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The health status of community based elderly in the United Arab Emirates
Arch. Gerontol. Geriatr. 37 (2003) 1 /12 www.elsevier.com/locate/archger
The health status of community based elderly in the United Arab Emirates Stephen Andrew Margolis *, Tom Carter, Earl V. Dunn, Richard Lewis Reed Department of Family Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, POB 17666, Al Ain, United Arab Emirates Received 3 July 2002; received in revised form 3 December 2002; accepted 5 December 2002
Abstract Little is known about the elderly in the United Arab Emirates (UAE), a country with both developing country features (high fertility rate, few elderly, strong traditional culture) and developed country characteristics (high-income economy, urbanized population, high growth rate of people aged 65/ years). In this cross sectional survey of 184 randomly chosen community based people aged 65/ years, the mean age was 71.89/6.3, 52% were female, 76% were married, 11% were literate, 89% lived in multi-generational households, 85% lived in households with servants and 15% had a personal servant. Health status was largely independent of age. Compared with the ambulatory aged USA population, the rate of functional independence in activities of daily living (ADL) (83%) was similar and chronic medical problems were less frequent, with the notable exception of diabetes (37% UAE, 10 / 12% USA). Almost all (95%) participants in this study rated their health as satisfactory or higher, compared with 82% of US ambulatory elderly. There appeared to be a significant under-diagnosis of psychological problems. In the presence of a high regard for traditional values, close family ties, universal practice of religion and high economic resources, the elderly in the UAE have a high level of health, which they maintain into their later years. There may be a need to substantially increase health care resources for aged care in the near future due to the high prevalence of diabetes, amount of hidden psychological morbidity and known demographic trends. Encouraging families to continue to provide home based long-term care may minimize the need for government intervention in this area. # 2003 Elsevier Science Ireland Ltd. All rights reserved.
* Corresponding author. Tel.: /97-1-3-7039655; fax: /97-1-3-7672022. E-mail address: [email protected] (S.A. Margolis). 0167-4943/03/$ - see front matter # 2003 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0167-4943(02)00174-7
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Keywords: Aged care; Middle East; Health status; Ambulatory care
1. Introduction Since Omran (1971) first described the concept of epidemiological transition, the global population pyramid has changed from a wide base/narrow peak to a more barrel shaped form. Following industrialization and modernization, fertility rates decrease, infectious disease becomes less frequent, chronic illnesses become predominant, and mortality rates fall (Social Development and Aging: Crisis or Opportunity, 2000; Executive Summary, 2002). This process of ‘demographic aging’, results in the proportion of aged people (i.e. those aged 65/ years old) in the population increasing over time (Dictionary of Demographic and Reproductive Health Terminology, 1999). Although in the 1960s, most elderly people lived in the developed world, by 2025, 70% of the 1.2 billion aged people will be living in developing countries (Social Development and Aging: Crisis or Opportunity, 2000). As the number of older people continues to climb, health planners, policy makers, decision makers and health care workers will need to re-orientate their thinking to incorporate care of the elderly in their wider focus (Andrews, 1987). In particular, epidemiological research is a key component in planning for future change and the associated impact on health, social and economic systems, so that proactive planning and infrastructure development can occur (Health of Older Persons, 1998; GutierrezRobeldo, 2002). The United Arab Emirates (UAE) is an unusual environment in which, to examine demographic aging as features of both developing and developed countries, sit side by side. Traditional life and culture remain powerful forces in this nation of approximately 2.9 million people (World Development Indicators, 2002), located on the Arabian Gulf. Little had changed over the last 1000 years, until oil was discovered in 1959. Only then did modernization and development begin, which included the establishment of the first medical services and secular schools. Emirati people, citizens of the UAE, now comprise approximately 35% of the population, the remainder being predominantly expatriate guest workers (World Fact Book, 2002). In common with other developing countries, the fertility rate is high (4.85 children per Emirati woman; Al-Qassimi and Farid, 1997) and the proportion of the population aged 65/ years old is quite low (1.1%) with an age dependency ratio (dependents as a proportion of working age population) of 0.4, equal to the lowest in the world (World Development Indicators, 2002). In contrast to developing countries, the UAE demonstrated many features of a developed nation: the gross national product (GNP) per capita is high (US$ 17 870 in 1998, ranking 17th after USA, Canada, Western European countries, Japan, Hong Kong, Australia and Singapore) (World Development Indicators, 2002) and the population is highly urbanized with only 21% living in rural areas (Health Status Indicators, 2002). This study was performed in Al Ain. This inland regional city and surrounding district had an estimated population in 1998 of 341 300 of whom an estimated 1% were aged above 65 (Noor, 1998). With a predicted average annual growth rate in the
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UAE for those aged 65/ years of 10.3 (1999 /2025), by far the highest in the world (World Development Indicators, 2002), addressing the future needs of the aging population of the UAE is becoming more urgent. As a first step, this study aimed to establish the health status of community-based elderly. We hypothesized that the elderly in this community would be similar to that found in the USA, a high income, developed country because of the economic similarities having a greater influence on health outcomes than socio-cultural differences.
2. Materials and methods 2.1. Sample All people resident in the UAE are recorded in the Health Card database, a governmental listing maintained by the Ministry of Health. In the absence of addresses being recorded in the database, only those with a telephone number recorded in the database were included in the sample. This was stratified by age into those aged 65/74 and those aged 75/ years. Each group was randomly ordered by use of a random number table. The first 160 people of the 65/74 years old group and the first 40 people in the 75/ group, were contacted by telephone and asked if they would like to participate. 2.2. Measurement instruments for the health assessment A series of demographic, social, health and clinical data were collected by interviewer administered questionnaires and limited examination by trained bilingual field workers who visited the subjects in their homes. This was conducted in Arabic, the first language of participants and the field workers. Questionnaires in English were translated into Arabic. These translations were verified by backtranslation and any areas of disagreement were resolved by discussion between both translators. The items assessed were: 1) Demographic: age, sex, nationality, marital status, number of wives per husband, spouse nationality, number of living children. 2) Social: literacy, smoking, domestic living arrangements. 3) Health: a) Self-view of health: each participant was asked, ‘Do you view your health as satisfactory, poor or high?’. b) Anthropometrics: weight was measured using the Tanita model HP309 scale and height was measured with the Seca model 214 Road Rod. Body mass index (BMI) was calculated (kg/m2), with those above 30 classified as obese. The percentage of body fat was estimated by a bioelectric impedance meter (Kotler et al., 1996), the Quantum 2, manufactured by RJL Systems, using proprietary equations supplied by the manufacturer.
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c)
d)
e)
f)
g)
Psychological: this was measured by the Hospital Anxiety and Depression Scale, an outpatient questionnaire scale whose Arabic version has been validated in this community (Zigmond and Snaith, 1983; El-Rufaie and Absood, 1995). A positive result in this screening test, suggests a strong likelihood of a clinical diagnosis of anxiety or depression. Nutritional: this was assessed using the Mini-Nutritional Assessment, a validated scale, which combines questionnaire and measured cognitive and anthropometrical data (Vellas et al., 1999). Those with a score below 24 were classified as having decreased nutrition. Cognitive: short term memory and orientation to place were tested as they have been shown to be a reliable indicators of cognitive function, especially in the presence of low levels of literacy (Tierney et al., 2000). Functional: dependency status in each of eight domains of physical activities of daily living (ADL-8) was assessed by asking the person or the carer, rather than direct observation. The domains measured were: bathing, dressing/undressing, personal grooming, toileting, continence, transferring, walking and eating. Ability to take medications was assessed by verbal reporting. Physical strength: handgrip strength, one aspect of physical strength, was measured with the Jamar# hand dynamometer, according to the protocol suggested by the manufacturer (Robertson et al., 1993). Low grip strength was defined as being below the 25th quartile for each sex.
Following the assessment in the subjects’ home, the second author abstracted the participants’ medical records held at the Primary Health Care (PHC) center which each participant nominated as providing their primary care services. Those subjects, who had attended at the center or by home visit, within the prior 24 months from the day of their participation in this study, were included. This included visits to the clinic and home visits from the staff attached to these clinics. The weighted index of co-morbidity, an index of clinical ill health determined by diagnosis, was calculated from the abstracted data (Charlson et al., 1987). 2.3. Analysis methodology The Statistical Package for the Social Sciences was used (SPSS, 2001). Simple frequency analysis was used to describe demographics and health status. Comparative statistics were calculated using chi-square (x2) analysis or independent sample t test. Continuous variables, which did not display normal distributions, were analyzed by Mann /Whitney U -test. Multinomial logistic regression was performed. The level of statistical significance was defined as P B/0.05. 2.4. Approval by institutional review board The UAE University Faculty of Medicine and Health Sciences Research Ethics Committee and the Ministry of Health Research Review Committee at Tawam
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Hospital, both of which comply with the ethical rules for human experimentation that are stated in the Declaration of Helsinki, approved the project.
3. Results Initial funding in 1999, provided for 140 subjects to be contacted, of which 96 people aged 65/74 years and 36 people aged 75/ years participated. The results of a different analysis involving this group have been described in a previous report (Margolis et al., 2003). Additional funding in 2002, allowed an additional 60 subjects to be contacted of which an additional 49 people aged 65 /74 years and three people aged 75/ years participated. The mean age9/standard deviation (S.D.) of all participants was 71.89/6.3, with a female to male ratio of 1.07. All 100% were practicing Muslims and spoke Arabic as their first language. All were citizens of an Arabic country, Iran or Sudan, with 73 (82%) men and 63 (66%) women being Emirati citizens. The social and demographic data are detailed in Table 1. For married men, 69 (83%) had one wife at the time of the study, while seven (8%) had two and seven (8%) had three. Of the 57 women who were married, only two were part of polygamous marriages, being the first of two wives. Table 1 Social and demographic data
Female Emirati nationality Marital status Married Widow Divorced Literate (able to read and write) Smoker Never Previously Currently Live in multi-generational household Presence of servant in the household Presence of personal servant
Number of living children Number of residents in house Number of residents per household servant (if servant present)
All n
(%)
n /184 95 136
52 74
140 35 9 21
76 19 5 11
146 30 8 163 157 27 Mean9/S.D.
79 16 4 89 85 15
6.09/3.8 12.39/6.8 7.59/4.9
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Self view of health Satisfactory or higher Unsatisfactory ADL-8a Independent Partially dependent Dependent Ability to take medicines Independent Partially dependent Dependent Short term memory Intact Remember two of three Remember one of three Remember zero of three Orientation to place Anxiety: positive screening test Depression: positive screening test Nutrition Normal Decreased Pressure ulcers present Uses/three different medications/day Obesity (BMI]/30) n BMI % Body fat Nutrition scoreb Hand grip strength (males) Hand grip strength (females) Systolic BP Diastolic BP a b
174 169 169 86 93 183 183
n /174 166 8 n /184 153 22 9
(%) 95 5
151 20 13 n /183
82 11 7
125 32 19 7 174 n /174 13 n /173 31 n /169 133 36 n /184 5 53 n /174 53 Mean9/S.D.
68 17 10 4 95
83 12 5
7 18 79 21 3 29 30
27.79/5.5 29.89/12.4 25.29/3.3 26.69/8.3 20.59/7.7 140.99/21.8 80.79/9.7
Activities of daily living: eight domains measured. Nutrition index (Vellas et al., 1999).
The Health status of participants is detailed in Table 2. As not all participants answered every question or participated in every component of the examination, the numbers of participants per item is detailed. Using multiple logistic regression, there was an association between independence in ADL and three of the measured variables: screening negative for depression (odds ratio 4.39, 95% confidence intervals 1.62 /11.95, P /0.004), normal nutritional status (odds ratio 8.00, 95%
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confidence intervals 3.17 /20.08, P B/0.001) and absence of a household servant (odds ratio 4.44, 95% confidence intervals 1.24 /15.95, P /0.022). Comparisons with USA normative data (Kramarow et al., 1999) regarding physical function are detailed in Table 3. The clinical status of the 130 participants who had attended a PHC center within 24 months prior to the date of assessment is detailed in Table 4. Comparisons with USA (Kramarow et al., 1999) normative data are also included. Utilizing logistic regression, no statistically significant association existed between attending a PHC and all measured variables, suggesting the PHC data was representative of the entire population studied. There was no statistically significant variation in disease frequency between the sexes or between those aged 65 and 74 years and those aged 75/ years. The PHC services were utilized by 71% of the aged. The average number of visits per year was 9.69/10.7 (median /5.5), while the average number of months since the last visit prior to the study assessment was 2.69/5.0 (median / 0.56). In comparison, ambulatory people aged 65/ in the USA visited their doctor in an office environment on average, only 6.9 times per year (Kramarow et al., 1999). Diabetes was recorded as a diagnosis in 37% of the 130 aged people who attended the PHC. As has been described in other populations, those with diabetes had a significantly lower level of nutrition compared with their non-diabetic counterparts (24.29/3.8 diabetics, 26.19/2.8 non diabetics; P /0.004 by Mann/Whitney U -test) (Turnbull and Sinclair, 2002). Logistic regression analysis of screening positive for depression showed three associations: dependent in ADL (odds ratio 3.91, 95% confidence intervals 1.49 / 10.20, P /0.006), poor self-view of health (odds ratio 10.49, 95% confidence intervals 1.72 /64.10, P /0.011) and absence of a household servant (odds ratio 3.62, 95% confidence intervals 1.17 /11.22, P /0.026). No variable had a statistically significant association with screening positive for anxiety. Of those who attended the PHC, there was a positive screen for anxiety in six people and a positive screen for depression in 21. Nevertheless, no person had a PHC recorded diagnosis of anxiety or depression, nor was there was a correlation between a positive screening test for depression and the PHC recorded diagnosis of neurological disease or dementia. Association between sex and measured variables is displayed in Table 5. Only two women had ever smoked and of these, only one continued to do so. Personal Table 3 Functional and cognitive status (aged 70/) UAE study
USA
Male (%)
Female (%)
Male (%)
Female (%)
17.5
16.6
22.2
8.8
7.1
9.9
ADL: of the domains measured, required assistance or was 22.0 dependent in at least one ADL: of the domains measured, was dependent in at least one 10.0 Comparison with USA normative data (Kramarow et al., 1999).
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Table 4 Clinical Status of those attending a PHC centre Documented illness
Self reported illness, ambulatory population
UAE study (n /130)a
Aged 65/ years, USA (Kramarow et al., 1999)
Male (%) Female (%) Male (n /66) (n /64) (%)
Female (%)
Diagnosis Arthritis Diabetes Hypertension Hyperlipidemia Heart disease Respiratory disease Peptic disease Dementia Cerebrovascular disease Neurological disase (excluding dementia) Diabetic end-organ disease Cancer
30 23 17 9 14 11 11 3 0 2 1 1
45 35 26 14 21 17 17 5 0 3 2 2
28 25 26 13 7 7 5 3 4 1 2 0
44 39 41 20 11 11 8 5 6 2 3 0
49.5 11.6 31.5
63.3 10.4 39.6
30.0 11.0
24.1 10.3
10.4
7.6
6.0
2.3
Weighted index co-morbidity 0 1 2 3 4 5 Average
30 30 3 3 0 0 0.68
45 45 5 5 0 0
35 22 1 4 1 1 0.70
55 34 2 6 2 2
Within 24 months of participating in this study. Comparison with Normative data USA. a No statistically significance between males and females for any of these variables.
Table 5 Statistically significant associations between measured variables and being male
Normal cognition Married Emirati citizen Not Having a personal servant Ever having smoked Multiple logistic regression.
Odds ratio
95% confidence intervals
P value
3.36 6.49 2.56 3.98 35.97
8.26 19.42 6.58 1.09 185.19
0.008 0.001 0.040 0.037 B/0.001
1.37 2.16 1.05 14.58 6.99
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servants were in the service of 19 (20%) of women but only 8 (9%) of men. Normal cognitive function was present in 70 (82%) of men, but only 55 (60%) of women. The only statistically significant association found by logistic regression between all measured variables and age group was between those aged 75/ years and poor self view of health (odds ratio 7.58, 95% confidence intervals 1.71 /33.33, P /0.008). Two of the measured variables demonstrated a statistically significant association, using multiple logistic regression, with satisfactory or higher self view of health: independence in ADL (odds ratio 37.486, 95% confidence intervals 3.964 /354.514, P /0.002) and screening negative for depression (odds ratio 10.24, 95% confidence intervals 1.53 /68.49, P /0.016).
4. Discussion This study has demonstrated that aged people in the UAE have characteristics of both developing and developed countries. In common with other traditional societies in developing countries, this study found a high rate of marriage (Cattell, 1997), a low level of literacy (Lloyd-Sherlock, 2000), large numbers of offspring and that most people live in multi-generational households (Hashimoto, 1991). Yet, in contradistinction, the wealth of this society is reflected by 85% of those studied living in households with servants and 15% having a personal servant. The people in this study demonstrated similar levels of functional capacity and lower levels of chronic illness, compared with their US counterparts with the exception of diabetes. This suggests their overall health status may be similar or higher. The absence of progression of ill health with age in the study group and the similarity with US normative data suggests that the ‘old /old’ are in extremely good health, especially considering health facilities only began in the 1960s and people now entering old age are generally in better health and more able than those of earlier generations (Health of Older Persons, 1998). Another consideration is that very few elderly in the UAE reside in institutionalized care facilities and those that do are severely disabled (Margolis and Reed, 2001). Hence, in the UAE, those people with lesser degrees of impairment remain in the community and reflect on the community derived data, while in the US, community based data excludes these people. This further suggests that the UAE aged are in very good health. An alternative explanation is that only ‘survivors’ are present in the ‘old /old’ group and represent a different cohort of people, who were hardier than their younger counterparts. If this later explanation were true, then the expectation would be for the health of the younger aged to deteriorate as they become older. When combined with increased longevity, the result may be longer periods of disability and dependence (Gutierrez-Robeldo, 2002) and thus, require more health care services than the ‘old /old’ currently utilize. Combined with the projected average annual growth rate in the UAE for those aged 65/ years of 10.3% (World Development Indicators, 2002), this would result in an exponential increase in health care services requirements and health care costs.
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Self-view of health has been consistently found to be a valid predictor of mortality, although the explanation is somewhat uncertain (Idler and Benyamini, 1997). Almost all (95%) participants in this study rated their health as satisfactory or higher, while only 90.5% of Singaporean (Chan et al., 1998), 82% of US (Kramarow et al., 1999), 64/69% of Thai elderly (aged 70/) (Zimmer and Amornsirisomboon, 2001) and 79.6% of Spanish (Damian et al., 1999) ambulatory elderly were able to do so. There were also a lower number of statistically significant variables which correlated with decreased self-view of health, (depression and loss of function), compared the number of variables reported in studies conducted in Singapore, Spain and Thailand. Perhaps, the UAE result reflects their high level of health and an ability to recognize this. Alternatively, as the UAE elderly spent their formative years in a period of considerable hardship, they may have lower expectations than older people elsewhere. However, as the Thai elderly, whose formative years may have presented similar hardship, have lower self-view of health, this appears less likely. The relationship between loss of functional independence and presence of a household servant suggests that families may be providing carers for their elderly from the family budget. The combination of the tradition of children caring for their elderly with the economic means to fund household staff, suggests that the UAE may be able to avoid the experience of other nations, were large government outlays are required in the short and medium term to provide resources to maintain the aged in the community. Hence, the very low rate of institutionalized care for infirm elderly could remain unchanged. This study has demonstrated a high prevalence rate of diagnosed diabetes (37%). The UAE has already surpassed the high rate of diabetes projected for developing countries by the year 2020 (Gutierrez-Robeldo, 2002), suggesting rates may continue to rise over the next decade. Hence, provision of diabetic care appears a major issue for health care planning that needs to be addressed. The very low level of diagnosis and treatment of psychological disorders in this community has been previously described (Margolis et al., 2002). This study found that no participant who screened positive for anxiety or depression had this diagnosis recorded in their PHC records. Although the screening test is not a conclusive diagnosis, it seems unlikely that all were false positives. Hence, there appears to be a significant group of people with hidden psychological morbidity.
5. Conclusion In the presence of a high regard for traditional values, close family ties, universal practice of religion and high economic resources, the elderly in the UAE have a high level of health, which they maintain into their later years and 95% view their own health to be satisfactory or better. There may be a need to substantially increase in health care resources for aged care in the near future due to a combination of high growth rate of number of older people, high prevalence of diabetes and hidden
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psychological morbidity. Encouraging families to continue to fund carers within the home may minimize the need for government intervention in this area.
Acknowledgements The authors gratefully acknowledge funding for this study provided by the Faculty of Medicine and Health Sciences, UAE University. Permission was granted to use the Arabic Version of the Hospital Anxiety and Depression scale by the copyright holder, Nfer /Nelson Publishing Company, Windsor, UK.
References Al-Qassimi, S., Farid, S. (Eds.), Reproductive Patterns and Child Survival in the United Arab Emirates. United Arab Emirates Ministry of Health, Abu Dhabi 1997. Andrews, G.R., 1987. Ageing in the developing countries of Asia and the Pacific-implications for health care. Ann. Acad. Med. Singapore 16, 3 /10. Cattell, M., 1997. African widows, culture and social change: case studies from Kenya. In: Sokolovsky, J. (Ed.), The Cultural Context of Aging. Bergin and Garvey, Westport, pp. 71 /98. Chan, K.M., Pang, W.S., Ee, C.H., Ding, Y.Y., Choo, P., 1998. Self-perception of health among elderly community dwellers in Singapore. Ann. Acad. Med. Singapore 27, 461 /467. Charlson, M.E., Pompei, P., Ales, K.L., MacKenzie, C.R., 1987. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J. Chronic Dis. 40, 373 /383. Damian, J., Ruigomez, A., Pastor, V., Martin-Moreno, J.M., 1999. Determinants of self assessed health among Spanish older people living at home. J. Epidemiol. Community Health 53, 412 /416. Dictionary of Demographic and Reproductive Health Terminology, 1999. Population Information Network, United Nations, New York. El-Rufaie, O.E., Absood, G.H., 1995. Retesting the validity of the Arabic version of the hospital anxiety and depression (HAD) scale in primary health care. Soc. Psychiatry Psychiatr. Epidemiol. 30, 26 /31. Executive Summary, 2002. World Population Aging, 1950 /2050. Population Division, DESA, United Nations, New York. Gutierrez-Robeldo, L.M., 2002. Looking at the future of geriatric care in developing countries. J. Gerontol. 57A, M162 /167. Hashimoto, A., 1991. Living arrangements of the aged in seven countries: a preliminary analysis. J. Crosscultural Gerontol. 6, 359 /382. Health of Older Persons, 1998. 122nd meeting, Executive Committee of the Directing Council. Pan American Health Organization, World Health Organization. Health Status Indicators, 2002. World Health Organization Regional Office for the Eastern Mediterranean, Cairo. Idler, E.L., Benyamini, Y., 1997. Self-rated health and mortality: a review of 27 community studies. J. Health Soc. Behav. 38, 21 /37. Kotler, D.P., Burastero, S., Wang, J., Pierson, R.N., Jr, 1996. Prediction of body cell mass, fat-free mass, and total body water with bioelectrical impedance analysis: effects of race, sex, and disease. Am. J. Clin. Nutr. 64, 489S /497S. Kramarow, E., Lentzner, H., Rooks, R., Weeks, J., Saydah, S., 1999. Health and Aging Chartbook. National Center for Health Statistics, Hyattsville. Lloyd-Sherlock, P., 2000. Population ageing in developed and developing regions: implications for health policy. Soc. Sci. Med. 51, 887 /895. Margolis, S.A., Reed, R.L., 2001. Institutionalized older adults in a health district in the United Arab Emirates: health status and utilization rate. Gerontology 47, 161 /167.
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S.A. Margolis et al. / Arch. Gerontol. Geriatr. 37 (2003) 1 /12
Margolis, S., Carter, T., Reed, R., 2002. The low usage of psychotropic medication and high level of appropriate prescribing experienced by older people in the United Arab Emirates: a country with a newly developed economy. Arch. Gerontol. Geriatr. 35, 35 /44. Margolis, S.A., Carter, T., Dunn, E.V., Reed, R.L., 2003. Validation of additional domains in activities of daily living, culturally appropriate for Muslims. Gerontology 49, 61 /65. Noor, A.M.M. (Ed.), Annual Report. Preventative Medicine Department, Ministry of Health, United Arab Emirates, Abu Dhabi 1998. Omran, A., 1971. The epidemiological transition. A theory of the epidemiology of population change. Milbank Mem Fund Q. 49, 509 /538. Robertson, L.D., Mullinax, C.M., Brodowicz, G.R., Miller, R.A., Swafford, A.R., 1993. The relationship between two power-grip testing devices and their utility in physical capacity evaluations. J. Hand Ther. 6, 194 /201. Social Development and Aging: Crisis or Opportunity, 2000. World Health Organization, Geneva. SPSS for Windows Release 11.0.0, 2001. SPSS Inc, Chicago. Tierney, M.C., Szalai, J.P., Dunn, E., Geslani, D., McDowell, I., 2000. Prediction of probable Alzheimer disease in patients with symptoms suggestive of memory impairment. Value of the mini-mental state examination. Arch. Fam. Med. 9, 527 /532. Turnbull, P.J., Sinclair, A.J., 2002. Evaluation of nutritional status and its relationship with functional status in older citizens with diabetes mellitus using the mini nutritional assessment (MNA) tool. A preliminary investigation. J. Nutr. Health Aging. 6, 116 /120. Vellas, B., Guigoz, Y., Garry, P.J., Nourhashemi, F., Bennahum, D., Lauque, S., Albarede, J.L., 1999. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 15, 116 /122. World Development Indicators, 2002. World Bank, Washington, DC. World Fact Book, 2002. Office of Public Affairs, Central Intelligence Agency, Washington, DC. Zigmond, A.S., Snaith, R.P., 1983. The hospital anxiety and depression scale. Acta. Psychiatr. Scand. 67, 361 /370. Zimmer, Z., Amornsirisomboon, P., 2001. Socioeconomic status and health among older adults in Thailand: an examination using multiple indicators. Soc. Sci. Med. 52, 1297 /1311.
The health status of community based elderly in the United Arab Emirates Stephen Andrew Margolis *, Tom Carter, Earl V. Dunn, Richard Lewis Reed Department of Family Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, POB 17666, Al Ain, United Arab Emirates Received 3 July 2002; received in revised form 3 December 2002; accepted 5 December 2002
Abstract Little is known about the elderly in the United Arab Emirates (UAE), a country with both developing country features (high fertility rate, few elderly, strong traditional culture) and developed country characteristics (high-income economy, urbanized population, high growth rate of people aged 65/ years). In this cross sectional survey of 184 randomly chosen community based people aged 65/ years, the mean age was 71.89/6.3, 52% were female, 76% were married, 11% were literate, 89% lived in multi-generational households, 85% lived in households with servants and 15% had a personal servant. Health status was largely independent of age. Compared with the ambulatory aged USA population, the rate of functional independence in activities of daily living (ADL) (83%) was similar and chronic medical problems were less frequent, with the notable exception of diabetes (37% UAE, 10 / 12% USA). Almost all (95%) participants in this study rated their health as satisfactory or higher, compared with 82% of US ambulatory elderly. There appeared to be a significant under-diagnosis of psychological problems. In the presence of a high regard for traditional values, close family ties, universal practice of religion and high economic resources, the elderly in the UAE have a high level of health, which they maintain into their later years. There may be a need to substantially increase health care resources for aged care in the near future due to the high prevalence of diabetes, amount of hidden psychological morbidity and known demographic trends. Encouraging families to continue to provide home based long-term care may minimize the need for government intervention in this area. # 2003 Elsevier Science Ireland Ltd. All rights reserved.
* Corresponding author. Tel.: /97-1-3-7039655; fax: /97-1-3-7672022. E-mail address: [email protected] (S.A. Margolis). 0167-4943/03/$ - see front matter # 2003 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0167-4943(02)00174-7
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Keywords: Aged care; Middle East; Health status; Ambulatory care
1. Introduction Since Omran (1971) first described the concept of epidemiological transition, the global population pyramid has changed from a wide base/narrow peak to a more barrel shaped form. Following industrialization and modernization, fertility rates decrease, infectious disease becomes less frequent, chronic illnesses become predominant, and mortality rates fall (Social Development and Aging: Crisis or Opportunity, 2000; Executive Summary, 2002). This process of ‘demographic aging’, results in the proportion of aged people (i.e. those aged 65/ years old) in the population increasing over time (Dictionary of Demographic and Reproductive Health Terminology, 1999). Although in the 1960s, most elderly people lived in the developed world, by 2025, 70% of the 1.2 billion aged people will be living in developing countries (Social Development and Aging: Crisis or Opportunity, 2000). As the number of older people continues to climb, health planners, policy makers, decision makers and health care workers will need to re-orientate their thinking to incorporate care of the elderly in their wider focus (Andrews, 1987). In particular, epidemiological research is a key component in planning for future change and the associated impact on health, social and economic systems, so that proactive planning and infrastructure development can occur (Health of Older Persons, 1998; GutierrezRobeldo, 2002). The United Arab Emirates (UAE) is an unusual environment in which, to examine demographic aging as features of both developing and developed countries, sit side by side. Traditional life and culture remain powerful forces in this nation of approximately 2.9 million people (World Development Indicators, 2002), located on the Arabian Gulf. Little had changed over the last 1000 years, until oil was discovered in 1959. Only then did modernization and development begin, which included the establishment of the first medical services and secular schools. Emirati people, citizens of the UAE, now comprise approximately 35% of the population, the remainder being predominantly expatriate guest workers (World Fact Book, 2002). In common with other developing countries, the fertility rate is high (4.85 children per Emirati woman; Al-Qassimi and Farid, 1997) and the proportion of the population aged 65/ years old is quite low (1.1%) with an age dependency ratio (dependents as a proportion of working age population) of 0.4, equal to the lowest in the world (World Development Indicators, 2002). In contrast to developing countries, the UAE demonstrated many features of a developed nation: the gross national product (GNP) per capita is high (US$ 17 870 in 1998, ranking 17th after USA, Canada, Western European countries, Japan, Hong Kong, Australia and Singapore) (World Development Indicators, 2002) and the population is highly urbanized with only 21% living in rural areas (Health Status Indicators, 2002). This study was performed in Al Ain. This inland regional city and surrounding district had an estimated population in 1998 of 341 300 of whom an estimated 1% were aged above 65 (Noor, 1998). With a predicted average annual growth rate in the
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UAE for those aged 65/ years of 10.3 (1999 /2025), by far the highest in the world (World Development Indicators, 2002), addressing the future needs of the aging population of the UAE is becoming more urgent. As a first step, this study aimed to establish the health status of community-based elderly. We hypothesized that the elderly in this community would be similar to that found in the USA, a high income, developed country because of the economic similarities having a greater influence on health outcomes than socio-cultural differences.
2. Materials and methods 2.1. Sample All people resident in the UAE are recorded in the Health Card database, a governmental listing maintained by the Ministry of Health. In the absence of addresses being recorded in the database, only those with a telephone number recorded in the database were included in the sample. This was stratified by age into those aged 65/74 and those aged 75/ years. Each group was randomly ordered by use of a random number table. The first 160 people of the 65/74 years old group and the first 40 people in the 75/ group, were contacted by telephone and asked if they would like to participate. 2.2. Measurement instruments for the health assessment A series of demographic, social, health and clinical data were collected by interviewer administered questionnaires and limited examination by trained bilingual field workers who visited the subjects in their homes. This was conducted in Arabic, the first language of participants and the field workers. Questionnaires in English were translated into Arabic. These translations were verified by backtranslation and any areas of disagreement were resolved by discussion between both translators. The items assessed were: 1) Demographic: age, sex, nationality, marital status, number of wives per husband, spouse nationality, number of living children. 2) Social: literacy, smoking, domestic living arrangements. 3) Health: a) Self-view of health: each participant was asked, ‘Do you view your health as satisfactory, poor or high?’. b) Anthropometrics: weight was measured using the Tanita model HP309 scale and height was measured with the Seca model 214 Road Rod. Body mass index (BMI) was calculated (kg/m2), with those above 30 classified as obese. The percentage of body fat was estimated by a bioelectric impedance meter (Kotler et al., 1996), the Quantum 2, manufactured by RJL Systems, using proprietary equations supplied by the manufacturer.
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c)
d)
e)
f)
g)
Psychological: this was measured by the Hospital Anxiety and Depression Scale, an outpatient questionnaire scale whose Arabic version has been validated in this community (Zigmond and Snaith, 1983; El-Rufaie and Absood, 1995). A positive result in this screening test, suggests a strong likelihood of a clinical diagnosis of anxiety or depression. Nutritional: this was assessed using the Mini-Nutritional Assessment, a validated scale, which combines questionnaire and measured cognitive and anthropometrical data (Vellas et al., 1999). Those with a score below 24 were classified as having decreased nutrition. Cognitive: short term memory and orientation to place were tested as they have been shown to be a reliable indicators of cognitive function, especially in the presence of low levels of literacy (Tierney et al., 2000). Functional: dependency status in each of eight domains of physical activities of daily living (ADL-8) was assessed by asking the person or the carer, rather than direct observation. The domains measured were: bathing, dressing/undressing, personal grooming, toileting, continence, transferring, walking and eating. Ability to take medications was assessed by verbal reporting. Physical strength: handgrip strength, one aspect of physical strength, was measured with the Jamar# hand dynamometer, according to the protocol suggested by the manufacturer (Robertson et al., 1993). Low grip strength was defined as being below the 25th quartile for each sex.
Following the assessment in the subjects’ home, the second author abstracted the participants’ medical records held at the Primary Health Care (PHC) center which each participant nominated as providing their primary care services. Those subjects, who had attended at the center or by home visit, within the prior 24 months from the day of their participation in this study, were included. This included visits to the clinic and home visits from the staff attached to these clinics. The weighted index of co-morbidity, an index of clinical ill health determined by diagnosis, was calculated from the abstracted data (Charlson et al., 1987). 2.3. Analysis methodology The Statistical Package for the Social Sciences was used (SPSS, 2001). Simple frequency analysis was used to describe demographics and health status. Comparative statistics were calculated using chi-square (x2) analysis or independent sample t test. Continuous variables, which did not display normal distributions, were analyzed by Mann /Whitney U -test. Multinomial logistic regression was performed. The level of statistical significance was defined as P B/0.05. 2.4. Approval by institutional review board The UAE University Faculty of Medicine and Health Sciences Research Ethics Committee and the Ministry of Health Research Review Committee at Tawam
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Hospital, both of which comply with the ethical rules for human experimentation that are stated in the Declaration of Helsinki, approved the project.
3. Results Initial funding in 1999, provided for 140 subjects to be contacted, of which 96 people aged 65/74 years and 36 people aged 75/ years participated. The results of a different analysis involving this group have been described in a previous report (Margolis et al., 2003). Additional funding in 2002, allowed an additional 60 subjects to be contacted of which an additional 49 people aged 65 /74 years and three people aged 75/ years participated. The mean age9/standard deviation (S.D.) of all participants was 71.89/6.3, with a female to male ratio of 1.07. All 100% were practicing Muslims and spoke Arabic as their first language. All were citizens of an Arabic country, Iran or Sudan, with 73 (82%) men and 63 (66%) women being Emirati citizens. The social and demographic data are detailed in Table 1. For married men, 69 (83%) had one wife at the time of the study, while seven (8%) had two and seven (8%) had three. Of the 57 women who were married, only two were part of polygamous marriages, being the first of two wives. Table 1 Social and demographic data
Female Emirati nationality Marital status Married Widow Divorced Literate (able to read and write) Smoker Never Previously Currently Live in multi-generational household Presence of servant in the household Presence of personal servant
Number of living children Number of residents in house Number of residents per household servant (if servant present)
All n
(%)
n /184 95 136
52 74
140 35 9 21
76 19 5 11
146 30 8 163 157 27 Mean9/S.D.
79 16 4 89 85 15
6.09/3.8 12.39/6.8 7.59/4.9
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6 Table 2 Health status data
Self view of health Satisfactory or higher Unsatisfactory ADL-8a Independent Partially dependent Dependent Ability to take medicines Independent Partially dependent Dependent Short term memory Intact Remember two of three Remember one of three Remember zero of three Orientation to place Anxiety: positive screening test Depression: positive screening test Nutrition Normal Decreased Pressure ulcers present Uses/three different medications/day Obesity (BMI]/30) n BMI % Body fat Nutrition scoreb Hand grip strength (males) Hand grip strength (females) Systolic BP Diastolic BP a b
174 169 169 86 93 183 183
n /174 166 8 n /184 153 22 9
(%) 95 5
151 20 13 n /183
82 11 7
125 32 19 7 174 n /174 13 n /173 31 n /169 133 36 n /184 5 53 n /174 53 Mean9/S.D.
68 17 10 4 95
83 12 5
7 18 79 21 3 29 30
27.79/5.5 29.89/12.4 25.29/3.3 26.69/8.3 20.59/7.7 140.99/21.8 80.79/9.7
Activities of daily living: eight domains measured. Nutrition index (Vellas et al., 1999).
The Health status of participants is detailed in Table 2. As not all participants answered every question or participated in every component of the examination, the numbers of participants per item is detailed. Using multiple logistic regression, there was an association between independence in ADL and three of the measured variables: screening negative for depression (odds ratio 4.39, 95% confidence intervals 1.62 /11.95, P /0.004), normal nutritional status (odds ratio 8.00, 95%
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confidence intervals 3.17 /20.08, P B/0.001) and absence of a household servant (odds ratio 4.44, 95% confidence intervals 1.24 /15.95, P /0.022). Comparisons with USA normative data (Kramarow et al., 1999) regarding physical function are detailed in Table 3. The clinical status of the 130 participants who had attended a PHC center within 24 months prior to the date of assessment is detailed in Table 4. Comparisons with USA (Kramarow et al., 1999) normative data are also included. Utilizing logistic regression, no statistically significant association existed between attending a PHC and all measured variables, suggesting the PHC data was representative of the entire population studied. There was no statistically significant variation in disease frequency between the sexes or between those aged 65 and 74 years and those aged 75/ years. The PHC services were utilized by 71% of the aged. The average number of visits per year was 9.69/10.7 (median /5.5), while the average number of months since the last visit prior to the study assessment was 2.69/5.0 (median / 0.56). In comparison, ambulatory people aged 65/ in the USA visited their doctor in an office environment on average, only 6.9 times per year (Kramarow et al., 1999). Diabetes was recorded as a diagnosis in 37% of the 130 aged people who attended the PHC. As has been described in other populations, those with diabetes had a significantly lower level of nutrition compared with their non-diabetic counterparts (24.29/3.8 diabetics, 26.19/2.8 non diabetics; P /0.004 by Mann/Whitney U -test) (Turnbull and Sinclair, 2002). Logistic regression analysis of screening positive for depression showed three associations: dependent in ADL (odds ratio 3.91, 95% confidence intervals 1.49 / 10.20, P /0.006), poor self-view of health (odds ratio 10.49, 95% confidence intervals 1.72 /64.10, P /0.011) and absence of a household servant (odds ratio 3.62, 95% confidence intervals 1.17 /11.22, P /0.026). No variable had a statistically significant association with screening positive for anxiety. Of those who attended the PHC, there was a positive screen for anxiety in six people and a positive screen for depression in 21. Nevertheless, no person had a PHC recorded diagnosis of anxiety or depression, nor was there was a correlation between a positive screening test for depression and the PHC recorded diagnosis of neurological disease or dementia. Association between sex and measured variables is displayed in Table 5. Only two women had ever smoked and of these, only one continued to do so. Personal Table 3 Functional and cognitive status (aged 70/) UAE study
USA
Male (%)
Female (%)
Male (%)
Female (%)
17.5
16.6
22.2
8.8
7.1
9.9
ADL: of the domains measured, required assistance or was 22.0 dependent in at least one ADL: of the domains measured, was dependent in at least one 10.0 Comparison with USA normative data (Kramarow et al., 1999).
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Table 4 Clinical Status of those attending a PHC centre Documented illness
Self reported illness, ambulatory population
UAE study (n /130)a
Aged 65/ years, USA (Kramarow et al., 1999)
Male (%) Female (%) Male (n /66) (n /64) (%)
Female (%)
Diagnosis Arthritis Diabetes Hypertension Hyperlipidemia Heart disease Respiratory disease Peptic disease Dementia Cerebrovascular disease Neurological disase (excluding dementia) Diabetic end-organ disease Cancer
30 23 17 9 14 11 11 3 0 2 1 1
45 35 26 14 21 17 17 5 0 3 2 2
28 25 26 13 7 7 5 3 4 1 2 0
44 39 41 20 11 11 8 5 6 2 3 0
49.5 11.6 31.5
63.3 10.4 39.6
30.0 11.0
24.1 10.3
10.4
7.6
6.0
2.3
Weighted index co-morbidity 0 1 2 3 4 5 Average
30 30 3 3 0 0 0.68
45 45 5 5 0 0
35 22 1 4 1 1 0.70
55 34 2 6 2 2
Within 24 months of participating in this study. Comparison with Normative data USA. a No statistically significance between males and females for any of these variables.
Table 5 Statistically significant associations between measured variables and being male
Normal cognition Married Emirati citizen Not Having a personal servant Ever having smoked Multiple logistic regression.
Odds ratio
95% confidence intervals
P value
3.36 6.49 2.56 3.98 35.97
8.26 19.42 6.58 1.09 185.19
0.008 0.001 0.040 0.037 B/0.001
1.37 2.16 1.05 14.58 6.99
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servants were in the service of 19 (20%) of women but only 8 (9%) of men. Normal cognitive function was present in 70 (82%) of men, but only 55 (60%) of women. The only statistically significant association found by logistic regression between all measured variables and age group was between those aged 75/ years and poor self view of health (odds ratio 7.58, 95% confidence intervals 1.71 /33.33, P /0.008). Two of the measured variables demonstrated a statistically significant association, using multiple logistic regression, with satisfactory or higher self view of health: independence in ADL (odds ratio 37.486, 95% confidence intervals 3.964 /354.514, P /0.002) and screening negative for depression (odds ratio 10.24, 95% confidence intervals 1.53 /68.49, P /0.016).
4. Discussion This study has demonstrated that aged people in the UAE have characteristics of both developing and developed countries. In common with other traditional societies in developing countries, this study found a high rate of marriage (Cattell, 1997), a low level of literacy (Lloyd-Sherlock, 2000), large numbers of offspring and that most people live in multi-generational households (Hashimoto, 1991). Yet, in contradistinction, the wealth of this society is reflected by 85% of those studied living in households with servants and 15% having a personal servant. The people in this study demonstrated similar levels of functional capacity and lower levels of chronic illness, compared with their US counterparts with the exception of diabetes. This suggests their overall health status may be similar or higher. The absence of progression of ill health with age in the study group and the similarity with US normative data suggests that the ‘old /old’ are in extremely good health, especially considering health facilities only began in the 1960s and people now entering old age are generally in better health and more able than those of earlier generations (Health of Older Persons, 1998). Another consideration is that very few elderly in the UAE reside in institutionalized care facilities and those that do are severely disabled (Margolis and Reed, 2001). Hence, in the UAE, those people with lesser degrees of impairment remain in the community and reflect on the community derived data, while in the US, community based data excludes these people. This further suggests that the UAE aged are in very good health. An alternative explanation is that only ‘survivors’ are present in the ‘old /old’ group and represent a different cohort of people, who were hardier than their younger counterparts. If this later explanation were true, then the expectation would be for the health of the younger aged to deteriorate as they become older. When combined with increased longevity, the result may be longer periods of disability and dependence (Gutierrez-Robeldo, 2002) and thus, require more health care services than the ‘old /old’ currently utilize. Combined with the projected average annual growth rate in the UAE for those aged 65/ years of 10.3% (World Development Indicators, 2002), this would result in an exponential increase in health care services requirements and health care costs.
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Self-view of health has been consistently found to be a valid predictor of mortality, although the explanation is somewhat uncertain (Idler and Benyamini, 1997). Almost all (95%) participants in this study rated their health as satisfactory or higher, while only 90.5% of Singaporean (Chan et al., 1998), 82% of US (Kramarow et al., 1999), 64/69% of Thai elderly (aged 70/) (Zimmer and Amornsirisomboon, 2001) and 79.6% of Spanish (Damian et al., 1999) ambulatory elderly were able to do so. There were also a lower number of statistically significant variables which correlated with decreased self-view of health, (depression and loss of function), compared the number of variables reported in studies conducted in Singapore, Spain and Thailand. Perhaps, the UAE result reflects their high level of health and an ability to recognize this. Alternatively, as the UAE elderly spent their formative years in a period of considerable hardship, they may have lower expectations than older people elsewhere. However, as the Thai elderly, whose formative years may have presented similar hardship, have lower self-view of health, this appears less likely. The relationship between loss of functional independence and presence of a household servant suggests that families may be providing carers for their elderly from the family budget. The combination of the tradition of children caring for their elderly with the economic means to fund household staff, suggests that the UAE may be able to avoid the experience of other nations, were large government outlays are required in the short and medium term to provide resources to maintain the aged in the community. Hence, the very low rate of institutionalized care for infirm elderly could remain unchanged. This study has demonstrated a high prevalence rate of diagnosed diabetes (37%). The UAE has already surpassed the high rate of diabetes projected for developing countries by the year 2020 (Gutierrez-Robeldo, 2002), suggesting rates may continue to rise over the next decade. Hence, provision of diabetic care appears a major issue for health care planning that needs to be addressed. The very low level of diagnosis and treatment of psychological disorders in this community has been previously described (Margolis et al., 2002). This study found that no participant who screened positive for anxiety or depression had this diagnosis recorded in their PHC records. Although the screening test is not a conclusive diagnosis, it seems unlikely that all were false positives. Hence, there appears to be a significant group of people with hidden psychological morbidity.
5. Conclusion In the presence of a high regard for traditional values, close family ties, universal practice of religion and high economic resources, the elderly in the UAE have a high level of health, which they maintain into their later years and 95% view their own health to be satisfactory or better. There may be a need to substantially increase in health care resources for aged care in the near future due to a combination of high growth rate of number of older people, high prevalence of diabetes and hidden
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psychological morbidity. Encouraging families to continue to fund carers within the home may minimize the need for government intervention in this area.
Acknowledgements The authors gratefully acknowledge funding for this study provided by the Faculty of Medicine and Health Sciences, UAE University. Permission was granted to use the Arabic Version of the Hospital Anxiety and Depression scale by the copyright holder, Nfer /Nelson Publishing Company, Windsor, UK.
References Al-Qassimi, S., Farid, S. (Eds.), Reproductive Patterns and Child Survival in the United Arab Emirates. United Arab Emirates Ministry of Health, Abu Dhabi 1997. Andrews, G.R., 1987. Ageing in the developing countries of Asia and the Pacific-implications for health care. Ann. Acad. Med. Singapore 16, 3 /10. Cattell, M., 1997. African widows, culture and social change: case studies from Kenya. In: Sokolovsky, J. (Ed.), The Cultural Context of Aging. Bergin and Garvey, Westport, pp. 71 /98. Chan, K.M., Pang, W.S., Ee, C.H., Ding, Y.Y., Choo, P., 1998. Self-perception of health among elderly community dwellers in Singapore. Ann. Acad. Med. Singapore 27, 461 /467. Charlson, M.E., Pompei, P., Ales, K.L., MacKenzie, C.R., 1987. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J. Chronic Dis. 40, 373 /383. Damian, J., Ruigomez, A., Pastor, V., Martin-Moreno, J.M., 1999. Determinants of self assessed health among Spanish older people living at home. J. Epidemiol. Community Health 53, 412 /416. Dictionary of Demographic and Reproductive Health Terminology, 1999. Population Information Network, United Nations, New York. El-Rufaie, O.E., Absood, G.H., 1995. Retesting the validity of the Arabic version of the hospital anxiety and depression (HAD) scale in primary health care. Soc. Psychiatry Psychiatr. Epidemiol. 30, 26 /31. Executive Summary, 2002. World Population Aging, 1950 /2050. Population Division, DESA, United Nations, New York. Gutierrez-Robeldo, L.M., 2002. Looking at the future of geriatric care in developing countries. J. Gerontol. 57A, M162 /167. Hashimoto, A., 1991. Living arrangements of the aged in seven countries: a preliminary analysis. J. Crosscultural Gerontol. 6, 359 /382. Health of Older Persons, 1998. 122nd meeting, Executive Committee of the Directing Council. Pan American Health Organization, World Health Organization. Health Status Indicators, 2002. World Health Organization Regional Office for the Eastern Mediterranean, Cairo. Idler, E.L., Benyamini, Y., 1997. Self-rated health and mortality: a review of 27 community studies. J. Health Soc. Behav. 38, 21 /37. Kotler, D.P., Burastero, S., Wang, J., Pierson, R.N., Jr, 1996. Prediction of body cell mass, fat-free mass, and total body water with bioelectrical impedance analysis: effects of race, sex, and disease. Am. J. Clin. Nutr. 64, 489S /497S. Kramarow, E., Lentzner, H., Rooks, R., Weeks, J., Saydah, S., 1999. Health and Aging Chartbook. National Center for Health Statistics, Hyattsville. Lloyd-Sherlock, P., 2000. Population ageing in developed and developing regions: implications for health policy. Soc. Sci. Med. 51, 887 /895. Margolis, S.A., Reed, R.L., 2001. Institutionalized older adults in a health district in the United Arab Emirates: health status and utilization rate. Gerontology 47, 161 /167.
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S.A. Margolis et al. / Arch. Gerontol. Geriatr. 37 (2003) 1 /12
Margolis, S., Carter, T., Reed, R., 2002. The low usage of psychotropic medication and high level of appropriate prescribing experienced by older people in the United Arab Emirates: a country with a newly developed economy. Arch. Gerontol. Geriatr. 35, 35 /44. Margolis, S.A., Carter, T., Dunn, E.V., Reed, R.L., 2003. Validation of additional domains in activities of daily living, culturally appropriate for Muslims. Gerontology 49, 61 /65. Noor, A.M.M. (Ed.), Annual Report. Preventative Medicine Department, Ministry of Health, United Arab Emirates, Abu Dhabi 1998. Omran, A., 1971. The epidemiological transition. A theory of the epidemiology of population change. Milbank Mem Fund Q. 49, 509 /538. Robertson, L.D., Mullinax, C.M., Brodowicz, G.R., Miller, R.A., Swafford, A.R., 1993. The relationship between two power-grip testing devices and their utility in physical capacity evaluations. J. Hand Ther. 6, 194 /201. Social Development and Aging: Crisis or Opportunity, 2000. World Health Organization, Geneva. SPSS for Windows Release 11.0.0, 2001. SPSS Inc, Chicago. Tierney, M.C., Szalai, J.P., Dunn, E., Geslani, D., McDowell, I., 2000. Prediction of probable Alzheimer disease in patients with symptoms suggestive of memory impairment. Value of the mini-mental state examination. Arch. Fam. Med. 9, 527 /532. Turnbull, P.J., Sinclair, A.J., 2002. Evaluation of nutritional status and its relationship with functional status in older citizens with diabetes mellitus using the mini nutritional assessment (MNA) tool. A preliminary investigation. J. Nutr. Health Aging. 6, 116 /120. Vellas, B., Guigoz, Y., Garry, P.J., Nourhashemi, F., Bennahum, D., Lauque, S., Albarede, J.L., 1999. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 15, 116 /122. World Development Indicators, 2002. World Bank, Washington, DC. World Fact Book, 2002. Office of Public Affairs, Central Intelligence Agency, Washington, DC. Zigmond, A.S., Snaith, R.P., 1983. The hospital anxiety and depression scale. Acta. Psychiatr. Scand. 67, 361 /370. Zimmer, Z., Amornsirisomboon, P., 2001. Socioeconomic status and health among older adults in Thailand: an examination using multiple indicators. Soc. Sci. Med. 52, 1297 /1311.