Prevalence of comorbidity and polypharmacy status and their impact on health-related
quality of life (HRQL), frailty, and functional status among older CVD patients: A
hospital-based cross-sectional study
Respondent’s name: Data collectors name: Date:
Address: Patient category: Ambulatory (Outpatient)/ Inpatient (Hospitalized)
A. Socio-Demographic characteristics
SD Demographic characteristics Category
1. Gender (0) Female (1) Male
2 Age group (0)55-60 (1)61-65 (2) 66-70 (3) ≥70
3 Level of education (0) Unable to read and write (1) Able to read and write (2) Elementary
school (3) High school/secondary school (4) College and vocational training
(5) university
4 Marital Status (0) Single (1) Married (2) Widow (3) Divorce (4) separated
5 Family size (0) ≤4 (1) >4
6 Family income (BDT) (0) ≤10,000 (1)10,000-15000 (2) 15-20 (3) >20
7 Residence (0) Urban (1) Rural
8 Current occupation (0) Employee (1) Merchant /private business/self-employed (2) Farmer (3)
Housewife (4) Retired (5) other
9 Living arrangement (0) Live alone (1) Live with family
10 Smoking history (0) No (1) Yes. If yes, how many cigarettes per day----?
11 Self-reported health status (0) Poor (1) Moderate (2) Good
12 Family history of CVD (0) No (1) Yes
13 Cardiovascular disease (CVD) status (0) No (1) Yes
15 Self-reported physical activity (0) Light intensity (<3 METS) [Walking slowly (i.e. Shopping, Walking
around the office), sitting at your computer, making the bed, eating,
preparing food, and washing dishes, light housework such as cooking,
dusting, ironing, folding laundry, and putting away groceries.]
(1) Moderate intensity (3-<6 METS) [Sweeping the floor, slow dancing,
shooting a basketball, Walking very briskly (4 mph), Cleaning heavy
(washing windows, vacuuming, mopping), Bicycling light effort (10-12
mph)]
(2) Vigorous intensity (≥ 6 METS) [Running (5 mph >), swimming,
Shovelling jumping rope, carrying heavy loads (i.e. bricks), Bicycling fast
(14-16 mph), Jogging at 6 mph, Basketball, soccer, tennis game, etc.]
17 Self-reported mental health (0) Bad/Very bad (1) Good/average (2) Very good/excellent
16 Having problems in memory or concentration (0) No problem (1) Low memory or concentration
during the last month preceding the survey?
17 Do you depend on your family members for (0) No (1) Yes
your daily living activities (DLA)?
18 How did CVD impact your family’s earnings (0) Earnings decreased (1) Earnings increased (2) Earnings not changed
in the last 5 years?
19 Age of diagnosis: 20. Number of years with the diagnosis:
B. Anthropometric Status C. Physiological status
Anthropometric status Height Weight BMI MUAC 1. Blood pressure
2. Lipid profile HDL: LDL: TG: TC:
3. Breathlessness
4. HbA1c (%) S. Creatinine
D. Comorbidity status E. polypharmacy status
Name of diseases Yes(0) No (1) 1. <5 (less than five concurrent drugs)
1. Arterial hypertension 2. ≥5 (five or more concurrent drugs)
2. Hyperlipidemia/dyslipidemia 3. <2 (less than two drugs) (OTC drugs)
3. Diabetes mellitus 4. ≥2 (two or more two drugs) (OTC drugs)
4. Coronary Artery Disease (CAD)
5. COPD (coronary obstructive pulmonary disease) F. Frail questionnaire (Fatigue, Resistance, Aerobic, Illnesses, Weight)
6. Arthritis and other neurological Yes No
disorders (1) (2)
7. Chronic liver disease 1. Are you too tired to exercise? (Fatigue)
8. Constipation 2. Can you climb one flight of stairs without
9. Valvular heart assistance? (Resistance)
10. Chronic kidney Diseases 3. Can you walk one block without assistance?
11. Ischemic heart diseases (Aerobic)
12. Stroke 4. Five or more illnesses (confirmed with EMR)
13. Hyperthyroid disorder (Illnesses)
14. Congestive heart failure 5. >5%Weight loss over the past year (Obtained
15. No-comorbidity from EMR) (Weight loss)
G. Barthel index for functional evaluation (Functional status)
Activity Score Score Patients
score
1. Feeding Unable (0) Needs help cutting, spreading Independent (10)
butter, etc., or requires a
modified diet (5)
2. Bathing Dependent (0) Independent (or in the shower) (5)
3. Grooming Needs help with Independent face/hair/shaving
personal care (0) (Implements provided) (5)
4. Dressing Dependent (0) Need help but can do about half Independent (including buttons, zips,
unaided (5) laces, etc..)
5. Bowels Incontinent (or needs Occasional accident (5) Continent (10)
to be given enemas)
(0)
6. Bladder Incontinent, or Occasional accident (5) Continent (10)
catheterized and
unable to manage
alone (0)
7. Toilet use Dependent (0) Need some help, but can do Independent (10)
something alone (5)
8. Stairs Unable (0) Needs help (verbal, physical, Independent (10)
carrying aids) (5)
9. Transfers Unable, no sitting in Major help (one or two people, Minor help Independent
(bed to chair balance (0) physical) can sit (5) (verbal or (15)
and back) physical) (10)
10. Mobility Immobile or <50 yards Wheelchair independent, Walk with the Independent (but may
(on surface (0) including corners, >50 yards (5) help of one use any aid; for
levels) person (verbal example, stick)> 50
or physical) yards (15)
(10)
H. Health-related quality of life (HRQoL) (ED-5Q-5l) I. Adopted drugs
o Amlodipine
o Clarithromycin
o Metformin
o Prednisolone
o Vitamin B1
o Simvastatin
o Lovastatin
o Ceftriaxone
o Warfarin
o Omeprazole
o NPH insulin
o Glibenclamide
o Hydrochlorothiazide
o Digoxin
o Atenolol
o Spironolactone
o Nifedipine
o Furosemide
o Enalapril
o Aspirin
o Statins
J. DDQ (FFQ and 24-hour recall method)
Food Group FFQ Conditions 24 hours Frequency Weekly
Yes No Eat almost Eat one Eat one or Seldom eat
every day (4) every two twice a (1)
days (3) week (2)
Cereals/Grains corn/maize, rice, wheat, sorghum,
bread, noodles, porridges
Roots and sweet potatoes, beets, carrots, radishes,
tubers/Potatoes Potatoes
Legumes & Beans, peas, lentils, nuts, seeds.
nuts
Fats and oils Soybean oils, olive oil, sunflower oil,
Animal fat, butterfat, ghee
Meat and Beef, goat, buffalo, mutton, duck,
poultry Pigeon, quail, chicken, other birds, etc.
Fish fresh or dried fish or shellfish
Eggs chicken, duck, guinea hen, or any other
Dark green dark green/leafy vegetables, including
leafy vitamin-A-rich leaves such as cassava,
vegetables kale, spinach, bean, etc.
Milk/dairy Yoghurt, cheese, butter,
product Sour cream, milk powder, lassi, etc.
Fruits Lemon, orange, grapefruit, tomato