Indonesian Elderly Research Articles

T Allele of FOXO3 rs2802292 Increases CCL2 Concentration and Slightly Decreases TGF-β Concentration in Indonesian Elderly

T Allele of FOXO3 rs2802292 Increases CCL2 Concentration and Slightly Decreases TGF-β Concentration in Indonesian Elderly

The Association between Religious Activities Participation and Physical Function in Indonesian Elderly

The Association between Religious Activities Participation and Physical Function in Indonesian Elderly

Contributing Factors of Dysphagia in Indonesian Elderly

Abstract Objective Dysphagia is one of the signs that can describe oral hypofunction in the elderly. This condition is usually not noticed nor realized by the elderly and their families, resulting in disability and death. Studies on the relationship between age, gender, education, the number of systemic diseases, and the number of remaining teeth toward dysphagia in the elderly are still limited, so further research is needed. The aim of this study was to analyze the relationship between age, sex, education level, the number of systemic diseases, and the number of remaining teeth with dysphagia and find out which factors contribute the most to dysphagia. The contributing factors need to be known to minimize the risk of dysphagia. Materials and Methods This is a cross-sectional study with 121 elderly aged 60 years living in community dwellings as subjects of this study. General health data were obtained from anamnesis; demographic data were also collected and an examination of the number of remaining teeth was carried out and recorded on the odontogram by one researcher. After that, a dysphagia screening tool was given for self-assessment or assisted by the two researchers according to the conditions felt. Two researchers were calibrated before collecting data. Results In the bivariate analysis, age, the number of remaining teeth, and several systemic diseases were associated with dysphagia (p = 0.027, 0.023, and 0.047, respectively). No association was found between gender, education, and dysphagia status (p > 0.05). Age (p = 0.027), gender (p = 0.165), number of remaining teeth (p = 0.023), and the number of systemic diseases (p = 0.047) are the risk factors that were included in the multivariate model. From the final multivariate model, the number of remaining teeth (p = 0.017; odds ratio [OR] = 4.318), several systemic diseases (p = 0.036; OR = 2.427), and age (p = 0.072; OR = 1.962) contributed most to the dysphagia status, after controlling for confounding variables. Conclusion It is concluded that the number of remaining teeth, several systemic diseases, and age are the factors that contribute the most to the occurrence of dysphagia.

Polymorphism of the Forkhead box-O3 (FOXO3) Longevity Gene rs2802292 and senescence-associated secretory phenotype (SASP) in Indonesian Elderly Population

BACKGROUND: Forkhead box O3 (FOXO3) is a transcription factor that regulates stress resistance, metabolism, cell cycle, and apoptosis. Several studies exhibited the association of the FOXO3 polymorphism rs2802292 with human longevity and protects individuals from degenerative diseases. The emergence of degenerative diseases in the elderly is associated with the accumulation of senescent cells that secrete a secretome known as a senescence-associated secretory phenotype (SASP) consists of several cytokines, chemokines, growth factors, proteases. OBJECTIVE: The aim of this research was to analysis polymorphism of FOXO3 gene rs2802292 G-allele and its impact to the SASP by measuring IL-1α, IL-6, IL-8, and IL-10 in Indonesian elderly populations. METHODS: This study was conducted on 92 elderly subjects living at Jakarta. DNA was isolated from the whole blood then continued with PCR and sequencing for FOXO3 rs2802292 analysis. SASP was analyzed from the plasma using Luminex. Statistical analysis was performed using ANOVA and Kruskal Wallis. RESULTS: The results showed that FOXO3 rs2802292 was detected in Indonesian elderly population as follows GG, GT, TT genotype frequencies were 17.4 %, 42.4 % and 40.2 % respectively. Meanwhile, G and T allele frequencies based on the Hardy-Weinberg equilibrium test were 0.385 and 0.615 respectively. GG genotype was significantly found in subjects with longevity. Nevertheless, SASP analysis was found no significant differences both among GG, GT, TT genotypes. CONCLUSION: The frequency of FOXO3 rs2802292 G-allele in Indonesian elderly population was 0.385 and significantly detected in subjects with longevity. However, the FOXO3 rs2802292 polymorphism did not affect cytokines level as the component of SASP.

2. Hypertension, a Major Risk Factor Doubles Arthritis Odds in Indonesian Elderly Population

Background: Arthritis is a highly debilitating disease prevalent in the elderly population. Despite its comparable inflammatory pathophysiology, few studies especially in the Indonesian population have explored the links between arthritis and the ever-increasing metabolic syndrome. Objective: This study aims to analyze the relationship between four metabolic syndrome components (obesity, hypertension, dyslipidemia, and diabetes mellitus) and arthritis in the Indonesian elderly population. Methods: Data are gathered from the fifth wave of Indonesian Family Life Survey fielded in 2014–2015. After sampling weight adjustments, 3493 respondents aged 60+ years fulfilled the inclusion and exclusion criteria. Independent variables of interest are analyzed using Pearson chi-square (CI = 95%, p < 0.05) and logistic regression (CI = 95%, p < 0.05). Result: The prevalence of arthritis in the sample population is 12.8%. The number of elderly with central obesity, hypertension, dyslipidemia, and diabetes mellitus is 44.1%, 28.4%, 8.2%, and 7.8% respectively. Multivariate analysis shows that baseline sample characteristics of female gender and low economic status, as well as three metabolic syndrome components obesity, hypertension, and dyslipidemia shows a significant association toward arthritis (p < 0.05). Hypertension poses the highest risk on arthritis out of all the variables analyzed in this study (OR 2.131; 95% CI 1.723 - 2.636). Conclusion: A significant association is found between 3 out of the 4 metabolic syndrome components, namely obesity, hypertension, and dyslipidemia on arthritis. Thus, early and comprehensive treatment of these modifiable metabolic risk factors, especially hypertension, may help to lower arthritis rates in the elderly population in Indonesia.

The Relationship Between Knowledge of Dental and Oral Health and The Number of Functioning Teeth in Indonesian Elderly People

Tooth loss is a cause of decreased masticatory function that affects the oral cavity and general health in the elderly. The elderly was expected to have at least 20 working teeth, meaning that the masticatory, aesthetic and speech functions were considered normal, although less than 32 teeth. This study aims to determine the relationship between the dental and oral health of the elderly with the number of functioning teeth at the Hargo Dedali Nursing Home in Surabaya. This type of research is analytic with a cross sectional design. The total population is 38 elderly and the research sample is 35 elderly using random sampling technique with purposive sampling. Method analyzed technique uses the Pearson Correlation test. The result of this research is the elderly population is female. Their age range is between 60-92 years. Questions were answered correctly overall by 48.1%. The most questions answered incorrectly about tooth loss by 67.9%. There are 3 elderly who have 20 working teeth. The average working gear is 9.3 or 9 teeth per person. Data are normally distributed. There is a relationship between the two variables (0.000 < 0.05). Conclusion of this research is smaller the value of dental and oral health knowledge of the elderly, the less the number of teeth that work. The benefits of this research can provide awareness and motivation for families, nursing home managers, health workers in an effort to serve dental and oral health in the elderly.

Prevalence of Anemia and Factors Associated With Handgrip Strength in Indonesian Elderly Population.

Introduction: Anemia is a common blood disorder in the elderly which is associated with numerous poor medical outcomes. However, there is currently no study that assesses anemia prevalence of the Indonesian elderly population aged ≥60 years old in multiple provinces and analyzes its association with handgrip muscle strength using a large sample size.Aim: We aimed to elucidate the prevalence of anemia and analyze factors associated with handgrip strength in elderly.Method: This was a cross-sectional study using data from the Indonesian Family Life Survey-5 (IFLS-5). All participants aged ≥60 years old were included in this study. Exclusion criteria were: (1) respondents who refused to take health measurements (hemoglobin (Hb) level, handgrip strength, weight, stature, and waist circumference); (2) respondents with incomplete or missing data; (3) respondents with history of stroke; and (4) respondents with history of pain, swelling, inflammation, injury, and surgery on one or both hands within the last 6 months. The dependent variable for this study was handgrip strength. Subjects were classified as weak if the handgrip strength was <28 kg for men and <18 kg for women based on classification from the Asian Working Group for Sarcopenia (AWGS) 2019. The independent variables were Hb level, gender, age, body mass index (BMI), waist circumference, smoking history, comorbidities, and current use of drug therapies. Based on WHO standard, male and female participants with Hb less than 13 g/dL and 12 g/dL, respectively, are defined as anemic. Statistical analyses used included correlation, bivariate logistic regression, and multivariate logistic regression.Result: A total of 3192 individuals were selected for analysis. Overall, 38.8% of participants had anemia, and the prevalence of anemia increases with age. A total of 56.30% of participants aged ≥80 years had anemia. There was a positive correlation between Hb level and handgrip strength in the Indonesian elderly population (r: 0.349; p value: <0.001). Multivariate analysis showed that anemia was significantly associated with weak handgrip strength (OR: 1.557; 95% CI: 1.314-1.846; p value: <0.001). Age ≥ 80 years (OR: 5.234), age 70-79 years (OR: 3.152), low BMI (OR: 1.827), and hypertension (OR: 1.340) were associated with weak handgrip strength in multivariate analysis.Conclusion: The prevalence of anemia in the Indonesian elderly was 38.8% and anemia was associated with weak handgrip strength. The association of anemia with weak handgrip strength is more pronounced in males and the elderly aged ≥80 years.

Prevalence and Risk Factors of Hypertension and Diabetes Mellitus among the Indonesian Elderly

Background: Epidemiological and demographic transitions lead to the emergence of non-communicable diseases (NCD) among the elderly. This study aimed to examine the risk factors of hypertension and diabetes mellitus (DM) among the elderly by using secondary data (Basic Health Research 2018). Methods: Secondary data from Basic Health Research (N = 88,911) were used. Cut-off values for measurement were WHO standard of 126 mg/dl for fasting and 200 mg/dl for non-fasting for DM and 140 mmHg for systole and 90 mmHg for diastole for hypertension. Univariate, bivariate, and multivariate (binary logistic regression) analyses were conducted using STATA version 15. Results: The prevalence of hypertension and DM among the elderly was about 22.30% and 5.39%, respectively. Age, sex, educational level, marital status, place of residence, and employment status were substantially associated with hypertension and were risk factors for DM. Conclusions: There is significant correlation between hypertension and DM are risk factors of one another and therefore show a relationship. Various sectors must develop appropriate programs, including community and family support, to address this situation.

Intrinsic and Extrinsic Risk Factor for Fall among Community Dwelling Indonesian Elderly

BACKGROUND: Fall-related injuries are identified as a public health problem that has major consequences in affecting the lives of elderly people. Recent studies showed that one out of four elderly people suffers from this condition annually. AIM: This study aims at identification of fall risk factors that involve intrinsic and extrinsic factor to predict the future fall. MATERIALS AND METHODS: This study uses an observational design and a descriptive-analytic approach with a cross-sectional method which was used to identify risk factors for falls. This study targeted 60 years and above who live in West Java region. Afterward, a total of 420 people were obtained and divided into two regions, 215 people in Bandung Regency and 205 people in Bandung City. Furthermore, the sampling technique used was for cluster random sampling. RESULTS: The elderly who experienced incontinence in controlling urination had the potential of falling by 4 times compared to those who did not AOR = 3.73; 95% CI (1.038–13.428). Furthermore, those who had history of falling in the past 12 months were 2.4 times exposed compared to those who had not fallen AOR = 2.438; 95% CI (1.219–4.875). Balance disorders also contributed in increasing the risk of fall by 2 times with a value of AOR = 1.703; 95% CI (1.018–2.849). An extrinsic factor, namely, unsafe home environment has higher possibility to increase the risk of falling 2.6 times compared to those in safer environment (AOR = 2.603; 95% CI [1.331–5.087]). CONCLUSION: This study succeeded in identifying the risk factors for falls among the elderly in intrinsic and extrinsic approach. This finding can be used as a reference in planning health promotion programs for elderly people, specifically in the primary prevention of morbidity and mortality that occur due to falls.

Anthropometry Showed Better Correlation in Insulin Sensitivity Compared to 25(OH)D Levels in Indonesian Elderly

Abstract Objectives In Indonesia, diabetes mellitus prevalence escalated from 1,6% in 2013 to 2% in 2018 with the highest age group between 55–64 years old followed by 65–74 years old. Various theories have been postulated in the pathogenesis of diabetes mellitus. Low vitamin D, high body mass index (BMI), body fat (BF), waist circumference (WC), low skeletal mass (SM) and recently high waist-hip ratio (WHtR) gain attention and widely been researched. The differences in body composition between Caucasian and Asian people specially in elderly might give new perception in understanding the mechanism of diabetes. The objective of this study was to determine the correlation between 25(OH)D levels and anthropometry measurements with insulin sensitivity in Indonesian elderly. Methods A cross sectional design was conducted involving 77 elderly (&amp;gt;60 years old) both men and women live in Pusat Santunan Dalam Keluarga (PUSAKA) in Central Jakarta. Anthropometry measurent included the measurement of complete BMI, BF, WC, WHtR. Laboratory assessment include 25(OH)D, fasting glucose plasma, fasting insulin, Homa-B, Homa-IR, HbA1C, and QUICKI. Pearson and Spearman's correlation test was used to assess the associations of age, sex, BMI, BF, SM, WC, WHtR, 25(OH)D, fasting glucose plasma, fasting insulin, Homa-B, Homa-IR, HbA1C with insulin sensitivity. Results: Most of subjects were women (81.8%) and the Spearman's correlation test showed strong negative correlation with insulin sensitivity in fasting insulin (r = −0.939; P &amp;lt; 0.01), HOMA-IR (r = −0.999; P &amp;lt; 0.01) and mild negative correlation with fasting glucose (r = −0.502; P &amp;lt; 0.01), HOMA-B (r = −0.474; P &amp;lt; 0.01), HbA1C (r = −0.291; P = 0.01), BMI (r = −0.409; P &amp;lt; 0.01) and WHtR (r = −0.278; P &amp;lt; 0.01). Based on Pearson's correlation tes, there was a mild negative correlation between WC (r = −0.373, P &amp;lt; 0.01) and SM (r = −0.415, P &amp;lt; 0.01) and insulin sensitivity. Contrary 25 (OH)D, age and BF showed no significant correlation (r = 0.170; P = 0.140), (r = 0.154; P = 0.181) and (r = 0.574, P = 0.56). Conclusions The anthropometry assessment except BF showed significant mild correlation with insulin sensitivity, while age and 25(OH)D did not significant correlation and should be explore more specially in elderly. Funding Sources Trisakti University.

Health and Social Problems in Indonesian Elderly. How Can Health Care System To Overcome ?

Increasing elderly population is a problem in Indonesia. Many problems faced in elderly. Elderly are high risk to experience a disease or illness. As well as, long term care is needed for release the disease. A changing in biopsychosocial also important for service provider to control the effect. Collaboration and partnerships is useful to develop strengthening in creating health care system. Furthermore, policy maker and service provider are also better able to review and refine their existing measure, policies, product and geriatric service, which target elderly population in Indonesia.

45 The Association between Sensory Impairment and the Incidence of Fall among Indonesian Elderly

Abstract Fall is the biggest caused of injury among elderly. It can be markers of poor health and declining function, and they are often associated with significant morbidity moreover it cause disability in the elderly that may increase health funding. The prevalence of fall among elderly in Indonesia is 8.2%. Most of them occur at home and the environment (63.7%), on the highway (18.9%) and the workplace (8.8%) (Ministry of Health Republic Indonesia, 2019). The normal changes of aging, like poor eyesight or poor hearing, considered as the risk of fall among the elderly. This condition has been linked to all-cause of mortality through three mediating variables i.e. disability in walking, cognitive impairment, and self-rated health (WHO, 2007) . This study aimed to assess the association between sensory impairment (hearing impairment and visual impairment) and the incidence of falls among the Indonesian elderly. This study conducted in cross sectional setting. Populations of this study are the elderly from 3 provinces namely Jakarta, West Java and Yogyakarta and selected in cluster random sampling. A total of 427 elderly (those who are above 60 years old) are participated this study. Hearing impairment is evaluated in self-reported and observation and visual acuity test performed to identify the visual impairment. The incidence of fall is identified by self-reported fall in the last 12 months. The multiple regression analysis identifies the model predictor for fall is statistically significant. The result showed that after adjusted to age and gender, elderly with vision impairment likely to have 2.054 times (95%CI 1.265 -3.335) to fall, the elderly with hearing impairment have 1.66 higher odds to fall (95%CI 1,005 - 2,793); Male Gender OR =0.46 (95% CI 0,288 -0,783) and Ages OR=1.84 (95%CI 1.1.67 -2.894). This finding indicates that after adjusted to ages and gender sensory impairments are increase the risk of fall among Indonesian elderly.

Depression in Indonesian Elderly Inmates: A Preliminary Study

Background: Physical and social environments in prisons cause mental disorders, the prevalence of depression is higher in correctional settings than in general population. Depression is one of mental disorders among older adult including elderly prisoners, however the incidence is uncertain particularly in Indonesia.&#x0D; Objectives: This study aims to describe the prevalence of depression among elderly inmates in Indonesia.&#x0D; Methods: A survey study design was employed on 21 elderly inmates selected by total sampling method in a prison in Indonesia. Data was collected by a face to face interview using Depression Anxiety Stress Scale and statistical analysis used descriptive statistics.&#x0D; Results: The study revealed that 4.76% elderly had extremely severe depression, 4.76% elderly had severe depression, 9.52% elderly had medium depression,23.81%elderlyhadmilddepression,and57.14%elderlyhadnodepression.&#x0D; Conclusions: Prevalence of depression among elderly inmates was relatively high. Thus, providing counseling to elderly to cope with prison environment will increase problem solving.

A Study of Psychoactive Medicines and Risk of Falls Among Indonesian Elderly Patients

One of the causes of injury to the elderly is due to falls. Falling can be prevented by identifying and controlling risk factors. One risk factor that can be controlled is the use of fall risk medicines including psychoactive. This study aims to identify the association between the use of psychoactive medicine and its characteristic with the risk of falls among the elderly in Indonesia. The study utilized a case-control study design for a total number of 414 elderly patients, during October until December 2018. Cases were elderly aged 60 years or above with a high risk of falling assessed using the Morse Fall Scale (MFS≥45). Each case was matched with up to two randomly selected controls of the same age who are classified as low to moderate risk of falling (MFS<45). The use of psychoactive medicines was screened from a history of drug use for the past six months. Psychoactive medicine-fall risk associations were estimated via logistic regression. There were 138 cases and 276 controls. The median age of subjects was 66 years old and 54.83% was a woman. Elderly with a high risk of falling had higher psychoactive medicines use when compare with controls (31.16 % vs 21.38 %, p< 0.05). After adjusting for potential confounders, the use of psychoactive medicines was significantly associated with higher fall risk in elderly patients (OR 1.79 95% CI 1.10-2.90). Only the duration of psychoactive medication use over 90 days was significantly associated with a high risk of falling (AOR 3.65 95% CI 1.46-9.14). In elderly patients, the continued use of psychoactive medicines increased the risk of fall. Prescribers need to weigh risk and benefit from the use of psychoactive medicines in the elderly to prevent future fall.

Multimorbidity Increases the Risk of Falling among Indonesian Elderly Living in Community Dwelling and Elderly Home: A Cross Sectional Study

Multimorbidity Increases the Risk of Falling among Indonesian Elderly Living in Community Dwelling and Elderly Home: A Cross Sectional Study

The Development of a Questionnaire on Factors Affecting Non Adherence Behavior among Indonesian Elderly Population

I nstruments which can be used to identify factors affecting the medication adherence of elderly with diabetes mellitus (DM) have not been discovered in Indonesia. The objective of this study was to develop a questionnaire to identify factors affecting elderly patients’ medication adherence . The development of the questionnaire was conducted based on published references attained through the exploration of research evidence with several keywords and database s . C ontent validity and face validity test were conducted using experts’ assessment. Construct validity test was conducted based on calculated R against table R while reliability test was conducted with Chronbach’s Alpha . Present study produced a valid and reliable questionnaire comprising 35 questions in 14 subcategories from 4 factor domains with the calculated R = 0,357-0,788 and Chronbach’s Alpha = 0,934. The questionnaire can be used for further research throughout Indonesia, hence a complete overview of factors affecting elderly DM patients’ medicine consumption adherence can be obtained. The identification of factors related to the usage of DM patients’ medicine is expected to serve as a base for the government, both of state and local government, to produce policies related to health interventions to be implemented.

Osteoporosis-Concerned Group and Empowering Elderly Model to Increase Calcium Intake: a Study Among Indonesian Elderly

&lt;p&gt;Aging process leads to decline in body functions, including in musculoskeletal system. Bone mass loss (osteoporosis) is one of the problems in musculoskeletal system which often experienced by elderly. Osteoporosis could have a great impact on elderlys life, such as increased risk of fractures and decreased quality of life. The objective was to construct models of the formation of osteoporosis care group (OCG) and empowerment of the elderly to increase calcium intake to reduce the osteoporosis incidence. This study uses Participatory Rural Appraisal (PRA) approach. Participants are Posyandu Lansia cadresand members of Posyandu Lansia in the Dawuhan village, Padamara District, Central Java, Indonesia. The following steps were implemented in this study 1) problem identification 2) formation of OCG, 3) OCG training, and 4) OCG mentoring process. Data was analyzed using qualitative method. Results showed that knowledge and skills of OCG members in regards to osteoporosis management were improved following training andmentoring process. Further, OCG members can apply their knowledge and skills toempower elderly for increasing calcium intake. OCG which is involving cadres and community leaders and elderly as its members are very important to cultivate awareness in health maintaining in order to prevent osteoporosis.&lt;/p&gt;

The Assessment Model of Quality of Life in Indonesian Elderly

The Assessment Model of Quality of Life in Indonesian Elderly

Oral Hygiene Status and Cognitive Function in Indonesian Elderly

Oral Hygiene Status and Cognitive Function in Indonesian Elderly

Recommended Alternative Daily Intake of Fruits and Vegetables for Indonesian Elderly

Abstrak Latar belakang:Organisasi Kesehatan se Dunia (WHO) merekomendasin konsumsi sayur dan buah paling sedikit 400 gr atau 5 (lima) porsi sayur dan buah sehari. Penelitian ini untuk menentukan alternatif jumlah dan jenis anjuran konsumsi sayur dan buah untuk usia 65 tahun atau lebih untuk kecukupan zat gizi vitamin A, vitamin C, potassium, asam folat, dan serat. Metode:Penelitian menggunakan data konsumsi sayur dan buah dari data Riset Kesehatan Dasar (Riskesdas) tahun 2010. Analisis data menggunakan program analisis linier untuk memperoleh lima alternatif jumlah dan jenis sayur dan buah untuk usia lebih dari 65 tahun. Hasil:Subjek yang dapat dianalisis sebanyak 7087 orang. Lima jenis buah yang paling banyak dikonsumsi adalah pisang, jeruk, pepaya, apel dan semangka. Lima jenis sayur yang paling banyak dikonsumsi adalah sayur bayam, sayur kangkung, sayur daun singkong, sayur asam, dan sayur sop. Berdasarkan hasil analisis progam linier dan ngka Kecukupan Gizi tahun 2004 untuk vitamin A, vitamin C, asam folat, serat, dan potasium bagi usia lebih dari 65 tahun, maka jumlah anjuran konsumsi sayur dan buah adalah 300 gram sayuran dan 200-400 gram buah. Kesimpulan: Anjuran alternatif konsumsi sayur dan buah untuk usia lebih dari 65 tahun adalah 300 gram (3 mangkok) sayuran dan 200-400 gram (2-4 potong) buah. (Health Science Indones 2014;1:30-4) Kata kunci:anjuran konsumsi harian, sayur, buah, usia lajut Abstract Background: The WHO recommends the daily consumption of fruits and vegetables of at least 400 grams or 5 servings. This study was conducted to assess consumption of fruits and vegetables in 65 year-old and above Indonesians, and the adequacy of daily requirements of vitamin A, vitamin C, potassium, folic acid, and fiber. Methods: The study used data from 2010 National Health Survey Indonesia. Using linier programming, 5 alternatives of combination of fruits and vegetables were presented for 65 year-old and above. Result: The number of subjects that could be analyzed was 7087 subjects. The study found the five most frequently consumed fruits were bananas, oranges, papayas, apples, and watermelons. Five most frequently consumed vegetables dishes were cooked spinach, water spinach (kangkung), cassava leaves, tamarind vegetable dish and vegetable soup. The alternative amount of fruits and vegetables consumption for 65 year-olds and above is 300 grams of cooked vegetables and 200-400 grams of fruits. Conclusion: Alternative fruits and cooked vegetables consumptions for 65 year-old and above Indonesians were 300 grams (3 bowls) grams of cooked vegetables and 200-300 grams (2-4 pieces) of fruits. (Health Science Indones 2014;1:30-4) Key words: daily consumption guide, fruits, vegetables, elderly