
Conflict of interest
    All authors have not declared conflict of interest in this project.
 
Funding 
    This project was supported by university of social welfare and rehabilitation sciences, Tehran, Iran.
 
Authors' contributions
    All authors have participated in the design and implementation of the study. All authors have participated to draft or modify the manuscript, read and approved the final version of the article.
 
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Type of Study: Research | Subject: General
Received: 2021/04/11 | Accepted: 2021/05/31 | Published: 2021/06/27

References
1. Wandera SO, Kwagala B, Ntozi J. Prevalence and risk factors for self-reported non-communicable diseases among older Ugandans: a cross-sectional study. Global Health Action. 2015; 8(1): 1-10.
2. Papi S, Karimi Z, Zilaee M, Shahry P. Malnutrition and its relation to general health and multimorbidity in the older people. Journal of Holistic Nursing and Midwifery. 2019; 29(4): 228-35. [Persian]
3. Yang G, Kong L, Zhao W, Wan X, Zhai Y, Chen L, et al. Health system reform in China 3 emergence of chronic non-communicable diseases in China. The Lancet. 2008; 11: 42-50.
4. Phaswana-Mafuya N, Peltzer K, Chirinda W, Musekiwa A, Kose Z, Hoosain E, et al. Self-reported prevalence of chronic non-communicable diseases and associated factors among older adults in South Africa. Global Health Action. 2013; 6(1): 1-8.
5. Kanitkar S, Kalyan M, Gaikwad A, Deshmukh S, Saha R. Prevalence of non-communicable diseases in elderly. Journal of the Indian Academy of Geriatrics. 2018; 14(3): 108-12.
6. Khosravi Shadmani F, Farzadfar F, Larijani B, Mirzaei M, Haghdoost AA. Trend and projection of mortality rate due to non-communicable diseases in Iran: a modeling study. PloS One. 2019; 14(2): 1-18.
7. Khorrami Z, Rezapour M, Etemad K, Yarahmadi S, Khodakarim S, Hezaveh AM, et al. The patterns of non-communicable disease multimorbidity in Iran: a multilevel analysis. Scientific Reports. 2020; 10(1): 1-11.
8. Emamgholipour S. The Burden of elderly’s non-communicable diseases in Iran. Evidence Based Health Policy, Management and Economics. 2017; 1(3): 128-30. [Persian]
9. Moran A, Gu D, Zhao D, Coxson P, Wang YC, Chen C-S, et al. Future cardiovascular disease in China: Markov model and risk factor scenario projections from the coronary heart disease policy model–China. Circulation: Cardiovascular Quality and Outcomes. 2010; 3(3): 243-52.
10. Cheng X, Yang Y, Schwebel DC, Liu Z, Li L, Cheng P, et al. Population ageing and mortality during 1990–2017: a global decomposition analysis. PloS Medicine. 2020; 17(6):1-17.
11. Christian AK, Sanuade OA, Okyere MA, Adjaye-Gbewonyo K. Social capital is associated with improved subjective well-being of older adults with chronic non-communicable disease in six low-and middle-income countries. Globalization and Health. 2020; 16(1): 1-11.
12. Ghimire S, Mishra SR, Baral BK, Dhimal M, Callahan KE, Bista B, et al. Non-communicable disease risk factors among older adults aged 60–69 years in Nepal: findings from the STEPS survey 2013. Journal of Human Hypertension. 2019; 33(8): 602-12.
13. Papi S, Zanjari N, Karimi Z, Motamedi SV, Fadayevatan R. The role of health-promoting lifestyle in predicting cognitive status of older clergymen. Salmand: Iranian Journal of Ageing. 2021; 15(4): 472-83. [Persian]
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