Morbidity profile among older people at primary health care centers in Saudi Arabia during the period 2012-2020

Objectives: To evaluate the morbidity profile and explore the geriatric giants, health problems, and their risk factors among old people in the older people health clinics at primary health care centers (PHCCs) in Saudi Arabia. Methods: This is a record-based descriptive cross-sectional study. Data was collected between 2012-2020 using the health data of older people to whom comprehensive geriatric assessment (CGA) was carried out at 1,481 PHCCs in Saudi Arabia. Data included sociodemographic and health related characteristics, medications, results of CGA, complete clinical examination, and laboratory results. Assessment was carried out for diabetes, hypertension, obesity, underweight, vision and hearing impairments, depression, memory and cognitive impairment, risk of falls, urine incontinence, bronchial asthma, and anemia. Results: A total of 193,715 older people were screened. A high prevalence of diabetes (55.4%), hypertension (49.1%), diabetes and hypertension co-morbidity (26.8%), and obesity (22.2%) were found. The overall prevalence of anemia was 4.7% and asthma 8.9%. The prevalence of positive screening for depression was 5.9%, 2.9% for memory and cognitive impairment, 6.3% for urine incontinence, and 4.0% for risk of fall. The prevalence of vision impairment was 20.6%, hearing impairments was 12.6%, and for underweight it was 5.4%. There was high prevalence of risk factors like smoking (8.5%), and polypharmacy (25.3%). Health regions varied widely in prevalence of the studied health conditions. Conclusion: The study findings highlight the importance of CGA in early detection of geriatric giants, health problems, and associated risk factors among Saudi older people.

T he world's population is aging rapidly alongside broader social and economic changes taking place throughout the world. 1 Globally, the population aged 60 years or over is estimated to be one in 6 people by 2030, and will double by 2050 )2.1 billion(, with nearly two-thirds of them in low-and middle-income countries. 2 Saudi Arabia is also witnessing an increase in its aging population mainly due to an increase in life expectancy that has improved from 64.4 years in the 1980s to 74.3 years in the 2000s. 3 As a result, the elderly population aged 60 and above is projected to increase from 3% in 2010 to 9.5% in 2035 and 18.4% in 2050. 4,5 As the proportion of older people increases, the prevalence of chronic diseases also rises together with the risk of having 2 or more chronic conditions )multimorbidity(. 6 Chronic diseases cause medical, social, and psychological problems that limit the activities of elderly people in the community. 7 Common health conditions among older people include sensory disorders )hearing loss, cataracts, and refractive errors(, musculoskeletal disorders )back and neck pain, and osteoarthritis(, chronic obstructive pulmonary disease, diabetes, depression, and dementia. Furthermore, as people age, they are more likely to experience geriatric syndromes which refer to several complex health conditions that occur simultaneously and do not fall into discrete disease categories; these are often the consequence of multiple underlying factors and include frailty, urine incontinence, falls, delirium, and pressure ulcers. 2 The combination of multimorbidity, age-related frailty, geriatric syndromes, and acute illness places older people at increased risk for adverse outcomes such as long-term dependence, increased demands on costs for health and social care including increased admission to a nursing home, and ultimately death. 8,9 Comprehensive geriatric assessment )CGA( has been developed in response to the health issues and problems experienced by older people who require hospital-level care that not early discovered and managed, and refers to a multi-dimensional diagnostic and therapeutic process that is focused on determining a frail older person's medical, functional, mental, and social capabilities and limitations with the goal of ensuring that problems are identified, quantified, and managed appropriately. CGA has the potential to improve health outcomes, reduce the costs of health care and social care, and reduce the caregiver's burden. 9,10 In Saudi Arabia, the health services to older people aged 60 years and above are provided at primary health care centers )PHCCs( through the Older People Health Care Program )OPHCP( since 2012, when the program was established. This program is the first step obtained by the Saudi Ministry of Health )MOH( to improve the health services as a response to meet the health demands of the older people and introduce the geriatric health services in MOH health institutes. 11,12 Since the services are provided at the PHCC level, the main scope of these services is preventive as well as curative for chronic diseases usually managed at PHCCs. The preventive services include CGA, health education to older people and their caregiver, and immunization. The aim of CGA is to detect the common health conditions among older people targeted by the program. 12 The aim of this study is to evaluate the morbidity profile and explore the geriatric giants, common health problems, and their risk factors among older people in the older people health clinics and to whom CGA was carried out at PHCCs during the period 2012-2020. This will help improve the planning and prioritizing of the health services, resource allocation and appropriate effective interventions for older people.
Methods. This was a record-based descriptive crosssectional study using the health data of older people 60 years and above to whom geriatric health services were delivered at the 1,481 PHCCs that implement OPHCP during the period 2012-2020. The total number of older people screened was 193,715.
The health data of older people involved in the OPHCP that were registered in the CGA file for older people were collected annually. These data included sociodemographic characteristics, health-related characteristics, medications, results of CGA, results of complete clinical examination and assessment, and laboratory results.
The CGA was carried out to the target group during the first visit to the PHCC. The components of the CGA were the assessments of the common geriatric conditions recommended by the Wolrd Health Organization )WHO( for age-friendly PHC setting. This included assessment of the 4 geriatric giants )depression, memory impairment, risk of falls, and urine incontinence(, vision and hearing impairments, and 2 common chronic conditions )diabetes [DM] and hypertension [HTN](. 13 In addition, bronchial asthma, Disclosure. This study was funded by the Ministry of Health, Riyadh, Kingdom of Saudi Arabia, as a part of the total fund provided for Older People Health Care Program in 2019 )approval number: 22-26 M(. obesity, underweight, and anemia were assessed. The assessment was carried out by trained doctors and nurses.
The final results of the CGA of the studied group were recorded in the CGA files of the older people, then routinely collected from the PHCCs by filling a data collection sheet, then reported periodically to the OPHCP head office for analysis, and then reported to the higher authorities to provide the necessary appropriate feedback or action to the health region. 12 12,14,15 This was taken into consideration during data analysis of cognitive impairment where the percentage of the cognitive impairment )total and for each region( was calculated for the total older people to whom Mini-Cog test was carried out from 2014-2021. III( For screening risk of fall, a multi-factorial risk assessment was carried out along with history of fall if any. Gait assessment Up and Go, and Romberg's balance tests were used. 13,16 IV( Urine incontinence among the studied group was assessed by history taking, medication review, and investigations. 13 V( Special sense assessment of the participants: assessment of visual acuity was carried out by history taking and Snellen's chart. Assessment of hearing acuity was carried out by history taking and whispering test. 13 VI( The body mass index )BMI( )[weight in kg/)height in m 2 (]( was calculated for each participant to determine obesity )BMI≥30 kg/m 2 ( and underweight )BMI<18.5 kg/ m 2 based on the WHO international standard. 17 VII( Anemia was diagnosed by using WHO criteria for anemia )hemoglobin of less than 13 g/dL in men and less than 12 g/dL in women (. 18 Statistical analysis. Data were analyzed using the Statistical Package for Social Sciences, version 22.0 )IBM Corp., Armonk, NY, USA(. Microsoft Excel 2016 MSO )version 2209( was also used. Categorical variables were expressed as percentages. Statistical tests of significance were not carried out.
Results. The total number of screened older people during the period from 2012-2020 was 193,715. Most of these participants )39.5%( belonged to the age group 60-64 years, and only 7.9% were above 80 years. Females represented 51.5% of the participants, 64.5% of participants were illiterate, while only 2.5% were highly educated, and 7.7% were working. The percentage of older people caring for themselves was 51.5%, while 37.5% of them were cared for by a family member. Walking aids were used by 21.9% while 4.7% were using a wheelchair )Table 1(. Table 2 illustrates the region-wise distribution of the investigated chronic diseases and conditions among the studied group during the period 2012-2020. The overall prevalence of clinically diagnosed DM was 55.4%, and it was higher among males )56.1%( than among females )54.7%(. The overall prevalence of HTN was 49.1%, and the prevalence among females )50%( was higher than among males )48.1%(. The screened older people with both DM and HTN was 26.8%, with a higher prevalence among females )27.6%( than among  19.4%(. The overall prevalence of underweight was 5.4%, and it is higher among males )5.6%( than females )5.2%(. The overall prevalence of anemia was 4.7% and it was higher among females )5.5%( than males )3.9%(. Asthma was reported in 8.9% of the total participants, and it was higher among females )8.9%( than males )8.8%(. Table 2 illustrates that the prevalence of DM )67.9%(, HTN )71.9%(, and both DM and HTN )46.4%( co-morbidity were the highest among participants from Alahsaa region. Gurayyat had the highest obesity prevalence )38.5%( while Jeddah showed the highest prevalence of underweight )25.4%(. Both anemia )13.5%( and bronchial asthma )21.3%( prevalence were the highest in Bisha. Table 3 illustrates the region-wise distribution of the investigated geriatric giants among the studied  The prevalence of hearing impairment among the studied group was 12.6% while the prevalence of deafness was 1.4%. Visual impairment was found in 20.6% of the screened older persons and 1.1% were blind. Konfothah reported the highest prevalence of hearing )29.7%( and vision impairment )32.7%(, Bisha reported the highest prevalence of blindness )3.8%(, Table 3 -Region-wise distribution of the geriatric giants among the studied group during the period 2012-2020. Discussion. In the present study, a high prevalence of the studied chronic diseases DM, HTN, DM and HTN co-morbidity, and obesity was reported among the screened Saudi older people. In addition, the prevalence of special sense disorders )vision and hearing impairment( was also high, while the prevalence of positive screening results of the studied geriatric giants )depression, memory and cognitive impairment, risk of fall, and urine incontinence( was found to be less frequent. Moreover, there was a high prevalence of other risk factors like smoking and polypharmacy. The health regions varied widely in the prevalence of the studied chronic diseases and geriatric health conditions, and females reported a higher prevalence of most of the studied conditions.

Health regions
In the current study, the prevalence of DM was 55.4%, this percentage is slightly higher than the Saudi Health Information Survey )SHIS(, 19 which reported a DM prevalence of 50.4% among those aged 65 years and above but slightly lower than the estimated DM prevalence by Al-Modeer et al 20 who reported it to be 57.3%. Conversely, Khoja et al 5 reported a lower prevalence of 32%, and when the use of anti-diabetic medication was accounted for, the prevalence of DM increased to 47%.
The prevalence of HTN was found to be 49.1%. A higher rate )59.1%( was reported by Al Modeer et al 20 and by SHIS )51.2% among those aged 55-64 years and 70% among those aged 65 years and above(. 19 According to the household health survey report, the rate of high blood pressure increases with increasing age, gradually before the age of 40 years, and then rises sharply at 40 years and above, and it is noted that the percentage of high blood pressure diagnosed in the age group 65 years and over is the highest for both genders. The prevalence in this category is 54.5% among females, compared to 44.4% among males. 21 However, lower prevalence of 30% was reported by Khoja et al 5 and when antihypertensive medications were accounted for in estimating the prevalence of HTN, the prevalence increased to 42%.
In the present study, the prevalence of both DM and HTN among females )27.6%( was higher than males )25.9%(. A higher prevalence of diagnosed chronic diseases was seen in the age group 65 years and over, and consisted of 75.8% females compared to 66.3% males. 21 This can be explained by the fact that this study involved participants in the age group 60 and above while the household survey figures are related to those 65 years and above.
In the current study, the overall prevalence of underweight )BMI<18.5 kg/m 2 ( was 5.4% )5.2% among females and 5.6% among males(. This is lower compared to a cross-sectional study carried out among 38 females aged ≥60 years who were residents at the social welfare home for elderly females in Riyadh, Saudi Arabia, which reported 21% of the participants to be underweight. 22 Similarly, another Saudi cross-sectional descriptive study carried out in PHCCs in Riyadh, Saudi Arabia, among 2045 older adults aged ≥60, reported the prevalence of malnutrition to be 20.9%. 23 This difference may be related to the target population, sample size, and the location of the study.
Regarding the overall prevalence of anemia, in the current study using the WHO criteria, it was 4.7% with a higher rate among females )5.5%( than among males )3.9%(. This finding differs from previous studies carried out in other countries, for instance, in the United States of America, using the same criteria, the prevalence of anemia in the elderly was found to range from 8-44%, with the highest prevalence in men aged 85 years and older. 24 As anemia is a common condition in adults aged 60 years and older, and given the demographic growth of this population and the morbidity and mortality associated with anemia, primary care physicians should be familiar with the evaluation and management of anemia in older people. 25 Regarding the prevalence of physician-diagnosed asthma among the studied group, it was found to be 8.9%. A higher physician-diagnosed asthma prevalence of 10.9% was observed in a nationwide, populationbased survey of individuals aged ≥65 years, living in mainland Portugal. 26 The current study found that 8.5% of older people were smokers. This rate is lower than that reported by SHIS )12.2%( among older people aged 65 years and above. 19 These differences may be related to the age of the target population, sample size, socioeconomic status, culture, and lifestyle factors.
In the current study, the overall prevalence of positive screening for depression was 5.9%, ranging regionally between 2.1-18.9%. On the other hand, there was variation in depression prevalence reported by other studies carried out in Saudi Arabia. A study in 2021 that used PHQ-9 to assess the prevalence of Saudi Med J 2023; Vol. 44 )1( https://smj.org.sa depression among the geriatric population visiting PHCCs in the eastern region found that the prevalence was up to 42%. 27 Furthermore, a 2017 study reported that 17% of the hospitalized patients were diagnosed with a major depressive disorder and 10.5% with other depressive disorders. 28 The differences in the prevalence of depression among older people could be attributed to the target population, location of the study, social and cultural differences, and the use of different screening tools. Table 4 -Region-wise distribution of special sense disorders among the studied group during the period 2012-2020. All  screened  Deafness  Hearing impairment  Blindness  Vision impairment   Male  Female  Total  Male  Female  Total  Male  Female  Total  Male  Female  Total   Asir  27643  128  70  198  1209  974  2183  113  101  219  1992  1704    In the current study, the overall prevalence of those screened positive for cognitive impairment was 2.9%, with a wide range among the health regions )0.2-10.7%(. Other studies in Saudi Arabia reported a more common prevalence. A cross-sectional multistage study that involved 1299 older individuals attending PHCCs in Riyadh between January 2015 and April 2017, using the Arabic version of the Mini-Mental State Examination )MMSE(; found that 21% of the studied population had cognitive impairment. 29 Furthermore, a community-based study in 2018 among 170 persons aged ≥60 years using the Arabic  30 In addition, a recent study in Portugal that assessed the prevalence and incidence of cognitive impairment in the elderly population )65-85 years old( reported the prevalence of cognitive impairment to be 15.5%. 31 These dissimilarities may be attributed to the differences related to age, language and education level of the studied group, sample size, and differences in the screening tool used, and cut-off scores for cognitive impairment. Therefore, for future studies, the homogenization of the definition of cognitive impairment and standardized cut-off scores of cognitive tests to compare different studies were proposed. 32 In this study it was observed that the prevalence of DM, HTN, both DM and HTN co-morbidity, and cognitive impairment positive screening results was the highest among participants from Al-Ahsa region. This may be an interesting finding that warrants further studies. In this study, the overall risk of fall among the studied older people was 4%, with a wide range among the regions )1.3-24.5%(. Higher rates were observed by other Saudi studies such as a study in Unaizah, Qassim, Saudi Arabia, that reported it as 31.5% among 280 elderly patients aged >60 years old attending 10 randomly selected PHCCs during the period between January and October 2019. 33 Similarly, higher prevalence of falls )49.9%( among the elderly was reported in a previous study carried out in Riyadh. 34 The lower risk of fall rate in the current study compared to other studies may be attributed to the difference in the assessment tools, the study duration, and the target population number. The annual prevalence of falls has increased by age, from 28-35% for people aged ≥65 years to 32-42% for those aged >70 years. The frequency of falls increases with age and frailty level. 35 Regarding the prevalence of urine incontinence in this study, it was 6.3%. Regionally, the prevalence range was 2.2-10.6%. A higher rate )41.4%( was reported by another Saudi study. 36 In Mexico, the prevalence of urine incontinence was 9.5%, this rate is within the range of the regions observed in this study. 37 In the present study, the prevalence of hearing impairment among the studied group was 12.6% and deafness was 1.4%. This is lower than that observed in a Saudi study by Al Rubeaan et al 38 among patients with type 2 DM where 49% of patients had hearing loss in both ears, 8.3% in the right ear only, 8.9% in the left ear only, and 29% had disabling hearing loss.

Health regions
In this study, the prevalence of vision impairment was 20.6% and blindness was 1.1%. The results of the current study are near to those reported by a previous Saudi population-based cross-sectional study carried out among 705 adults aged 18 years and older in Arar, Saudi Arabia, where 166 )23.5%( cases were found to have vision impairment while only 12 )1.7%( cases were considered as blind. 39 In the current study, the overall prevalence of polypharmacy among the studied older people was 25.3%. This result is lower than that reported by an earlier Saudi retrospective cross-sectional study to evaluate the utilization of medications and comorbidities among 3009 geriatric patients )65 years and older( in the Prince Sultan Military Medical City, Riyadh, Saudi Arabia, database in 2018 which found that 55% of the patients had polypharmacy. 40 This high prevalence of polypharmacy was explained by the fact that the elderly group admitted to the hospital were expected to have multiple comorbidities, which could lead to higher utilization and medication consumption.
Study limitation. Statistical significance tests could not be carried out since we analyzed retrospective pooled data and could not compare the means of the males and females or the regions.
In conclusion, the study findings highlight the importance of CGA in the early detection of geriatric giants, common health problems, and associated risk factors among Saudi older people, which facilitate early intervention and management of any detected disorder to maintain and improve their health and quality of life. The current study indicates that the regions varied in the number of total people aged 60 years and above serviced by the program and delivered CGA. In addition, the regions had a wide range of prevalence of chronic diseases, geriatric giants, and health conditions. This was reflected in reporting a low mean prevalence of some of these conditions such as depression, memory and cognitive impairment, risk of fall, urine incontinence, and impairments of vision and hearing. The variation in the prevalence of chronic diseases among the regions was also reported by other Saudi health reports. 21 Future in-depth clinical studies are needed to investigate the geriatric health conditions utilizing homogenous definitions, and screening and diagnostic tools and cut-off points. The impact of socio-demographic and biological risk factors on older people's health should be thoroughly explored. A detailed national registry for older people health data is warranted.