Patterns of multimorbidity and their association with hospitalisation: a population-based study of older adults in urban Tanzania

Longitudinal changes in blood pressure and fasting plasma glucose among 5,398 primary care patients with concomitant hypertension and diabetes: An observational study and implications for community-based cardiovascular prevention

Aims

To assess longitudinal changes in blood pressure (BP) and fasting plasma glucose (FPG) in primary care patients with concomitant hypertension and type 2 diabetes mellitus (T2DM), and to explore factors associated with patients' inability to improve BP and FPG at follow-up.

Methods

We constructed a closed cohort in the context of the national basic public health (BPH) service provision in an urbanised township in southern China. Primary care patients who had concomitant hypertension and T2DM were retrospectively followed up from 2016 to 2019. Data were retrieved electronically from the computerised BPH platform. Patient-level risk factors were explored using multivariable logistic regression analysis.

Results

We included 5,398 patients (mean age 66 years; range 28.9 to 96.1 years). At baseline, almost half [48.3% (2,608/5,398)] of patients had uncontrolled BP or FPG. During follow-up, more than one-fourth [27.2% (1,467/5,398)] of patients had no improvement in both BP and FPG. Among all patients, we observed significant increases in systolic BP [2.31 mmHg, 95% confidence interval (CI): 2.04 to 2.59, p < 0.001], diastolic BP (0.73 mmHg, 0.54 to 0.92, p < 0.001), and FPG (0.12 mmol/l, 0.09 to 0.15, p < 0.001) at follow-up compared to baseline. In addition to changes in body mass index [adjusted odds ratio (aOR)=1.045, 1.003 to 1.089, p = 0.037], poor adherence to lifestyle advice (aOR = 1.548, 1.356 to 1.766, p < 0.001), and unwillingness to actively enrol in health-care plans managed by the family doctor team (aOR = 1.379, 1.128 to 1.685, p = 0.001) were factors associated with no improvement in BP and FPG at follow-up.

Conclusion

A suboptimal control of BP and FPG remains an ongoing challenge to primary care patients with concomitant hypertension and T2DM in real-world community settings. Tailored actions aiming to improve patients' adherence to healthy lifestyles, expand the delivery of team-based care, and encourage weight control should be incorporated into routine healthcare planning for community-based cardiovascular prevention.

Global and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis

BACKGROUND

Knowing the prevalence of multimorbidity among adults across continents is a crucial piece of information for achieving Sustainable Development Goal 3.4, which calls for reducing premature death due to non-communicable diseases. A high prevalence of multimorbidity indicates high mortality and increased healthcare utilization. We aimed to understand the prevalence of multimorbidity across WHO geographic regions among adults.

METHODS

We performed a systematic review and meta-analysis of surveys designed to estimate the prevalence of multimorbidity among adults in community settings. We searched PubMed, ScienceDirect, Embase and Google Scholar databases for studies published between January 1, 2000, and December 31, 2021. The random-effects model estimated the pooled proportion of multimorbidity in adults. Heterogeneity was quantified using I² statistics. We performed subgroup analyses and sensitivity analyses based on continents, age, gender, multimorbidity definition, study periods and sample size. The study protocol was registered with PROSPERO (CRD42020150945).

FINDINGS

We analyzed data from 126 peer-reviewed studies that included nearly 15.4 million people (32.1% were male) with a weighted mean age of 56.94 years (standard deviation of 10.84 years) from 54 countries around the world. The overall global prevalence of multimorbidity was 37.2% (95% CI = 34.9-39.4%). South America (45.7%, 95% CI = 39.0-52.5) had the highest prevalence of multimorbidity, followed by North America (43.1%, 95% CI = 32.3-53.8%), Europe (39.2%, 95% CI = 33.2-45.2%), and Asia (35%, 95% CI = 31.4-38.5%). The subgroup study highlights that multimorbidity is more prevalent in females (39.4%, 95% CI = 36.4-42.4%) than males (32.8%, 95% CI = 30.0-35.6%). More than half of the adult population worldwide above 60 years of age had multimorbid conditions (51.0%, 95% CI = 44.1-58.0%). Multimorbidity has become increasingly prevalent in the last two decades, while the prevalence appears to have stayed stable in the recent decade among adults globally.

INTERPRETATION

The multimorbidity patterns by geographic regions, time, age, and gender suggest noticeable demographic and regional differences in the burden of multimorbidity. According to insights about prevalence among adults, priority is required for effective and integrative interventions for older adults from South America, Europe, and North America. A high prevalence of multimorbidity among adults from South America suggests immediate interventions are needed to reduce the burden of morbidity. Furthermore, the high prevalence trend in the last two decades indicates that the global burden of multimorbidity continues at the same pace. The low prevalence in Africa suggests that there may be many undiagnosed chronic illness patients in Africa.

FUNDING

None.

Frailty and Aging in HIV- Status Post 13 Years of National Awareness

The People aged 50 years and above comprise over 50% of people living with HIV (PLWH) in the US. Despite the advances made with anti-retroviral therapy in increasing their life span, PLWH are plagued with non-AIDS associated conditions which increase their risk for morbidity and mortality. Frailty, a decline in physical and functional reserve, is one of the manifestations of aging, has a prevalence of 5-30%, and occurs up to 2 decades earlier in people aging with HIV (PAWH). The majority of providers for PAWH have minimal experience with the concept of gerontology, frailty, and aging. Hence, there is a gap in clinicians' knowledge on how to address frailty and aging in PAWH. This review will focus on the clinical interventions that mitigate frailty and aging in PAWH as well as highlight areas of investigation towards achieving these mediations. Beyond the identification of the roles of exercise and nutrition, more studies are needed on the pragmatic approach to apply these resources to routine care. There should be continued reinforcement of the proven strategy of combination antiretroviral therapy as well as treatment of co-infections and age-appropriate health and cancer screening in PAWH.

Multimorbidity and its socio-economic associations in community-dwelling older adults in rural Tanzania; a cross-sectional study

Objectives

This paper aims to describe the prevalence and socio-economic associations with multimorbidity, by both self-report and clinical assessment/screening methods in community-dwelling older people living in rural Tanzania.

Methods

A randomised frailty-weighted sample of non-institutionalised adults aged ≥ 60 years underwent comprehensive geriatric assessment and in-depth assessment. The comprehensive geriatric assessment consisted of a history and focused clinical examination. The in-depth assessment included standardised questionnaires, screening tools and blood pressure measurement. The prevalence of multimorbidity was calculated for self-report and non-self-reported methods (clinician diagnosis, screening tools and direct measurement). Multimorbidity was defined as having two or more conditions. The socio-demographic associations with multimorbidity were investigated by multiple logistic regression.

Results

A sample of 235 adults participated in the study, selected from a screened sample of 1207. The median age was 74 years (range 60 to 110 inter-quartile range (IQR) 19) and 136 (57.8%) were women. Adjusting for frailty-weighting, the prevalence of self-reported multimorbidity was 26.1% (95% CI 16.7–35.4), and by clinical assessment/screening was 67.3% (95% CI 57.0–77.5). Adjusting for age, sex, education and frailty status, multimorbidity by self-report increased the odds of being financially dependent on others threefold (OR 3.3 [95% CI 1.4–7.8]), and of a household member reducing their paid employment nearly fourfold (OR 3.8. [95% CI 1.5–9.2]).

Conclusions

Multimorbidity is prevalent in this rural lower-income African setting and is associated with evidence of household financial strain. Multimorbidity prevalence is higher when not reliant on self-reported methods, revealing that many conditions are underdiagnosed and undertreated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14340-0.

Household and area determinants of emergency department attendance and hospitalisation in people with multimorbidity: a systematic review

OBJECTIVES

Multimorbidity is one of the greatest challenges facing healthcare internationally. Emergency department (ED) attendance and hospitalisation rates are higher in people with multimorbidity, but most research focuses on associations with individual characteristics, ignoring household or area mediators of service use.

DESIGN

Systematic review reported using the synthesis without meta-analysis framework.

DATA SOURCES

Twelve electronic databases (1 January 2000-21 September 2021): MEDLINE/OVID, Embase, Global Health, PsycINFO, ASSIA, CAB Abstracts, Science Citation Index Expanded/ISI Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, Sociological Abstracts, the Cochrane Library, and OpenGrey.

ELIGIBILITY CRITERIA

Adults aged ≥16 years, with multimorbidity. Exposure(s) were household and/or area determinants of health. Outcomes were ED attendance and/or hospitalisation. The literature search was limited to publications in English.

DATA EXTRACTION AND SYNTHESIS

Independent double screening of titles and abstracts to select relevant full-text studies. Methodological quality was assessed using an adaptation of the Newcastle-Ottawa Quality Assessment Scale tool. Given high study heterogeneity, narrative synthesis was performed.

RESULTS

After deduplication, 10 721 titles and abstracts were screened, and 142 full-text articles were reviewed, of which 10 were eligible for inclusion. In people with multimorbidity, household food insecurity was associated with hospitalisation (OR 1.58 (95% CI 1.06 to 2.36) in concordant multimorbidity). People with multimorbidity living in the most versus least deprived areas attended ED more frequently (8.9% (95% CI 8.6 to 9.1) in most versus 6.3% (95% CI 6.1 to 6.6) in least), had higher rates of hospitalisation (26% in most versus 22% in least), and higher probability of hospitalisation (6.4% (95% CI 5.8 to 7.2) in most versus 4.2% (95% CI 3.8 to 4.7) in least). There was non-conclusive evidence that household income is associated with ED attendance and hospitalisation. No statistically significant relationships were found between marital status, living with others with multimorbidity, or rurality with ED attendance or hospitalisation.

CONCLUSIONS

There is some evidence that household and area contexts mediate associations of multimorbidity with ED attendance and hospitalisation, but firm conclusions are constrained by the small number of studies published and study design heterogeneity. Further research is required on large population samples using robust analytical methods.

PROSPERO REGISTRATION NUMBER

CRD42021283515.

Social vulnerability, frailty and their association with mortality in older adults living in rural Tanzania

Background

Social vulnerability correlates with frailty and is associated with mortality and disability. However, few studies have investigated this relationship outside of high-income country settings. This study aimed to produce and analyze a culturally adapted social vulnerability index (SVI) to investigate the relationship between social vulnerability, frailty, and mortality in older adults in Tanzania.

Methods

An SVI was produced using data from a cohort study investigating frailty in older adults in Tanzania. Variables were selected based on previous SVI studies using the categories established by Andrew et al. from the Canadian Study of Health and Aging, and National Population Health Survey. The SVI distribution was examined and compared with a frailty index (FI) produced from the same sample, using mutually exclusive variables. Cox regression survival analysis was used to investigate the association between social vulnerability, frailty, and mortality.

Results

A stratified cohort of 235 individuals were included in the study at baseline, with a mean age of 75.2 (SD 11.5). Twenty-six participants died within the follow-up period, with a mean of 503 days (range: 405–568) following the initial assessment. The SVI had a median score of 0.47 (interquartile range: 0.23, range: 0.14–0.86). Social vulnerability significantly predicted mortality when adjusting for age and gender, but not when also adjusting for frailty.

Conclusions

Social vulnerability can be successfully operationalized and culturally adapted in Tanzania. Social vulnerability is associated with mortality in Tanzania, but not independently of frailty.

Patterns of comorbidity and multimorbidity among middle-aged and elderly women in peri-urban Tanzania

Background

Multimorbidity poses an increasing challenge to health care systems in Sub-Saharan Africa. We studied the extent of multimorbidity and patterns of comorbidity among women aged 40 years or older in a peri-urban area of Dar es Salaam, Tanzania.

Methods

We assessed 15 chronic conditions in 1528 women who participated in a cross-sectional survey that was conducted within the Dar es Salaam Urban Cohort Study (DUCS) from June 2017 to July 2018. Diagnoses of chronic conditions were based on body measurements, weight, blood testing, screening instruments, and self-report.

Results

The five most prevalent chronic conditions and most common comorbidities were hypertension (49.8%, 95% CI 47.2 to 52.3), obesity (39.9%, 95% CI 37.3 to 42.4), anemia (36.9%, 95% CI 33.3 to 40.5), signs of depression (32.5%, 95% CI 30.2 to 34.9), and diabetes (30.9%, 95% CI 27.6 to 34.2). The estimated prevalence of multimorbidity (2+ chronic conditions) was 73.8% (95% CI 71.2 to 76.3). Women aged 70 years or older were 4.1 (95% CI 1.5 to 10.9) times mores likely to be affected by multimorbidity and had 0.7 (95% CI 0.3 to 1.2) more chronic conditions than women aged 40 to 44 years. Worse childhood health, being widowed, not working, and higher food insecurity in the household were also associated with a higher multimorbidity risk and level.

Conclusion

A high prevalence of multimorbidity in the general population of middle-aged and elderly women suggests substantial need for multimorbidity care in Tanzania. Comorbidity patterns can guide multimorbidity screening and help identify health care and prevention needs.

Elder abuse/mistreatment and associated covariates in India: results from the Longitudinal Aging Study in India wave 1, 2017-2018

OBJECTIVES

Elder abuse has significant adverse consequences for the overall health and well-being of the elderly, including premature mortality. Using cross-sectional data, we assessed the prevalence of elder abuse in India, its variation across states, and associated factors.

METHODS

Nationally representative data from the first wave of the Longitudinal Aging Study in India were analyzed. Bivariate and multivariate analyses were used to study the prevalence, state variations, and associated factors of elder abuse.

RESULTS

Overall, 5.2% of elderly adults (≥60 years) had experienced abuse in the year prior to the survey and 3% had experienced abuse within their own household. Verbal abuse or disrespect was the most common form of abuse. Considerable variation was observed in the prevalence of elder abuse across states and union territories, with the highest prevalence observed in Bihar (11.6%) and Karnataka (10.1%). In regression analysis, education level emerged as a protective factor against elder abuse, particularly among women. Older adults who lived alone, had functional limitations, had multiple morbidities, and had been hospitalized in the past year were more likely to experience abuse. Older adults who experienced abuse were 2 times more likely to experience depressive symptoms.

CONCLUSIONS

Cross-state variation in the prevalence of elder abuse and subgroup differences suggest that state-specific interventions and essential monitoring of older adults with functional limitations, chronic diseases, and recent hospitalization can further reduce the prevalence and consequences of elder abuse in India.