Presentation to healthcare and the prevalence of frailty among older adults to the outpatient department of a tertiary care hospital in Sri Lanka

Background: Sri Lanka is one of the fastest-ageing countries in the world, with the proportion of the population aged 60 years or older projected to increase from 12.5% in 2016 to 16.7% in 2021. By 2041, one out of every four individuals in Sri Lanka is expected to be an elderly person. In this study, the burden of geriatric presentation to a hospital’s outpatient department (OPD) was assessed. These patients’ frailty, along with comorbidities, the existing level of geriatric care by the healthcare team at the OPD, and the level of patient satisfaction were also studied. Methods: A cross sectional study was conducted in March 2021. Results: Of 406 recruits 58.4% were female and their mean (+SD) age was 72.25 (+5.63) years. Among them, 39.7% (95% CI 34.9% to 44.6%) were frail. There was a higher prevalence of frailty among men than women (p=.001). Hypertension was the most common comorbidity. The most common diagnosis was musculoskeletal pain followed by leg ulcers. The mean consultation time with waiting time was 56 (+54 SD) minutes. Most patients classified their overall feeling of satisfaction as “good” (80.3%) while 5% stated it was poor. Conclusions: The prevalence of frailty among this sub-urban population is higher than previous studies. A majority of patients presented with non-life-threatening conditions and classified their overall satisfaction as relatively good.


Introduction
Sri Lanka is one of the fastest-ageing countries in the world, with the proportion of population aged 60 years or older projected to increase from 12.5% in 2016 to 16.7% in 2021.By 2041, one out of every four people in Sri Lanka is expected to be an elderly person (1-3).Categorical definitions of the old, elderly, aged and ageing are neither straightforward nor universally applicable (4).The United Nations considers an older person as a person who is over 60 years of age.But most countries of the developed world have accepted the chronological age of 65 years as a definition of 'elderly' or older persons.In this study, the elderly subjects considered are those above the age of 65 years.The population of older adults (>65 years) in Colombo district is 235,463 (5) Frailty is an ageing -related syndrome of Asian J Intern Med.2023 January; 2(1): 15-20 DOI: http://doi.org/10.4038/ajim.v2i1.64physiological decline which increases the risk for developing negative health outcomes and the risk for hospitalisation (6).Clinical presentation in the elderly and the frail individuals can be very nonspecific.

RESEARCH
time at OPD, time taken for consultation, specimen collection, drug delivery , and their perception of overall care.
To establish separate services for geriatric care, there is a need for identifying the number of geriatric admissions to the OPD and the type of their presentations.Hence our study assessed the proportion of the geriatric admissions to the OPD, presenting problems of older adults, any frailty and comorbidities among them, and their satisfaction levels.

Study tool:
An interviewer-administered questionnaire was utilised.The questionnaire consisted of sociodemographic data, a frailty assessment using Prisma 7 questionnaire, comorbidities, reason for OPD care, primary diagnosis based on International Classification of Primary Care (ICPC) and overall satisfaction of the patients.Prisma 7 questionnaire has been used in clinical practice for a long time in different countries and it is convenient for the OPD set up as it consumes less time .Face validity and content validity were obtained for Prisma 7 with three different clinicians.Patients' satisfaction was assessed using five responses (very good, good, fair, poor, very poor).The complete questionnaire underwent the same process of face and content validity with three different clinicians (two physicians, one with special interest in geriatric care and a clinical psychologist).Patients' identities were not disclosed, with each patient being assigned a code.

Methods
Patients brought by the community without a guardian (two patients for the study period) and critically ill patients were excluded from the study.
Noncommunicable diseases have become one of the leading causes of hospitalisation among the elderly population (2).Although not specifically aimed at the elderly, a large proportion of curative healthcare services are consumed by them.Therefore, healthcare institutions should be equipped with both specialist multidisciplinary staff and assistive infrastructure to deliver targeted quality healthcare.
Patient satisfaction is an important and commonly used indicator for measuring the quality of healthcare.It is affected by timeliness, efficiency, and patient-centred care.It is thus a proxy but a very effective indicator to measure the overall performance of healthcare workers, and institutions.
A cross sectional study was conducted from 1ˢᵗ March 2021 to 31ˢᵗ March 2021 at the outpatient department (OPD) of University Hospital KDU.Most of the population was from a suburban area (Piliyandala-Colombo district).
Sample size was calculated using the formula (n = Z²p (1 -p)/m²=400) with a 95% confidence level, 50% population proportion and 5% margin of error.For the study, systematic random sampling was performed by selecting every fourth geriatric patient who presented to the outpatient department (OPD) over the period of one month, above the age of 65 years.Patients' overall satisfaction was assessed in terms of the waiting The interviewer administered questionnaire was delivered by co-investigators who were trained and supervised by the principal investigator throughout the study duration.
Data was analysed using SPSS version 24.Mean differences were compared using t test and proportions were compared using chi-squared test.One-way ANOVA was used to find the statistical significance in comorbidity among the study group.
Ethical clearance was obtained from the Ethical Review Committee of General Sir John Kotelawala Defence university and special permission was obtained from the executive director of UHKDU.Informed written consent was obtained from patients depending on their preference.When the patient was unable to give details, details were Asian J Intern Med.2023 January; 2(1):15-20 taken from the carer.

Results
of them had more than three comorbidities which were hypertension, diabetes mellitus, and dyslipidaemia.Assistance with daily activities was required by 97(23.9%)patients.Three hundred and seventy-four (92%) of them stated that they had someone around to ask for help but 32 (7.9%) of them did not have anyone from whom to request support.Frailty was more prevalent among men than women which is similar to findings in a comparable study performed in Colombo (7).These elderly individuals were between 65 and 101 years of age.Interestingly, 29.3% of a younger group (65-74 years) among them were frail to the point that they required serious consideration.The Colombo district study was performed with a newly-validated frailty validated instrument which differed from the one used in this study.The prevalence of frailty in the Colombo study was 14.9%, and higher in elders above the age of 75 years, which is comparable to the findings in this study (7).In a study done in rural Kegalle, Sri Lanka using "Fried phenotype", prevalence of frailty was 15.2%, out of which 47.5% were above the age of 80 years without any gender variation (8) .The population surveyed in this study largely consists of people seeking medical care from the hospital, which may explain the high prevalence of frailty in the study.
Presenting complaints were somewhat similar to a Singapore emergency unit study (9) which reported abnormalities of breathing (10.6%), falls (9.4%) and musculoskeletal pain (8.2%).This study is missing breathing difficulties and falls as they were diverted to COVID triage and accident service respectively.A South Indian study done in a geriatric outpatient department stated that their main presentations were hypertension, diabetes followed by musculoskeletal disorders (10) where this study had limited hypertensive and diabetes issues as presenting problems, but majority had hypertension as a comorbidity.But that study was conducted in a dedicated geriatric outpatient Asian J Intern Med.2023 January; 2(1):15-20 department, not a common unit which was the case in this study.This study had more female population than the above studies.Mean age (72.2 years) of our study was compatible with the Singapore study (72.8 years) whereas the Indian study's mean age was 65 years (9,10).In both the Singapore and Indian studies, the cut off age was taken as 60 years whereas our cut off was 65 years.Our study setting was a recently built spacious hospital which has a more pleasant environment than other surrounding hospitals where most of the patients had good overall satisfaction.
There are limited studies in outpatient departments of Asian countries in this field.The increasing demand on healthcare by geriatric patients will be a burden to the health sector.If there are community geriatric clinics, minor complaints could be directed there, and it would be much more convenient for them to get treatment than taking all the trouble to come to a busy hospital.
It is important that Sri Lanka should recognise the special need for elderly care due to the ageing population.Compiling the profile of geriatric cases presenting to the OPD and finding the prevalence of frailty among them will help to identify crucial areas of need and prepare the healthcare workers and healthcare system to confirm the challenges of delivering care for minor complaints and acute geriatric care.
The prevalence of frailty among this sub-urban population is higher than previous studies and frailty was more prevalent among men than women.A majority of patients presented with nonlife-threatening conditions and musculoskeletal pain was the commonest diagnosis.Majority had more than three comorbidities while hypertension was the commonest.Many categorised their overall satisfaction as relatively good.

Limitations
Throughout the study period, according to the guidelines issued by the Ministry of Health, OPD received patients after COVID triage at the gate.Therefore, most of the patients with respiratory symptoms and fever secondary to respiratory illness were directed to COVID screening and treatment unit.Further, as an active accident service is not running, falls were directed to a nearby tertiary care hospital.Both categories were not included in the audit.Prisma 7 frailty score is not validated in Sri Lanka but that was the most convenient and less time-consuming instrument which had face and content validity in this study.Patients brought by the community were not recruited due to high vulnerability and to avoid legal issues, but there were only two patients under that category over that period.

Declarations
Ethics: Ethical clearance was obtained from Ethical review committee of Faculty of Medicine, General Sir John Kotelawala Defence university.

Availability of data and material: Electronic data is available on request
Consent for publication: All authors agreed.

Table 1 -
Frailty among elders DiscussionThis study reflects the proportion of geriatric patients presenting to the outpatient department of university hospital KDU. .Though the study had Asian J Intern Med.2023 January; 2(1): 15-20