Prospective Disability in Different Combinations of Somatic and Mental Multimorbidity

Mental-somatic multimorbidity in trajectories of cognitive function for middle-aged and older adults

INTRODUCTION

Multimorbidity may confer higher risk for cognitive decline than any single constituent disease. This study aims to identify distinct trajectories of cognitive impairment probability among middle-aged and older adults, and to assess the effect of changes in mental-somatic multimorbidity on these distinct trajectories.

METHODS

Data from the Health and Retirement Study (1998-2016) were employed to estimate group-based trajectory models identifying distinct trajectories of cognitive impairment probability. Four time-varying mental-somatic multimorbidity combinations (somatic, stroke, depressive, stroke and depressive) were examined for their association with observed trajectories of cognitive impairment probability with age. Multinomial logistic regression analysis was conducted to quantify the association of sociodemographic and health-related factors with trajectory group membership.

RESULTS

Respondents (N = 20,070) had a mean age of 61.0 years (SD = 8.7) at baseline. Three distinct cognitive trajectories were identified using group-based trajectory modelling: (1) Low risk with late-life increase (62.6%), (2) Low initial risk with rapid increase (25.7%), and (3) High risk (11.7%). For adults following along Low risk with late-life increase, the odds of cognitive impairment for stroke and depressive multimorbidity (OR:3.92, 95%CI:2.91,5.28) were nearly two times higher than either stroke multimorbidity (OR:2.06, 95%CI:1.75,2.43) or depressive multimorbidity (OR:2.03, 95%CI:1.71,2.41). The odds of cognitive impairment for stroke and depressive multimorbidity in Low initial risk with rapid increase or High risk (OR:4.31, 95%CI:3.50,5.31; OR:3.43, 95%CI:2.07,5.66, respectively) were moderately higher than stroke multimorbidity (OR:2.71, 95%CI:2.35, 3.13; OR: 3.23, 95%CI:2.16, 4.81, respectively). In the multinomial logistic regression model, non-Hispanic Black and Hispanic respondents had higher odds of being in Low initial risk with rapid increase and High risk relative to non-Hispanic White adults.

CONCLUSIONS

These findings show that depressive and stroke multimorbidity combinations have the greatest association with rapid cognitive declines and their prevention may postpone these declines, especially in socially disadvantaged and minoritized groups.

The effect of multimorbidity patterns on physical and cognitive function in diabetes patients: a longitudinal cohort of middle-aged and older adults in China

Background

The prevalence of diabetes has increased rapidly, and comorbid chronic conditions are common among diabetes patients. However, little is known about the pattern of multimorbidity in diabetes patients and the effect on physical and cognitive function. This study aimed to assess the disease clusters and patterns of multimorbidity in diabetes patients using a novel latent class analysis (LCA) approach in middle-aged and older adults and explore the association between different clusters of multimorbidity in diabetes and the effect on physical and cognitive function.

Methods

This national observational study included 1,985 diabetes patients from the four waves of the China Health and Retirement Longitudinal Study (CHARLS) in 2011 to 2018. Thirteen chronic diseases were used in latent class analysis to identify the patterns of multimorbidity in diabetes, which span the cardiovascular, physical, psychological, and metabolic systems. Cognitive function is assessed via a structured questionnaire in three domains: memory, executive function, and orientation. We combined activities of daily living (ADL) with instrumental activities of daily living (IADL) to measure physical function. Linear mixed models and negative binomial regression models were used to analyze the association between patterns of multimorbidity in diabetes and the effect on cognitive function and disability, respectively.

Results

A sample of 1,985 diabetic patients was identified, of which 1,889 (95.2%) had multimorbidity; their average age was 60.6 years (standard deviation (SD) = 9.5), and 53.1% were women. Three clusters were identified: "cardio-metabolic" (n = 972, 51.5%), "mental-dyslipidemia-arthritis" (n = 584, 30.9%), and "multisystem morbidity" (n = 333, 17.6%). Compared with diabetes alone, the "multisystem morbidity" class had an increased association with global cognitive decline. All patterns of multimorbidity were associated with an increased risk of memory decline and disability; however, the "multisystem morbidity" group also had the strongest association and presented a higher ADL-IADL disability (ratio = 4.22, 95% CI = 2.52, 7.08) and decline in memory Z scores (β = -0.322, 95% CI = -0.550, -0.095, p = 0.0058).

Conclusion

Significant longitudinal associations between different patterns of multimorbidity in diabetes patients and memory decline and disability were observed in this study. Future studies are needed to understand the underlying mechanisms and common risk factors for multimorbidity in diabetes patients and to propose treatments that are more effective.

The Role of Depression and Anxiety in the Relationship Between Arthritis and Cognitive Impairment in Chinese Older Adults

BACKGROUND

Mental disorders and cognitive impairment are common in older patients with arthritis. While it is recognized that mental conditions may play a role in the connection between arthritis and cognitive impairment, the precise underlying relationship remains uncertain.

METHODS

The data was derived from the baseline survey of the Guangdong Mental Health Survey in South China, involving a sample of 3,764 citizens aged 65 and older. An array of aspects were explored, including socio-demographics, lifestyle behaviors, self-reported chronic conditions, depression, anxiety, and cognitive impairment. Logistic regression analyses examined the association between arthritis and cognitive impairment after adjustment for potential confounders. Serial mediation models were used to examine whether depression or anxiety played a mediating role in the arthritis-cognitive impairment linkage.

RESULTS

The prevalence rates of cognitive impairment and arthritis of the older adults were 28.9% and 12.1%, respectively. Compared to those without arthritis, participants with arthritis were at a higher risk of cognitive impairment (OR = 1.322, 95%CI: 1.022-1.709) after adjustment for socio-demographics, lifestyle behaviors, and mental health conditions. Serial mediation analyses indicated that depressive and anxiety symptoms co-played a serial mediating role in the association between arthritis and cognitive impairment (B1 = 0.025, 95%CI: 0.005-0.052; B2 = 0.050, 95%CI: 0.021-0.086).

CONCLUSIONS

Arthritis may heighten cognitive impairment risk in Chinese older adults, and the relationship was potentially mediated by depressive and anxiety symptoms. Future interventions should be considered, integrating mental health assessments into arthritis care frameworks and being alert to possible cognitive impairment.

Depressive symptoms, alone or together with physical comorbidity, are predictive of healthcare use and spending in older adults

OBJECTIVE

Depressive symptoms and physical comorbidity are common health problems in older adults and are both posing increasingly considerable challenges to global healthcare systems. This study investigated the relationships of depressive symptoms, alone or together with physical comorbidity, with healthcare utilization and spending among older adults, as well as examined sex differences.

METHODS

We used data of the China Health and Retirement Longitudinal Study (CHARLS) from 2011 to 2018 and enrolled 6519 participants. Depressive symptoms was operationalized following the Center for Epidemiological Studies Depression Scale and physical comorbidity was assessed according to the presence of 11 physical non-communicable diseases. The relationships of depressive symptoms and comorbidity with healthcare outcomes were examined using mixed-effects regression models.

RESULTS

Compared with the neither depressive symptoms nor physical comorbidity category, older adults classified as depressive symptoms-only, physical comorbidity-only or both conditions were all associated with elevated risks for healthcare use and spending (all OR/IRR > 1; all p < 0.001). Depressive symptoms and physical comorbidity in combination consistently led to higher risks for studied endpoints than either condition alone (outpatient visit: OR = 3.50, outpatient visit number: IRR = 3.39, inpatient visit: OR = 3.35, hospitalization days: IRR = 2.82, catastrophic health expenditure: OR = 1.70; all p-trend < 0.001). Stratification analyses revealed similar relationships irrespective of sex.

CONCLUSION

Depressive symptoms and physical comorbidity are separately and jointly associated with increased healthcare utilization and spending among Chinese older adults. These two conditions in combination lead to highest risks than either condition alone. Early screen for depressive symptoms, alone or together with physical comorbidity, may offer implications for appropriate policy interventions.

Racial, ethnic, and socioeconomic disparities in trajectories of morbidity accumulation among older Americans

Introduction

Multimorbidity, the presence of multiple chronic health conditions, generally starts in middle and older age but there is considerable heterogeneity in the trajectory of morbidity accumulation. This study aimed to clarify the number of distinct trajectories and the potential associations between race/ethnicity and socioeconomic status and these trajectories.

Methods

Data from 13,699 respondents (age ≥51) in the Health and Retirement Study between 1998 and 2016 were analyzed with growth mixture models. Nine prevalent self-reported morbidities (arthritis, cancer, cognitive impairment, depressive symptoms, diabetes, heart disease, hypertension, lung disease, stroke) were summed for the morbidity count.

Results

Three trajectories of morbidity accumulation were identified: low [starting with few morbidities and accumulating them slowly (i.e., low intercept and low slope); 80% of sample], increasing (i.e., low intercept and high slope; 9%), and high (i.e., high intercept and low slope; 11%). Compared to non-Hispanic (NH) White adults in covariate-adjusted models, NH Black adults had disadvantages while Hispanic adults had advantages. Our results suggest a protective effect of education for NH Black adults (i.e., racial health disparities observed at low education were ameliorated and then eliminated at increasing levels of education) and a reverse pattern for Hispanic adults (i.e., increasing levels of education was found to dampen the advantages Hispanic adults had at low education). Compared with NH White adults, higher levels of wealth were protective for both NH Black adults (i.e., reducing or reversing racial health disparities observed at low wealth) and Hispanic adults (i.e., increasing the initial health advantages observed at low wealth).

Conclusion

These findings have implications for addressing health disparities through more precise targeting of public health interventions. This work highlights the imperative to address socioeconomic inequalities that interact with race/ethnicity in complex ways to erode health.

Is the combination of depression symptoms and multimorbidity associated with the increase of the prevalence of functional disabilities in Brazilian older adults? A cross-sectional study

Introduction: Functional disabilities are more prevalent in older adults with multimorbidity and depression. However, few studies have investigated the combination of multimorbidity and depression with functional disability. This study aims to verify whether symptoms of depression and multimorbidity combined increase the prevalence of functional disability in Brazilian older adults. Material and methods: This is a cross-sectional study conducted with data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil) baseline examination in 2015-2016 in adults aged 50 years and older. The variables included were basic (BADL) and instrumental activities of daily living (IADL), depressive symptoms, multimorbidity (≥2 chronic diseases), sociodemographic variables, and lifestyle. Logistic regression was performed to estimate crude and adjusted odds ratios. Results: A total of 7,842 participants over 50 years of age were included. Of these, 53.5% were women and 50.5% were between 50 and 59 years old, 33.5% reported ≥4 depressive symptoms, 51.4% had multimorbidity, 13.5% reported difficulty in performing at least one BADL, and 45.1% reported difficulty in performing the IADL. In the adjusted analysis, the prevalence of difficulty on BADL was 6.52 (95% CI: 5.14; 8.27) and on IADL was 2.34 (95% CI: 2.15; 2.55), higher for those with depression and multimorbidity combined when compared with those without these conditions. Conclusion: The combination of symptoms of depression and multimorbidity may increase functional impairments in the BADL and IADL of Brazilian older adults, impairing self-efficacy, independence, and autonomy. Early detection of these factors benefits the person, their family, and the healthcare system for health promotion and disease prevention.

Long-term care units: a Portuguese study about the functional profile

Aim: In this study, we analyze the relationship between the functional profile of older people admitted to long-term care units in Portugal and some demographic variables such as education level, sex, and age as well as the emotional state of mind. Methods: A sample of 59,516 older people from the National Network of Integrated Continuous Care of Portugal were analyzed in this longitudinal study. All the retrospective data of the older people were collected during the period of hospitalization at the long-term care units. The database records of these units were analyzed, and a functional profile spanning the period of hospitalization was calculated. Results: Activities of daily living and cognitive states improved, in the first 90 days of hospitalization, while mobility and instrumental activities of daily living worsened for the same period of 90 days. Generally, there was a decline in all domains after 450 days of hospitalization. The older women that did not attend school, those over 85 years old, and those who suffered from anxiety were pre-dominantly placed in the group of those with greater dependence (severe/complete dependence). Conclusion: The participants hospitalized between 90 and 360 days presented the best results in the long-term care units of the National Network of Integrated Continuous Care of Portugal. With this study, we highlight the importance of evaluating the functional status of persons in long-term hospitalizations and the influence exerted by the level of education on the recovery and rehabilitation of dependence.

Multimorbidity combinations and their association with functional disabilities among Indian older adults: evidence from Longitudinal Ageing Study in India (LASI)

OBJECTIVE

This study aims to identify the unique multimorbidity combinations (MMCs) and their associations with the functional disability of Indian older adults. Moreover, the population attributable fractions (PAFs) were calculated to assess the potential impact of additional diseases in the nested groups on disability.

DESIGN

A cross-sectional data were analysed in this study.

SETTING AND PARTICIPANTS

The present study uses data from the first wave of the Longitudinal Ageing Study in India (2017-2018). The sample for the study consists of 27 753 aged 60 years and over.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome variable was functional disability, measured by the combined activities of daily living (ADL)-instrumental activities of daily living (IADL) index.

RESULTS

Out of 197 uniquely identified MMCs, the combination of hypertension and high depressive symptoms (HDS) was the most prevalent (10.3%). Overall, all MMCs were associated with increased functional limitation. Specifically, the combination of hypertension, arthritis and HDS was associated with greater ADL-IADL disability than any other MMC. The addition of HDS in group 3 (hypertension and arthritis) (incidence rate ratios (IRR)=1.44; 95% CI 1.26 to 1.64) and the addition of arthritis in group 1 (hypertension, HDS) (IRR=1.48; 95% CI 1.28 to 1.71) and group 2 (hypertension, diabetes) (IRR=1.49; 95% CI 1.22 to 1.82) significantly increases the rates of ADL-IADL disability. The estimated PAFs of the group 1 (hypertension and HDS), group 3 (hypertension and arthritis) and group 4 (arthritis and HDS) for ADL-IADL disability were 22.5% (19.2-25.5), 21.6% (18.7-24.4) and 23.5% (20.6-26.3), respectively.

CONCLUSION

The findings from this study underscore the importance of addressing the morbidity combinations which are more disabling than the others in older adults. Understanding the somatic and psychological relevance of the morbidities in functional health is necessary and can help reduce disabilities among older adults.

Depressive Multimorbidity and Trajectories of Functional Status among Older Americans: Differences by Racial/Ethnic Group

OBJECTIVE

This study aims to evaluate the impact of depressive multimorbidity (ie, including depressive symptoms) on the long-term development of activities of daily living (ADL) and instrumental activities of daily living (IADL) limitations according to racial/ethnic group in a representative sample of US older adults.

DESIGN

Prospective, observational, population-based 16-year follow-up study of nationally representative sample.

SETTING AND PARTICIPANTS

Sample of older non-Hispanic Black, Hispanic, and nonHispanic White Americans from the Health and Retirement Study (2000‒2016, N = 16,364, community-dwelling adults ≥65 years of age).

METHODS

Data from 9 biennial assessments were used to evaluate the accumulation of ADL-IADL limitations (range 0‒11) among participants with depressive (8-item Center for Epidemiologic Studies Depression score≥4) vs somatic (ie, physical conditions only) multimorbidity vs those without multimorbidity (no or 1 condition). Generalized estimating equations included race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White), baseline age, sex, body mass index, education, partnered, and net worth.

RESULTS

Depressive and somatic multimorbidity were associated with 5.18 and 2.95 times greater accumulation of functional limitations, respectively, relative to no disease [incidence rate ratio (IRR) = 5.18, 95% confidence interval, CI (4.38,6.13), IRR = 2.95, 95% CI (2.51,3.48)]. Hispanic and Black respondents experienced greater accumulation of ADL-IADL limitations than White respondents [IRR = 1.27, 95% CI (1.14, 1.41), IRR = 1.31, 95% CI (1.20, 1.43), respectively].

CONCLUSIONS AND IMPLICATIONS

Combinations of somatic diseases and high depressive symptoms are associated with greatest accumulation of functional limitations over time in adults ages 65 and older. There is a more rapid growth in functional limitations among individuals from racial/ethnic minority groups. Given the high prevalence of multimorbidity and depressive symptomatology among older adults and the availability of treatment options for depression, these results highlight the importance of screening/treatment for depression, particularly among older adults with socioeconomic vulnerabilities, to slow the progression of functional decline in later life.

Tooth Loss and Associated Factors in Mexican Older Adults in Nursing Homes: A Multicenter Cross-Sectional Study

The objective of this study was to determine the experience of tooth loss and associated factors in older adults and elderly residing in nursing homes. A cross-sectional study was conducted in Mexican older adults and elderly aged ≥60 years living in four nursing homes (two in Mexico City, Mexico: one in Cuernavaca, Morelos, and one in Oaxaca, Oaxaca). The data were collected at the facility (home nursing) by two dentists in 2019. To determine the number of tooth loss and DMFT, a clinical oral examination was performed. In addition, a questionnaire was applied to determine diverse independent variables (demographic, socioeconomic, and behavioral). The analysis was performed using nonparametric tests and negative binomial regression (p < 0.05). 257 subjects were included. The mean age was 81.25 ± 9.02 years, and 60.7% were women. The mean number of lost teeth was 18.78 ± 9.05 (women = 19.43 ± 8.59 and men = 17.77 ± 9.68; p > 0.05). In the multivariate negative binomial regression model, it was found that, for each one-year increase in age, the mean tooth loss increased 0.92% (p < 0.05). In current smokers (p < 0.01) and in those who brush their teeth < 2 times a day (p < 0.01), the average of tooth loss increased 22.04% and 61.46%, respectively. The experience of tooth loss in Mexican older adults and elderly was high. Demographic (age) and habit of behavior (tobacco use and less frequent tooth brushing) were associated with increased tooth loss. It is important to promote oral health programs for institutionalized older adults.

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.

Moderated-mediation analysis of multimorbidity and health-related quality of life among the Chinese elderly: The role of functional status and cognitive function

OBJECTIVES

To investigate the relationship between multimorbidity and health-related quality of life (HRQoL), and explore the effects of functional status and cognitive function on Chinses elderly behind this relationship.

METHODS

The Multivariate logistic regression and Tobit regression models were used to determine the influence of multimorbidity on HRQoL. Bootstrap analysis was used to probe the mediating effects of functional status and the moderating role of cognition on multimorbidity and HRQoL.

RESULTS

Results of the 2,887 participants age  ≥ 60  years included in the analysis, 51.69% had chronic diseases. Stroke (β = -0.190; 95% confidence interval [CI], -0.232, -0.149; p < 0.001) and the combination of hypertension and stroke (β = -0.210; 95% CI, -0.259, -0.160; p < 0.001) had the greatest influence on HRQoL. Functional status partially mediated the relationship between the number of non-communicable diseases (No. of NCDs) and HRQoL, while cognitive function had a moderating effect not only in the A-path (No. of NCDs to functional status, β = 0.143; t = 7.18; p < 0.001) and but also in the C-path (No. of NCDs to HRQoL, β = 0.007; t = 6.08; p < 0.001).

CONCLUSION

Functional status partially mediated the relationship between multimorbidity and HRQoL in older adults. And cognitive function, if declined, may strengthen this relationship. These findings suggested that improving cognitive function and functional status in those who developed multimorbidity could be a viable prevention or treatment strategy to improve HRQoL in elderly patients.

Depression in older adults during the COVID-19 pandemic: a systematic review protocol

INTRODUCTION

Depression is a common mental disorder and is a major cause of years lived with disability. The COVID-19 pandemic has caused an increase in the prevalence of depression worldwide. Our aim is to identify and synthesise the determinants of depression, the diagnostic assessment tools used to evaluate depression, and the interventions carried out since the beginning of the COVID-19 pandemic in the population aged 60 and older.

METHODS AND ANALYSIS

A systematic review of the literature will be conducted. The following databases will be searched: CINAHL Plus with Full Text, MedicLatina, MEDLINE with Full Text, and Psychology and Behavioural Sciences Collection. The search strategy will include the following Medical Subject Headings or similar terms: "Depression", "Depressive Disorder", "Depressive Symptoms", "Older Adults", "Aging", "Elderly", Pandemic" and "COVID-19". Two independent reviewers will ascertain whether the resulting articles meet inclusion and exclusion criteria, and perform the analysis of data quality. Disagreements will be resolved by a third reviewer. All studies reported between December 2019 and March 2022 meeting the following criteria will be included: studies in adults aged 60 and over, and articles written in English, Portuguese, Spanish or German. Information on determinants of depression, assessment instruments used to assess depressive symptoms and/or interventions to decrease depression are reported. Studies will not be excluded based on geographical area study context (eg, community, culture or specific environment). All studies related to diagnostic assessment, care planning and/or intervention strategies specifically for older adults with depression will be included.

ETHICS AND DISSEMINATION

As only secondary data will be analysed, no ethical approval is required for this study. This scientific article is a systematic review protocol for which data have not yet been extracted or analysed. The results will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42022299775.

An association between multi-morbidity and depressive symptoms among Indian adults based on propensity score matching

Keeping in view the cascade of disturbances caused by the co-existence of multi-morbidity and depression among aged population, this study aims to ascertain the independent impact of multi-morbidity as a risk factor for the development of depressive symptoms among adults living in India. The present study utilizes data from the nationally representative survey “Longitudinal Ageing Study in India” (LASI, Wave-1, 2017–2018). The eligible sample size was 62,244 adults aged 45 years and above. Descriptive statistics along with bivariate analysis was used to understand the prevalence of depressive symptoms. Further, binary logistic regression and Propensity Score Matching (PSM) methods were applied to examine the independent effect of multi-morbidity on depressive symptoms while controlling the selected background characteristics. Overall, around one-third respondents had at least one chronic disease and one-fifth had multi-morbidity. The most prevalent chronic disease reported in the sampled population was hypertension followed by diabetes and joint disease. It is observed that older adults with multiple chronic diseases had 77% higher odds of having depressive symptoms as compared to those without a history of chronic disease in the multivariable logistic regression model. Results obtained from PSM indicate that the risk of having depressive symptoms was 3.7% higher for adults with multi- morbidity. Depressive symptom was identified to be associated with a wider range of multiple physical health problems and people with multi-morbidity are at a higher risk of having depressive symptoms. It is imperative that multi-morbidity can be used as a screener for identifying people with depressive symptoms.

BigMove: A Group Intervention for People with Physical and Mental Health Conditions

Introduction:

This article describes an innovative, integrated care intervention, called BigMove, which aims to improve the functioning, capabilities and quality of life of people with a combination of physical and mental health conditions.

Description:

Theoretical frameworks reflected in the intervention are the Capability Approach (CA) and Self-Determination Theory (SDT). Essential elements of the intervention included to expand participants’ behavioural repertoire are motivational interviewing; functional goal setting (using the International Classification of Functioning, Disability and Health (ICF); cognitive behavioural therapy; enjoyment; support of the group; and physical activity. The design combines individual sessions and group sessions.

Discussion:

By integrating the CA and the SDT, the intervention enables participants to make self-directed and value-driven choices in life and change their behaviour accordingly to strengthen their functioning and capabilities. To foster person-centred, integrated care, it is crucial to reform the interaction between professionals and patients and to re-structure the organisation and financing of care to enable the provision of complex integrated care interventions.

Conclusion:

For people with physical and mental health conditions, the intervention BigMove provides an innovative integrated care approach that addresses aspirations people have regarding their functioning and focuses on individual goal setting and behaviour change.

Chronic condition clusters and associated disability over time

Objectives

Recent evidence shows that more complex clusters of chronic conditions are associated with poorer health outcomes. Less clear is the extent to which these clusters are associated with different types of disability (activities of daily living (ADL) and functional mobility (FM)) over time; the aim of this study was to investigate this relationship.

Methods

This was a longitudinal analysis using the National Health and Aging Trends Study (NHATS) (n = 6179). Using latent class analysis (LCA), we determined the optimal clusters of chronic conditions, then assigned each person to a best-fit class. Next, we used mixed-effects models with repeated measures to examine the effects of group (best-fit class), time (years from baseline), and the group by time interaction on each of the outcomes in separate models over 4 years.

Results

We identified six chronic condition clusters: Minimal Disease, Cognitive/Affective, Multiple Morbidity, Osteoporosis, Vascular, and Cancer. Chronic condition cluster was related to ADL and FM outcomes, indicating that groups experienced differential disability over time. At time point 4, all chronic condition groups had worse FM than Minimal Disease.

Discussion

The clusters of conditions identified here are plausible when considered clinically and in the context of previous research. All groups with chronic conditions carry risk for disability in FM and ADL; increased screening for disability in primary care could identify early disability and prevent decline.

Multimorbidity Patterns and 5-Year Mortality in Institutionalized Older Adults

OBJECTIVES

The aim was to characterize multimorbidity patterns in a large sample of older individuals living in nursing homes (NHs) and to investigate their association with mortality, also considering the effect of functional status.

DESIGN

Observational and retrospective study.

SETTING AND PARTICIPANTS

We analyzed data on 4131 NH residents in Italy, aged 60 years and older, assessed through the interRAI long-term care facility instrument. Entry date was between 2014 and 2018, and participants were followed until 2019.

METHODS

Multimorbidity patterns were identified through principal component analysis; for the identified components, subjects were stratified in quintiles (Q) with respect to their loading values, with the higher quantiles indicating greater expression of the component's pattern. Their association [hazard ratio (HR) and 95% CI] with mortality was tested in Cox regression models. Analyses were stratified by disability status.

RESULTS

Four patterns of multimorbidity were identified: (1) heart diseases; (2) dementia and sensory impairments; (3) heart, respiratory, and psychiatric diseases; and (4) diabetes, musculoskeletal, and vascular diseases. For the heart diseases pattern [HR Q5 vs Q1 = 1.83 (1.53-2.20)] and the dementia and sensory impairments pattern [HR Q5 vs Q1 = 1.23 (1.06-1.42)], as the specific multimorbidity expression increases, the risk of mortality increases. On stratifying by disability status, the association between the multimorbidity patterns and mortality was not always present.

CONCLUSIONS AND IMPLICATIONS

Different multimorbidity patterns are differentially associated with mortality in older residents of NHs, confirming that multimorbidity's prognosis is strictly dependent on the underlying disease combinations. This knowledge may be useful to implement personalized preventive and therapeutic care pathways for institutionalized older adults, which respond to individuals' health needs.

Fundamental Clock of Biological Aging: Convergence of Molecular, Neurodegenerative, Cognitive and Psychiatric Pathways: Non-Equilibrium Thermodynamics Meet Psychology

In humans, age-associated degrading changes, widely observed in molecular and cellular processes underly the time-dependent decline in spatial navigation, time perception, cognitive and psychological abilities, and memory. Cross-talk of biological, cognitive, and psychological clocks provides an integrative contribution to healthy and advanced aging. At the molecular level, genome, proteome, and lipidome instability are widely recognized as the primary causal factors in aging. We narrow attention to the roles of protein aging linked to prevalent amino acids chirality, enzymatic and spontaneous (non-enzymatic) post-translational modifications (PTMs ^SP), and non-equilibrium phase transitions. The homochirality of protein synthesis, resulting in the steady-state non-equilibrium condition of protein structure, makes them prone to multiple types of enzymatic and spontaneous PTMs, including racemization and isomerization. Spontaneous racemization leads to the loss of the balanced prevalent chirality. Advanced biological aging related to irreversible PTMs ^SP has been associated with the nontrivial interplay between somatic (molecular aging) and mental (psychological aging) health conditions. Through stress response systems (SRS), the environmental and psychological stressors contribute to the age-associated “collapse” of protein homochirality. The role of prevalent protein chirality and entropy of protein folding in biological aging is mainly overlooked. In a more generalized context, the time-dependent shift from enzymatic to the non-enzymatic transformation of biochirality might represent an important and yet underappreciated hallmark of aging. We provide the experimental arguments in support of the racemization theory of aging.

Functional Profile of Older Adults Hospitalized in Convalescence Units of the National Network of Integrated Continuous Care of Portugal: A Longitudinal Study

Aim: To evaluate the evolution of the functional profile of older adults admitted to a health unit in Portugal; to relate the functional profile of these individuals with age, sex, education level and emotional state; and to evaluate the probability of the degree of dependence as a function of age and sex. Methods: longitudinal, retrospective study with a sample of 59,013 older adults admitted to convalescence units of the National Network of Integrated Continuous Care of Portugal. Results: In the first 75 days of hospitalization, activities of daily living, mobility and cognitive state improved, but there was a decline after 75 days of hospitalization. The ability to perform instrumental activities of daily living improved in the first 15 days of hospitalization, stabilized until 45 days and then began to worsen. Women had a higher probability of having a severe/complete dependence three years earlier than men (88 years to 91 years). A higher education level and stable emotional state were protective factors against functional decline. Conclusions: The functional profile of older adults improved during the length of stay recommended for hospitalization in convalescence units (30 days). It is critical for health systems to adopt strategies to prevent declines in the emotional state of frail individuals.

Multimorbidity, depressive symptoms and disability in activities of daily living amongst middle-aged and older Chinese: Evidence from the China Health and Retirement Longitudinal Study

BACKGROUND

Given that multimorbidity is strongly associated with disability in activities of daily living (ADL) and the mechanism still remains unclear, this study sought to investigate the mediating effect of depressive symptoms on such association.

METHODS

A longitudinal dataset was drawn from the China Health and Retirement Longitudinal Study (CHARLS, 2011-2015), including 3951 adults aged 45 years and above. By sex, logistic regression and mediation analysis (the Karlson, Holm, and Breen Method) were employed.

RESULTS

The presence of multimorbidity was associated with increased odds of having depressive symptoms and developing ADL disability, and depressive symptoms was significantly associated with ADL disability among middle-aged and older women. Mediation analysis illustrated that depressive symptoms accounted for 6.36% of the effect of multimorbidity on ADL disability in women.

LIMITATIONS

Results might not generalize to all middle-aged and older Chinese due to missing data on depressive symptoms and ADL.

CONCLUSIONS

Multimorbidity increased the likelihood of ADL disability onset partially through depressive symptoms in middle-aged and older women, suggesting that emphasizing mental wellness of females with multimorbidity are necessary to prevent impairments in physical function.

Functional limitations in people with multimorbidity and the association with mental health conditions: Baseline data from the Canadian Longitudinal Study on Aging (CLSA)

INTRODUCTION

Increasing multimorbidity is often associated with declining physical functioning, with some studies showing a disproportionate impact on functioning when mental health conditions are present. More research is needed because most multimorbidity studies exclude mental health conditions.

OBJECTIVES

This study aims to improve our understanding of the association between functional limitation and multimorbidity, including a comparison of those with multimorbidity that includes versus excludes mental health conditions.

METHODS

This is a population-based, cross-sectional analysis of data from The Canadian Longitudinal Study on Aging. Functional limitation was defined as the presence of any of 14 activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Multimorbidity, measured by the number of chronic conditions, included mood and anxiety disorders. Logistic regression explored the association between multimorbidity (with and without mental health conditions) and functional limitation. Factor analysis identified common condition clusters to help understand clinical complexity in those with mood/anxiety disorders and the potential influences on functional limitation.

RESULTS

There were 51,338 participants, with a similar proportion of men and women (49% versus 51%) and 42% age 65 years or older. Fifteen percent (15%) had no chronic conditions and 17% had 5+. Ten percent (10%) reported at least one ADL or IADL limitation. Odds ratios (ORs) for functional limitation increased with multimorbidity and were generally higher for those with versus without mental health conditions (e.g., ORs from 1 to 5+ chronic conditions increased 1.9 to 15.8 for those with mood/anxiety disorders versus 1.8 to 10.2 for those without). Factor analysis showed that mood/anxiety conditions clustered with somatic conditions (e.g., migraines, bowel/gastrointestinal disorders).

CONCLUSION

This study found higher odds of functional limitation for those with multimorbidity that included versus excluded mental health conditions, at all levels of multimorbidity. It highlights the need for concurrent management of mental and physical comorbidities to prevent functional limitations and future decline. This approach is aligned with the NICE clinical assessment and management guidelines for people with multimorbidity.

Prognostic Interplay of Functional Status and Multimorbidity Among Older Patients Discharged From Hospital

OBJECTIVES

The purpose of this study was to investigate the prognostic weight of multimorbidity and functional impairment over long-term mortality among older patients discharged from acute care hospitals.

DESIGN

A prospective multicenter observational study.

SETTING AND PARTICIPANTS

Our series consisted of 1967 adults aged ≥65 years consecutively admitted to acute care wards in Italy, in the context of the Report-AGE project.

METHODS

After signing a written informed consent, all patients underwent comprehensive geriatric assessment by Inter-RAI Minimum Data Set acute care. The primary endpoint of the present study was long-term mortality. Patients were grouped into 3 functional clusters and 3 disease clusters using the K-medians cluster analysis. The association of functional clusters, disease clusters, and Charlson score categories with long-term mortality was investigated through Cox regression analysis and the intercluster classification agreement was further estimated. Finally, the additive effect of either disease clusters or Charlson score on predictive ability of functional clusters was assessed by using changes in Harrell's C-index and categorical Net Reclassification Index (NRI).

RESULTS

Functional clusters, disease clusters, and Charlson score were significant predictors of long-term mortality, but the interclassification agreement was poor. Functional clusters predicted mortality with greater accuracy [C-index 0.66, 95% confidence interval (CI) 0.65-0.68] compared with disease clusters (C-index 0.54, 95% CI 0.53-0.56), and Charlson score (C-index 0.58, 95% CI 0.56-0.59). Adding multimorbidity (NRI 0.23, 95% CI 0.14-0.31) or Charlson score (NRI 0.13, 95% CI 0.03-0.20) to functional cluster model slightly improved the accuracy of prediction.

CONCLUSIONS AND IMPLICATIONS

Functional impairment may better predict prognosis compared with multimorbidity, which may be relevant to optimally address individuals' needs and to design tailored preventive interventions.

Individual-Level and Couple-Level Discordant Chronic Conditions: Longitudinal Links to Functional Disability

BACKGROUND

Multiple chronic conditions may erode physical functioning, particularly in the context of complex self-management demands and depressive symptoms. Yet, little is known about how discordant conditions (i.e., those with management requirements that are not directly related and increase care complexity) among couples are linked to functional disability.

PURPOSE

We evaluated own and partner individual-level discordant conditions (i.e., discordant conditions within individuals) and couple-level discordant conditions (i.e., discordant conditions between spouses), and their links to levels of and change in functional disability.

METHODS

The U.S. sample included 3,991 couples drawn from nine waves (1998-2014) of the Health and Retirement Study. Dyadic growth curve models determined how individual-level and couple-level discordant conditions were linked to functional disability over time, and whether depressive symptoms moderated these links. Models controlled for age, minority status, education, each partner's baseline depressive symptoms, and each partner's number of chronic conditions across waves.

RESULTS

Wives and husbands had higher initial disability when they had their own discordant conditions and when there were couple-level discordant conditions. Husbands also reported higher initial disability when wives had discordant conditions. Wives had a slower rate of increase in disability when there were couple-level discordant conditions. Depressive symptoms moderated links between disability and discordant conditions at the individual and couple levels.

CONCLUSIONS

Discordant chronic conditions within couples have enduring links to disability that partly vary by gender and depressive symptoms. These findings generate valuable information for interventions to maintain the well-being of couples managing complex health challenges.

Association of self-rated health with chronic disease, mental health symptom and social relationship in older people

Chronic disease, mental health symptoms and poor social relations are reported common causes for poor self-rated health in older people. To assess the co-occurrence rate of chronic diseases, poor mental health and poor social relationships in older people, and determine their association with self-rated health. 6,551 older people in Zhongshan, China, participated a large health surveillance program were randomly selected and questioned about their SRH, chronic conditions, mental health symptoms and social relationships. The association between self-rated health and chronic conditions, poor mental health, social relationships, and their co-occurrence were analyzed. 56.4% of participants reported poor self-rated health. 39.1% experienced at least one chronic disease. 29.0% experienced one or more mental health symptoms; 19.5% experienced at least one poor social relationship. 7.8% had co-occurrence of chronic diseases, mental health problems, and poor social relationships. Logistic regressions showed that poor self-rated health was associated with chronic diseases, poor mental health, poor social relationships and their co-occurrence. The findings indicate the importance of managing chronic disease, poor mental health and poor social relationships for older people.

Longitudinal Follow-Up Studies on the Bidirectional Association between ADL/IADL Disability and Multimorbidity: Results from Two National Sample Cohorts of Middle-Aged and Elderly Adults

BACKGROUND AND OBJECTIVES

Few studies have investigated the bidirectional relationship between disability and multimorbidity, which are common conditions among the older population. Based on the data from the China Health and Retirement Longitudinal Study (CHARLS) and the Survey of Health, Ageing and Retirement in Europe (SHARE), we aimed to investigate the bidirectional relationship between disability and multimorbidity.

METHODS

The activities of daily living (ADLs) and the instrumental activities of daily living (IADLs) scales were used to measure disability. In stage I, we used multinomial logistic regression to assess the longitudinal association between ADL/IADL disability and follow-up multimorbidity. In stage II, binary logistic regression was used to evaluate the multimorbidity effect on future disability.

RESULTS

Compared with those free of disability, people with disability possessed ascending risks for developing an increasing number of diseases. For ADL disability, the odds ratio (OR) (95% confidence interval [CI]) values of developing ≥4 diseases were 4.10 (2.58, 6.51) and 6.59 (4.54, 9.56) in CHARLS and SHARE; for IADL disability, the OR (95% CI) values were 2.55 (1.69, 3.84) and 4.85 (3.51, 6.70) in CHARLS and SHARE. Meanwhile, the number of diseases at baseline was associated, in a dose-response manner, with future disability. Compared with those without chronic diseases, participants carrying ≥4 diseases had OR (95% CI) values of 4.82 (3.73, 6.21)/4.66 (3.65, 5.95) in CHARLS and 3.19 (2.59, 3.94)/3.28 (2.71, 3.98) in SHARE for developing ADL/IADL disability.

CONCLUSION

The consistent findings across 2 national longitudinal studies supported a strong bidirectional association between disability and multimorbidity among middle-aged and elderly adults. Thus, tailored interventions should be taken to prevent the mutual development of disability and multimorbidity.

Prevalence of function-limiting late effects in Hodgkin lymphoma survivors

BACKGROUND

Hodgkin lymphoma (HL) is highly curable, but survivors often develop function-limiting impairments. Screening guidelines for neuromuscular and musculoskeletal late effects are not as well recognized across medical disciplines. Early identification and management of functional late effects are instrumental in improving the longitudinal care of HL survivors.

OBJECTIVE

To define the prevalence of neuromuscular, musculoskeletal, visceral, oncologic, and other late effects affecting function and quality of life (QOL) in HL survivors.

DESIGN

A retrospective cohort analysis.

SETTING

Outpatient cancer rehabilitation clinic.

PARTICIPANTS

One hundred HL survivors.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Prevalence of neuromuscular, musculoskeletal, visceral, oncologic, and other late effects contributing to functional impairment and disability in HL survivors.

RESULTS

Among the 100 HL survivors, 43% received chemotherapy, 94% radiation therapy, and 38% a combination of chemo-radiation for their initial cancer treatment. Nearly all HL survivors were diagnosed with myelopathy (83%), radiculoplexopathy (93%), mononeuropathy (95%), and localized myopathy (93%). Musculoskeletal sequelae included dropped head syndrome (83%), cervicalgia (79%), shoulder girdle dysfunction (73%), and dysphagia (42%). Visceral disorders included cardiovascular (70%), pulmonary (44%), endocrine (63%), gastrointestinal (29%), and genitourinary (11%) dysfunction. Lymphedema affected 21% of survivors and 30% had a history of a secondary malignancy. Pain (71%), fatigue (45%), and dyspnea (43%) were major function-limiting impairments. Nearly all (95%) of survivors were referred to at least one therapy discipline including physical therapy, occupational therapy, speech and language pathology, and/or lymphedema therapy.

CONCLUSION

Neuromuscular, musculoskeletal, visceral, oncologic, and other late effects are extremely common in HL survivors seeking physiatric evaluation. Multiple function-limiting disorders can coexist in HL survivors with the potential to severely compromise function and QOL. Safe and effective rehabilitation may depend on the physiatrist's ability to identify, evaluate, and manage the multitude of complex and often interrelated functional late effects seen in HL survivors.

Examination of Cancer and Aging Through Activities of Daily Living: A National Health and Aging Trends Study Analysis

Objectives: This study longitudinally examined how older adult cancer survivors perceive disability in activities of daily living over time compared to older adults who have not had cancer. Methods: This was a secondary analysis of the National Health and Aging Trends Study examining participants with a new cancer diagnosis and age-, gender-, and comorbidity-matched comparison participants without a history of cancer. Generalized linear mixed models examined time and group interaction and main effects in disability. Results: There was a significant main effect of time (F_4,771 = 12.81; p < .0001) demonstrating increasing disability levels for both groups. There were significant group differences, with higher disability in the cancer group than the comparison group (β = 0.628, SE = 0.263; t = 2.39, p = 0.017). Discussion: Although perceived disability was greater immediately following cancer diagnosis, older adult cancer survivors and comparison participants appear to have similar perceived disability over time.

SymTrak-8 as a Brief Measure for Assessing Symptoms in Older Adults

BACKGROUND

Patient- and caregiver-reported 23-item SymTrak scales were validated for monitoring clinically actionable symptoms and impairments associated with multiple chronic conditions (MCCs) in older adults. Items capture physical and emotional symptoms and impairments in physical and cognitive functioning. An abbreviated SymTrak is desirable when response burden is a concern.

OBJECTIVE

Develop and validate the 8-item SymTrak.

DESIGN AND PARTICIPANTS

Secondary analysis of SymTrak validation study; 600 participants (200 patient-caregiver dyads; 200 patients without an identified caregiver).

MAIN MEASURES

Demographic questions, SymTrak, and Health Utility Index Mark 3 (HUI3).

KEY RESULTS

SymTrak-8 demonstrated good fit to a one-factor model using confirmatory factor analysis (CFA). Concurrent criterion validity was supported by high standardized linear regression coefficients (STB) between baseline SymTrak-8 total score (independent variable) and baseline HUI3 preference-based overall HRQOL utility score (dependent variable; 0 = death, 1 = perfect health), after adjusting for demographics, comorbid conditions, and medications, with strength comparable to SymTrak-23 (STB = - 0.81 and - 0.84, respectively, for SymTrak-8 and SymTrak-23, when patient-reported; and - 0.60 and - 0.62, respectively, when caregiver-reported). Coefficient alpha (0.74; 0.76) and 24-h test-retest reliability (0.83; 0.87) were high for SymTrak-8 for patients and caregivers, respectively. The convergent correlation between brief and parent SymTrak scales was high (0.94). SymTrak-8 demonstrated approximate normality and a linear relationship with SymTrak-23 and HUI3. Importantly, a 3-month change in SymTrak-8 was sensitive to detecting the criterion (3-month reliable change categories; improved, stable, declined in HUI3 overall utility), with results comparable to SymTrak-23.

CONCLUSIONS

SymTrak-8 total score demonstrates internal reliably, test-retest reliability, criterion validity, and sensitivity to change that are comparable to SymTrak-23. Thus, patient- or caregiver-reported SymTrak-8 is a viable option for identifying and monitoring the aggregate effect of symptoms and functional impairments in patients with multimorbidity when response burden is a concern.

Racial and Ethnic Differences in Multimorbidity Changes Over Time

BACKGROUND

Our understanding of how multimorbidity progresses and changes is nascent.

OBJECTIVES

Assess multimorbidity changes among racially/ethnically diverse middle-aged and older adults.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study using latent class analysis to identify multimorbidity combinations over 16 years, and multinomial logistic models to assess change relative to baseline class membership. Health and Retirement Study respondents (age 51 y and above) in 1998 and followed through 2014 (N=17,297).

MEASURES

Multimorbidity latent classes of: hypertension, heart disease, lung disease, diabetes, cancer, arthritis, stroke, high depressive symptoms.

RESULTS

Three latent classes were identified in 1998: minimal disease (45.8% of participants), cardiovascular-musculoskeletal (34.6%), cardiovascular-musculoskeletal-mental (19.6%); and 3 in 2014: cardiovascular-musculoskeletal (13%), cardiovascular-musculoskeletal-metabolic (12%), multisystem multimorbidity (15%). Remaining participants were deceased (48%) or lost to follow-up (12%) by 2014. Compared with minimal disease, individuals in cardiovascular-musculoskeletal in 1998 were more likely to be in multisystem multimorbidity in 2014 [odds ratio (OR)=1.78, P<0.001], and individuals in cardiovascular-musculoskeletal-mental in 1998 were more likely to be deceased (OR=2.45, P<0.001) or lost to follow-up (OR=3.08, P<0.001). Hispanic and Black Americans were more likely than White Americans to be in multisystem multimorbidity in 2014 (OR=1.67, P=0.042; OR=2.60, P<0.001, respectively). Black compared with White Americans were more likely to be deceased (OR=1.62, P=0.01) or lost to follow-up (OR=2.11, P<0.001) by 2014.

CONCLUSIONS AND RELEVANCE

Racial/ethnic older adults are more likely to accumulate morbidity and die compared with White peers, and should be the focus of targeted and enhanced efforts to prevent and/or delay progression to more complex multimorbidity patterns.

Association between multimorbidity patterns and disability among older people covered by long-term care insurance in Shanghai, China

BACKGROUND

Functional disability and multimorbidity are common among older people. However, little is known about the relationship between functional disability and different multimorbidity combinations. We aimed to identify multimorbidity patterns and explore the associations between these patterns and functional disability.

METHODS

We investigated a multi-stage random sample of 1871 participants aged ≥60 years and covered by long-term care insurance in Shanghai, China. Multimorbidity was defined as the simultaneous presence of two or more chronic diseases in an individual. Participants completed scales to assess basic and instrumental activities of daily living (BADL and IADL, respectively). Multimorbidity patterns were identified via exploratory factor analysis. Binary logistic regression models were used to determine adjusted associations between functional disability and number and patterns of multimorbidity.

RESULTS

Multimorbidity was present in 74.3% of participants. The prevalence of BADL disability was 50.7% and that of IADL disability was 90.7%. There was a strong association between multimorbidity and disability. We identified three multimorbidity patterns: musculoskeletal, cardio-metabolic, and mental-degenerative diseases. The cardio-metabolic disease pattern was associated with both BADL (OR 1.28, 95%CI 1.16-1.41) and IADL (OR 1.41, 95%CI 1.19-1.68) disability. The mental-degenerative disease pattern was associated with BADL disability (OR 1.55, 95%CI 1.40-1.72).

CONCLUSIONS

Multimorbidity and functional disability are highly prevalent among older people covered by long-term care insurance in Shanghai, and distinct multimorbidity patterns are differentially associated with functional disability. Appropriate long-term healthcare and prevention strategies for older people may help reduce multimorbidity, maintain functional ability, and improve health-related quality of life.

Patterns of multimorbidity and risk of disability in community-dwelling older persons

The aim was to analyze the association between specific patterns of multimorbidity and risk of disability in older persons. Data were gathered from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K); 2066 60 + year-old participants living in the community and free from disability at baseline were grouped according to their multimorbidity patterns and followed-up for six years. The association between multimorbidity patterns and disability in basic (ADL) and instrumental (IADL) activities of daily living was examined through multinomial models. Throughout the follow-up, 434 (21.0%) participants developed at least one ADL and 310 (15.0%) at least one IADL. Compared to the unspecific pattern, which included diseases not exceeding their expected prevalence in the total sample, belonging to the cardiovascular/anemia/dementia, the sensory impairment/cancer and the musculoskeletal/respiratory/gastrointestinal patterns was associated with a higher risk of developing both ADL and IADL, whereas subjects in the metabolic/sleep disorders pattern showed a higher risk of developing only IADL. Multimorbidity patterns are differentially associated with incident disability, which is important for the design of future prevention strategies aimed at delaying functional impairment in old age, and for a better healthcare resource planning.

Diabetes multimorbidity combinations and disability in the Mexican Health and Aging Study, 2012-2015

PURPOSE

The aim of this study was to investigate the relationship between specific combinations of chronic conditions and disability in Mexican older adults with diabetes.

METHODS

This was a prospective cohort study of Mexican adults (n = 2558) with diabetes and aged 51 or older that used data from the 2012 and 2015 waves of the Mexican Health and Aging Study. The main outcome was an index that measured ability to perform activities of daily living and instrumental activities of daily living. The main independent variables were diabetes multimorbidity combinations, defined as diabetes and at least one other chronic condition. The authors calculated the prevalence of each multimorbidity combination present in the sample in 2012 and used negative binomial regression models to estimate the association of the most prevalent of these combinations with disability incidence in 2015.

RESULTS

The three most prevalent combinations were: 1) diabetes-hypertension (n = 637, 31.9%) 2) diabetes-hypertension-depression (n = 388, 19.4%) and 3) diabetes-depression (n = 211, 10.6%). In fully adjusted models comparing participants with specific multimorbidity combinations to participants with diabetes alone, the combinations that had an increased association with disability were diabetes-hypertension-depression, diabetes-depression and diabetes-hypertension-arthritis-depression. In nested models, the addition of arthritis to combinations including depression increased this association.

CONCLUSIONS

Consistent with prior studies, multimorbidity combinations including depression were associated with increased risk of disability. However, the effect size of this relationship was lower than what had been previously been reported internationally. This highlights the need for globally oriented multimorbidity research.

Tracking Multimorbidity Changes in Diverse Racial/Ethnic Populations Over Time: Issues and Considerations

Multimorbidity is widely recognized as having adverse effects on health and wellbeing and may threaten the ability of older adults to live independently. Much of what is known about multimorbidity rests on research that has largely focused on one point in time, or from a static perspective. Given that there remains a lack of agreement in the field on how to standardize multimorbidity definitions and measurement, it is not surprising that analyzing and predicting multimorbidity development, progression over time, and its impact are still largely unaddressed. As a result, there are important gaps and challenges to measuring and studying multimorbidity in a longitudinal context. This Research Practice perspective summarizes pressing challenges and offers practical steps to move the field forward.

Twelve-year clinical trajectories of multimorbidity in a population of older adults

Multimorbidity-the co-occurrence of multiple diseases-is associated to poor prognosis, but the scarce knowledge of its development over time hampers the effectiveness of clinical interventions. Here we identify multimorbidity clusters, trace their evolution in older adults, and detect the clinical trajectories and mortality of single individuals as they move among clusters over 12 years. By means of a fuzzy c-means cluster algorithm, we group 2931 people ≥60 years in five clinically meaningful multimorbidity clusters (52%). The remaining 48% are part of an unspecific cluster (i.e. none of the diseases are overrepresented), which greatly fuels other clusters at follow-ups. Clusters contribute differentially to the longitudinal development of other clusters and to mortality. We report that multimorbidity clusters and their trajectories may help identifying homogeneous groups of people with similar needs and prognosis, and assisting clinicians and health care systems in the personalization of clinical interventions and preventive strategies.

Prevalence of somatic-mental multimorbidity and its prospective association with disability among older adults in China

We aimed to identify prevalent somatic-mental multimorbidity (SMM) and examine its prospective association with disability among a nationally representative sample. A total of 6728 participants aged 60 years and older in the China Health and Retirement Longitudinal Study were included. A total of 14 somatic or mental conditions were assessed in 2013. SMM was defined as any combination of two or more conditions in which at least one condition was somatic and at least one condition was mental. Disability risk was measured using the combined Activities of Daily Living (ADL)-Instrumental Activities of Daily Living (IADL) index (range 0–11; higher index indicates higher disability) in 2013 and 2015. Overall, the prevalence of SMM was 35.7% (95% confidence interval (CI): 34.1%-37.3%) in 2013. After adjustment for sociodemographic characteristics, lifestyles and baseline ADL-IADL index, over a maximum follow-up period of 2 years, SMM was associated with a 2.61 (95% CI: 2.12-3.22)-fold increase in ADL-IADL disability risk compared with that of healthy participants. In conclusion, SMM was prevalent in older Chinese adults, and it was associated with a higher risk of prospective disability.

Changes in instrumental activities of daily living functioning associated with concurrent common mental disorders and physical multimorbidity in older adults

Introduction: Instrumental activities of daily living (IADL) are key indicators of general functional status that are frequently used to assess the autonomy of older adults living in the community.Aims: To evaluate the changes in IADL in community-living older adults and the role of common mental disorders and physical multimorbidity in predicting these changes.Method: A secondary analysis including participants from the Longitudinal Survey on Senior's Health and Health Services. Self-reported sociodemographic and clinical information on chronic conditions were obtained at baseline interview (n = 1615). Measures of IADL were obtained at two time points, 3 years apart. Administrative data on physician diagnoses of chronic diseases were linked to self-reported information. Logistic and multinomial regression models were used to study the outcomes of interest.Results: More than one-third of participants reported disability. Significant increase in global and specific IADL tasks disability were observed over time. Concurrent mental and physical chronic conditions predicted persistent and future incidence of disability.Conclusions: We draw attention to the synergistic effect of mental and physical co-morbidities on IADL functioning and to the importance of the simultaneous management of these conditions in order to prevent disability, future decline and the associated health and societal burden.Implications for RehabilitationBy establishing the prevalence of global and specific IADL disability, we can better recognize the needs of older adults and inform health and social care planning.Influenced by the morbidity profile, older adults may experience decline, improvement or maintenance of autonomy in IADL over time.The presence of synergistic effect of physical and mental chronic conditions on functioning suggests that their simultaneous management is crucial in delaying or preventing disability.Reports of significant impairment in tasks such as taking medication calls attention to the need for increased accessibility to programs on medication management.The progressive loss of ability to take medication among multimorbid patients emphasize the need for therapeutic plans that circumvent polypharmacy.

Associations between complex multimorbidity, activities of daily living and mortality among older Norwegians. A prospective cohort study: the HUNT Study, Norway

Background

With increasing age, having multiple chronic conditions is the norm. It is of importance to study how co-existence of diseases affects functioning and mortality among older persons. Complex multimorbidity may be defined as three or more conditions affecting at least three different organ systems. The aim of this study was to investigate how complex multimorbidity affects activities of daily living and mortality amongst older Norwegians.

Methods

Participants were 60–69-year-olds at baseline in the Nord-Trøndelag Health Study 1995-1997 (HUNT2) n = 9058. Multinomial logistic regression models were used to investigate the association between complex multimorbidity in HUNT2, basic and instrumental activities of daily living in HUNT3 (2006–2008) and mortality during follow-up (n = 5819/5836). Risk ratios (RR) and risk differences (RD) in percentage points (pp) with 95% confidence intervals (CI) were reported.

Results

47.8% of 60–69-year-olds met the criteria of complex multimorbidity at baseline (HUNT2). Having complex multimorbidity was strongly associated with the need for assistance in IADL in HUNT3 11 years later (RR = 1.80 (1.58–2.04) and RD = 8.7 (6.8–10.5) pp) and moderately associated with mortality during the follow-up time (RR = 1.22 (1.12–1.33) and RD = 5.1 (2.9–7.3) pp). Complex multimorbidity was to a lesser extent associated with basic activities of daily living 11 years later (RR = 1.24 (0.85–1.83) and RD = 0.4 (− 0.3–1.1) pp).

Conclusions

This is the first study to show an association between complex multimorbidity and activities of daily living. Complex multimorbidity should receive more attention in order to prevent future disability amongst older persons.

An Agenda for Addressing Multimorbidity and Racial and Ethnic Disparities in Alzheimer's Disease and Related Dementia

Advancements in Alzheimer's disease and related dementias (ADRD) research on the U.S. population acknowledge the importance of the high burden of ADRD on segments of the population and yet-to-be characterized risks attributable to the burden of multiple chronic diseases (multimorbidity). These realizations suggest successful strategies in caring for people with ADRD and their caregivers will rely not only on clinical treatments but also on more refined and comprehensive models of ADRD that take its broad effects on the whole-person and the whole of society into consideration. To this end, it is critical to characterize and address the relationship between ADRD and multimorbidity combinations that complicate care and lead to poor outcomes, particularly with regard to racial and ethnic disparities in the occurrence, course, and effects of ADRD. Several research and policy recommendations are presented to address the intersection of ADRD, multimorbidity, and underrepresented populations most at risk for adverse outcomes.

Walking Speed Drives the Prognosis of Older Adults with Cardiovascular and Neuropsychiatric Multimorbidity

BACKGROUND

We investigated the impact of multiple cardiovascular and neuropsychiatric diseases on all-cause and cause-specific mortality in older adults, considering their functional status.

METHODS

This cohort study included 3241 participants (aged ≥60 years) in the Swedish National study of Aging and Care in Kungsholmen (SNAC-K). Number of cardiovascular and neuropsychiatric diseases was categorized as 0, 1, or ≥2. Functional impairment was defined as walking speed of <0.8m/s. Death certificates provided information on 3- and 5-year mortality. Hazard ratios (HR) were derived from Cox models (all-cause mortality) and Fine-Gray competing risk models (cardiovascular and non-cardiovascular mortality).

RESULTS

After 3 years, compared with participants with preserved walking speed and without either cardiovascular or neuropsychiatric diseases, the multivariable-adjusted HR (95% confidence interval) of all-cause mortality for people with functional impairment in combination with 0, 1, and ≥2 cardiovascular diseases were 1.88 (1.29-2.74), 3.85 (2.60-5.70), and 5.18 (3.45-7.78), respectively. The corresponding figures for people with 0, 1, and ≥2 neuropsychiatric diseases were, respectively, 2.88 (2.03-4.08), 3.36 (2.31-4.89), and 3.68 (2.43-5.59). Among people with ≥2 cardiovascular or ≥2 neuropsychiatric diseases, those with functional impairment had an excess risk for 3-year all-cause mortality of 18/100 person-years and 17/100 person-years, respectively, than those without functional impairment. At 5 years, the association between the number of cardiovascular diseases and mortality resulted independent of functional impairment.

CONCLUSIONS

Functional impairment magnifies the effect of cardiovascular and neuropsychiatric multimorbidity on mortality among older adults. Walking speed appears to be a simple clinical marker for the prognosis of these two patterns of multimorbidity.

Differences in function and recovery profiles between patterns of multimorbidity among older medical patients the first year after an acute admission-An exploratory latent class analysis

INTRODUCTION

Multimorbidity is common among older people and may contribute to adverse health effects, such as functional limitations. It may help stratify rehabilitation of older medical patients, if we can identify differences in function under and after an acute medical admission, among patient with different patterns of multimorbidity.

AIM

To investigate differences in function and recovery profiles among older medical patients with different patterns of multimorbidity the first year after an acute admission.

METHODS

Longitudinal prospective cohort study of 369 medical patients (77.9 years, 62% women) acutely admitted to the Emergency Department. During the first 24 h after admission, one month and one year after discharge we assessed mobility level using the de Morton Mobility Index. At baseline and one-year we assessed handgrip strength, gait speed, Barthel20, and the New Mobility Score. Information about chronic conditions was collected by national registers. We used Latent Class Analysis to determine differences among patterns of multimorbidity based on 22 chronic conditions.

RESULTS

Four distinct patterns of multimorbidity were identified (Minimal chronic disease; Degenerative, lifestyle, and mental disorders; Neurological, functional and sensory disorders; and Metabolic, pulmonary and cardiovascular disorders). The "Neurological, functional and sensory disorders"-pattern showed significant lower function than the "Minimal chronic disease"-pattern in all outcome measures. There were no differences in recovery profile between patients in the four patterns.

CONCLUSION

The results support that patients with different patterns of multimorbidity among acutely hospitalized older medical patients differ in function, which suggests a differentiated approach towards treatment and rehabilitation warrants further studies.

Associations between prevalent multimorbidity combinations and prospective disability and self-rated health among older adults in Europe

Background

Multimorbidity is associated with greater likelihood of disability, health-related quality of life, and mortality, greater than the risk attributable to individual diseases. The objective of this study is to examine the association between unique multimorbidity combinations and prospective disability and poor self-rated health (SRH) in older adults in Europe.

Methods

We conducted a prospective analysis using data from the Survey of Health, Ageing and Retirement in Europe in 2013 and 2015. We used hierarchical models to compare respondents with multiple chronic conditions to healthy respondents and respondents reporting only one chronic condition and made within-group comparisons to examine the marginal contribution of specific chronic condition combinations.

Results

Less than 20% of the study population reported having zero chronic conditions, while 50% reported having at least two chronic conditions. We identified 380 unique disease combinations among people who reported having at least two chronic conditions. Over 35% of multimorbidity could be attributed to five specific multimorbidity combinations, and over 50% to ten specific combinations. Overall, multimorbidity combinations that included high depressive symptoms were associated with increased odds of reporting poor SRH, and increased rates of ADL-IADL disability.

Conclusions

Multimorbidity groups that include high depressive symptoms may be more disabling than combinations that include only somatic conditions. These findings argue for a continued integration of both mental and somatic chronic conditions in the conceptualization of multimorbidity, with important implications for clinical practice and healthcare delivery.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1214-z) contains supplementary material, which is available to authorized users.

Association Between Adverse Childhood Events and Multimorbidity in a Racial and Ethnic Diverse Sample of Middle-Aged and Older Adults

Background and Objectives

Adverse childhood events (ACEs) have been associated with increased health risks later in life. However, it is unclear whether ACEs may be associated with multimorbidity among diverse racial/ethnic middle-aged and older adults. We evaluated whether there were racial and ethnic differences in the association between ACEs and the number of somatic and psychiatric multimorbidity in a sample of U.S. middle-aged and older adults.

Research Design and Methods

Data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (N = 10,727; ≥55 years) were used to test whether the number of self-reported somatic conditions (i.e., heart disease, hypertension, stroke, diabetes, arthritis, cancer, osteoporosis, and chronic lung problems) as well as DSM-5 psychiatric disorders (i.e., depression) during the past 12 months differed by history of ACEs while stratifying by age (i.e., 55-64 or ≥65) and racial/ethnic group (i.e., non-Hispanic White [NHW; n = 7,457], non-Hispanic Black [NHB; n = 1,995], and Hispanic [n=1275]).

Results

The prevalence of reporting more than two somatic conditions and psychiatric disorders was 48.8% and 11.4% for those with a history of ACEs, and 41.1% and 3.3% for those without a history of ACEs. Adjusting for sociodemographic and other health risk factors, ACEs was significantly associated with greater numbers of somatic multimorbidity among racial and ethnic middle-aged adults but this was not the case for older adults.

Discussion and Implications

Our findings suggest that middle-aged adults with a history of ACEs are more likely to suffer from somatic and psychiatric multimorbidity, highlighting the importance of screening for ACEs in promoting healthy aging.

Diabetes-Multimorbidity Combinations and Disability Among Middle-aged and Older Adults

BACKGROUND

Older adults with diabetes rarely have only one chronic disease. As a result, there is a need to re-conceptualize research and clinical practice to address the growing number of older Americans with diabetes and concurrent chronic diseases (diabetes-multimorbidity).

OBJECTIVE

To identify prevalent multimorbidity combinations and examine their association with poor functional status among a nationally representative sample of middle-aged and older adults with diabetes.

DESIGN

A prospective cohort study of the 2012-2014 Health and Retirement Study (HRS) data. We identified the most prevalent diabetes-multimorbidity combinations and estimated negative binomial models of diabetes-multimorbidity on prospective disability.

PARTICIPANTS

Analytic sample included 3841 HRS participants with diabetes, aged 51 years and older.

MAIN MEASURES

The main outcome measure was the combined activities of daily living (ADL)-instrumental activities of daily living (IADL) index (range 0-11; higher index denotes higher disability). The main independent variables were diabetes-multimorbidity combination groups, defined as the co-occurrence of diabetes and at least one of six somatic chronic diseases (hypertension, cardiovascular disease, lung disease, cancer, arthritis, and stroke) and/or two mental chronic conditions (cognitive impairment and high depressive symptoms (CESD score ≥ 4).

KEY RESULTS

The three most prevalent multimorbidity combinations were, in rank-order diabetes-arthritis-hypertension (n = 694, 18.1%); diabetes-hypertension (n = 481, 12.5%); and diabetes-arthritis-hypertension-heart disease (n = 383, 10%). Diabetes-multimorbidity combinations that included high depressive symptoms or stroke had significantly higher counts of ADL-IADL limitations compared with diabetes-only. In head-to-head comparisons of diabetes-multimorbidity combinations, high depressive symptoms or stroke added to somatic multimorbidity combinations was associated with a higher count of ADL-IADL limitations (diabetes-arthritis-hypertension-high depressive symptoms vs. diabetes-arthritis-hypertension: IRR = 1.95 [1.13, 3.38]; diabetes-arthritis-hypertension-stroke vs. diabetes-arthritis-hypertension: IRR = 2.09 [1.15, 3.82]) even after adjusting for age, gender, education, race/ethnicity, BMI, baseline ADL-IADL, and diabetes duration. Coefficients were robust to further adjustment for diabetes treatment.

CONCLUSIONS

Depressive symptoms or stroke added onto other multimorbidity combinations may pose a substantial functional burden for middle-aged and older adults with diabetes.

Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways

This review discusses the interplay between multimorbidity (i.e. co-occurrence of more than one chronic health condition in an individual) and functional impairment (i.e. limitations in mobility, strength or cognition that may eventually hamper a person's ability to perform everyday tasks). On the one hand, diseases belonging to common patterns of multimorbidity may interact, curtailing compensatory mechanisms and resulting in physical and cognitive decline. On the other hand, physical and cognitive impairment impact the severity and burden of multimorbidity, contributing to the establishment of a vicious circle. The circle may be further exacerbated by people's reduced ability to cope with treatment and care burden and physicians' fragmented view of health problems, which cause suboptimal use of health services and reduced quality of life and survival. Thus, the synergistic effects of medical diagnoses and functional status in adults, particularly older adults, emerge as central to assessing their health and care needs. Furthermore, common pathways seem to underlie multimorbidity, functional impairment and their interplay. For example, older age, obesity, involuntary weight loss and sedentarism can accelerate damage accumulation in organs and physiological systems by fostering inflammatory status. Inappropriate use or overuse of specific medications and drug-drug and drug-disease interactions also contribute to the bidirectional association between multimorbidity and functional impairment. Additionally, psychosocial factors such as low socioeconomic status and the direct or indirect effects of negative life events, weak social networks and an external locus of control may underlie the complex interactions between multimorbidity, functional decline and negative outcomes. Identifying modifiable risk factors and pathways common to multimorbidity and functional impairment could aid in the design of interventions to delay, prevent or alleviate age-related health deterioration; this review provides an overview of knowledge gaps and future directions.

Impact of Multiple Chronic Conditions on Activity Limitations Among Older Mexican-American Care Recipients

INTRODUCTION

Older Mexican Americans are living longer with multiple chronic conditions (MCCs). This has placed greater demands on caregivers to assist with basic activities of daily living (ADL) or instrumental activities of daily living (IADL). To understand the needs of older Mexican-American care recipients, we examined the impact of MCC on ADL and IADL limitations.

METHODS

We analyzed data from 485 Mexican American care-receiving/caregiving dyads. Selected MCCs in the analysis were diabetes, hypertension, stroke, heart disease, arthritis, emphysema/chronic obstructive pulmonary disease, cognitive impairment, depression, and cancer. Care recipients were dichotomized as having 3 or more conditions or as having 2 or fewer conditions. Three comorbidity clusters were established on the basis of the most prevalent health conditions among participants with comorbid arthritis and hypertension. These clusters included arthritis and hypertension plus: diabetes (cluster 1), cognitive impairment (cluster 2), and heart disease (cluster 3).

RESULTS

Care recipients with 3 or more chronic conditions (n = 314) had higher odds of having mobility limitations (OR = 1.98; 95% CI, 1.34-2.94), self-care limitations (OR = 2.53; 95% CI, 1.70-3.81), >3 ADL limitations (OR = 2.00; 95% CI, 1.28-3.17), and >3 IADL limitations (OR = 1.88; 95% CI, 1.26-2.81). All clusters had increased odds of ADL and severe ADL limitations. Of care recipients in cluster 2, those with arthritis, hypertension, and cognitive impairment had significantly higher odds of mobility limitations (OR = 2.33; 95% CI, 1.05-5.24) than those with just arthritis and hypertension.

CONCLUSION

MCCs were associated with more ADL and IADL limitations among care recipients, especially for those with hypertension and arthritis plus diabetes, cognitive impairment, or heart disease. These findings can assist in developing programs to meet the needs of older Mexican-American care recipients.

Trajectories of functional decline in older adults with neuropsychiatric and cardiovascular multimorbidity: A Swedish cohort study

BACKGROUND

Functional decline is a strong health determinant in older adults, and chronic diseases play a major role in this age-related phenomenon. In this study, we explored possible clinical pathways underlying functional heterogeneity in older adults by quantifying the impact of cardiovascular (CV) and neuropsychiatric (NP) chronic diseases and their co-occurrence on trajectories of functional decline.

METHODS AND FINDINGS

We studied 2,385 people ≥60 years (range 60-101 years) participating in the Swedish National study of Aging and Care in Kungsholmen (SNAC-K). Participants underwent clinical examination at baseline (2001-2004) and every 3 or 6 years for up to 9 years. We grouped participants on the basis of 7 mutually exclusive clinical patterns of 0, 1, or more CV and NP diseases and their co-occurrence, from a group without any CV and NP disease to a group characterised by the presence of CV or NP multimorbidity, accompanied by at least 1 other CV or NP disorder. The group with no CV and/or NP diseases served as the reference group. Functional decline was estimated over 9 years of follow-up by measuring mobility (walking speed, m/s) and independence (ability to carry out six activities of daily living [ADL]). Mixed-effect linear regression models were used (1) to explore the individual-level prognostic predictivity of the different CV and NP clinical patterns at baseline and (2) to quantify the association between the clinical patterns and functional decline at the group level by entering the clinical patterns as time-varying measures. During the 9-year follow-up, participants with multiple CV and NP diseases had the steepest decline in walking speed (up to 0.7 m/s; p < 0.001) and ADL independence (up to three impairments in ADL, p < 0.001) (reference group: participants without any CV and NP disease). When the clinical patterns were analyzed as time varying, isolated CV multimorbidity impacted only walking speed (β -0.1; p < 0.001). Conversely, all the clinical patterns that included at least 1 NP disease were significantly associated with decline in both walking speed (β -0.21--0.08; p < 0.001) and ADL independence (β -0.27--0.06; p < 0.05). Groups with the most complex clinical patterns had 5%-20% lower functioning at follow-up than the reference group. Key limitations of the study include that we did not take into account the specific weight of single diseases and their severity and that the exclusion of participants with less than 2 assessments may have led to an underestimation of the tested associations.

CONCLUSIONS

In older adults, different patterns of CV and NP morbidity lead to different trajectories of functional decline over time, a finding that explains part of the heterogeneity observed in older adults' functionality. NP diseases, alone or in association, are prevalent and major determinants of functional decline, whereas isolated CV multimorbidity is associated only with declines in mobility.