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in MyanmarT Wada
et al.
ORIGINAL ARTICLE
Comprehensive geriatric
assessment for community-
dwelling elderly in Asia compared
with those in Japan: VI. Maubin
in Myanmar
Taizo Wada,1 Kiyohito Okumiya,2 Kentaro Suzuki,3 Matheus Roriz-Cruz,3
Masayuki Ishine,3 Teiji Sakagami,4 Toru Kita5 and Kozo Matsubayashi6
1
Department of Geriatric Medicine, 2The Research Institute of Nature and Humanity, and Departments of
3
Field Medicine, 4Psychiatry, 5Cardiovascular Medicine and 6The Center for South-East Asian Studies,
Kyoto University, Kyoto, Japan
Background: The objective of the present study is to compare the findings of compre-
hensive geriatric assessments of community-dwelling elderly in Maubin township, Myan-
mar with those in Japan.
Methods: A cross-sectional, study was undertaken of community-dwelling people aged
60 years and over who were living in downtown Maubin and two rural villages near
Maubin city, and 411 people aged 65 years and over who were living in Sonobe, Kyoto,
Japan. They were examined using a common comprehensive geriatric assessment tool,
which included interviews regarding activities of daily living (ADL), medical and social his-
tory, quality of life (QOL) and the 15-item Geriatric Depression Scale. Anthropometric,
neurobehavioral and blood chemical examinations were also conducted. Using ANOVA and
Post Hoc Scheffe’s F-test, findings from the three groups were compared.
Results: Scores of basic ADL, instrumental self-maintenance, intellectual activities,
social roles, QOL, Tokyo Metropolitan Institute of Gerontology Index of Competence,
body mass index, total cholesterol levels, blood hemoglobin levels and HDL levels were
lower in Myanmar’s elderly subjects than in Japanese ones. There was no significant dif-
ference in prevalence of depression. Mean blood pressure measurements and rates of sub-
jects with systolic pressure > 140 mmHg or diastolic pressure > 90 mmHg and prevalence
of stroke were higher in downtown Maubin than in Japan. The atherogenic index was
higher in Myanmar’s elderly than in Japanese.
Conclusion: In Myanmar subjects had lower ADL and QOL scores than Japanese eld-
erly. Of particular note is the higher prevalence of anemia and subjects with history of
stroke in Myanmar than in Japan. Further study is needed to detect the cause of high prev-
alence of stroke in Myanmar.
Introduction
Accepted for publication 6 June 2005.
Correspondence: Dr Taizo Wada, 54 Shogoin Kawahara- Since 1990, we have carried out comprehensive geriat-
cho Sakyo-ku Kyoto 606-8507, Japan. Email: ric assessments of the functioning of community-
taizow@kuhp.kyoto-u.ac.jp dwelling elderly and providing efficient education
Table 1 Comparison of the general and geographic factors between Myanmar and Japan
Myanmar Japan
Ethnicity Burmar Japanese
Total population in 2004 43 million 127 million
% 65 years or older 4.9% 19%
Religion Buddhism (Hinayana) Buddhism (Mahayana) or Shintoism
Economics
GDP/capita in 2003 US$1800 US$28 200
Population bellow poverty line 25% NA
Official Language Burmese, English Japanese
Adults literacy
Total, per cent (male : female) 85.3 (89.2 : 81.4) 99 (99 : 99)
Life expectancy at birth in 2004
Total (male : female) 56.0 (54.2 : 57.9) 81.0 (77.7 : 84.5)
Climate Tropical wet climate Humid subtropical climate
NA, not applicable.
Statistical analysis
Statistical analysis was performed using StatView ver.5
for Macintosh (SAS institute, Inc., Cary, NC). The one-
factor ANOVA was used for continuous variables and the
χ2 test was used for categorical variables. P-values less
than 0.05 were used to indicate statistical significance.
Where P-values were less than 0.05 by one-factor
ANOVA, Post Hoc Scheffe’s F-test were performed to
compare the scores between the two groups.
Results
Table 2 shows the comparison of baseline characteris-
tics among the three elderly groups living in downtown
Maubin, those in rural villages near in Myanmar
Maubin and those in Sonobe, Kyoto, in Japan. The eld-
erly subjects in rural villages in Myanmar were signifi-
cantly younger (68.7 years old) than those in Sonobe
Figure 2 The study areas; Maubin township is situated in (71.7 years old) and those in downtown Maubin
Irrawaddy delta, 80 km southeast of Yangon. (71.2 years old). There were differences in the ratio of
men to women between downtown Maubin and
matters; all rated on a yes/no basis); and (iii) social role Sonobe (55.2% and 42.3% male respectively). The per-
(four items, the ability to visit friends, give advice to rel- centage of the widowed was higher in downtown
atives and friends who confide, visit someone at the Maubin and rural villages in Myanmar (41.6% and
hospital and initiate conversation with younger people; 36.2%) than in Sonobe (18.8%). The proportions of
rated on a yes/no basis). elderly living alone in downtown Maubin and rural vil-
lages in Myanmar (13.9% and 13.4%) were higher than
those in Sonobe (7.6%). The rates of the elderly work-
Depression and quality of life scores
ing or do gardening every day in the two groups in
We screened for depressive symptoms using the Japa- Myanmar (56.0% and 59.1%) were higher than those in
nese version of the 15-item Geriatric Depression Scale Sonobe (15.1%). More elderly in the rural villages were
(GDS-15).18–20 We defined depression as a GDS-15 engaged in agriculture than in downtown Maubin,
score of 6 or more, with a score of 6–9 indicating ‘mild while the percentage of merchants and other workers
depression’, and a score of 10 or more indicating ‘severe was higher in downtown Maubin than the other. The
depression’. QOLs were assessed using a 100 mm visual proportions of subjects in the two groups in Myanmar
analog scale (VAS), with the worst QOL on the left end who walked and exercised every day were higher (63.2%
of the scale and best on the right, in the following five and 67.7%) than those in Sonobe (8.5%). The propor-
items; subjective sense of health, relationships with tions of subjects who drank alcohol ‘every day’ in the
family, relationships with friends, financial status and two groups in Myanmar (1.4% and 0.8%) were lower
subjective happiness.21–23 An explanation in Burmese than those in Sonobe (22.0%), while the percentages of
was added for better understanding of the VAS. subjects who were ‘past’ smokers were higher in the two
areas in Myanmar (32.4% and 46.5%) than in Sonobe
(14.1%).
Social, anthropometrical and medical assessments
The rates of elderly subjects taking any medication
Living conditions, lifestyle (drinking alcohol and smok- ‘every day’ were lower in downtown Maubin and in the
ing), and medical histories (histories of stroke, heart dis- rural villages in Myanmar (27.6% and 4.7%) than in
eases and osteoarthropathies) were also assessed. Two Sonobe (47.2%), while the rates of elderly subjects tak-
blood pressure measurements in a sitting position were ing any medication, most of which were traditional ones
taken using an auto-sphygmomanometer (HEM 757, ‘occasionally’ were higher in Myanmar (40.9% and
Omron, Japan) were averaged into blood pressure level 48.7%) than in Sonobe (9.8%). The proportions of eld-
of the subjects. In Myanmar, blood chemical analysis was erly subjects taking antihypertensive medication every
conducted in the study area using a portable blood day were lower in downtown Maubin and rural villages
chemical analyzer (SP-4420, Arkray, Japan), and in Japan, in Myanmar (13.9% and 2.4%) than in Sonobe
it was done by a laboratory company, SRL. Blood sugar (31.1%), but there were more people taking such med-
was measured casually both in Myanmar and in Japan. ication ‘sometimes’ in Myanmar (28.7% and 29.9%)
Table 2 Baseline Characteristics between the community-dwelling elderly living in Myanmar and in Japan
Table 2 Continued
Downtown Maubin, Villages near Sonobe, P
Myanmar Maubin, Myanmar Kyoto Japan
(n = 209) (n = 127) (n = 411)
Recognition of blood pressure (%) < 0.0001
Normal 30.8 21.2 60.6
High (usually) 6.3 6.3 12.2
High (occasionally) 38.0 29.9 24.8
Do not know 25.0 42.5 2.4
History of Stroke (%) < 0.0001
Yes (male : female) 15.7* (18.1 : 12.8) 7.1** (6.7 : 7.4) 4 (5.2 : 3.1)
No 83.8 92.9 96.0
Do not know 0.5 0.0 0.0
History of heart disease (%) < 0.0001
Yes 11.4 2.4 21.2
No 49 60.3 78.8
Do not know 39.5 37.3 0.0
History of osteoarthropathy (%) < 0.0001
Yes 22.6* 22.0* 59.4
No 76.9 77.2 40.6
Do not know 0.5 0.8 0.0
History of fall (%) 26.2* 22* 12.8 0.0001
*P < 0.05 by Fisher’s PLSD and by χ2 test (comparison between downtown Maubin and Sonobe or the two rural villages near
Maubin city and Sonobe); **P < 0.05 by Fisher’s PLSD and by χ2 test (comparison between downtown Maubin and the two rural
villages near Maubin city).
P-values were determined by ANOVA and χ2 test (comparison among three groups).
NA, data is not available.
than in Sonobe (2.9%). Actually more people in down- depression, was higher in women than men in these
town Maubin and rural villages in Myanmar (25.0% and three groups, but the difference was more obvious in
42.5%) did not know their blood pressure history. The Myanmar than in Japan (downtown Maubin: men
proportion of subjects who recognized their own appar- 16.4%, women 30.9%; rural villages near Maubin city:
ent history of stroke was higher in downtown Maubin men, 13.3%; women, 22.7%; Sonobe: men, 21.9%,
(15.7%) than in rural villages (7.1%) and than those in women, 23.3%). The elderly in Myanmar had signifi-
Sonobe (4.0%). In downtown Maubin and Sonobe, cantly lower scores in all QOL items. Compared with
more men than women had a histories of stroke. Many Myanmar, scores for a subjective sense of financial sat-
elderly in the two groups in Myanmar (39.5% and isfaction was significantly higher in elderly subjects in
37.3%) did not know if they had suffered heart disease rural villages near Maubin city than those in Maubin
or not. The rates of osteoarthropathies were much downtown.
lower in the two areas in Myanmar (22.6% and 22.0%) Table 4 shows the comparison of anthropometrical
than in Sonobe (59.4%). A history of falls in the last year indicators among the three elderly groups. Systolic and
was more frequent in the two areas in Myanmar (26.2% diastolic blood pressures were higher in subjects in
and 22.0%) than in Sonobe (12.8%). Myanmar than in Japanese subject, although body mass
Table 3 shows the comparison of scores in ADL, index was significantly higher in elderly subjects in
GDS-15 and quantitative QOL among the three com- Japan than those in Myanmar. Within Myanmar, the
munity-dwelling elderly groups. Scores in basic ADL, mean value of systolic blood pressure and body mass
instrumental self-maintenance, intellectual activities, index (BMI) were significantly higher in subjects in
social role and TMIG-IC were higher in Japanese eld- downtown Maubin than those in rural villages near
erly subjects than those in those in Myanmar. In com- Maubin city. Rates of subjects with systolic pressure
parison within Myanmar, there were no significant > 140 mmHg or diastolic pressure > 90 mmHg based on
differences in any mean score in ADL, GDS-15 or in the measurements of casual blood pressure was a great
the prevalence of depression, defined as cut-point deal higher in elderly subjects in downtown Maubin
(GDS ≥ 6) between downtown Maubin and the two than those in the two villages near Maubin city or in
rural villages near Maubin city. The prevalence of Japan.
Table 3 Comparison of scores for activities of daily living (ADL) and quality of life (QOL) between community-
dwelling elderly living in Myanmar and in Japan
Table 5 shows the comparison of blood chemical find- WHO criteria (defined as Hb < 13 g/dL in men, < 12 g/dL
ings among three elderly groups. Levels of serum total in women) was substantially higher in subjects in Myan-
cholesterol (TC), HDL and GOT and hemoglobin con- mar than those in Japan. There were differences in total
centrations were lower in elderly subjects in Myanmar cholesterol levels, hemoglobin concentration and serum
than those in Japan. Atherogenic index ((TC – HDL)/ uric acid levels between the two groups in Myanmar.
HDL) and blood glucose levels were significantly higher
in subjects in Myanmar than those in Japan. Of particular Discussion
note are the facts that the rate of subjects with casual
blood glucose level > 140 mg/dL was significantly higher We found that the subjects in Myanmar had lower scores
in Myanmar and the prevalence of anemia, based on the in basic ADL and TMIG-IC than Japanese subjects. The
Table 4 Comparison of anthropometrical indicators and blood pressure measurement among the community-
dwelling elderly in Myanmar and in Japan
Table 5 Comparison of blood chemical findings among the community-dwelling elderly in Myanmar and in Japan
difference in scores in ADL between Myanmar and Japan tual activities depend on literacy of old people and the
was more obvious in higher functional capacities, such average literacy level was lower in Myanmar (85.3%)
as instrumental ADL and intellectual activities than in than Japan (99%). It was also shown that there is a lower
the basic one. These higher functions may be more quantitative QOL score in Myanmar elderly subjects
greatly influenced by differences in economic status, than in Japanese ones. Analysis of other contributing fac-
infrastructure and educational level between two coun- tors to lower QOL scores in Myanmar elderly, such as
tries than basic ADL, because instrumental ADL was social, economic or spiritual factors remained to be
associated with economic activities, such as public trans- determined due to the limitation of this study, but dif-
portation and shopping. But there were no significant ferences in the subjective sense of financial satisfaction
differences in social ADL among the subjects. Intellec- between elderly subjects in downtown Maubin and in
rural villages may be partly due to recent economic dially thanks to four researchers from Yangon Univer-
development and the changing life. (Electricity was avail- sity; U Thein Soe, Daw Thi Da Myint, Daw Yin Yin
able in Maubin downtown, but that not in rural villages.) Win, Daw Cho Cho Thwing, and eight medical students
In anthropometric measures, Myanmar elderly people in the Institute of Medicine I in Yangon; Ko Zaw Paing
had lower body height, body weight and BMI than Jap- Soe, Ma San Zar Aung, Ma Lwin Lwin Nyo, Ma Myat
anese people. Mean systolic blood pressures and rates of Su Aung, Ko Myint Lwin, Ma San San Nyein, Ma Ngu
subjects with systolic pressure >140 mmHg or diastolic Thinzan Kyaw Kyaw, Ma Swe Swe Win, for their excel-
pressure >90 mmHg were higher in Myanmar’s elderly lent cooperation. We sincerely thank again U Soe Mynt
subjects than in Japanese ones in spite of lower BMI in in SEAMEO-CHAT and U Aung Mya who actively pre-
Myanmar elderly. This dissociation may be partly due to pared the program in Maubin city and Kyon Sot and
‘white-coat hypertension’, but is supposed mainly to be Allangyi villages in advance. This study was partially
due to different nutritional factors, including salt intake supported by the Over-Sea Scientific Research Grant
and to genetic differences between Myanmar elderly no. 14241005, 15406031 from the Ministry of Educa-
and Japanese one.24 Rate of subjects with histories of tion, Science, Culture and Sports, Tokyo Japan.
stroke are extraordinarily higher in downtown Maubin
than in Japan or the rural villages. Although this study
could not prove a causal relationship, a higher preva-
References
lence of hypertension and atherosclerosis may raise the
1 Ishine M, Wada T, Kita T, Kannagi T, Fushida M, Mat-
prevalence of stroke. One of the reasons why a higher subayashi K. Depression, age and ADL in community-
prevalence of elderly subjects with stroke in Myanmar dwelling elderly. Geriatr Gerontol Intern 2003; 3: 262–264.
might be, partly due to over intake of oily and salty food 2 Ho HK, Matsubayashi K, Wada T, Kimura M, Kita T,
or genetic factors. Saijoh K. A comparative study of residential care home and
community-dwelling elderly in Japan. Geriatr Gerontol Intern
In blood chemical examinations, total cholesterol,
2002; 2: 80–86.
HDL and hemoglobin concentrations were lower in 3 Matsubayashi K, Okumiya K, Wada T, Osaki Y, Doi Y,
Myanmar elderly than in Japanese. Low density lipopro- Ozawa T. Secular improvement in self-care independence
tein (LDL) data is not available in this study, but a of old people living in community in Kahoku, Japan. Lancet
higher atherogenic index in Myanmar elderly suggests 1996; 347: 60.
4 Wada T, Matsubayashi K, Okumiya K et al. Serum choles-
a higher prevalence of high LDL-cholesterolemia in
terol levels and cognitive function assessed by P300 laten-
Myanmar. Fasting glucose levels were also not available, cies in an older population living in the community. J Am
but higher rates of elderly subjects with casual glucose Geriatr Soc 1997; 45: 122–123.
levels > 140 mg/dL in Myanmar elderly subjects sug- 5 Matsubayashi K, Okumiya K, Wada T, Osaki Y, Doi Y,
gests a high prevalence of impaired glucose tolerance. Ozawa T. Cognitive and functional status of the Japanese
oldest old. J Am Geriatr Soc 1997; 45: 385–386.
This may be associated with the differences in intake of
6 Matsubayashi K, Okumiya K, Wada T, Doi Y, Ozawa T.
nutrition, lifestyle, prevalence of infectious diseases or Home blood-pressure control in Japanese hypertensive
other environmental, economic, and hereditary factors population. Lancet 1997; 350: 290–291.
among three groups. 7 Matsubayashi K, Okumiya K, Nakamura T, Fujisawa M,
Osaki Y. Global burden of disease. Lancet 1997; 350: 144.
8 Matsubayashi K, Okumiya K, Wada T et al. Postural dys-
Conclusion regulation in systolic blood pressure is associated with
worsened scoring on neurobehavioral function tests and
Comparative findings of comprehensive geriatric assess- leukoaraiosis in the older elderly living in a community.
ments of community-dwelling elderly between Myan- Stroke 1997; 28: 2169–2173.
mar and Japan were reported. In the economically 9 Matsubayashi K, Okumiya K, Osaki Y, Fujisawa M, Doi Y.
Frailty in elderly Japanese. Lancet 1999; 353: 1445.
developing country, Myanmar, the elderly had lower
10 Okumiya K, Matsubayashi K, Nakamura T et al. The timed
scores for ADL and QOL than Japanese elderly. Of par- ‘Up & Go’ test and manual button score are useful pre-
ticular note are the facts that the proportion of elderly dictors of functional decline in basic and instrumental
with a history of stroke and prevalence of hypertension ADL in community-dwelling older people. J Am Geriatr Soc
were significantly higher in Myanmar, and the preva- 1999; 47: 497–498.
11 Okumiya K, Matsubayashi K, Wada T et al. A U–shaped
lence of anemia was very much higher in Myanmar than
association between home systolic blood pressure and
in Japan. Further study is needed to detect the cause of four-year mortality in community-dwelling older men. J
the high prevalence of stroke, which worsens the health Am Geriatr Soc 1999; 47: 1415–1421.
of the elderly in those areas. 12 Matsubayashi K, Okumiya K, Wada T et al. Improvement
in self-care may lower the increasing rate of medical
expenses for community-dwelling older people in Japan.
Acknowledgments J Am Geriatr Soc 1998; 46: 1484–1485.
13 Wada T, Ishine M, Kita T, Fujisawa M, Matsubayashi K.
We would thank all the elderly people who participated Depression screening of elderly community-dwelling Jap-
in this study both in Myanmar and Japan. We also cor- anese. J Am Geriatr Soc 2003; 51: 1328–1329.
14 The World Fact Book. In: CIA. Available from URL: Brink TL, ed. Clinical Gerontology: A Guide to Assessment and
http://www.cia.gov/cia/publications/factbook/fields/2004. Intervention. New York: Haworth Press, 1986; 165–173.
html, 2004. 20 Yesavage JA. Geriatric Depression Scale. Psychopharmacol
15 Wada T, Ishine M, Sakagami T et al. Depression in Jap- Bull 1988; 24: 709–711.
anese community-dwelling elderly–prevalence and ass- 21 Morrison DP. The Crichton Visual Analogue Scale for the
ociation with ADL and QOL. Arch Gerontol Geriat 2004; 39: assessment of behaviour in the elderly. Acta Psychiatr Scand
15–23. 1983; 68: 408–413.
16 Ishizaki T, Watanabe S, Suzuki T, Shibata H, Haga H. Pre- 22 Matsubayashi K, Okumiya K, Osaki Y, Fujisawa M, Doi Y.
dictors for functional decline among nondisabled older Quality of life of old people living in the community. Lancet
Japanese living in a community during a 3-year follow-up. 1997; 350: 1521–1522.
J Am Geriatr Soc 2000; 48: 1424–1429. 23 Matsubayashi K, Wada T, Okumiya K et al. Comparative
17 Koyano W, Shibata H, Nakazato K, Haga H, Suyama Y. study of quality of life in the elderly between in Kahoku
Measurement of competence: reliability and validity of the and in Yaku. Nippon Ronen Igakkai Zasshi 1994; 31: 790–
TMIG Index of Competence. Arch Gerontol Geriat 1991; 13: 799.
103–116. 24 Staessen J, Bulpitt CJ, Fagard R, Joossens JV, Lijnen P,
18 Koyano W, Hashimoto M, Fukawa T, Shibata H, Gunji A. Amery A. Salt intake and blood pressure in the general
Functional capacity of the elderly: measurement by the population: a controlled intervention trial in two towns. J
TMIG Index of Competence. Nippon Koshu Eisei Zasshi Hypertens 1988; 6: 965–973.
1993; 40: 468–474.
19 Sheikh JI, Yesavage JA. Geriatric depression scale (GDS);
recent evidence and development of a shorter version. In: