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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION Ms. SUNITHA ANN KURUVILLA 1 NAME OF THE I YEAR M. Sc NURSING CANDIDATE E.T.C.M COLLEGE OF NURSING AND ADDRESS P.O. BOX No. 4, KOLAR – 563 101 KARNATAKA NAME OF THE E.T.C.M COLLEGE OF NURSING INSTITUTION PO BOX NO 4, KOLAR - 563101 COURSE OF STUDY MASTER OF SCIENCE IN NURSING AND SUBJECT MEDICAL SURGICAL NURSING 2 3 DATE OF ADMISSION 1-7-2011 4 TO COURSE “EFFECTIVENESS OF VIDEO ASSISTED TEACHING MODULE ON KNOWLEDGE TITLE OF THE OF OLDER ADULTS REGARDING 5 TOPIC PREVENTION OF SELECTED GASTROINTESTINAL DISORDERS OF GERIATRICS” 1 6. BRIEF RESUME OF THE INTENDED WORK 6.1 NEED FOR THE STUDY I truly believe that age … if you are healthy… age is just a number - Hugh Hefner Health is a central issue associated with increase in longevity and population ageing. The maintenance of health status and functioning with age is a critical factor impacting upon many other aspects of the lives of older persons, their families and communities.1 Old age is the evening of life. It is an integral part of human life. It is unavoidable, undesirable and problem ridden phase of life. Ageing is a time of numerous illnesses and common disability. Old people have limited regenerative capabilities and are more prone to disease, syndromes, and sickness than other age groups.2 It is estimated that presently in 2011, there are around 600 million persons aged 60 years and over all over the world. This figure may double by 2025 and will reach virtually two billion by 2050. Out of these, a vast majority of the older persons will be in the developing world. According to an estimate of the United Nations Organization (UNO), presently one out of every 10 persons is 60 years or older.3 According to Indian Scenario of Geriatric population in India in 2011, Seven per cent of the 1.1 billion Indian population are over the age of 60. According to an estimate, by 2021, India’s elderly population will cross 137 million. Currently, India has the second largest aged population in the world.3 As age progresses, the health problems faced by the adults are neurological disorders, Sensory disorders, Cardiovascular disorders, Endocrine Disorders, Respiratory disorders, Genito-urinary disorders, Gastro-intestinal Disorders and 2 Musculoskeletal disorders. The most common health problems seen in all the elderly people are Gastro-intestinal Disorders. Ageing is accompanied by several changes in the gastro-intestinal (GI) system and older adults frequently present with GI problems. According to John Hopkins Medicine, almost 40 percent of all older adults experience digestive symptoms.4 Depending on their age and any illness in the elderly; they have a slower gastrointestinal motility.5 Physician visits for constipation are more frequent by individuals 65 years of age or older. Elderly people report problems with constipation five times more frequently than younger people. They are more likely to suffer from constipation due to changes in diet, medication, decreased mobility and intestinal motility. The incidence of constipation is over 10% worldwide and over 15% in India. Around 2% of the population suffers recurrent and constant constipation and is more common in women than in men. In the elderly, up to 50% self-report constipation and up to 74% use laxatives daily. It occurs due to poor diet and liquid intake, Immobility and lack of exercise, stress, ignoring the urge to defecate, medications and may be secondary to another disease.6 Another gastrointestinal problem in the older adults is dyspepsia (indigestion). An abnormality in digesting food or lack of proper digestion is termed as dyspepsia. Globally, the prevalence of uninvestigated dyspepsia varies between 7% - 45%, while the prevalence of functional dyspepsia has been noted to vary between 11% - 29.2%. In India, dyspepsia was more prevalent in adults above 40 years of age. Among the Asian countries, India stood second highest with an incidence of 30.4% having dyspepsia among the population.7 Gastroesophageal reflux disease (GERD) is a chronic condition caused by the reflux of acidic gastric contents into the esophagus and this problem is highly 3 prevalent and is considered common in the elderly and may present with various symptoms, such as heartburn, regurgitation, dysphagia, or chest pain. 8 Studies show that 15% of older individuals have heartburn and regurgitation at least once a week and 7% have symptoms daily.9 Another common disorder seen in the elderly is peptic ulcer disease. It is a focal area of the stomach or duodenum that has been destroyed by digestive juices and stomach acid.10 There are many ways to prevent these disorders through proper nutrition, physical activity and with regular exercise, etc. The challenges in treating this population include communication, education, and breaking through barriers. The objective of geriatric care is to meet long term care needs, improve the quality of life, and to maintain their independence for as long as possible. Media plays an active role in creating awareness among people. The module of video assisted teaching is an audio visual aid and it is used as an instructional device in which the message can be heard as well as seen. The images initiates, stimulates and reinforce learning. It provides significant gains in informational learning, retention, recall, thinking, reasoning and activity interest, which enhances personal growth and development. Most of the geriatric people are ignorant and it is necessary to educate. Education of patient is the key to success, and skilled nurses in the health care delivery system are the important member in enhancing the knowledge of the public. Based on the above mentioned information and the personal observations by the investigator, she feels the need to educate older adults regarding prevention of selected gastrointestinal disorders of geriatrics using a video assisted teaching module. 4 6.2 REVIEW OF LITERATURE The review of literature is arranged under the following categories: 6.2.1 Review of literature related to geriatric people. 6.2.2 Review of literature related to gastrointestinal disorders in geriatric people. 6.2.3 Review of literature related to effectiveness of video assist teaching module. LITERATURE RELATED TO GERIATRIC PEOPLE As we enter the 21st century, population aging has emerged as a major demographic trend worldwide. Throughout the world today, there are more people aged 65 and older than the entire populations of Russia, Japan, France, Germany and Australia -combined. By 2030, 55 countries are expected to see their 65 and older populations at least 20 percent of their total. By 2040, the global population is projected to number 1.3 billion older people—accounting for 14 percent of the total. By 2050, the U.N. estimates that the proportion of the world's population age 65 and over will more than double, from 7.6% today to 16.2%. China and India have the largest older populations. By 2050, China will see its number of elders grow 30% from 109 million to 350 million and India, from 62 million to 240 million.11 According to the United Nations Department of Economic and Social Affairs, one out of every ten people on the planet is now 60 years of age or older and they predicted that, by the year 2050 one out of five people will be aged 60 years and by 2150, one out of every three people will be aged 60 years or older. Additionally, the oldest old are the most rapidly expanding segment of the elderly population. Currently, the oldest old make up 11 percent of the 60+ age group will grow to 19 percent by 2050. With the number of elderly people on earth at any one time rising 5 rapidly, there is an increased urgency to address the rights and roles of elderly persons in our world.11 Population aging is a worldwide phenomenon, and India is no exception. Indian population has approximately tripled during the last 50 years, but the number of elderly Indians has increased more than fourfold. The 2001 census has shown that the elderly population (60+) of India accounted for 77 million and census 2011 projections indicate that the elderly population has crossed the 100 million mark. It took more than 100 years for the aged population to double in most of the countries in the world, but in India it has doubled in just 20 years. The life expectancy has also gone up to over 70 years today. With fast changing socio-economic scenario, industrialization, rapid urbanization, higher aspirations among the youth and the increasing participation of women in the workforce, roots of traditional joint family system has been eroding very fast. In urban areas of the country traditional joint family system has become thing of past. In such changing situations, majority of older persons, who have passed most part of their life with their joint or extended families are on the verge of isolation or marginalization in old age.12 A study conducted on identifying unmet needs in older patients at Australia. The study raveled that out of 546 participants 50 percent of women, 25 percent of men lived alone, over percent participants reported one or more health problems. The researcher found that health assessment was effective in identifying significant physical and psychological problems in older adults. Thus the researcher felt that identifying unmet physical and psychological needs to improve quality of life in older adults.13 6 LITERATURE RELATED TO GASTROINTESTINAL DISORDERS AMONG GERIATRICS Senior health is the most important requirement when it comes to needs of the elderly. With advancing age, the body tends to slow down and becomes less efficient. Elderly people are prone to a few age related health issues. This is a normal aspect of life and one cannot help it. However, through proper care and nursing facilities, one can definitely help in keeping most of these health issues in check and preventing them from causing any serious harm. Regular medical checkup is necessary. They can help in anticipating potential future health-related issues. At the same time, they may help in identifying serious health problems at an early enough stage during which treatment is possible.14 As people age, their digestive system gradually starts weakening. Aged and elderly people especially, face this problem wherein they start finding certain foods indigestible or difficult to digest. What one must realize is that their diet can no longer be the same as it was twenty years ago. Their diet should now be modified accordingly such that it remains a nutritious, balanced diet and yet, contains foodstuffs that their system is able to accept, without causing them any discomfort or problems. Often, the diets of elderly people need to be altered depending on their medicinal prescriptions.15 A study was conducted to assess the prevalence of chronic constipation (CC) in adult population in Moscow. Data was collected from 1189 randomly selected subjects older than 18 years. A specially designed Questionnaire, which included questions for constipation, dietary habits, physical activity, and obstetric history was used. 34.3% subjects said that they had constipation and 16.5% had chronic constipation. Females had significantly (p < 0.001) higher rate of symptoms of constipation. Prevalence of CC has a tendency to increase with age reaching 7 maximum 32.8% in subjects older 65 years. It was concluded that Chronic Constipation is a common condition especially in the elderly, associated with female gender, dietary habits, and physical activity.16 A Cohort study was conducted to identify dietary and physiological characteristics of older individuals with chronic constipation, compared with a control group of individuals without constipation in University hospital and affiliated clinics, Pennsylvania. The sample was 18 subjects with constipation and 18 control subjects who were ambulatory, community-dwelling outpatients over the age of 60 years. Measures included a 1-week food diary, diet questionnaire, bowel diary, the Hopkins Symptom Checklist (SCL-90R), colonic transit study, and medical history, including queries about activity, medications, medical illnesses, and bowel symptoms. Subjects with constipation reported consuming fewer meals per day compared with control subjects (P < 0.01) and a tendency to consume fewer calories (P = 0.07). There were no differences between groups on fiber or fluid intake or any of the other dietary parameters. However, slow colonic transit was significantly related to low caloric intake (P < 0.0001), higher percent of protein in the diet (P < 0.05), low fluid intake (P < 0.05). The data suggested that constipation in the older population is related to caloric intake rather than fiber consumption or other dietary qualities.17 A study was conducted to evaluate the prevalence of upper gastrointestinal symptoms in elderly outpatients in Italy. The study involved 3238 outpatients aged 60 years and above. Information on social, behavioral and demographic characteristics, function in the activities of daily living (ADL), co-morbidities and drug use were collected by a structured interview. Data was collected by a upper gastro-intestinal symptom questionnaire for the elderly, a validated diagnostic tool which includes the following five symptom clusters: abdominal pain syndrome, reflux syndrome, indigestion syndrome, bleeding and non-specific symptoms. Presence and severity of 8 gastrointestinal symptoms were analyzed through a logistic regression model. 3100 subjects were included in the final analysis. The overall prevalence of upper gastrointestinal symptoms was 43%. The prevalence of Abdominal pain syndrome was 13.9%, reflux syndrome was 21.9%, indigestion syndrome was 30.2%, bleeding was 1.2%, and other non-specific symptoms were 4.5%. Upper gastrointestinal symptoms were more frequently reported by females (P < 0.0001), with high number of co-morbidities (P < 0.0001), who were taking higher number of drugs (P < 0.0001). Logistic regression analysis demonstrated that female sex, disability in the ADL, smoking habit, and body mass index, as well as the presence of upper and lower gastroenterological diseases, psychiatric and respiratory diseases were significantly associated with the presence of upper gastrointestinal symptoms. Among all the symptoms evaluated, there was highest prevalence of indigestion syndrome in the elderly people.18 A survey was conducted to estimate the prevalence and characteristics of symptomatic gastroesophageal reflux disease in the elderly in City of Turku, Finland. Stratified random sampling was used. A questionnaire was sent to 559 subjects over 65 years of age. The questionnaire inquired about the following symptoms: heartburn, regurgitation, chest pain, dysphagia, dyspepsia, respiratory symptoms, vomiting, and belching. The response rate was 92%. Twenty-nine incompletely filled forms were rejected. Thus, the questionnaires from 487 subjects, representing 87% of the original number, constitute the basis for the study. The age related prevalence of daily symptoms suggestive of gastroesophageal reflux disease was 8% in men and 15% in women (P < 0.05). Fifty-four percent of men and 66% of women reported that they had symptoms at least once a month (P < 0.05). It was found that gastroesophageal reflux disease are common in elderly subjects. Women suffer from these symptoms 9 more frequently than men. Typical reflux symptoms are often associated with atypical complaints, such as abdominal symptoms, chest pain, or respiratory symptoms.19 A cross sectional study was conducted in an intensive field practice area of Comprehensive Rural Health Services Project Ballabgarh in district Faridabad, Haryana. The study aimed to find out the prevalence of self-reported health problems and health seeking behaviour among rural elderly population. Out of the 1117 aged (60 yrs. of age) a total of 987 (88.4%) could be interviewed. Among these 490 (49.6%) were males and 497 (50.4%) were females. The sample was selected using stratified random cluster sampling. The duration of recall was one month for acute problems and one year for chronic problems. Majority of the aged were illiterate (81.6%), living in joint families (82.9%), belonging to lower socio-economic status (48.8%), living with spouse and children (56.0%), presently head of the house-hold (40.1%), not working (64.5%) and fully dependent (71.1%). In response to an open ended question about any health problem experienced in last one month, 86.1% females and 78.2% males reported having had at least one problem and this difference was statistically significant (p<0.001). Overall, 21.6% men and 17.1% women reported occurrence of single health problem in last one month but 57% men and 69% of women reported at least 2 or more health problems. Frequency of self-reported gastrointestinal health problems in a month among males and females were as follows: Constipation in males was 4.1% and in females was 2.8%, Indigestion/Gas in males was 3.9% and females was 8.5%, Loss of appetite in males was 3.5% and in females was 3.4%, Abdominal Pain in males was 3.3% and in females was 5%, Vomiting/Nausea in males was 1.2% and in females was 3.2%, Loose stools in males was 6.7% and in females was 7.2%, Weakness in males was 6.5% and in females was 9.4%.20 10 A study was conducted to assess the knowledge, general attitudes towards nutrition, dietary restriction attitudes, and dietary restriction behavior in the elderly in Taiwan. The nutrition knowledge, attitudes and behavior scales were developed by the researchers. A multi-staged, stratified random sampling method was used. The interview was completed by 1937 elderly persons aged above 65 years. The Pearson product-moment correlation coefficient was used to study the relationships between nutrition knowledge, attitudes, and behavior. The results indicated that the elderly had poor nutrition knowledge in all three aspects, especially about the relationship between nutrition and disease. An average of 49.4% answered correctly. Elderly people expressed favorable attitudes toward healthy foods. From the percentages of positive responses to dietary restriction behaviours, it was found that a moderate to high number of elderly people abided by their traditional dietary restrictions.21 LITERATURE RELATED TO EFFECTIVENESS OF VIDEO ASSISTED TEACHING MODULE A study was conducted on effectiveness of DVD computer based teaching on the use of inhaler and ability to correctly demonstrate inhaler technique. Total of 34 adults with pulmonary disease and experience using inhalers were randomized into the control or intervention groups. The intervention group viewed the tutorial, after which they demonstrated their inhaler technique and completed an Inhaler Technique Knowledge Test. The intervention group demonstrated significantly better inhaler technique, with a mean Observed Inhaler Technique Score of 88.3 ± 12.3 compared with 67.4 ± 19.2 for the control group (p = 0.001). The intervention group also scored significantly higher on the Inhaler Technique Knowledge Test, with a score of 80.9 ± 17.0 versus 67.4 ± 11.8 for the control group (p = 0.01). Overall, the program was acceptable to patients.22 11 An evaluative study was done to assess the effectiveness of video assisted teaching programme regarding self care management among patients with COPD in terms of knowledge and practice in 2010. The research design adopted was one group pretest, post test, pre experimental design was used for the study which was conducted at IRT Perundurai Medical College Hospital. The total sample of the study was 50 patients with COPD. The Samples were selected by purposive sampling method. Structured interview schedule was used to assess the knowledge through pre test. Following this, video assisted teaching was administered for 40 minutes. Post test was done on 7th day. The data collected was analyzed and interpreted using descriptive and inferential statistics. Prior to implementation of Video assisted teaching programme 66% had inadequate knowledge and 15% had moderately adequate knowledge whereas after implementation of video assisted teaching programme 82% had adequate knowledge and 16% had moderately adequate knowledge. Finding showed that the video assisted teaching programme was effective in increasing the knowledge and practice among patients with COPD regarding self care management.23 A study was conducted to examine the efficacy of DVD technology compared to print-based material in COPD self-management education of 40 rural patients in rural health using random assignment of samples to two groups. Pretest - Posttest design with a control group. A MANCOVA testing planned Multivariate contrasts determined patients receiving a DVD reported statistically significant higher levels of lung-specific physical functioning as compared to patients receiving a Pamphlet. Additionally, DVD patients Reported clinically significant improvements on two dimensions of lung-Specific quality of life.24 12 STATEMENT OF THE PROBLEM To assess the effectiveness of Video Assisted Teaching Module (VATM) on knowledge of older adults regarding Prevention of selected Gastrointestinal Disorders of Geriatrics in a selected old age home at Bangalore. 6.3 OBJECTIVES OF THE STUDY 1. To assess the existing level of Knowledge regarding Prevention of selected Gastrointestinal Disorders of Geriatrics among older adults on the basis of pretest score. 2. To develop a Video Assisted Teaching Module regarding Prevention of selected Gastrointestinal Disorders of Geriatrics. 3. To administer the Video Assisted Teaching Module regarding Prevention of selected Gastrointestinal Disorders of Geriatrics. 4. To evaluate the effectiveness of Video Assisted Teaching Module (VATM) on knowledge regarding Prevention of selected Gastrointestinal Disorders of Geriatrics among older adults by comparing pre and post test knowledge score. 5. To determine the association between post test knowledge level of older adults regarding Prevention of selected Gastrointestinal Disorders of Geriatrics with their selected demographic variables. 6.4 OPERATIONAL DEFINITIONS 1. EFFECTIVENESS: In this study it measures the improvement score in post test when compared with the pre test score after exposing to video assisted teaching module. 13 2. VIDEO ASSISTED TEACHING MODULE (VATM): In this study Video Assisted Teaching Module refers to information in compact disc comprising systematic instructions on prevention of selected Gastrointestinal Disorders of Geriatrics like Gastroesophageal reflux disease, Constipation, Dyspepsia and Peptic ulcer with verbal interactions. 3. KNOWLEDGE: In this study it refers to the written responses received from the older adults to the knowledge items listed in the structured questionnaire. 4. OLDER ADULTS: It refers to the patients aged 60 years and above who reside in a selected old age home. 5. PREVENTION: It refers to avoidance of occurrence of selected gastrointestinal disorders in the geriatrics. 6. GASTROINTESTINAL DISORDER: In this study it refers to health problems related to digestive system of the geriatric people such as Gastroesophageal reflux disease, constipation, dyspepsia and peptic ulcer. 7. GERIATRICS: It refers to the elderly population of age 60 years and above. 8. OLD AGE HOME: It refers to the institution which provides long care facilities with physical, social, psychological and economic support for the aged people. 6.5 ASSUMPTIONS The older adults will have some knowledge about prevention of gastrointestinal disorders of geriatrics. Teaching through Video Assisted Module will enhance the knowledge of older adults. 14 The written responses to the questionnaires would accurately reflect the actual knowledge of the older adults regarding prevention of selected gastrointestinal disorders of geriatrics. 6.6 NULL HYPOTHESIS H01: There will be no significant statistical association between post test knowledge scores of older adults regarding prevention of selected gastrointestinal disorders of geriatrics with their demographic variables. H02: There will be no difference between the knowledge of older adults regarding prevention of selected gastrointestinal disorders of geriatrics prior to and after the video assisted teaching module. 7. MATERIALS AND METHODS 7.1 SOURCES OF DATA Data will be collected from the older adults in a selected old age home at Bangalore. 7.1.1 RESEARCH APPROACH Evaluative research approach 7.1.2 RESEARCH DESIGN Pre experimental research with one group pre and post test design. 7.1.3 VARIABLES UNDER THE STUDY Independent variable: Video Assisted Teaching Module on Prevention of selected Gastrointestinal Disorders of Geriatrics. 15 Dependent variable: Knowledge of older adults regarding Prevention of selected gastrointestinal disorders of Geriatrics. Extraneous variables: Selected demographic variables such as age, gender, educational qualification, occupation before retirement and source of information, type of food, number of meals per day, years of stay in old age home, habits, sleep pattern, source of information on GI problems. 7.1.4 SETTING OF THE STUDY The study will be conducted in a selected old age home at Bangalore. 7.1.5 POPULATION The population for the study comprises of older adults who are residing in the old age homes. 7.1.6 SAMPLE The sample will be older adults aged 60 years and above and who are residing in a selected old age homes at Bangalore. 7.1.7 SAMPLE SIZE The sample size will be 40 older adults 7.1.8 SAMPLING TECHNIQUE Simple random sampling technique will be used. 16 7.1.9 CRITERIA FOR SELECTION OF THE SAMPLE i. Inclusion criteria Both male and female older adults. Older adults who are in the age group of 60 years and above. Older adults who are willing to participate in the study. Older adults who are able to read and understand English and Kannada. ii. Exclusion criteria Older adult who are sick and confined to bed. Older adults who are not able to follow the instructions. 7.2 METHOD OF DATA COLLECTION: A structured questionnaire 7.2.1 TOOLS FOR DATA COLLECTION The researcher will collect data through structured questionnaire. It comprises of two parts. Part I : Demographic Variables like age, gender, educational qualification, type of food, number of meals per day, years of stay in old age home, habits, sleep pattern, occupation if any before retirement and source of information on GI problems. Part II : Structured knowledge Questionnaire on prevention of selected gastrointestinal disorders of geriatrics like GERD, Constipation, dyspepsia and peptic ulcer. 7.2.2 DATA COLLECTION PROCEDURE Structured questionnaires will be used to collect data. The data will be collected in the following stages: 17 Formal permission will be obtained from the authorities of the old age homes. Formal permission will be obtained from study participants after explaining the objectives of study. The study participant will be selected by using simple random sampling technique who fulfills the inclusion criteria. Pre test data will be collected by the researcher herself using structured questionnaire and then administer Video Assist Teaching Module to all the subjects. Post test will be conducted on 8th day after the teaching programme using the same structured knowledge questionnaire. 7.2.3 METHOD OF DATA ANALYSIS Collected data will be analyzed using descriptive and inferential statistics. Descriptive statistics The data collected will be organized and summarized by using descriptive statistics like mean, frequency and percentage distribution and standard deviation. Inferential statistics Significance of difference between pre test and post test knowledge scores of older adults regarding prevention of selected gastrointestinal disorders of geriatrics will be found using paired “t” test. The association between knowledge of older adults with their demographic variables will be found using chi-square test. 18 7.3. DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENT OR OTHER HUMANS OR ANIMALS? Yes, non - invasive intervention will be done. The pre test knowledge of older adults will be assessed by using a structured knowledge questionnaire followed by video assist teaching module on prevention of selected gastrointestinal disorders of geriatrics will be conducted and on 8th day post test will be done using the same questionnaire. 7.4. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION? a. Permission will be obtained from the research committee. b. Permission will be obtained from the authorities of the selected old age homes. c. Informed consent will be obtained from the subjects enrolled before the study. 19 8. LIST OF REFERENCES 1. Koonin EB. Altschul SF. Bork P. The Mark Manual of Geriatrics. 2nd edition, Functional Motifs. 1996. 2. Anonymous. Old Age. http://en.wikipedia.org/wiki/Old_age. 2011 3. International Day of Older Persons. 2011. October 1. http://www.gits4u.com/renew/snrctz8.htm 4. David Fisher. Digestive disorders in adults. 2010. June 17. http://www.livestrong.com/article/152144/ 5. Penny Tenzer. Persistent Pain and the Older Patient. 2008. April 4. http://www.medscape.org/viewarticle/571472 6. Smeltzer C.Suzanne. Bare G. Brenda. Brunner and Suddarths text book of medical and surgical nursing. 10th edition. Lippincott publication. Philadelphia. 2004 7. Sanjiv M. Khean L. Epidemiology of functional dyspepsia: a global perspective.. 2006. May 7; available from:URL: http://www.wjgnet.com/1007-9327/12/2661.asp 8. Judith AR. et al. Age Differences in the Epidemiology and Treatment of GERD-Related Symptoms. 2003. May. available from:URL: www.ispor.org/research_source/free/PGS13.pdf 9. Kasper DL. et al. Harrison’s Principles of Internal Medicine; Vol 2, 16th edition, New York: McGraw-Hill. 2004 10. Anonymous. Gastrointestinal specialists. Ulcer disease. Available from : URL: https://www.gis.md/fact-ulcer.html 11. James J. The Demographics of ageing. Available from : URL: http://transgenerational.org/aging/demographics.htm. 2010. 20 12. Agewell Foundation. Study on human rights of older persons in India. http://social.un.org/ageing-working-group.pdf. 2011. April 20. 13. Wade MJ, Pine D. Weinstock RS. A Comparison of Healthy related Quality on elderly. 2003. p. 32; 613-618. 14. Anonymous. Health Care Requirements. http://www.buzzle.com/articles/needs-of-the-elderly.html. 2011 15. Anonymous. Dietary Requirements. http://www.buzzle.com/articles/needs-ofthe-elderly.html. 2011 16. Lazebnik LB. et al. Prevalence and risk factors of constipation in the adult population of Moscow. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed/21695954. 2011 17. Towers AL. et al. Constipation in the elderly: influence of dietary, psychological, and physiological factors. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed. 1994 18. Pilotto A. et al. Association of upper gastrointestinal symptoms with functional and clinical charateristics in elderly. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed/21799648. 2011 19. Raiha IJ. Prevalence and characteristics of symptomatic gastroesophageal reflux disease in the elderly. Available from URL: http://www.ncbi.nlm.nih.gov/pubmed 20. Anil G. et al. Indian Journal of Physical Medicine and Rehabilitation. Prevalence and determinants of disability in the rural elderly population in Northern India. 16(2). 2005. October:39 – 44 21. Wei Lin. Ya Wen Lee. Nutrition knowledge, attitudes, and dietary restriction behavior of the Taiwanese elderly. Available from URL: http://apjcn.nhri.org.tw/ 21 22. Navarre et al. conducted a study on effectiveness of DVD computer based teaching on the use of inhaler. 2007 23. Angelin S. Efectiveness of Video Assisted Teaching Programme regarding self care management among patients with COPD. 2010 24. Stellfson C. et al. The efficacy of DVD technology versus print-based material in COPD self-management. 2009 22 9. SIGNATURE OF THE CANDIDATE The research topic selected is relevant 10. 11. and feasible for the study. REMARKS OF THE GUIDE MRS. BEENA MARREL. M NAME AND DESIGNATION PRINCIPAL 11.1. GUIDE ETCM College of Nursing, Kolar 11.2. SIGNATURE OF THE GUIDE 11.3. CO-GUIDE (if any) 11.4. SIGNATURE OF THE CO-GUIDE MRS. BEENA MARREL. M ASSISTANT PROFESSOR HOD OF MEDICAL SURGICAL 11.5. HEAD OF THE NURSING DEPARTMENT ETCM College of Nursing, Kolar 11.6. SIGNATURE OF THE HOD 12. This topic was discussed with the 12.1. REMARKS OF THE members of the research committee and PRINCIPAL finalized. She is permitted to conduct the study. 12.2. SIGNATURE 23