Evaluation of the Functional Capacity of a Group of Patients Aged over 65 Years: A Cross-Sectional Study at the Yaoundé Central Hospital ()
1. Background
The aging population is poised to increase this century, attributed to a better understanding and management of the factors affecting mortality and birthrates [1]. The functional capacity of elderly patients decreases with age due to a combination of age-related decline in physiologic functions and chronic conditions [2]. A severe decrease leads to an inability to carry out activities of daily living leading to a loss of autonomy and an increased dependence [3] [4]. Therefore, understanding the functional capacity of older individuals is essential for creating appropriate strategies to implement effective interventions in order to prevent, treat or rehabilitate them [5]. Several tools have been described to evaluate the functional capacity of older adults by their abilities to carry out activities of daily living and instrumental activities of daily living or by subjective methods or objective methods, which entails measuring directly or indirectly their maximum oxygen consumption [6] [7] [8]. The subjective tools are available in the form of questionnaires that assess the ability to carry out activities of daily living while those that assess functional capacity in an objective manner revolve around the measurement of maximal oxygen consumption during aerobic exercise [6] [9]. We observed that only a few studies have been carried out in our context to evaluate this decline. Our aim was to evaluate the functional capacity of the elderly followed up at the Yaoundé Central Hospital.
2. Methods
2.1. Study Design and Setting
We carried out a cross-sectional study, over a period of 7 months (1 December 2021 to 29 May 2022) in the geriatric and cardiology department of the Yaoundé Central Hospital.
2.2. Participants
We carried out a non-probabilistic consecutive sampling among elderly patients who consulted in the geriatric and cardiology outpatient units during our study period. This is due to the high number of elderly patients who consult in these units.
Eligibility criteria:
Inclusion criteria
• At least 65 years of age.
• Having given their willful and informed consent.
Non-inclusion criteria
• Patients less than 65 years.
• Current infections.
• Recent myocardial infarction.
• Orthopedic limitations.
• People with Alzheimer’s.
Exclusion criteria
• Severe arrhythmias.
• Severe hypertension.
• Incomplete data.
We included consenting patients at least 65 years of age. Patients with current infections, recent myocardial infarction, severe arrhythmias, severe hypertension, and with orthopedic limitations were excluded.
2.3. Sample Size
We carried out a non-probabilistic consecutive sampling among patients who consulted in the geriatric and cardiology outpatient units during our study period. This is due to the high number of elderly patients who consult in these units.
2.4. Data Collection
The data was collected using a pre-established data collection sheet. For all the participants, we reported sociodemographic characteristics (age, gender, level of education, professional status, marital status, ethnic origin) and past history which includes chronic conditions, history of falls within the previous 12 months, total number of medications consumed daily, smoking and drinking habits. We then administered questionnaires to evaluate depression level and level of physical activity. The functional capacity was assessed subjectively using the WHO Global Physical Activity Questionnaire (GPAQ), which was answered by each participant.
• It was developed by WHO for physical activity surveillance in countries. It collects information on physical activity participation in three settings (or domains) and sedentary behavior. These domains are:
‒ Activity at work.
‒ Travel to and from places.
‒ Recreational activities.
• Weekly energy expenditure is assessed by summing the answers from the various sections and expressed in Metabolic Equivalents (METs) as recommended in the guidelines of the Compendium of Physical Activities.
• MET (Metabolic Equivalent) is the ratio of the work metabolic rate to the resting metabolic rate. One MET is defined as 1 kcal/kg/hour and is equivalent to the energy cost of sitting quietly.
• A MET is also defined as oxygen uptake in ml/kg/min with one MET equal to the oxygen cost of sitting quietly, around 3.5 ml/kg/min.
• Level of total physical activity was divided into three groups depending on their total weekly METs. Participants with MET less than 600 are considered to have a low physical; participants with MET equal to or greater than 600 are considered to have a moderate level of physical active and a MET greater than or equal to 3000 was considered high.
A six-minute walk test for objective measure of their functional capacity: After the morphological and physiological assessments, a six-minute walk test was performed in a 30 long corridor in the Cardiology service. This was done according to the guidelines established by the American thoracic Society. A timer was set to 6 minutes and the track prepared. The participant was prepared for the test using the scribe, “The object of this test is to walk as far as possible for 6 minutes. You will walk back and forth in this hallway. Six minutes is a long time to walk, so you will be exerting yourself. You will probably get out of breath or become tired. You are permitted to slow down, to stop, and to rest as necessary. You may lean against the wall while resting, but resume walking as soon as you are able. You will be walking back and forth around the cones (or poles). You should walk around the cones (or poles) and continue back the other way without hesitation. Now I’m going to show you. Please watch the way I turn without hesitation.” A lap was done on the track for demonstration. The participant was then positioned at the starting line and the timer was started. A worksheet was used to keep tract of the laps. The rate of perceived dyspnea and exertion were evaluated using the Borg scale and were recorded at the beginning and end of the exercise.
The self-paced step test: Step tests are tests which are used to estimate the maximal oxygen uptake during exercise (VO2max). They are easy to realize and can provide a close estimate the VO2max using submaximal exercises. For our study we used the model implemented by Petrella et al.: We let the participants select their own stepping pace for slow, normal and fast stages. The time to complete 20 step-ups for each stage, as well as an immediate post-exercise heart rate were recorded. The stepping height was set to 20 cm and the VO2max was estimated using the formula:
estimated VO2max = 129.6 + (−3.82 O2 pulse) + (−5.32 STTime) + (−0.22 age) + (−0.24 BMI + (−0.12 heart rate), for women.
estimated VO2max = 116.4 + (−5.10 O2 pulse) + (−2.81 STTime) + (−0.12 age) + (−0.24 BMI + (−0.14 heart rate), for men.
A standard 12-lead resting ECG was then done to record the electrical activity of the heart using a Mac 1200 ST electrocardiograph and for morphological assessment, a transthoracic echocardiography was done using a Philips IE33 ultrasound machine.
2.5. Statistical Analysis
All the data collected were analyzed using the software SPSS version 23.0. The qualitative variables were expressed in frequency and percentages. The quantitative variables were expressed in terms of means and standard deviation in the case of a Normal distribution, or medians and interquartile ranges when this was not the case. The measurement of the strength of associations between different variables was carried out using binary logistic regression with multivariate analysis. The threshold of significance was set at 0.05.
3. Results
3.1. Sociodemographic and Clinical Characteristics of the Sample
Overall 66 participants were included in the study. Among them, 35 (53%) were females. Their median age was 70 years (IQR: 67 - 75) ranging from 65 to 100 years. The most represented age group was those with ages from 65 - 75 years old. Most of our participants (80.3%) lived in an urban setting. A majority of patients were married (54.5%), and there was equally a preponderance of retired individuals (72.7%). The most prevalent cardiovascular risk factor was hypertension (71.2%) followed by abdominal obesity (40.9%). In our study population 24.2% had heart failure and 12.1% osteoarthritis. The median drug consumption per day was 2 (1 - 3) ranging 0 medications to 7 medications. The prevalence of polypharmacy was 7.6%.
The sociodemographic and clinical characteristics are summarized in Table 1.
3.2. Standard 12 Lead ECG and Transthoracic Echocardiogram Findings
The majority of our patients had a sinusal rythm (94%). A majority equally had a normal heart rate (73.8%), and most of the participants had a normal QTc interval.
On transthoracic echocardiogram, the LVEF was determining with the Simpson Biplane method which revealed a mean of 63.3% ± 8.2% ranging from 37% to 79%. Also, majority of patients had preserved LVEF (95.4%). in addition, a majority did not show left ventricular hypertrophy (70.8%).
3.3. Evaluation of Fragility (TUG), Falls and Depression
The Median time taken to perform the Timed Up and Go test (TUG) was 12 s (11 - 14) with a range from 9 s to 23 s. a majority of the study population had a normal TUG (78.8%). The majority of the participants reported no falls within the last 12 months (90.9%). These are illustrated in Table 2.
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Table 1. Sociodemographic and clinical characteristics of the study population.
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Table 2. TUG, falls and depression in study population.
The mean GDS, 30 score was 25.1 ± 2.4 ranging from 19 to 30. A majority of participants had symptoms of depression (see Table 2).
3.4. Functional Capacity of Study Population
• Subjective evaluation: A majority of the study population had a low level of physical activity (81.8%) with a median weekly energy expenditure of 370 METs (330 - 491.3) and ranged from 230 METs to 690 METs
• Objective evaluation: The mean distance covered during the 6 MWT was 353.2 ± 72.2. The median RPE at the end of the test was 2 (1 - 4) and the median RPD at the end of the test was 2 (1 - 2). Among the participants, 39.4% had an altered Functional capacity with respect to distance covered. The mean estimated VO2max was 27.7 ± 8.3 ml/kg/min ranging from 12.4 to 43.1 ml/kg/min. This is shown in Table 3.
3.5. Factors Associated to an Altered Functional Capacity
On multivariate analysis, factors found to be independently associated to an altered functional capacity were age ≥ 75 years (OR = 2.9, p < 0.05), heart failure (OR = 3.2, p < 0.05), Osteo-arthritis (OR = 5.1, p < 0.05), and TUG < 15 s (OR = 39, p < 0.05) (see Table 4).
4. Discussion
The Functional capacity of older adults decreases with age, this is due to the combination of genetic factors, biological factors, environmental factors, lifestyle and chronic conditions [10] [11]. A severe decrease below physiological thresholds lead to increasing difficulties in carrying out activities of daily living which leads to a decrease in their independence and decrease in quality of life [3] [4]. Assessment of functional capacity is therefore necessary while screening for individuals at risk and in diagnosing elderly patients with debilitating chronic conditions [12]. Our objective in this study was to evaluate the functional capacity of community dwelling adults using both subjective and objective tools.
About 81% of our study populations were found to have a low physical activity from the Global Physical Activity Questionnaire. This is different from the results obtained by Alves et al. who found that 51.3% of elderly Brazilians in dwelling community had a low level of physical activity [13]. This disparity may
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Table 3. Exercise capacity and Estimated VO2max.
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Table 4. Factors associated to an altered functional capacity on multivariate analysis.
be due to the fact that the population in our study mainly lived in an urban setting, compared to the study carried out by Alves et al. in which was done with elderly people in a rural setting. This high prevalence indicates low physical activity amongst the elderly especially in urban settings. The mean distance covered during the six-minute walk test was 355.7 ± 72 and 39.4% covered a distance indicative of an altered functional capacity. The mean estimated VO2max was 29.3 ± 10.2 ml/kg/min. This is indicative of an average aerobic capacity level and functional capacity. The median energy expenditure per week was 370 METs (330 - 491.3), 81.8% having a low weekly energy expenditure. This is indicative of a low level of physical activity and by extension a low functional capacity. Essomba et al. found a prevalence of 38% of adults with a decreased functional capacity. This discrepancy might be attributed to the lower median age of patients recruited by Essomba et al. [14].
The factors documented to influence functional capacity in the elderly which were evaluated in this study include: the age, comorbidities, depression, cognitive impairment, physical activity and polypharmacy [15] [16] [17]. On univariate analysis, age, heart failure, osteoarthritis and an elevated TUG was found to be associated to an altered functional capacity. We observed an association between age and an altered functional capacity in our study population. This is similar to results obtained by Benefice et al. in a 2005 study to evaluate the relationship between anthropometry, cardiorespiratory fitness indices and physical activity levels in different age and sex groups in rural Senegal [18]. In a study carried out Arnett et al. to evaluate the aerobic reserve and physical functional performance in older adults in San Jose, California, age was found to have a negative correlation to VO2 PEAK [2]. The association between increasing age and decreasing functional capacity can be explained by the fact that ageing is accompanied with a decrease in muscle mass and strength which leads to a steady drop in the maximal oxygen consumption during aerobic exercises [18]. In addition to that we had an association between heart failure and an altered functional capacity. Masoudi et al. [19] equally observed a similar trend between heart failure and an altered functional capacity (OR = 2.35, p < 0.001) in a large multicenter study. Furthermore, we observed an association between osteoarthritis and an altered functional capacity (OR = 5.7, p < 0.05). This results compares to that observed by Essomba et al. had a similar association while evaluating geriatric syndromes in Yaoundé in 2019 between osteoarthritis and a decreased functional status (OR 3.3, p = 0.055) [14]. The relationship between osteoarthritis and an altered functional capacity can be explained by the fact that osteoarthritis is due to degeneration of joint cartilage, which causes pain after usage, thus limiting functional use of the joint causing sarcopenia which leads to a decrease in the ability to carry out activities of daily living [20].
The results presented here should be interpreted in the light of some study limitations. This was a cross-sectional study and therefore, any causal relationship cannot be established from our results. The small size of our sample did not permit an overall assessment of the Functional Capacity of Older Cameroonian Adults. Also, the measure of aerobic fitness lacked the precision that could be obtained from using a cardiopulmonary testing exercise.
5. Conclusion
The functional capacity of the elderly reflects their ability to carry out activities of daily living. In this study, we found 39.4% of older adults had an altered functional capacity when self-reported. Age, heart failure, osteoarthritis, and poor balance are associated with an altered functional capacity in older patients. More studies and resources need to be invested in the amelioration of the functional capacity of older adults as this age group is poised to constitute an important number of our population in the coming decades.
Acknowledgements
The authors would like to thank the staff of the geriatric and cardiology department of the Yaoundé Central Hospital.
Authors’ Contribution
Conception and Design:
Data collection: NKV.
Data analysis and interpretation: NKV.
Manuscript drafting: KYH.
Manuscript revision: NKV.
Approval of the final manuscript: All the authors.
Availability of Data and Materials
The datasets used for this study are available from the corresponding author upon request.
Ethical Approval and Consent to Participate
The study was approved by the Institutional Ethical Review Board of the University Yaoundé I (Cameroon). All the participants read and signed informed consent before their inclusion in the study.
Appendix
Data Collection Sheet
Serial code: 
Section 1: Identification
Section 2: Comorbidities
Section 3: Physical examination
Section 4: Paraclinical examination
1) Echocardiogram
2) Electrocardiogram
Global Physical Activity Questionnaire (GPAQ)
Interpretation: <600 METs sedentary, >600 METS moderate
Section 7: Six minute walk test worksheet (Before exercises)
Medications taken before the test (dose and time)
__________________________________________________________________________________________________________________________________
Supplemental O2: no yes ____ L/min Assistive device: No Yes _______
Pre Test/Baseline End of Test
BP__________________ BP_________________
HR _________________ HR ________________
SpO2________________ SpO2_______________
Dyspnea (Borg) _______ Dyspnea (Borg) _______
Fatigue (Borg) ________ Fatigue (Borg) ________
Stopped or paused before 6 minutes completed?
No Yes, reason________________________________________________
Other symptoms at the end of test:
Angina, dizziness hip, knee, calf pain, other ________________________
Number of laps__________ (×100 meters) + final partial lap________meters
Total distance walked in 6 minutes: ______________ meters
Section: Self-paced step test
Height of step:
Resting heart rate:
VO2max_________
Abbreviations
CVRF: Cardiovascular Risk Factor
ECG: Electro Cardio Gram
GDS: Geriatric Depression Scale questionnaire
GPAQ: Global Physical Activity Questionnaire
IQR: InterQuartile Range
LVEF: Left Ventricular Ejection Fraction
METs: Metabolic Equivalent for Tasks
MMSE: Mini Mental State Examination
SPSS: Statistical Package for the Social Sciences
TUG: Timed Up and Go test
WHO: World Health Organization
NOTES
*First author.
#Corresponding author.