Causes and consequences of comorbidity: a review

Prevalence of sleep disturbances in people with mild cognitive impairment: A systematic review and meta-analysis

This review was performed to determine sleep disturbance prevalence in individuals with mild cognitive impairment (MCI). The MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science databases were systematically searched from inception to January 20, 2024. Fifty-two studies fulfilling the eligibility criteria were included. However, six of these studies were excluded from data synthesis due to poor methodological quality. The subjective sleep disturbance prevalence among all individuals with MCI was 35.8 % (95 % CI: 31.9-39.7) across 44 studies, and the objective sleep disturbance prevalence was 46.3 % (95 % CI: 36.3-56.3) across 6 studies. Five studies examined TST and WASO, while three assessed SE. Among all potential objective assessments of sleep disturbance prevalence, only TST, WASO, and SE could be meta-analyzed in MCI because of the limited number of studies available. The estimated sleep disturbance prevalence differed significantly according to measurement method, geographical region, and research design. However, the data source did not significantly influence prevalence estimates. In meta-regression analysis, publication year, participant age, percentage of females, and study quality did not predict prevalence. As subjective and objective sleep disturbances are common in people with MCI, effective intervention strategies should be developed to alleviate them.

Reciprocal Relations of Social Isolation and Multimorbidity in Chinese Elderly

INTRODUCTION

This study aims to investigate the bidirectional associations between Social Isolation (SI) and multimorbidity among Chinese older adults.

METHODS

Data from six waves of the Chinese Longitudinal Healthy Longevity Survey spanning from 2002 to 2018 were analyzed. A General Cross-Lagged Model was employed in 2023 to investigate the temporal interrelationships between SI and multimorbidity among individuals aged 65 years and older.

RESULTS

In the short-term, significant bidirectional associations between SI and multimorbidity were found. Higher levels of SI at a given time point were associated with increased multimorbidity scores in the future, while greater levels of multimorbidity at a given time were associated with higher future SI scores. In the long-term, it is more likely that initial multimorbidity affect SI rather than initial SI affecting multimorbidity.

CONCLUSIONS

This study contributes to the understanding of the bidirectional associations between SI and multimorbidity among Chinese older adults, highlighting that initial multimorbidity was associated with future SI.

The Impact of Transcatheter Aortic Valve Implantation on Health Care Costs and Clinical Outcomes Based on Frailty Risk: A Nationwide Cohort Analysis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is preferred for treating severe aortic stenosis in older, frail populations, yet the impact of frailty on economic and clinical outcomes of TAVI is not well studied.

METHODS

This retrospective cohort study included 2175 TAVI patients from 2015 to 2019, using Korea's National Health Insurance Service database, stratifying patients into low, intermediate, and high-frailty groups, using the Hospital Frailty Risk Score (HFRS). Health care costs, admissions, and total length of hospitalization were analyzed using Wilcoxon-rank test 12 months pre- and post-TAVI. Composite endpoint of death, stroke, and major bleeding, with individual outcomes, were compared using χ2 tests and Kaplan-Meier analysis.

RESULTS

Mean age was 80.2 years, and 47.3% were male; 747 (34.3%) were low frailty, 1159 (53.3%) were moderate frailty, and 269 (12.4%) were high frailty. After TAVI, medical costs decreased in the intermediate- (pre-TAVI: 2,269,000 KRW [$1668 USD], post-TAVI: 1,607,000 KRW [$1181 USD]; P < 0.001) and high-frailty groups (pre-TAVI: 3,949,000 KRW [$2904 USD], post-TAVI: 2,188,000 KRW [$1609 USD]; P < 0.001). All frailty groups had shorter length of hospital stay post-TAVI (26 to 21 days in the low-frailty, 44 to 31 days in the intermediate-frailty, and 65 to 41 days in the high-frailty group; all P <0.001). The composite outcome was higher in the frailer groups (27.8% in the low-frailty vs 31.5% in the intermediate-frailty vs 37.9% in the high-frailty group; P = 0.008). All groups showed comparable rates of cardiovascular death, stroke, or bleeding.

CONCLUSIONS

TAVI is clinically viable and cost-saving treatment option for frail patients with severe aortic stenosis.

The influence of health literacy, anxiety and education on shared decision making and decisional conflict in older adults, and the mediating role of patient participation: A video observational study

OBJECTIVE

To explore the relationship between personal characteristics of older adults with multiple chronic conditions (MCCs) and perceived shared decision making (SDM) resp. decisional conflict.

METHODS

In a video-observational study (N = 213) data were collected on personal characteristics. The main outcomes were perceived level of SDM and decisional conflict. The mediating variable was participation in the SDM process. A twostep mixed effect multilinear regression and a mediation analysis were performed to analyze the data.

RESULTS

The mean age of the patients was 77.3 years and 56.3% were female. Health literacy (β.01, p < .001) was significantly associated with participation in the SDM process. Education (β = -2.43, p = .05) and anxiety (β = -.26, p = .058) had a marginally significant direct effect on the patients' perceived level of SDM. Education (β = 12.12, p = .002), health literacy (β = -.70, p = .005) and anxiety (β = 1.19, p = .004) had a significant direct effect on decisional conflict. The effect of health literacy on decisional conflict was mediated by participation in SDM.

CONCLUSION

Health literacy, anxiety and education are associated with decisional conflict. Participation in SDM during consultations plays a mediating role in the relationship between health literacy and decisional conflict.

PRACTICE IMPLICATIONS

Tailoring SDM communication to health literacy levels is important for high quality SDM.

Trends in the Prevalence of Multiple Chronic Conditions Among US Adults With Hypertension From 1999-2000 Through 2017-2020

BACKGROUND

The prevalence of many chronic conditions has increased among US adults. Many adults with hypertension have other chronic conditions.

METHODS

We estimated changes in the age-adjusted prevalence of multiple (≥3) chronic conditions, not including hypertension, using data from the National Health and Nutrition Examination Survey, from 1999-2000 to 2017-2020, among US adults with (n = 24,851) and without (n = 24,337 hypertension. Hypertension included systolic blood pressure (BP) ≥130 mm Hg, diastolic BP ≥80 mm Hg, or antihypertensive medication use. We studied 14 chronic conditions: arthritis, asthma, cancer, coronary heart disease, chronic kidney disease, depression, diabetes, dyslipidemia, hepatitis B, hepatitis C, heart failure, lung disease, obesity, and stroke.

RESULTS

From 1999-2000 to 2017-2020, the age-adjusted mean number of chronic conditions increased more among US adults with vs. without hypertension (2.2 to 2.8 vs. 1.7 to 2.0; P-interaction <0.001). Also, the age-adjusted prevalence of multiple chronic conditions increased from 39.0% to 52.0% among US adults with hypertension and from 26.0% to 30.0% among US adults without hypertension (P-interaction = 0.022). In 2017-2020, after age, gender, and race/ethnicity adjustment, US adults with hypertension were 1.94 (95% confidence interval: 1.72-2.18) times as likely to have multiple chronic conditions compared to those without hypertension. In 2017-2020, dyslipidemia, obesity, and arthritis were the most common 3 co-occurring chronic conditions among US adults with and without hypertension (age-adjusted prevalence 16.5% and 3.1%, respectively).

CONCLUSIONS

In 2017-2020, more than half of US adults with hypertension had ≥3 additional chronic conditions, a substantial increase from 20 years ago.

Optimizing drug therapy for older adults: shifting away from problematic polypharmacy

INTRODUCTION

The accelerated discovery and production of pharmaceutical products has resulted in many positive outcomes. However, this progress has also contributed to problematic polypharmacy, one of the rapidly growing threats to public health in this century. Problematic polypharmacy results in adverse patient outcomes and imposes increased strain and financial burden on healthcare systems.

AREAS COVERED

A review was conducted on the current body of evidence concerning factors contributing to and consequences of problematic polypharmacy. Recent trials investigating interventions that target polypharmacy and emerging solutions, including incorporation of artificial intelligence, are also examined in this article.

EXPERT OPINION

To shift away from problematic polypharmacy, a multifaceted interdisciplinary approach is necessary. Any potentially successful strategy must be adapted to suit various healthcare settings and must utilize all available resources, including artificial intelligence.

The comorbidity profiles and medication issues of patients with multiple system atrophy: a systematic cross-sectional analysis

BACKGROUND

Multiple system atrophy (MSA) is a complex and fatal neurodegenerative movement disorder. Understanding the comorbidities and drug therapy is crucial for MSA patients' safety and management.

OBJECTIVES

To investigate the pattern of comorbidities and aspects of drug therapy in MSA patients.

METHODS

Cross-sectional data of MSA patients according to Gilman et al. (2008) diagnostic criteria and control patients without neurodegenerative diseases (non-ND) were collected from German, multicenter cohorts. The prevalence of comorbidities according to WHO ICD-10 classification and drugs administered according to WHO ATC system were analyzed. Potential drug-drug interactions were identified using AiDKlinik®.

RESULTS

The analysis included 254 MSA and 363 age- and sex-matched non-ND control patients. MSA patients exhibited a significantly higher burden of comorbidities, in particular diseases of the genitourinary system. Also, more medications were prescribed MSA patients, resulting in a higher prevalence of polypharmacy. Importantly, the risk of potential drug-drug interactions, including severe interactions and contraindicated combinations, was elevated in MSA patients. When comparing MSA-P and MSA-C subtypes, MSA-P patients suffered more frequently from diseases of the genitourinary system and diseases of the musculoskeletal system and connective tissue.

CONCLUSIONS

MSA patients face a substantial burden of comorbidities, notably in the genitourinary system. This, coupled with increased polypharmacy and potential drug interactions, highlights the complexity of managing MSA patients. Clinicians should carefully consider these factors when devising treatment strategies for MSA patients.

Tools used to measure the impact of comorbidities on surgical outcomes in children with complex chronic conditions: A scoping review

AIM

To identify and describe assessment tools used to measure the impact of comorbidities on postoperative outcomes in children with complex chronic conditions (CCC).

METHOD

This was a scoping review using five electronic databases. The search was conducted in March 2022 by a medical librarian. There were no date or language restrictions. Included studies were full-text articles published in peer-reviewed journals that described a tool used to measure the impact of comorbidities in children with CCC to assess postoperative outcomes. A standardized data charting tool was used.

RESULTS

A total of 2157 articles were retrieved. Five studies reporting on six comorbidity measures met inclusion criteria. All were cohort studies and were secondary analyses of data from an administrative database (n = 4) or a patient registry (n = 1). Sample sizes ranged from 645 to 25 747 participants. One paper described the assessment of reliability. Only one form of validity - predictive validity - was assessed in three papers for five measures.

INTERPRETATION

Findings from this scoping review revealed a paucity of comorbidity assessment tools validated for use with children with CCC; significant conceptual and measurement challenges exist in the current scientific literature.

A Technological Tool Aimed at Self-Care in Patients With Multimorbidity: Cross-Sectional Usability Study

BACKGROUND

Information and communication technologies (ICTs) have been positioned as useful tools to facilitate self-care. The interaction between a patient and technology, known as usability, is particularly important for achieving positive health outcomes. Specific characteristics of patients with chronic diseases, including multimorbidity, can affect their interaction with different technologies. Thus, studying the usability of ICTs in the field of multimorbidity has become a key element to ensure their relevant role in promoting self-care.

OBJECTIVE

The aim of this study was to analyze the usability of a technological tool dedicated to health and self-care in patients with multimorbidity in primary care.

METHODS

A descriptive observational cross-sectional usability study was performed framed in the clinical trial in the primary care health centers of Madrid Health Service of the TeNDER (Affective Based Integrated Care for Better Quality of Life) project. The TeNDER technological tool integrates sensors for monitoring physical and sleep activity along with a mobile app for consulting the data collected and working with self-management tools. This project included patients over 60 years of age who had one or more chronic diseases, at least one of which was mild-moderate cognitive impairment, Parkinson disease, or cardiovascular disease. From the 250 patients included in the project, 38 agreed to participate in the usability study. The usability variables investigated were effectiveness, which was determined by the degree of completion and the total number of errors per task; efficiency, evaluated as the average time to perform each task; and satisfaction, quantified by the System Usability Scale. Five tasks were evaluated based on real case scenarios. Usability variables were analyzed according to the sociodemographic and clinical characteristics of patients. A logistic regression model was constructed to estimate the factors associated with the type of support provided for task completion.

RESULTS

The median age of the 38 participants was 75 (IQR 72.0-79.0) years. There was a slight majority of women (20/38, 52.6%) and the participants had a median of 8 (IQR 7.0-11.0) chronic diseases. Thirty patients completed the usability study, with a usability effectiveness result of 89.3% (134/150 tasks completed). Among the 30 patients, 66.7% (n=20) completed all tasks and 56.7% (17/30) required personalized help on at least one task. In the multivariate analysis, educational level emerged as a facilitating factor for independent task completion (odds ratio 1.79, 95% CI 0.47-6.83). The median time to complete the total tasks was 296 seconds (IQR 210.0-397.0) and the median satisfaction score was 55 (IQR 45.0-62.5) out of 100.

CONCLUSIONS

Although usability effectiveness was high, the poor efficiency and usability satisfaction scores suggest that there are other factors that may interfere with the results. Multimorbidity was not confirmed to be a key factor affecting the usability of the technological tool.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05681065; https://clinicaltrials.gov/study/NCT05681065.

A network-based approach to explore comorbidity patterns among community-dwelling older adults living alone

The detailed comorbidity patterns of community-dwelling older adults have not yet been explored. This study employed a network-based approach to investigate the comorbidity patterns of community-dwelling older adults living alone. The sample comprised a cross-sectional cohort of adults 65 or older living alone in a Korean city (n = 1041; mean age = 77.7 years, 77.6% women). A comorbidity network analysis that estimates networks aggregated from measures of significant co-occurrence between pairs of diseases was employed to investigate comorbid associations between 31 chronic conditions. A cluster detection algorithm was employed to identify specific clusters of comorbidities. The association strength was expressed as the observed-to-expected ratio (OER). As a result, fifteen diseases were interconnected within the network (OER > 1, p-value < .05). While hypertension had a high prevalence, osteoporosis was the most central disease, co-occurring with numerous other diseases. The strongest associations among comorbidities were found between thyroid disease and urinary incontinence, chronic otitis media and osteoporosis, gastric duodenal ulcer/gastritis and anemia, and depression and gastric duodenal ulcer/gastritis (OER > 1.85). Three distinct clusters were identified as follows: (a) cataracts, osteoporosis, chronic otitis media, osteoarthritis/rheumatism, low back pain/sciatica, urinary incontinence, post-accident sequelae, and thyroid diseases; (b) hyperlipidemia, diabetes mellitus, and hypertension; and (c) depression, skin disease, gastric duodenal ulcer/gastritis, and anemia. The results may prove valuable in guiding the early diagnosis, management, and treatment of comorbidities in older adults living alone.

Investigating the Prevalence of Comorbidity in Multiple Sclerosis Clinical Trial Populations

BACKGROUND AND OBJECTIVES

Comorbidity is common in multiple sclerosis (MS) with the most prevalent conditions being depression, anxiety, hypertension, and hyperlipidemia. Limited information regarding the representation of comorbidity status is available from phase III clinical trials in MS leading to concern about the potential underrepresentation of individuals with comorbidity in clinical trials. The objective was to estimate the prevalence of comorbidities in MS clinical trial populations.

METHODS

Individual-level data from multiple sponsors were requested for a 2-stage meta-analysis of phase III clinical trials of MS disease-modifying therapies. To ensure consistency of our approach across trials, we followed the Maelstrom retrospective harmonization guidelines. Chronic comorbidities at clinical trial enrollment recommended by the International Advisory Committee on Clinical Trials in MS were considered (depression, anxiety, hypertension, hyperlipidemia, migraine, diabetes, chronic lung disease). Additional comorbidities were also classified. Classification was based on medical history data. Individual comorbidities were summed and categorized as 0, 1, 2, or ≥3. We report the pooled prevalence (95% confidence interval [95% CI]) of comorbidity. The pooled prevalence and prevalence ratios across age, sex, race, disability level, and treatment were also reported. Heterogeneity was assessed using the I2 statistic.

RESULTS

Seventeen trials involving 17,926 participants were included. Fourteen trials enrolled participants with relapsing MS (RMS) while 3 enrolled participants with progressive MS (PMS). The distributions of sex, age, and disability level were generally consistent within RMS and PMS trials. When pooled, almost half of trial participants (46.5%) had ≥1 comorbidity (1: 25.0%, 95% CI 23.0-27.0, I2 = 89.9; 2: 11.4% [9.3-14.0], I2 = 96.3; ≥3: 6.0% [4.2-8.4], I2 = 97.7). Depression (16.45% [12.96-20.88], I2 = 98.3) was the most prevalent comorbidity reported, followed by hypertension (10.16% [8.61-11.98], I2 = 93.2). Heterogeneity was high across trials. Older age and female participants were associated with increased number of comorbidities. Older individuals and male participants had a higher prevalence of hyperlipidemia, while older individuals and female participants had a higher prevalence of depression and anxiety.

DISCUSSION

Individuals with comorbidities are included in clinical trials, although they may still be underrepresented compared with the general MS population. Given the comorbidity prevalence in the trial populations and studies suggesting an association of comorbidities with disease activity, comorbidity may influence outcomes in clinical trials.

Utility of preoperative comorbidity burden on PROMIS outcomes after lumbar decompression: Cohort matched analysis

The influence of Charlson Comorbidity Index (CCI) burden on Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes following lumbar decompression (LD) is limited. The objective of this study is to evaluate CCI burden impact on PROMIS outcomes. Retrospective review of elective LD excluding revision or surgeries for infectious, malignant, or traumatic reasons. Demographics and PROMIS scores collected preoperatively and postoperatively up to 2 years included: PROMIS-Physical Function (PF)/Sleep Disturbance (SD)/Pain Interference (PI)/Anxiety (A), VR-12 Physical/Mental Health Composite scores (VR-12 PCS/MCS)/Oswestry Disability Index (ODI). Patients were divided into two groups based on their preoperative CCI score <3 (mild) or ≥4 (moderate to severe). Descriptive statistical analysis and MCID achievement rate calculations were conducted. A total of 182 patients were included: 93 CCI < 3 and 88 CCI ≥ 4. No significant differences were reported across preoperative PROMIS/legacy PROMs or final follow-up (p > 0.05, all). At 6-weeks, VR-12 PCS and ΔPROM scores indicated improved physician function in the CCI < 3 group (p = 0.020 and p = 0.040, respectively). Significant PROMIS-A ΔPROM score at final post-op was noted for CCI < 3 group (p = 0.026). MCID achievement demonstrated no significant differences for PROMIS outcomes and legacy PROMs. Results demonstrated that PROMIS outcomes were not impacted by a greater baseline comorbidity burden. At 6-weeks, the physical function scores were improved for the lower CCI group, and at final reported less anxiety. Our data suggests that comorbidity burden has a limited effect on PROMIS and legacy outcomes in patients undergoing LD.

Comorbidity in lipoprotein apheresis: Their role in the era of new lipid-lowering therapies

BACKGROUND

Despite advance in pharmacotherapy of lipid disorders, lipoprotein apheresis (LA) plays a leading role in the management of severe hypercholesterolemia and in atherosclerosis prevention.

METHODS

Aim of this study was to retrospectively evaluate Charlson Comorbidity Index (CCI), presence of major comorbidity, and/or concomitant polypharmacy (definite as 5+ drugs daily) in patients with inherited dyslipidemias on chronic LA.

RESULTS

Since 1994, we performed more than 500 LA treatment/year and followed a total of 83 patients (age 56 [47-65] years, male 75%). In subjects with more than 5 years of LA treatment (38 patients, age 54 [45-62] years, male 66%), at the end of the observation time (9 [7-16] years), patients had higher CCI, polypharmacy, anemia, heart failure, peptic ulcer disease, and benign prostatic hyperplasia.

DISCUSSION

Even in the era of new lipid-lowering therapies, the LA treatment established itself as a safe and lifesaving intervention. Patients on chronic LA require a multidisciplinary approach to address their comorbidity and the apheresis unit's medical staff (doctors and nurses) play a pivotal role creating a bridge toward the general practitioner and other specialists for overcoming clinical issues.

Predictors of Deterioration in Mental Well-Being and Quality of Life among Family Caregivers and Older People with Long-Term Care Needs during the COVID-19 Pandemic

BACKGROUND

During the COVID-19 pandemic, reduced access to care services and fear of infection prompted families to increase home care for their older relatives with long-term care needs. This had negative effects on both members of the caring dyad, impacting their quality of life (QoL) and mental well-being. This study investigated the factors that influenced the mental well-being and QoL of 239 dyads, before and after the first pandemic wave in Italy.

METHODS

Data were collected through a survey on the use of health and social care services and interventions by older care recipients living in the community and their family caregivers. Factors associated with deterioration of mental well-being and QoL in older care recipients (mean age 86.1 years old) and their family caregivers after the pandemic were studied.

RESULTS

The importance attached by family caregivers to the skills and training of healthcare professionals was a protective factor against the deterioration in the well-being of older care recipients. Similarly, the importance associated by family caregivers to the help received from healthcare professionals was a protective factor for QoL. Financial hardship of older care recipients was a risk factor for deterioration in caregivers' mental well-being, while support from other family members was a protective factor for QoL.

CONCLUSIONS

The presence of attentive healthcare professionals, a supportive family environment, and economic support can reduce the burden on both the caregiver and the older care recipient. These aspects need to be considered in any future emergency situation and when planning care services for community-dwelling older people.

Characteristics of hospitalized elderly patients with CKD: a comparison between elderly and non-elderly CKD based on a multicenter cross-sectional study

PURPOSE

We undertook a multicenter epidemiological survey among hospitalized patients with chronic kidney disease (CKD), aiming to reveal the characteristics of elderly CKD by comparing it with non-elderly CKD.

METHODS

Medical records were obtained from 18 military hospitals across China from 1 January 2009 to 31 December 2011. The characteristics of chronic kidney disease in the elderly were analyzed through comparing with those in younger patients with chronic kidney disease.

RESULTS

A total of 380,461 hospitalized patients were included in the database, with 25,826 (6.8%) diagnosed with CKD. Unlike non-elderly, the top-three causes of chronic kidney disease among elderly patients were diabetic nephropathy (24.1%), hypertension-related renal impairment (20.9%), and primary glomerular disease (11.1%). 71.6% of the elderly patients with CKD had more than one comorbidities and the number of morbidities increased with age. In-hospital mortality of the elderly was significantly higher than those of younger patients (3.3% vs. 1.0%). Multiple logistic regression analysis showed that age, CKD 5 stage, acidosis, cardiovascular and cerebrovascular diseases, infection disease, neoplasm, and dementia were independent risk factors for death from CKD in the elderly. The median length of stay (LOS) was similar between elderly and younger CKD patients. The median cost was higher for elderly CKD patients than for younger CKD patients. Among elderly individuals with CKD, LOS, and hospitalization costs also increased with an increase in the number of coexisting diseases.

CONCLUSIONS

Diabetic nephropathy,  and hypertension-related kidney injury were the leading causes of chronic kidney disease in elderly patients, which is different from the non-elderly. Elderly patients with chronic kidney disease were more likely to have a higher burden of comorbidities, which were associated with worse in-hospital outcomes.

The Association of Epigenetic Age Acceleration and Multimorbidity at Age 90 in the Women's Health Initiative

BACKGROUND

Epigenetic age acceleration (EAA), a measure of accelerated biological aging, has been associated with an increased risk of several age-related chronic conditions. This is the first study to prospectively examine the relationship between EAA and both multimorbidity count and a weighted multimorbidity score among long-lived postmenopausal women.

METHODS

We included 1 951 women from the Women's Health Initiative who could have survived to age 90. EAA was estimated using the Horvath pan-tissue, Hannum, PhenoAge, and GrimAge "clocks." Twelve chronic conditions were included in the multimorbidity count. The multimorbidity score was weighted for each morbidity's relationship with mortality in the study population. Using mixed-effects Poisson and linear regression models that included baseline covariates associated with both EAA and multimorbidity, we estimated relative risks (RRs) and 95% confidence intervals (CIs) for the relationships between each EAA measure at the study baseline with both multimorbidity count and weighted multimorbidity score at age 90, respectively.

RESULTS

For every one standard deviation increase in AgeAccelPheno, the rate of multimorbidity accumulation increased 6% (RR = 1.06; 95% CI = 1.01-1.12; p = .025) and the multimorbidity score by 7% (RR = 1.07; 95% CI = 1.01-1.13; p = .014) for women who survived to age 90. The results for a one standard deviation increase in AgeAccelHorvath, AgeAccelHannum, and AgeAccelGrim with multimorbidity accumulation and score were weaker compared to AgeAccelPheno, and the latter 2 did not reach statistical significance.

CONCLUSION

AgeAccelPheno and AgeAccelHannum may predict multimorbidity count and score at age 90 in older women and, thus, may be useful as a biomarker predictor of multimorbidity burden in the last decades of life.

Multimorbidity patterns in older persons and their association with self-reported quality of life and limitations in activities of daily living

BACKGROUND

As populations age, multimorbidity (the presence of two or more chronic morbidities) is increasingly more common. These evolving demographics demand further research into the identification of morbidity patterns in different settings as well as the longitudinal effects of these patterns.

METHODS

Prospectively collected data on 12,755 older persons aged 65+ years were derived from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS, www.topics-mds.eu). Latent class analyses were performed to identify unobserved relationship patterns between morbidities in older persons. Using linear mixed models, the average difference in health-related quality of life (EQ-5D) and general quality of life scores (Cantril's Self Anchoring Ladder) as well as limitations in Activities of Daily Living and Instrumental Activities of Daily Living (ADL/IADL) were examined over a 12-month period.

RESULTS

Five multimorbidity patterns were identified: sensory (n = 3882), cardio-metabolic (n = 2627), mental health (n = 920), osteo-articular (n = 4486), and system decline (n = 840). Relative to older persons in the sensory group, multimorbidity patterns did not have a strong effect on health-related quality of life, general quality of life or ADL/IADLs over a one-year period.

CONCLUSIONS

The observed multimorbidity patterns are similar to others based on different methodologies and study populations. When examining the effect of such patterns on quality of life, the EQ-5D and Cantril's Ladder may be insufficient outcome measures. Further investigations into the prognostic value of morbidity patterns would be of benefit.

Investigation of mortality rates and the factors affecting survival in out-of-hospital cardiac arrest patients

BACKGROUND

It is known that even if spontaneous circulation returns after cardiopulmonary resuscitation(CPR) in geriatric out-of-hospital cardiac arrests(OHCA), the overall one-year survival rate of these patients is very low. In our study, we aimed to investigate the factors affecting survival in OHCA cases.

METHODS

OHCA patients over 18 years of age were examined in two different groups as 18-64 years old and over 65 years old. Demographic data, comorbidities, cardiac arrest rhythms and minutes, and the number of days they were hospitalized in the intensive care unit were recorded.

RESULTS

The mean age was 65.9 ± 15.8 years and 39.9% (n = 110) of the patients were female. The number of intensive care unit stays was significantly higher in the over-65 age group (p = 0.011). The mortality rate and one-year survival rate were significantly lower in the over-65 age group (p < 0.001). Median CPR time was 21 min (IQR:14-32) in the entire patient population. The duration of CPR was 22 min (IQR:14-35) in patients with in-hospital mortality, and 15 min (IQR:13-25) in patients discharged from the hospital. In this comparison, the difference is statistically significant (p = 0.008).

CONCLUSION

In our study, it was determined that especially over 65 years of age, coronary artery disease, and post-arrest CPR duration were determinant and predictive factors in in-hospital and long-term survival.

Long-term life satisfaction in ageing women with work disability due to mental and musculoskeletal disorders

BACKGROUND

Mental disorders (MDs) and musculoskeletal disorders (MSDs) are the major causes of global disability and increase in prevalence with age.

AIMS

To support healthy ageing, we studied how work disability due to MDs or MSDs is related to life satisfaction (LS) cross-sectionally and in 5- and 10-year follow-ups among ageing women.

METHODS

In the population-based OSTPRE cohort (women aged 58-67 in 1999), data on lifetime permanent work disability pensions (DPs) due to 'MDs only' (n = 337), 'MSDs only' (n = 942) and 'MDs + MSDs' (n = 212) and 'no DP' (n = 6322) until 1999 was obtained from the Finnish national register. The OSTPRE postal enquiry included a four-item life satisfaction (LS) scale (range 4-20: satisfied 4-6, intermediate 7-11, dissatisfied 12-20) at 5-year intervals, in 1999-2004 (n = 6548) and in 1999-2009 (n = 5562).

RESULTS

In 1999, the risks of belonging to the dissatisfied LS group (score 12-20) vs. the satisfied group (score 4-6) were higher in 'MDs only' (OR = 4.30; 95%CI 2.95-6.28), 'MSDs only' (OR = 2.69; 2.12-3.40) and 'MDs + MSDs' (OR = 2.72; 1.77-4.16) groups than in the 'no DP' group. In the follow-ups, these risks were OR5yr = 5.59 (3.54-8.84) and OR10yr = 4.94 (2.80-8.73) for 'MDs only', OR5yr = 3.36 (2.58-4.37) and OR10yr = 3.18 (2.40-4.21) for 'MSDs only', and OR5yr = 4.70 (2.75-8.05) and OR10yr = 6.84 (3.53-13.27) for 'MDs + MSDs' (all: p ≤ 0.001). Adjusting for baseline LS did not change the pattern (all p ≤ 0.001).

CONCLUSION

Work disability due to MDs and MSDs undermines healthy ageing among women via life dissatisfaction.

A pathological convergence theory for non-communicable diseases

The current paradigm considers the study of non-communicable diseases (NCDs), which are the main causes of mortality, as individual disorders. Nevertheless, this conception is being solidly challenged by numerous remarkable studies. The clear fact that the mortality, by virtually all NCDs, tends to cluster at old ages (with the exception of congenital malformations and certain types of cancer, among a few others); makes us intuitive to assume that the common convergence mechanism that exponentially increases mortality by almost all NCDs in older ages is cell aging. Moreover, when we study NCDs, we are not analyzing which disorders cause the mortality of the populations, rather that which disorders kill us before others do, because the aging of the individuals causes inevitably their death by one cause or another. This is not a defeatist perspective, but a challenging and efficient one. These intuitive assumptions have been supported by studies from the pathophysiologic, epidemiologic, and genetic fields, leading to the affirmation that, as NCDs share genetic and pathophysiological mechanisms (derived from mostly the same risk factors), they should no longer be considered independently. Those studies should make us reconsider our current conceptions of studying NCDs as individual disorders, and to hypothesize about a paradigm that would consider most NCDs (cancer, neurological pathologies, cardiovascular diseases, type II diabetes mellitus, chronic respiratory diseases, osteoarthritis, and osteoporosis, among others) different manifestations of the same process: the cell aging.

An Exploration of Methods to Resolve Inconsistent Self-Reporting of Chronic Conditions and Impact on Multimorbidity in the Canadian Longitudinal Study on Aging

OBJECTIVES

To quantify inconsistent self-reporting of chronic conditions between the baseline (2011-2015) and first follow-up surveys (2015-2018) in the Canadian Longitudinal Study on Aging (CLSA), and to explore methods to resolve inconsistent responses and impact on multimorbidity.

METHODS

Community-dwelling adults aged 45-85 years in the baseline and first follow-up surveys were included (n = 45,184). At each survey, participants self-reported whether they ever had a physician diagnosis of 35 chronic conditions. Identifiable inconsistent responses were enumerated.

RESULTS

32-40% of participants had at least one inconsistent response across all conditions. Illness-related information (e.g., taking medication) resolved most inconsistent responses (>93%) while computer-assisted software asking participants to confirm their inconsistent disease status resolved ≤53%. Using these adjudication methods, multimorbidity prevalence at follow-up increased by ≤1.6% compared to the prevalence without resolving inconsistent responses.

DISCUSSION

Inconsistent self-reporting of chronic conditions is common but may not substantially affect multimorbidity prevalence. Future research should validate methods to resolve inconsistencies.

Dual burden of chronic physical conditions and mental disorders: Findings from the Saudi National Mental Health Survey

Introduction

Comorbidities of mental disorders and chronic physical conditions are a common medical burden reported among Western countries. National estimates of such comorbidities among the general population of Arab countries like Saudi Arabia are unknown. This study examined the prevalence of lifetime chronic physical conditions among the Saudi general population with DSM-IV 12-month mental disorders, and the associations with disability in the Kingdom of Saudi Arabia (KSA).

Methods

The Saudi National Mental Health Survey, a cross-sectional household study - part of the World Mental Health (WMH) Survey Consortium - was conducted between 2013-2016 in the KSA, with 4,001 Saudi citizens aged 15-65 (response rate 61%). The World Health Organization Composite International Diagnostic Interview 3.0 was used to assess prevalence of lifetime chronic physical conditions and 12-month mental disorders; disability was measured in terms of days out of role.

Results

The prevalence of any comorbid 12-month mental disorder among those with chronic physical conditions was 24%. Major depressive disorder, social phobia, and adult separation anxiety disorder were the most common comorbid mental disorders across all chronic physical conditions. Gender, education, income, urbanicity, region, and employment were associated with the presence of any chronic physical condition. Respondents with mental / physical comorbidities had 2.97 days out of role (on average) in the last 30 days.

Conclusion

Comorbidities of mental disorders and chronic physical conditions are common among Saudis. National efforts are needed to increase awareness of such comorbidities among the general population, and develop prevention and treatment services tailored to the needs of individuals at-risk for comorbidities.

Impact, scope of practice and competencies of Advanced Practice Nurses within APN-led models of care for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings: a scoping review protocol

INTRODUCTION

The increase of young and middle-aged adult patients with multimorbid and/or complex chronic conditions has created new challenges for healthcare systems and services. Advanced Practice Nurses (APNs) play an essential role in treating these patients because of their expertise and advanced nursing skills. Little is known about competencies, scope of practice and impact of APNs within APN-led care models for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings. The objective of this scoping review is to describe the impact, scope of practice and competencies of APNs within APN-led care models for young and middle-aged adult patients in hospital settings.

METHODS AND ANALYSIS

This scoping review will be conducted using the methodological framework proffered by Arksey and O'Malley, incorporating the methodological enhancement of Levac et al. It will comply with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) for Scoping Reviews' guidelines of Tricco et al. Systematic research will be conducted in the databases MEDLINE (PubMed), CINAHL (EBSCO), EMBASE (Ovid), CENTRAL and PsycINFO (Ovid) using all recognised keywords, index terms and search strings. Grey literature will be scanned. Bibliography of all selected studies will be hand searched. Studies will be selected based on defined inclusion and exclusion criteria, screened by title and abstracts. Data from full-text articles meeting the inclusion criteria will be extracted independently by two authors. Disagreements in evaluation will be discussed and resolved by consensus. Results will be reported in the form of descriptive tables. Narrative summery is used to present the results of the review in the context of the study's objectives and questions.

ETHICS AND DISSEMINATION

This scoping review does not require ethics approval. The review will be handed in as part of a doctoral thesis and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER OSF

4PM38.

Comorbidity and outcomes among hospitalized patients with stroke: a nationwide inpatient analysis

Objective

We aimed to characterize healthcare utilization and comorbidity outcomes among hospitalized elderly stroke patients using a nationally representative dataset in the United States.

Methods

Using the 2019 National Inpatient Sample, patients aged 65 years or older with and without comorbidities who were hospitalized for acute stroke were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. Patient comorbidities were identified with the use of the Elixhauser Comorbidity Index. The prevalence of comorbidities, in-hospital mortality, length of stay, and total hospital costs were analyzed for these patients.

Results

Within 451,945 patients (mean age 78 years, 54.1% women, 73.7% white), we observed that more than 90% of patients had a minimum of two comorbidities. The median number of comorbidities was 4.0 (IQR 3.0-6.0). There was significant variation in the prevalence rate of comorbidities. The five most common comorbidities were uncomplicated hypertension (55.4%), paralysis (40.1%), congestive heart failure (39.8%), various neurological illnesses (38.3%), and complex hypertension (32.5%). After adjusting for patient- and hospital-level characteristics, a statistically significant association was observed between comorbidities and various adverse outcomes. Specifically, comorbidities were found to be significantly associated with an increased risk of inpatient mortality (odds ratio: 1.09; 95% CI: 1.08-1.11; P < 0.001), a longer duration of hospitalization (0.68 days; 95% CI: 0.66-0.71; P < 0.001), and higher total cost ($1,874.9; 95% CI: 1,774.6-1,975.2; P < 0.001).

Conclusion

This national data suggests that comorbidity is common among hospitalized older stroke patients and substantially increases the healthcare burden and inpatient mortality in the United States. These findings underscore the integration of comorbidity management into the care of older stroke patients.

Social Support, Religiosity, Wisdom and Well-Being Among Older Adults in Indonesia

Purpose

As the population ages, it is critical to understand the elements that contribute to the well-being of older individuals. Prior research suggests that a better sense of mastery and purpose in life may explain at least some of the beneficial link between wisdom, religion, and subjective well-being. This current study seeks to identify a model of older persons' psychological well-being formation in a religious group. Whether psychosocial strengths such as religiosity, social support, and wisdom are directly related to psychological well-being. Self-acceptance, autonomy, positive interpersonal relationships, environmental mastery, personal growth, and a sense of life purpose are all components of psychological well-being.

Participants and Methods

This cross-sectional study included 261 participants, 42 men and 219 women aged 60 and up with normal cognitive, hearing, and/or speech functions. Participants lived in The boarding house in South Tapanuli-North Sumatra, Indonesia, for over 6 months. A backward translated Likert scales is used for data collection. The data were analyzed using Structural Equation Model (SEM).

Results

The results indicate that social support and religiosity have an effect on psychological well-being through wisdom as a mediator.

Conclusion

These findings emphasize the relevance of internal strengths for psychological well-being and give credence to the mediated path model's applicability to older adult communities in Indonesia.

Familial aggregation of multimorbidity in Sweden: national explorative family study

Objectives

To examine whether multimorbidity aggregates in families in Sweden.

Design

National explorative family study.

Setting

Swedish Multigeneration Register linked to the National Patient Register, 1997-2015. Multimorbidity was assessed with a modified counting method of 45 chronic non-communicable diseases according to ICD-10 (international classification of diseases, 10th revision) diagnoses.

Participants

2 694 442 Swedish born individuals (48.73% women) who could be linked to their Swedish born first, second, and third degree relatives. Twins were defined as full siblings born on the same date.

Main outcome measures

Multimorbidity was defined as two or more non-communicable diseases. Familial associations for one, two, three, four, and five or more non-communicable diseases were assessed to examine risks depending on the number of non-communicable diseases. Familial adjusted odds ratios for multimorbidity were calculated for individuals with a diagnosis of multimorbidity compared with relatives of individuals unaffected by multimorbidity (reference). An initial principal component decomposition followed by a factor analysis with a principal factor method and an oblique promax rotation was used on the correlation matrix of tetrachoric correlations between 45 diagnoses in patients to identify disease clusters.

Results

The odds ratios for multimorbidity were 2.89 in twins (95% confidence interval 2.56 to 3.25), 1.81 in full siblings (1.78 to 1.84), 1.26 in half siblings (1.24 to 1.28), and 1.13 in cousins (1.12 to 1.14) of relatives with a diagnosis of multimorbidity. The odds ratios for multimorbidity increased with the number of diseases in relatives. For example, among twins, the odds ratios for multimorbidity were 1.73, 2.84, 4.09, 4.63, and 6.66 for an increasing number of diseases in relatives, from one to five or more, respectively. Odds ratios were highest at younger ages: in twins, the odds ratio was 3.22 for those aged ≤20 years, 3.14 for those aged 21-30 years, and 2.29 for those aged >30 years at the end of follow-up. Nine disease clusters (factor clusters 1-9) were identified, of which seven aggregated in families. The first three disease clusters in the principal component decomposition were cardiometabolic disease (factor 1), mental health disorders (factor 2), and disorders of the digestive system (factor 3). Odds ratios for multimorbidity in twins, siblings, half siblings, and cousins for the factor 1 cluster were 2.79 (95% confidence interval 0.97 to 8.06), 2.62 (2.39 to 2.88), 1.52 (1.34 to 1.73), and 1.31 (1.23 to 1.39), and for the factor 2 cluster, 5.79 (4.48 to 7.48) 3.24 (3.13 to 3.36), 1.51 (1.45 to 1.57), and 1.37 (1.341.40).

Conclusions

The results of this explorative family study indicated that multimorbidity aggregated in Swedish families. The findings suggest that map clusters of diseases should be used for the genetic study of common diseases to show new genetic patterns of non-communicable diseases.

Etiology, effects and management of comorbidities in multiple sclerosis: recent advances

Comorbid conditions commonly affect people with multiple sclerosis (MS). Population-based studies indicate that people with MS have an increased incidence of ischemic heart disease, cerebrovascular disease, peripheral vascular disease, and psychiatric disorders as compared to people without MS. People with MS from underrepresented minority and immigrant groups have higher comorbidity burdens. Comorbidities exert effects throughout the disease course, from symptom onset through diagnosis to the end of life. At the individual level, comorbidity is associated with higher relapse rates, greater physical and cognitive impairments, lower health-related quality of life, and increased mortality. At the level of the health system and society, comorbidity is associated with increased health care utilization, costs and work impairment. A nascent literature suggests that MS affects outcomes from comorbidities. Comorbidity management needs to be integrated into MS care, and this would be facilitated by determining optimal models of care.

Effect of multicomponent rehabilitation on independence and functioning in elderly patients with common age-associated diseases: protocol for a scoping review (REHOLD)

INTRODUCTION

Elderly patients after hospitalisation for acute events on account of age-related diseases (eg, joint or heart valve replacement surgery) are often characterised by a remarkably reduced functional health. Multicomponent rehabilitation (MR) is considered an appropriate approach to restore the functioning of these patients. However, its efficacy in improving functioning-related outcomes such as care dependency, activities of daily living (ADL), physical function and health-related quality of life (HRQL) remains unclarified. We outline the research framework of a scoping review designed to map the available evidence of the effects of MR on the independence and functional capacity of elderly patients hospitalised for age-related diseases in four main medical specialties beyond geriatrics.

METHODS AND ANALYSIS

The biomedical databases (PubMed, Cochrane Library, ICTRP Search Platform, ClinicalTrials) and additionally Google Scholar will be systematically searched for studies comparing centre-based MR with usual care in patients ≥75 years of age, hospitalised for common acute events due to age-related diseases (eg, joint replacement, stroke) in one of the specialties of orthopaedics, oncology, cardiology or neurology. MR is defined as exercise training and at least one additional component (eg, nutritional counselling), starting within 3 months after hospital discharge. Randomised controlled trials as well as prospective and retrospective controlled cohort studies will be included from inception and without language restriction. Studies investigating patients <75 years, other specialties (eg, geriatrics), rehabilitation definition or differently designed will be excluded. Care dependency after at least a 6-month follow-up is set as the primary outcome. Physical function, HRQL, ADL, rehospitalisation and mortality will be additionally considered. Data for each outcome will be summarised, stratified by specialty, study design and type of assessment. Furthermore, quality assessment of the included studies will be performed.

ETHICS AND DISSEMINATION

Ethical approval is not required. Findings will be published in a peer-reviewed journal and presented at national and/or international congresses.

TRIAL REGISTRATION NUMBER

https://doi.org/10.17605/OSF.IO/GFK5C.

Prediction of disease comorbidity using explainable artificial intelligence and machine learning techniques: A systematic review

OBJECTIVE

Disease comorbidity is a major challenge in healthcare affecting the patient's quality of life and costs. AI-based prediction of comorbidities can overcome this issue by improving precision medicine and providing holistic care. The objective of this systematic literature review was to identify and summarise existing machine learning (ML) methods for comorbidity prediction and evaluate the interpretability and explainability of the models.

MATERIALS AND METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used to identify articles in three databases: Ovid Medline, Web of Science and PubMed. The literature search covered a broad range of terms for the prediction of disease comorbidity and ML, including traditional predictive modelling.

RESULTS

Of 829 unique articles, 58 full-text papers were assessed for eligibility. A final set of 22 articles with 61 ML models was included in this review. Of the identified ML models, 33 models achieved relatively high accuracy (80-95%) and AUC (0.80-0.89). Overall, 72% of studies had high or unclear concerns regarding the risk of bias.

DISCUSSION

This systematic review is the first to examine the use of ML and explainable artificial intelligence (XAI) methods for comorbidity prediction. The chosen studies focused on a limited scope of comorbidities ranging from 1 to 34 (mean = 6), and no novel comorbidities were found due to limited phenotypic and genetic data. The lack of standard evaluation for XAI hinders fair comparisons.

CONCLUSION

A broad range of ML methods has been used to predict the comorbidities of various disorders. With further development of explainable ML capacity in the field of comorbidity prediction, there is a significant possibility of identifying unmet health needs by highlighting comorbidities in patient groups that were not previously recognised to be at risk for particular comorbidities.

Polypharmacy stewardship: a novel approach to tackle a major public health crisis

With growing global concern regarding medication-related harm, WHO launched a global patient safety challenge, Medication Without Harm, in March, 2017. Multimorbidity, polypharmacy, and fragmented health care (ie, patients attending appointments with multiple physicians in various health-care settings) are key drivers of medication-related harm, which can result in negative functional outcomes, high rates of hospitalisation, and excess morbidity and mortality, particularly in patients with frailty older than 75 years. Some studies have examined the effect of medication stewardship interventions in older patient cohorts, but focused on a narrow spectrum of potentially adverse medication practices, with mixed results. In response to the WHO challenge, we propose the novel concept of broad-spectrum polypharmacy stewardship, a coordinated intervention designed to improve the management of multimorbidities, taking into account potentially inappropriate medications, potential prescribing omissions, drug-drug and drug-disease interactions, and prescribing cascades, aligning treatment regimens with the condition, prognosis, and preferences of the individual patient. Although the safety and efficacy of polypharmacy stewardship need to be tested with well designed clinical trials, we propose that this approach could minimise medication-related harm in older people with multimorbidities exposed to polypharmacy.

Social determinants of multimorbidity patterns: A systematic review

Social determinants of multimorbidity are poorly understood in clinical practice. This review aims to characterize the different multimorbidity patterns described in the literature while identifying the social and behavioral determinants that may affect their emergence and subsequent evolution. We searched PubMed, Embase, Scopus, Web of Science, Ovid MEDLINE, CINAHL Complete, PsycINFO and Google Scholar. In total, 97 studies were chosen from the 48,044 identified. Cardiometabolic, musculoskeletal, mental, and respiratory patterns were the most prevalent. Cardiometabolic multimorbidity profiles were common among men with low socioeconomic status, while musculoskeletal, mental and complex patterns were found to be more prevalent among women. Alcohol consumption and smoking increased the risk of multimorbidity, especially in men. While the association of multimorbidity with lower socioeconomic status is evident, patterns of mild multimorbidity, mental and respiratory related to middle and high socioeconomic status are also observed. The findings of the present review point to the need for further studies addressing the impact of multimorbidity and its social determinants in population groups where this problem remains invisible (e.g., women, children, adolescents and young adults, ethnic groups, disabled population, older people living alone and/or with few social relations), as well as further work with more heterogeneous samples (i.e., not only focusing on older people) and using more robust methodologies for better classification and subsequent understanding of multimorbidity patterns. Besides, more studies focusing on the social determinants of multimorbidity and its inequalities are urgently needed in low- and middle-income countries, where this problem is currently understudied.

Association between maternal multimorbidity and preterm birth, low birth weight and small for gestational age: a prospective birth cohort study from the Japan Environment and Children's Study

OBJECTIVES

Multimorbidity is defined as the coexistence of two or more chronic physical or psychological conditions within an individual. The association between maternal multimorbidity and adverse perinatal outcomes such as preterm delivery and low birth weight has not been well studied. Therefore, this study aimed to investigate this association.

METHODS

We conducted a prospective cohort study using data from the Japan Environment and Children's Study of pregnant women between 2011 and 2014. Those with data on chronic maternal conditions were included in the study and categorised as having no chronic condition, one chronic condition or multimorbidities. The primary outcomes were the incidence of preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA). Adjusted logistic regression was performed to estimate ORs (aORs) and 95% CIs.

RESULTS

Of the 104 062 fetal records, 86 885 singleton pregnant women were analysed. The median maternal age and body mass index were 31 years and 20.5 kg/m², respectively. The prevalence of pregnant women with one or more chronic conditions was 40.2%. The prevalence of maternal multimorbidity was 6.3%, and that of PTB, LBW, and SGA were 4.6%, 8.1%, and 7.5%, respectively. Pre-pregnancy underweight women were the most common, observed in 15.6% of multimorbidity cases, followed by domestic violence from intimate partner in 13.0%. Maternal multimorbidity was significantly associated with PTB (aOR 1.50; 95% CI 1.33-1.69), LBW (aOR 1.49; 95% CI 1.35-1.63) and SGA (aOR 1.33; 95% CI 1.20-1.46).

CONCLUSION

Maternal multimorbidity was associated with adverse perinatal outcomes, including PTB, LBW and SGA. The risk of adverse perinatal outcomes tends to increase with a rise in the number of chronic maternal conditions. Multimorbidity becomes more prevalent among pregnant women, making our findings important for preconception counselling.

Clinical Outcomes Following Exercise Rehabilitation in People with Multimorbidity: A Systematic Review

OBJECTIVE

To determine the effectiveness of exercise rehabilitation in people with multimorbidity. Exercise capacity was the primary outcome. Secondary outcomes were: health-related quality of life, activities of daily living, cardiometabolic outcomes, mental health outcomes, symptom scores, resource utilization, health behaviours, economic outcomes, and adverse events.

DATA SOURCES

A search was conducted in MEDLINE, CINHAL, EMBASE, and Cochrane Central Register of Controlled Trials databases.

STUDY SELECTION AND EXTRACTION

Randomized and non-randomized controlled trials and cohort studies of exercise rehabilitation vs any comparison in people with multimorbidity.

DATA SYNTHESIS

Forty-four reports (38 studies) were included. Rehabilitation ranged from 8 weeks to 4 years, with 1-7 sessions of rehabilitation weekly. Exercise included aerobic and resistance, limb training, aquatic exercises and tai chi. Compared with usual care, exercise rehabilitation improved 6-min walk distance (weighted mean difference (WMD) 64 m, 95% CI 45-82) and peak oxygen consumption (WMD 2.74 mL/kg/min, 95% CI -3.32 to 8.79). Effects on cardiometabolic outcomes and health-related quality of life also favoured rehabilitation; however; few data were available for other secondary outcomes.

CONCLUSION

In people with multimorbidity, exercise rehabilitation improved exercise capacity, health-related quality of life, and cardiometabolic outcomes.

Transforming the perioperative medicine care model: The Singapore experience

More than 300 million surgeries are performed worldwide annually. Established perioperative centres in the UK, USA and Australia have demonstrated the impact of improving perioperative care in reducing costs, increasing patient satisfaction and improving population health. Likewise, the surgical burden of care in Asia is increasing, but with sociocultural, economic and epigenetic differences compared to the west. As Singapore's largest hospital, the Singapore General Hospital pre-admission perioperative clinic sees about 20,000 patients annually. We aim to illustrate Singapore General Hospital's perioperative model of care to contribute to the paucity of literature describing perioperative programme implementation within Asia, and to encourage the cross-sharing of perioperative practices internationally. Our perioperative framework navigates risk assessment, risk counselling, and mitigation of health, medical and functional risks to better patients' perioperative outcomes and population health. We have implemented evidence-based pathways for common conditions such as anaemia and malnutrition, including a multidisciplinary programme for the elderly to tackle frailty and reduce length of stay. We describe how we have enhanced local risk profiling with the Combined Assessment of Risk Encountered in Surgery surgical risk calculator derived locally using a gradient boosting machine learning model. Finally, we report clinical outcomes of these interventions and discuss further challenges and new initiatives at each tier of our perioperative model. Our perioperative care model provides a framework that other centres can adopt to promote value-driven care, while catering for differences in the Asian population, thereby promoting evidence-based improvements in the area of perioperative medicine.

Can markers of disease severity improve the predictive power of claims-based multimorbidity indices?

BACKGROUND

Claims-based measures of multimorbidity, which evaluate the presence of a defined list of diseases, are limited in their ability to predict future outcomes. We evaluated whether claims-based markers of disease severity could improve assessments of multimorbid burden.

METHODS

We developed 7 dichotomous markers of disease severity which could be applied to a range of diseases using claims data. These markers were based on the number of disease-associated outpatient visits, emergency department visits, and hospitalizations made by an individual over a defined interval; whether an individual with a given disease had outpatient visits to a specialist who typically treats that disease; and ICD-9 codes which connote more versus less advanced or symptomatic manifestations of a disease. Using Medicare claims linked with Health and Retirement Study data, we tested whether including these markers improved ability to predict ADL decline, IADL decline, hospitalization, and death compared to equivalent models which only included the presence or absence of diseases.

RESULTS

Of 5012 subjects, median age was 76 years and 58% were female. For a majority of diseases tested individually, adding each of the 7 severity markers yielded minimal increase in c-statistic (≤0.002) for outcomes of ADL decline and mortality compared to models considering only the presence versus absence of disease. Gains in predictive power were more substantial for a small number of individual diseases. Inclusion of the most promising marker in multi-disease multimorbidity indices yielded minimal gains in c-statistics (<0.001-0.007) for predicting ADL decline, IADL decline, hospitalization, and death compared to indices without these markers.

CONCLUSIONS

Claims-based markers of disease severity did not contribute meaningfully to the ability of multimorbidity indices to predict ADL decline, mortality, and other important outcomes.

ADP-ribose-acceptor hydrolase 2 ( Arh2 ) deficiency results in cardiac dysfunction, tumorigenesis, inflammation, and decreased survival

ADP-ribosylation is a reversible reaction with ADP-ribosyltransferases catalyzing the forward reaction and ADP-ribose-acceptor hydrolases (ARHs) hydrolyzing the ADP-ribose acceptor bond. ARH2 is a member of the 39-kDa ARH family (ARH1-3), which is expressed in heart and skeletal muscle. ARH2 failed to exhibit any in vitro enzymatic activity. To determine its possible in vivo activities, Arh2 -knockout (KO) and - heterozygous (Het) mice were generated using CRISPR-Cas9. Arh2 -KO mice exhibited decreased cardiac contractility by MRI, echocardiography and dobutamine stress with cardiomegaly and abnormal motor function. Arh2 -Het mice showed results similar to those seen in Arh2 -KO mice except for cardiomegaly. Arh2 -KO and -Het mice and mouse embryonic fibroblasts (MEFs) developed spontaneous tumors and subcutaneous tumors in nude mice. We identified 13 mutations in Arh2 -Het MEFs and heterozygous tumors, corresponding to human ARH2 mutations in cancers obtained from COSMIC. Of interest, the L116R mutation in Arh2 gene plays a critical role in aggressive tumorigenesis in nude mice, corresponding to human ARH2 mutations in stomach adenocarcinoma. Both genders of Arh2 -KO and -Het mice showed increased unexpectedly deaths and decreased survival rate during a 24-month observation, caused by tumor, inflammation, non-inflammation (e.g., cardiomegaly, dental dysplasia), and congenital diseases. Thus, Arh2 plays a pivotal role in cardiac function, tumorigenesis, inflammation, and overall survival.

Association between Sense of Loneliness and Quality of Life in Older Adults with Multimorbidity

BACKGROUND

Multimorbidity has been associated with adverse health outcomes, such as reduced physical function, poor quality-of-life (QoL), poor self-rated health.

OBJECTIVE

The association between quality of life, social support, sense of loneliness and sex and age in older adult patients affected by two or more chronic diseases (multimorbidity) was evaluated.

METHODS

Patients n. 162 with multimorbidity and living with family members.

TESTS

MMSE-Mini-Mental-State-Examination; ADL-Activities of Daily Living; Social Schedule: demographic variables; Loneliness Scale -de Jong Gierveld; Quality-of-Life-FACT-G; WHOQOL-BRIEF Social relationships.

STATISTICAL ANALYSIS

Multivariate Regression Analysis.

RESULTS

The patients with three or more diseases have worse dimensions of FACT-G total score (p = 0.029), QoL Physical-well-being (p = 0.003), Social well-being (p = 0.003), Emotional-well-being (p = 0.012), Functional-well-being (p < 0.001), than those with two. Multiple linear regression QoL: FACT_G total score, PWB, SWB, EWB, FWB as dependent variables. In the presence of multimorbidity with an increase in the patient's age FACT-G total score (B = -0.004, p = 0.482), PWB (B = -0.024, p = 0.014), SWB (B = -0.022, p = 0.051), EWB (B = -0.001, p = 0.939), FWB (B = -0.023, p = 0.013) decrease by an average of 0.1, and as the sense of solitude increases FACT-G total score (B = -0.285, p < 0.000), PWB (B = -0.435, p < 0.000), SWB(B = -0.401, p < 0.000), EWB(B = -0.494, p < 0.000), FWB(B = -0.429, p < 0.000) decrease by 0.4.

CONCLUSIONS

A sense of loneliness and advancing age are associated with bad quality-of life in self-sufficient elderly patients with multimorbidity.

IMPLICATIONS FOR PRACTICE

Demonstrating that loneliness, as well as in the presence of interpersonal relations, is predictive of worse quality of life in patients with multimorbidity helps identify people most at risk for common symptoms and lays the groundwork for research concerning both diagnosis and treatment.

Survival and comorbidities in lung cancer patients: Evidence from administrative claims data in Germany

Lung cancer is the most common cancer type worldwide and has the highest and second highest mortality rate for men and women respectively in Germany. Yet, the role of comorbid illnesses in lung cancer patient prognosis is still debated. We analyzed administrative claims data from one of the largest statutory health insurance (SHI) funds in Germany, covering close to 9 million people (11% of the national population); observation period was from 2005 to 2019. Lung cancer patients and their concomitant diseases were identified by ICD-10-GM codes. Comorbidities were classified according to the Charlson Comorbidity Index (CCI). Incidence, comorbidity prevalence and survival are estimated considering sex, age at diagnosis, and place of residence. Kaplan Meier curves with 95% confidence intervals were built in relation to common comorbidities. We identified 70,698 lung cancer incident cases in the sample. Incidence and survival figures are comparable to official statistics in Germany. Most prevalent comorbidities are chronic obstructive pulmonary disease (COPD) (36.7%), followed by peripheral vascular disease (PVD) (18.7%), diabetes without chronic complications (17.4%), congestive heart failure (CHF) (16.5%) and renal disease (14.7%). Relative to overall survival, lung cancer patients with CHF, cerebrovascular disease (CEVD) and renal disease are associated with largest drops in survival probabilities (9% or higher), while those with PVD and diabetes without chronic complications with moderate drops (7% or lower). The study showed a negative association between survival and most common comorbidities among lung cancer patients, based on a large sample for Germany. Further research needs to explore the individual effect of comorbidities disentangled from that of other patient characteristics such as cancer stage and histology.

Age-specific incidence of need for long-term care for men and women in Germany 2015: Cross-sectional study comprising 82 million people

Background: With the growing number of older people, the number of people in need of long-term care is increasing, too. Official statistics only report on the age-specific prevalence of long-term care. Therefore, there is no data on the age- and sex-specific incidence of the need for care at the population level for Germany available. Methods: Analytical relationships between age-specific prevalence, incidence rate, remission rate, all-cause mortality, and mortality rate ratio are used to estimate the age-specific incidence of long-term care among men and women in 2015. The data is based on the official prevalence data from the nursing care statistics for the years 2011 to 2019 and official mortality rates from the Federal Statistical Office. For Germany, there is no data on the mortality rate ratio of people with and without a need for care, which is why we use two extreme scenarios that were obtained in a systematic literature search to estimate the incidence. Results: The age-specific incidence is about 1 per 1000 person-years (PY) in men and women at the age of 50 and increases exponentially up to the age of 90. Up to about the age of 60, men have a higher incidence rate than women. Thereafter, women have a higher incidence. At the age of 90, women and men have an incidence rate of 145 to 200 and 94 to 153 per 1000 PY, respectively, depending on the scenario. Conclusion: We estimated the age-specific incidence of the need for long-term care for women and men in Germany for the first time. We observed a strong increase, leading to a huge number of people in need of long-term care in higher age groups. It is to be expected that this will result in an increased economic burden and a further increased need for nursing and medical staff.

Projecting the chronic disease burden among the adult population in the United States using a multi-state population model

Introduction

As the United States population ages, the adult population with chronic diseases is expected to increase. Exploring credible, evidence-based projections of the future burden of chronic diseases is fundamental to understanding the likely impact of established and emerging interventions on the incidence and prevalence of chronic disease. Projections of chronic disease often involve cross-sectional data that fails to account for the transition of individuals across different health states. Thus, this research aims to address this gap by projecting the number of adult Americans with chronic disease based on empirically estimated age, gender, and race-specific transition rates across predetermined health states.

Methods

We developed a multi-state population model that disaggregates the adult population in the United States into three health states, i.e., (a) healthy, (b) one chronic condition, and (c) multimorbidity. Data from the 1998 to 2018 Health and Retirement Study was used to estimate age, gender, and race-specific transition rates across the three health states, as input to the multi-state population model to project future chronic disease burden.

Results

The number of people in the United States aged 50 years and older will increase by 61.11% from 137.25 million in 2020 to 221.13 million in 2050. Of the population 50 years and older, the number with at least one chronic disease is estimated to increase by 99.5% from 71.522 million in 2020 to 142.66 million by 2050. At the same time, those with multimorbidity are projected to increase 91.16% from 7.8304 million in 2020 to 14.968 million in 2050. By race by 2050, 64.6% of non-Hispanic whites will likely have one or more chronic conditions, while for non-Hispanic black, 61.47%, and Hispanic and other races 64.5%.

Conclusion

The evidence-based projections provide the foundation for policymakers to explore the impact of interventions on targeted population groups and plan for the health workforce required to provide adequate care for current and future individuals with chronic diseases.

Frequency and Correlates of Multimorbidity Among the Oldest Old: Study Findings from the Representative "Survey on Quality of Life and Subjective Well-Being of the Very Old in North Rhine-Westphalia (NRW80+)"

Purpose

Our aim was to clarify the frequency and correlates of multimorbidity among the oldest old.

Patients and Methods

We used data from the representative "Survey on quality of life and subjective well-being of the very old in North Rhine-Westphalia (NRW80+)" covering participants ≥80 years living in private households and in institutionalized settings in North Rhine-Westphalia (n = 1484, mean age was 86.3 years). Multimorbidity is defined as the co-occurrence of at least two chronic conditions. Sociodemographic, lifestyle-related, and health-related (including health literacy) correlates were included in regression analysis.

Results

About 79% of the participants were multimorbid. Logistic regressions showed that the likelihood of multimorbidity significantly increased with living in a private household, having a larger network size, worse self-rated health, higher functional impairment, and more depressive symptoms, whereas the remaining sociodemographic and lifestyle-related factors as well as health literacy were not significantly associated with multimorbidity.

Conclusion

A large proportion of participants in very late life is multimorbid. Apart from health-related factors, also two sociodemographic factors (ie, living situation and network size) were associated with multimorbidity among the oldest old. This knowledge may help to identify individuals at risk for multimorbidity in very late life.

Multimorbidity and Complexity Among Patients with Cancer in Ontario: A Retrospective Cohort Study Exploring the Clustering of 17 Chronic Conditions with Cancer

BACKGROUND

Multimorbidity is a concern for people living with cancer, as over 90% have at least one other condition. Multimorbidity complicates care coming from multiple providers who work within separate, siloed systems. Information describing high-risk and high-cost disease combinations has potential to improve the experience, outcome, and overall cost of care by informing comprehensive care management frameworks. This study aimed to identify disease combinations among people with cancer and other conditions, and to assess the health burden associated with those combinations to help healthcare providers more effectively prioritize and coordinate care.

METHODS

We used a population-based retrospective cohort design including adults with a cancer diagnosis between March-2003 and April-2013, followed-up until March 2018. We used observed disease combinations defined by level of multimorbidity and partitive (k-means) clusters, ie groupings of similar diseases based on the prevalence of each condition. We assessed disease combination-associated health burden through health service utilization, including emergency department visits, primary care visits and hospital admissions during the follow-up period.

RESULTS

549,248 adults were included in the study. Anxiety, diabetes mellitus, hypertension, and osteoarthritis co-occurred with cancer 1.1 to 5.3 times more often than expected by chance. Disease combinations varied by cancer type and age but were similar between sexes. The largest partitive cluster included cancer and anxiety, with at least 25% of individuals also having osteoarthritis. Cancer also tended to co-occur with hypertension (8.0%) or osteoarthritis (6.2%). There were differences between clusters in healthcare utilization, regardless of the number of disease combinations or clustering approach used.

CONCLUSION

Researchers, clinicians, policymakers, and other stakeholders can use the clustering information presented here to improve the healthcare system for people with cancer multimorbidity by developing cluster-specific care management and clinical guidelines for common disease combinations.

A Call for Action on Chronic Respiratory Diseases within Physical Activity Policies, Guidelines and Action Plans: Let's Move!

Global policy documents for the promotion of physical activity (PA) play an important role in the measurement, evaluation, and monitoring of population PA levels. The World Health Organisation (WHO) guidelines include, for the first time, recommendations for specific populations, including individuals living with a range of non-communicable diseases. Of note, is the absence of any chronic respiratory diseases (CRDs) within the recommendations. Globally, CRDs are highly prevalent, are attributable to significant individual and societal burdens, and are characterised by low PA. As a community, there is a need to come together to understand how to increase CRD representation within global PA policy documents, including where the evidence gaps are and how we can align with PA research in other contexts. In this commentary, the potential for synergy between evidence into the relationships between PA in CRDs globally and the relevance to current policies, guidelines and action plans on population levels of PA are discussed. Furthermore, actions and considerations for future research, including the need to harmonize and promote PA assessment (particularly in low- and middle-income countries) and encompass the synergistic influences of PA, sedentary behaviour and sleep on health outcomes in CRD populations are presented.

Age-related mechanisms in the context of rheumatic disease

Ageing is characterized by a progressive loss of cellular function that leads to a decline in tissue homeostasis, increased vulnerability and adverse health outcomes. Important advances in ageing research have now identified a set of nine candidate hallmarks that are generally considered to contribute to the ageing process and that together determine the ageing phenotype, which is the clinical manifestation of age-related dysfunction in chronic diseases. Although most rheumatic diseases are not yet considered to be age related, available evidence increasingly emphasizes the prevalence of ageing hallmarks in these chronic diseases. On the basis of the current evidence relating to the molecular and cellular ageing pathways involved in rheumatic diseases, we propose that these diseases share a number of features that are observed in ageing, and that they can therefore be considered to be diseases of premature or accelerated ageing. Although more data are needed to clarify whether accelerated ageing drives the development of rheumatic diseases or whether it results from the chronic inflammatory environment, central components of age-related pathways are currently being targeted in clinical trials and may provide a new avenue of therapeutic intervention for patients with rheumatic diseases.

The New Version of the ANDDigest Tool with Improved AI-Based Short Names Recognition

The body of scientific literature continues to grow annually. Over 1.5 million abstracts of biomedical publications were added to the PubMed database in 2021. Therefore, developing cognitive systems that provide a specialized search for information in scientific publications based on subject area ontology and modern artificial intelligence methods is urgently needed. We previously developed a web-based information retrieval system, ANDDigest, designed to search and analyze information in the PubMed database using a customized domain ontology. This paper presents an improved ANDDigest version that uses fine-tuned PubMedBERT classifiers to enhance the quality of short name recognition for molecular-genetics entities in PubMed abstracts on eight biological object types: cell components, diseases, side effects, genes, proteins, pathways, drugs, and metabolites. This approach increased average short name recognition accuracy by 13%.

Multicomponent, high-intensity, and patient-centered care intervention for complex patients in transitional care: SPICA program

Multimorbidity is increasingly present in our environment. Besides, this is accompanied by a deterioration of social and environmental conditions and affects the self-care ability and access to health resources, worsening health outcomes and determining a greater complexity of care. Different multidisciplinary and multicomponent programs have been proposed for the care of complex patients around hospital discharge, and patient-centered coordination models may lead to better results than the traditional ones for this type of patient. However, programs with these characteristics have not been systematically implemented in our country, despite the positive results obtained. Hospital Universitario de Canarias cares for patients from the northern area of Tenerife and La Palma, Spain. In this hospital, a multicomponent and high-intensity care program is carried out by a multidisciplinary team (made up of family doctors and nurses together with social workers) with complex patients in the transition of care (SPICA program). The aim of this program is to guarantee social and family reintegration and improve the continuity of primary healthcare for discharged patients, following the patient-centered clinical method. Implementing multidisciplinary and high-intensity programs would improve clinical outcomes and would be cost-effective. This kind of program is directly related to the current clinical governance directions. In addition, as the SPICA program is integrated into a Family and Community Care Teaching Unit for the training of both specialist doctors and specialist nurses, it becomes a place where the specific methodology of those specialties can be carried out in transitional care. During these 22 years of implementation, its continuous quality management system has allowed it to generate an important learning curve and incorporate constant improvements in its work processes and procedures. Currently, research projects are planned to reevaluate the effectiveness of individualized care plans and the cost-effectiveness of the program.

Discovery and classification of complex multimorbidity patterns: unravelling chronicity networks and their social profiles

Multimorbidity can be defined as the presence of two or more chronic diseases in an individual. This condition is associated with reduced quality of life, increased disability, greater functional impairment, increased health care utilisation, greater fragmentation of care and complexity of treatment, and increased mortality. Thus, understanding its epidemiology and inherent complexity is essential to improve the quality of life of patients and to reduce the costs associated with multi-pathology. In this paper, using data from the European Health Survey, we explore the application of Mixed Graphical Models and its combination with social network analysis techniques for the discovery and classification of complex multimorbidity patterns. The results obtained show the usefulness and versatility of this approach for the study of multimorbidity based on the use of graphs, which offer the researcher a holistic view of the relational structure of data with variables of different types and high dimensionality.

Prevalence of multimorbidity combinations and their association with medical costs and poor health: A population-based study of U.S. adults

Background

Multimorbidity is common, but the prevalence and burden of the specific combinations of coexisting disease has not been systematically examined in the general U.S. adult population.

Objective

To identify and estimate the burden of highly prevalent combinations of chronic conditions that are treated among one million or more adults in the United States.

Methods

Cross-sectional analysis of U.S. households in the Medical Expenditure Panel Survey (MEPS), 2016-2019, a large nationally-representative sample of the community-dwelling population. Association rule mining was used to identify the most common combinations of 20 chronic conditions that have high relevance, impact, and prevalence in primary care. The main measures and outcomes were annual treated prevalence, total medical expenditures, and perceived poor health. Logistic regression models with poor health as the outcome and each multimorbidity combination as the exposure were used to calculate adjusted odds ratios and 95% confidence intervals.

Results

Frequent pattern mining yielded 223 unique combinations of chronic disease, including 74 two-way (dyad), 115 three-way (triad), and 34 four-way combinations that are treated in one million or more U.S. adults. Hypertension-hyperlipidemia was the most common two-way combination occurring in 30.8 million adults. The combination of diabetes-arthritis-cardiovascular disease was associated with the highest median annual medical expenditures ($23,850, interquartile range: $11,593-$44,616), and the combination of diabetes-arthritis-asthma/COPD had the highest age-race-sex adjusted odds ratio of poor self-rated health (adjusted odd ratio: 6.9, 95%CI: 5.4-8.8).

Conclusion

This study demonstrates that many multimorbidity combinations are highly prevalent among U.S. adults, yet most research and practice-guidelines remain single disease focused. Highly prevalent and burdensome multimorbidity combinations could be prioritized for evidence-based research on optimal prevention and treatment strategies.