Rapidly developing multimorbidity and disability in older adults: does social background matter?

10-Year Multimorbidity Trajectories in Older People Have Limited Benefit in Predicting Short-Term Health Outcomes in Comparison to Standard Multimorbidity Thresholds: A Population-Based Study

Purpose

To identify multimorbidity trajectories among older adults and to compare their health outcome predictive performance with that of cross-sectional multimorbidity thresholds (eg, ≥2 chronic conditions (CCs)).

Patients and Methods

We performed a population-based longitudinal study with a random sample of 99,411 individuals aged >65 years on April 1, 2019. Using health administrative data, we calculated for each individual the yearly CCs number from 2010 to 2019 and constructed the trajectories with latent class growth analysis. We used logistic regression to determine the increase in predictive capacity (c-statistic) of multimorbidity trajectories and traditional cross-sectional indicators (≥2, ≥3, or ≥4 CCs, assessed in April 2019) over that of a baseline model (including age, sex, and deprivation). We predicted 1-year mortality, hospitalization, polypharmacy, and frequent general practitioner, specialist, or emergency department visits.

Results

We identified eight multimorbidity trajectories, each representing between 3% and 25% of the population. These trajectories exhibited trends of increasing, stable, or decreasing number of CCs. When predicting mortality, the 95% CI for the increase in the c-statistic for multimorbidity trajectories [0.032-0.044] overlapped with that of the ≥3 indicator [0.037-0.050]. Similar results were observed when predicting other health outcomes and with other cross-sectional indicators.

Conclusion

Multimorbidity trajectories displayed comparable health outcome predictive capacity to those of traditional cross-sectional multimorbidity indicators. Given its ease of calculation, continued use of traditional multimorbidity thresholds remains relevant for population-based multimorbidity surveillance and clinical practice.

Multiple long-term conditions, loneliness and social isolation: A scoping review of recent quantitative studies

BACKGROUND

Multiple long-term conditions (MLTC), loneliness and social isolation are common in older adults. Recent studies have explored the association of MLTC with loneliness and social isolation. This scoping review aimed to map this current evidence and identify gaps in the literature.

METHODS

A scoping review was conducted following the PRISMA guidelines for scoping reviews. Ovid Medline, Embase, CINAHL, The Cochrane Library, PsycInfo, and Bielefeld Academic Search Engine were searched for studies published between January 2020-April 2023. Quantitative studies, published in any language, that assessed the association of MLTC with loneliness and/or social isolation were included.

RESULTS

1827 records were identified and screened. Of these, 17 met inclusion criteria. Most studies were cross-sectional and based on older adults. Studies were conducted in Europe, the US, Canada, and low- and middle-income countries. Ten studies focused on the association between MLTC and loneliness, six assessed the association between MLTC and social isolation and one examined associations with both loneliness and social isolation. Most studies reported a significant cross-sectional association of MLTC with loneliness, but there was weaker evidence for a longitudinal association between MLTC and loneliness and an association between MLTC and social isolation. Studies were heterogenous in terms of measures and definitions of loneliness/social isolation and MLTC, confounders adjusted for, and analytical models used, making comparisons difficult.

CONCLUSIONS

Further population-based longitudinal studies using consistent measures and methodological approaches are needed to improve understanding of the association of MLTC with both loneliness and social isolation.

Gender-specific association of the accumulation of chronic conditions and disability in activities of daily living with depressive symptoms

BACKGROUND

In the era of rapid aging with a rising prevalence of multimorbidity, complex interactions between physical and psychological conditions have challenged the health care system. However, little is known about the association of the accumulation of chronic conditions and disability in activities of daily living with depressive symptoms, especially in developed countries.

METHODS

This population-based cohort study used data from the Health and Retirement Study. A total of 22,335 middle-aged and older adults participated in the 2014 (T1), 2016 (T2), and 2018 (T3) waves of the cohort were included. The accumulation of chronic conditions and disability were defined as the number of chronic diseases and the five activities of daily living. Depressive symptoms were measured by the Center for Epidemiologic Studies Depression Scale. A longitudinal mediation model with a cross-lagged panel model was run. As robust check, the models were applied with a longer follow-up period (from 2012 to 2018). Additionally, results were estimated in China.

RESULTS

Bidirectional associations have been found among the accumulation of chronic conditions, disability, and depressive symptoms, especially between disability and depression. Disability (T2) mediated 11.11 % and 16.87 % of the association between the accumulation of chronic conditions (T1) and depression (T3) for men and women in the United States. The results were consistent in robust analysis.

CONCLUSIONS

This study found that men and women routinely experienced disability and depressive symptoms because of the accumulation of chronic conditions. In terms of depressive symptoms, women were more sensitive to the accumulation of chronic conditions through disability.

Trajectory of multimorbidity before dementia: A 24-year follow-up study

INTRODUCTION

Although the multimorbidity-dementia association has been widely addressed, little is known on the long-term trajectory of multimorbidity (TOM) in preclinical dementia.

METHODS

Based on the Health and Retirement Study, burden of multimorbidity was quantified with the total number of eight long-term conditions (LTC). Patterns of TOM before dementia diagnosis were investigated with mixed-effects models.

RESULTS

In 1752 dementia cases and 5256 matched controls, cases showed higher and faster increasing predicted number of LTC than controls, with a significant case-control difference from 20 years prior to dementia diagnosis. Larger increases in number of LTC during preclinical phase of dementia were found in White participants, females, those whose age at dementia onset was younger, and those who were less educated.

DISCUSSION

Our findings emphasize the faster accumulation of multimorbidity in prodromal dementia than in natural aging, as well as effect modifications by age and sex.

Highlights

TOM increased faster in prodromal dementia than in natural ageing.Patterns of TOM by dementia status diverged at 20 years before dementia diagnosis.Patterns of TOM were modified by age and sex.

Functional decline during the COVID-19 pandemic among U.S. military veterans: Results from the National Health and Resilience in Veterans Study

OBJECTIVES

The coronavirus disease-2019 pandemic has contributed to widespread social and economic stressors, along with substantial health problems, including loss of life. To date, however, relatively few studies have examined the prevalence and correlates of declines in mental and physical functioning in U.S. military veterans, an older and potentially vulnerable segment of the U.S. adult population.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative, longitudinal study of 3078 veterans. Veterans were surveyed prior to the pandemic (pre-pandemic) and 1 year later during the height of the pandemic (peri-pandemic). Multivariable analyses were conducted to identify risk and protective variables associated with pre-to-peri pandemic declines in self-reported physical and mental functioning.

RESULTS

The prevalence of veterans who experienced functional decline (≥0.5 standard deviation reductions) pre-to-peri-pandemic was 18.1% (N = 541) for physical functioning and 18.3% (N = 547) for mental functioning. Older age, greater adverse childhood experiences (ACEs), and pandemic-related posttraumatic stress symptoms were the strongest correlates of physical functional decline, while greater ACEs, loneliness, pandemic-related posttraumatic and social restriction stress symptoms, and lower protective psychosocial characteristics were the strongest correlates of mental functional decline.

CONCLUSIONS

Although the majority of U.S. Veterans showed functional maintenance or improvement 1 year into the pandemic, nearly one-in-five experienced a decline in physical or mental functioning. Results could help inform identification of veterans who may be at risk for functional decline during large-magnitude stressors, such as national or global pandemics.

The association between depression during perimenopause and progression of chronic conditions and multimorbidity: results from a Chinese prospective cohort

PURPOSE

The association between perimenopausal depression and many chronic conditions among women has been well-established. However, the role of depression during perimenopause in the progression of multiple chronic conditions (multimorbidity) remains poorly understood.

MATERIAL AND METHODS

A total of 1,216 community-dwelling women in their perimenopause period between 2010 and 2016 were enrolled in our analysis, and followed up for the progression of multimorbidity. Depression, as well as its severity, was evaluated by the Center for Epidemiologic Studies Depression 10-item scale (CES-D-10). Progression of multimorbidity was defined as the first report of two or more chronic conditions for participants without multimorbidity or the new report of one or more conditions for those with multimorbidity. Univariable and multivariable Cox proportional hazards model and the restricted cubic spline regression model were performed to assess the prospective association between perimenopausal depression and the progression of multimorbidity.

RESULTS

A total of 480 (39.5%) women reported depression during perimenopause, and 529 (43.5%) women progressed to multimorbidity. After adjusting for socio-demographic and lifestyle factors, perimenopausal depression was independently associated with the progression of multimorbidity (hazard ratio [HR]: 1.34; 95% confidence interval [CI]: 1.13 to 1.60). Moreover, the severity of depression was positively and linearly associated with the progression of multimorbidity (P < 0.05).

CONCLUSIONS

Our finding reveals a prospective association between perimenopausal depression and the progression of multimorbidity, indicating interventions targeting perimenopausal depression may reduce the burden of chronic diseases and multimorbidity in women's post-menopausal life.

The role of social connections and support in the use of emergency care in older adults

OBJECTIVES

Limited and inconsistent findings have been reported on the link between social connections and support and emergency department (ED) visits in older populations. Moreover, the adequacy of informal care for older adults has rarely been considered. This study explored the associations of social connections, social support, and informal care with ED visits in younger-old (<78 years) and oldest-old (≥78 years) adults.

METHODS

This is a prospective cohort study based on community-living adults ≥60 years old participating in the Swedish National Study on Aging and Care in Kungsholmen (N=3066 at wave 1, 2001-2004; N=1885 at wave 3, 2007-2010; N=1208 at wave 5, 2013-2016). Standardised indexes were developed to measure social connections, social support, and informal care. The outcome variable was hospital-based ED visits within 4 years of the SNAC-K interview. Associations between exposure variables and ED visits were assessed through negative binomial regressions using generalised estimating equations.

RESULTS

Medium (IRR 0.77; 95% CI 0.59-0.99) and high (IRR 0.77; 95% CI 0.56-0.99) levels of social support were negatively associated with ED visits compared to low levels of social support, but only in oldest-old adults. No statistically significant associations were observed between social connections and ED visits. Higher ED visit rates were seen in oldest-old adults with unmet informal care needs, even if the differences did not reach statistical significance.

CONCLUSIONS

ED visits were associated with social support levels among adults aged ≥78 years. Public health interventions to mitigate situations of poor social support may improve health outcomes and reduce avoidable ED visits in oldest-old adults.

Social Relationships and Onset of Functional Limitation among Older Adults with Chronic Conditions: Does gender matter?

Objectives

This study aimed to examine the longitudinal association between social relationships and physical functioning among community-dwelling older adults with chronic conditions.

Methods

Self-reported questionnaires were distributed and collected between 2014 and 2017 from participants ≥65 years old. The Index of Social Interaction was used to evaluate social relationships and the instrumental activities of daily living (IADL) subscale of the Tokyo Metropolitan Institute of Gerontology Index of Competence was used to examine functional status.

Results

A total of 422 participants (190 males and 232 females) were included in the final analysis. High social relationships demonstrated significant adverse effects (odds ratio [OR] = 0.77, 95% confidence interval [CI]: 0.64-0.93) on the decline of IADL in the overall sample, particularly for females (OR = 0.71, 95% CI: 0.55-0.93) but not as much for males (P = 0.131).

Conclusion

This finding suggests that functional limitation was influenced by social relationships among disabled older adults and the influence of social relationships on functional limitation differed based on gender.

Late-life depression and multimorbidity trajectories: the role of symptom complexity and severity

INTRODUCTION

as late-life depression is associated with poor somatic health, we aimed to investigate the role of depression severity and symptom phenotypes in the progression of somatic multimorbidity.

METHODS

we analysed data from 3,042 dementia-free individuals (60+) participating in the population-based Swedish National Study on Aging and Care in Kungsholmen. Using the baseline clinical assessment of 21 depressive symptoms from the Comprehensive Psychopathological Rating Scale, we: (i) diagnosed major, minor (in accordance with DSM-IV-TR) and subsyndromal depression; (ii) extracted symptom phenotypes by applying exploratory network graph analysis. Somatic multimorbidity was measured as the number of co-occurring chronic diseases over a 15-year follow-up. Linear mixed models were used to explore somatic multimorbidity trajectories in relation to baseline depression diagnoses and symptom phenotypes, while accounting for sociodemographic and behavioural factors.

RESULTS

in multi-adjusted models, relative to individuals without depression, those with major (β per year: 0.33, 95% confidence interval [CI]: 0.06-0.61) and subsyndromal depression (β per year: 0.21, 95%CI: 0.12-0.30) experienced an accelerated rate of somatic multimorbidity accumulation, whereas those with minor depression did not. We identified affective, anxiety, cognitive, and psychomotor symptom phenotypes from the network analysis. When modelled separately, an increase in symptom score for each phenotype was associated with faster multimorbidity accumulation, although only the cognitive phenotype retained its association in a mutually adjusted model (β per year: 0.07, 95%CI: 0.03-0.10).

CONCLUSIONS

late-life major and subsyndromal depression are associated with accelerated somatic multimorbidity. Depressive symptoms characterised by a cognitive phenotype are linked to somatic health change in old age.

Synergistic interactions of obesity with sex, education, and smoking and accumulation of multi-morbidity (MM) across the lifespan

Objectives

Obesity is a potentially modifiable risk factor that has been consistently associated with the development and progression of multi-morbidity (MM). However, obesity may be more problematic for some persons compared to others because of interactions with other risk factors. Therefore, we studied the effect of interactions between patient characteristics and overweight and obesity on the rate of accumulation of MM.

Methods

We studied 4 cohorts of persons ages 20-, 40-, 60-, and 80-years residing in Olmsted County, Minnesota between 2005 and 2014 using the Rochester Epidemiology Project (REP) medical records-linkage system. Body mass index, sex, race, ethnicity, education, and smoking status were extracted from REP indices. The rate of accumulation of MM was calculated as the number of new chronic conditions accumulated per 10 person years through 2017. Poisson rate regression models were used to identify associations between characteristics and rate of MM accumulation. Additive interactions were summarized using relative excess risk due to interaction, attributable proportion of disease, and the synergy index.

Results

Greater than additive synergistic associations were observed between female sex and obesity in the 20- and 40-year cohorts, between low education and obesity in the 20-year cohort (both sexes), and between smoking and obesity in the 40-year cohort (both sexes).

Conclusions

Interventions targeted at women, persons with lower education, and smokers who also have obesity may result in the greatest reduction in the rate of MM accumulation. However, interventions may need to focus on persons prior to mid-life to have the greatest effect.

Bidirectional association between functional disability and multimorbidity among middle-aged and older adults in Thailand

Objectives

The purpose of this study was to assess the bidirectional association between multimorbidity (MM) and functional disability among middle-aged and older adults in a longitudinal study in Thailand.

Methods

We analyzed longitudinal data of participants aged 45 years and older from two consecutive waves (in 2015 and 2017) of the Health, Aging, and Retirement in Thailand (HART). Functional disability was assessed with a 4-item activity of daily living (ADL) scale. Logistic regression analysis was conducted to assess the association between baseline functional disability and incident MM (≥2), and baseline morbidity and incident functional disability.

Results

The results indicate that a total of 1,716 individuals without morbidity at baseline and 3,529 without functional disability at baseline were included. At follow-up, 16.7 and 20.0% of functional disability cases and 7.1 and 3.6% of nonfunctional disability cases developed 2 morbidities and 3 or more morbidities, respectively, and 6.6% of MM cases and 4.0% of non-MM cases developed a functional disability. In the final logistic regression model adjusted for education, income, age, marital status, sex, smoking tobacco, body mass index (BMI), alcohol use, physical activity, and social engagement, functional disability at baseline was positively associated with incident MM (≥2) (adjusted odds ratio [aOR]: 2.58, 95% CI: 1.42-4.72), and MM (≥3) at baseline was positively associated with incident functional disability (aOR: 1.97, 95% CI: 1.13-3.43).

Conclusion

Multimorbidity and functional disability were bidirectionally associated.

Mobility experiences of adult lower limb orthosis users: a focus group study

PURPOSE

People with lower limb impairments are often prescribed orthoses to preserve or enhance their mobility. Exploration of mobility experiences common among orthosis users may provide insights into how orthoses, and other mobility aids, are utilized and regarded. The objective of this study was to broadly explore how lower limb orthosis users describe their mobility.

MATERIALS AND METHODS

Four focus groups were held online with participants who lived in the U.S. or Canada. Participants had at least six months of experience using an ankle-foot- and/or a knee-ankle-foot-orthosis for one or both legs. All discussions were transcribed and coded. Thematic analysis was used to identify cross-cutting themes.

RESULTS

Participants included 29 orthosis users with a variety of health conditions. Inter-related themes, including personal factors, situational contexts, and assistance were identified as elements that influenced participants' mobility. Participants described a process of modifying their mobility through the use and non-use of one or more mobility aids.

CONCLUSIONS

The current study findings may assist clinicians in developing strategies to optimize orthosis users' mobility in different situations. Experiences described by participants in this study may also help researchers identify aspects of mobility most pertinent to orthosis users and inform the development of new outcome measures.Implications for RehabilitationPeople who use lower-limb orthoses share common mobility experiences, despite differences in health diagnoses.Orthosis users often have opportunities to modify their mobility by choosing to use or not use their brace(s) and/or handheld mobility aids.When providing mobility aid interventions, clinicians should consider how each patient's individual characteristics, including physical characteristics (e.g., the health condition and how it presents, pain, fatigue) and psychosocial characteristics (e.g., fear and confidence, self-motivation, emotional responses), can affect mobility.Clinicians may be able to help patients optimize their mobility by asking about environmental obstacles they regularly encounter and recommending strategies for utilization of mobility aids, including simultaneous use of multiple aids, use of one aid, or choosing not to use any aids, depending on the activity and situation.Clinicians should inquire about all mobility aids available to a patient at home and in the community, including fixed objects, and consider how new mobility aid interventions might affect the patient's mobility when used alone and in combination with other forms of assistance.

Modeling of correlated cognitive function and functional disability outcomes with bounded and missing data in a longitudinal aging study

Longitudinal studies of correlated cognitive and disability outcomes among older adults are characterized by missing data due to death or loss to follow-up from deteriorating health conditions. The Mini-Mental State Examination (MMSE) score for assessing cognitive function ranges from a minimum of 0 (floor) to a maximum of 30 (ceiling). To study the risk factors of cognitive function and functional disability, we propose a shared parameter model to handle missingness, correlation between outcomes, and the floor and ceiling effects of the MMSE measurements. The shared random effects in the proposed model handle missingness (either missing at random or missing not at random) and correlation between these outcomes, while the Tobit distribution handles the floor and ceiling effects of the MMSE measurements. We used data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) and a simulation study. By ignoring the MMSE floor and ceiling effects in the analyses of the CLHLS, the association of systolic blood pressure with cognitive function was not significant and the association of age with cognitive function was lower by 16.6% (from -6.237 to -5.201). By ignoring the MMSE floor and ceiling effects in the simulation study, the relative bias in the estimated association of female gender with cognitive function was 43 times higher (from -0.01 to -0.44). The estimated associations obtained with data missing at random were smaller than those with data missing not at random, demonstrating how the missing data mechanism affects the analytic results. Our work underscores the importance of proper model specification in longitudinal analysis of correlated outcomes subject to missingness and bounded values.

Multimorbidity burden and developmental trajectory in relation to later‐life dementia: A prospective study

INTRODUCTION

This study assessed the associations of multimorbidity burden and its developmental trajectory with later-life dementia.

METHODS

Among 5923 Health and Retirement Study participants, major chronic conditions including hypertension, diabetes mellitus, cancer, lung diseases, heart disease, stroke, psychological disorders, and arthritis were self- or proxy-reported in 1994-2008. Dementia diagnosis was self- or proxy-reported in 2008-2018. We used Cox regression to assess the associations of multimorbidity with incident dementia.

RESULTS

During follow-up (median = 8 years), 701 participants developed dementia. Each additional chronic condition in 2008 was related to 15% (confidence interval: 9% to 22%) higher hazard of dementia. Multimorbidity trajectories in 1994-2008 were classified as "rapid growth", "steady growth", "slow growth", and "no new condition" by the group-based trajectory modelling methods. Compared to "no new condition", the "rapid growth" trajectory was related to 32% (3% to 69%) higher dementia risk.

CONCLUSIONS

Both multimorbidity burden and its developmental trajectory were prospectively associated with risk of dementia.

Chronic disease and depression among the elderly in China: the mediating role of instrumental activities of daily living and the moderating role of area of residence

Chronic diseases are associated with depressive symptoms in older adults. However, the mechanism of this relation is not clear. In this study, we explored the mediating role of instrumental activities of daily living and the moderating role of area of residence in the relationship between chronic diseases and depression. The data was from the Chinese Longitudinal Healthy Longevity Study. Results showed that chronic diseases were positively correlated with depression, and negatively associated with instrumental activities of daily living (IADLs). Moreover, IADLs mediated the relationship between chronic diseases and depression. In addition, area of residence (rural/urban) moderated the relation between IADLs and depression, such that this negative relation was stronger for old adults lived in rural area than for urban area. These results have important significance for prevention and intervention of depression in the elderly.

Beyond Chronological Age: A Multidimensional Approach to Survival Prediction in Older Adults

BACKGROUND

There is a growing interest in generating precise predictions of survival to improve the assessment of health and life-improving interventions. We aimed to (a) test if observable characteristics may provide a survival prediction independent of chronological age; (b) identify the most relevant predictors of survival; and (c) build a metric of multidimensional age.

METHODS

Data from 3 095 individuals aged ≥60 from the Swedish National Study on Aging and Care in Kungsholmen. Eighty-three variables covering 5 domains (diseases, risk factors, sociodemographics, functional status, and blood tests) were tested in penalized Cox regressions to predict 18-year mortality.

RESULTS

The best prediction of mortality at different follow-ups (area under the receiver operating characteristic curves [AUROCs] 0.878-0.909) was obtained when 15 variables from all 5 domains were tested simultaneously in a penalized Cox regression. Significant prediction improvements were observed when chronological age was included as a covariate for 15- but not for 5- and 10-year survival. When comparing individual domains, we find that a combination of functional characteristics (ie, gait speed, cognition) gave the most accurate prediction, with estimates similar to chronological age for 5- (AUROC 0.836) and 10-year (AUROC 0.830) survival. Finally, we built a multidimensional measure of age by regressing the predicted mortality risk on chronological age, which displayed a stronger correlation with time to death (R = -0.760) than chronological age (R = -0.660) and predicted mortality better than widely used geriatric indices.

CONCLUSIONS

Combining easily accessible characteristics can help in building highly accurate survival models and multidimensional age metrics with potentially broad geriatric and biomedical applications.

Socioeconomic vulnerability and frailty among community-dwelling older adults: cross-sectional findings from longitudinal aging study in India, 2017-18

INTRODUCTION

The Indian population is rapidly aging with huge proportion of illiterate and socioeconomically disadvantaged people and there is a dearth of research on the relationships between factors of socioeconomic vulnerability and frailty in older people. The present study examined the cross-sectional associations between socioeconomic vulnerability and physical frailty in community-dwelling older individuals in India.

MATERIALS AND METHODS

The data for the study were obtained from the Longitudinal Aging Study in India (LASI), which was conducted in 2017-18. The effective sample size was 14,652 older males and 15,899 older females aged 60 and over. The outcome variable was physical frailty phenotype measured from exhaustion, unintentional weight loss, weak grip strength, low physical activity, and slow walking time. The main explanatory variable was vulnerability status based on education, wealth and caste. The study carried out bivariate analysis to observe the association between vulnerability status and physical frailty. Further, multivariable binary logistic regression analysis was conducted to fulfil the objective of the study.

RESULTS

A proportion of 10.5 and 14.4% of older males and females respectively were in the overall vulnerable category. The prevalence of physical frailty was high among older males from vulnerable population (31.4% vs 26.9%; p < 0.001). The adjusted estimates from multivariate analysis revealed that older adults from vulnerable category had 14% significantly higher odds of being frail in comparison to non-vulnerable category [AOR: 1.14; CI: 1.06,1.24]. The adjusted model further revealed that there were no significant gender differentials in physical frailty among older adults. Model-3 (adjusted model) revealed that older males and females from vulnerable population had 18% [AOR: 1.18; CI: 1.04,1.34] and 8% [AOR: 1.08; CI: 1.01,1.21] significantly higher odds of being physically frail in comparison to older males from non-vulnerable population respectively.

CONCLUSIONS

Adverse socioeconomic circumstances such as low education, lower wealth and caste status that are associated with increased prevalence of physical frailty raise urgent questions both for public health practitioners and clinicians. The current findings may help to adapt public policies focusing on screening physical frailty in the clinical settings, especially among vulnerable populations as a marker of a possibly reversible vulnerability to adverse outcomes in old age.

Theoretical explanations for socioeconomic inequalities in multimorbidity: a scoping review

OBJECTIVE

To document socioepidemiological theories used to explain the relationship between socioeconomic disadvantage and multimorbidity.

DESIGN

Scoping review.

METHODS

A search strategy was developed and then applied to multiple electronic databases including Medline, Embase, PsychInfo, Web of Science, Scielo, Applied Social Sciences, ERIC, Humanities Index and Sociological Abstracts. After the selection of studies, data were extracted using a data charting plan. The last search was performed on the 28 September 2021. Extracted data included: study design, country, population subgroups, measures of socioeconomic inequality, assessment of multimorbidity and conclusion on the association between socioeconomic variables and multimorbidity. Included studies were further assessed on their use of theory, type of theories used and context of application. Finally, we conducted a meta-narrative synthesis to summarise the results.

RESULTS

A total of 64 studies were included in the review. Of these, 33 papers included theories as explanations for the association between socioeconomic position and multimorbidity. Within this group, 16 explicitly stated those theories and five tested at least one theory. Behavioural theories (health behaviours) were the most frequently used, followed by materialist (access to health resources) and psychosocial (stress pathways) theories. Most studies used theories as post hoc explanations for their findings or for study rationale. Supportive evidence was found for the role of material, behavioural and life course theories in explaining the relationship between social inequalities and multimorbidity.

CONCLUSION

Given the widely reported social inequalities in multimorbidity and its increasing public health burden, there is a critical gap in evidence on pathways from socioeconomic disadvantage to multimorbidity. Generating evidence of these pathways will guide the development of intervention and public policies to prevent multimorbidity among people living in social disadvantage. Material, behavioural and life course pathways can be targeted to reduce the negative effect of low socioeconomic position on multimorbidity.

Trends and biopsychosocial correlates of physical disabilities among older men and women in Taiwan: examination based on ADL, IADL, mobility, and frailty

Background

This study examines correlates of disabilities related to ADL, IADL, mobility, and frailty in men and women with a nationally representative sample of older adults living in the community.

Methods

A total of 10,898 noninstitutionalized Taiwanese nationals aged 65 years and older enrolled in the 2001 (N = 2,064), 2005 (N = 2,727), 2009 (N = 2,904), and 2013 (N = 3,203) National Health Interview Survey (NHIS) were analyzed.

Results

The prevalence of mobility disabilities and frailty in older adults in Taiwan decreased during the past decade (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\chi }_{Mobility}^{2}= -5.4$$\end{document}χMobility2=-5.4, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\chi }_{Frailty}^{2}= -6.2$$\end{document}χFrailty2=-6.2). Exercise, social engagement, and tea and coffee intake were found to be associated with lower levels of all types of disabilities in both men and women. In addition, a diet based on carbohydrates, falls, depressive symptomatology, lung and metabolic diseases were risks for most of the disabilities under consideration. Gender-specific independent correlates included: being married (OR = 0.63, 95%CI: 0.40–0.98), eggs/beans/fish/meat consumption (OR = 0.35, 95% CI = 0.16–0.80); depressive symptoms, obesity and cataracts, which were associated with higher IADL (OR = 3.61, 1.63, and 1.18, respectively) and frailty limitations (OR = 10.89, 1.27, and 1.20, respectively) in women. Cognitive impairment was found to be an important correlate for ADL limitations in men (OR = 3.64, 95%CI: 2.38–5.57).

Conclusions

Exercise, social participation and diet (more tea and coffee intake and lower carbohydrates) were correlates for lower levels of disability. Some gender-specific correlates were also identified, including associations of disability with depressive symptoms, obesity, and cataracts that were more distinct in women, and lower levels of disability which were especially significant in men who were married, eat more eggs, beans, fish, and meat, and those free from cognitive impairment.

Recognizing Depression in the Elderly: Practical Guidance and Challenges for Clinical Management

Depression is one of the most common mood disorders in the late-life population and is associated with poor quality of life and increased morbidity, disability and mortality. Nevertheless, in older adults, it often remains undetected and untreated. This narrative review aims at giving an overview on the main definitions, clinical manifestations, risk and protective factors for depression in the elderly, and at discussing the main reasons for its under/misdiagnosis, such as cognitive decline and their overlapping symptomatology. A practical approach for the global and multidisciplinary care of the older adult with depression, derived from cross-checking evidence emerging from the literature with everyday clinical experience, is thus provided, as a short and flexible "pocket" guide to orient clinicians in recognizing, diagnosing and treating depression in the elderly.

Multidimensional trajectories of multimorbidity, functional status, cognitive performance, and depressive symptoms among diverse groups of older adults

Background

Inter-relationships between multimorbidity and geriatric syndromes are poorly understood. This study assesses heterogeneity in joint trajectories of somatic disease, functional status, cognitive performance, and depressive symptomatology.

Methods

We analyzed 16 years of longitudinal data from the Health and Retirement Study (HRS, 1998-2016) for n = 11,565 older adults (≥65 years) in the United States. Group-based mixture modeling identified latent clusters of older adults following similar joint trajectories across domains.

Results

We identified four distinct multidimensional trajectory groups: (1) Minimal Impairment with Low Multimorbidity (32.7% of the sample; mean = 0.60 conditions at age 65, 2.1 conditions at age 90) had limited deterioration; (2) Minimal Impairment with High Multimorbidity (32.9%; mean = 2.3 conditions at age 65, 4.0 at age 90) had minimal deterioration; (3) Multidomain Impairment with Intermediate Multimorbidity (19.9%; mean = 1.3 conditions at age 65, 2.7 at age 90) had moderate depressive symptomatology and functional impariments with worsening cognitive performance; (4) Multidomain Impairment with High Multimorbidity (14.1%; mean = 3.3 conditions at age 65; 4.7 at age 90) had substantial functional limitation and high depressive symptomatology with worsening cognitive performance. Black and Hispanic race/ethnicity, lower wealth, lower education, male sex, and smoking history were significantly associated with membership in the two Multidomain Impairment classes.

Conclusions

There is substantial heterogeneity in combined trajectories of interrelated health domains in late life. Membership in the two most impaired classes was more likely for minoritized older adults.

Multi-morbidity and patient-reported functional limitations: a population-based cohort study

Background

Persons who accumulate chronic conditions at a rate faster than their peers may experience accelerated aging and poor health outcomes, including functional limitations.

Methods

Adults aged ≥40 years who resided in Olmsted County, Minnesota on 1 January 2006 were identified. The prevalence of 21 chronic conditions was ascertained, and age-specific quartiles of the number of chronic conditions was estimated within 4 age groups: 40–54, 55–64, 65–74, and ≥75 years. Difficulty with nine patient-reported functional limitations (including basic and instrumental activities of daily living and mobility activities) were ascertained through 31 October 2018. Cox regression was used to model associations of chronic condition quartiles with new-onset functional limitations considered separately. We estimated absolute risk differences and hazard ratios stratified by age group, and adjusted for sex, race, ethnicity, marital status, education, and the residual effect of age.

Results

Among 39,624 persons (44.5% men, 93.2% white), the most common reported new functional limitations were difficulty with climbing stairs, walking, and housekeeping. For all functional limitations, the absolute risk differences were largest among the oldest age group (≥75 years). Approximately twofold increased hazard ratios were observed among those in the highest vs. lowest quartile for the three oldest age groups, and approximately threefold or higher hazard ratios were observed for persons aged 40-54 years.

Conclusion

Persons with increased accumulation of chronic conditions experience increased risks of developing functional limitations compared to their peers. These findings underscore the importance of assessing health status and of employing interventions to prevent and effectively manage multi-morbidity at all ages.

The Differential Impact of Multimorbidity Patterns and Subsequent Accumulation on Longitudinal Trajectories of Physical Function Decline in a Population-based Cohort of Older People

BACKGROUND

Although both the patterns and accumulation of multimorbidity are important for predicting physical function, studies have not simultaneously examined their impact on functional decline. This study aimed to associate multimorbidity patterns and subsequently developed conditions with longitudinal trajectories of functional decline, and it tested whether the effects of newly developed conditions on functional decline varied across distinct multimorbidity patterns.

METHODS

We included 6,634 participants aged at least 60 years from the China Health and Retirement Longitudinal Survey. Latent class analysis identified multimorbidity patterns from 14 chronic conditions. Mixed negative binomial models estimated the changes in physical function measured across four waves as a function of multimorbidity patterns, subsequently developed conditions and their interactions.

RESULTS

Five distinct patterns were identified three years before wave 1: stomach/arthritis (15.7%), cardiometabolic (6.7%), arthritis/hypertension (47.9%), hepatorenal/multi-system (18.3%), and lung/asthma (11.4%). The hepatorenal/multi-system and the lung/asthma pattern were associated with worse baseline physical function, and the hypertension/arthritis pattern was associated with greater decline of physical function. The effect of developing new conditions on decline of physical function over time was most evident for individuals from the cardiometabolic pattern.

DISCUSSION

Considering both the combinations and progressive nature of multimorbidity is important for identifying individuals at greater risk of disability. Future studies are warranted to differentiate the factors responsible for the progression of chronic conditions in distinct multimorbidity patterns and investigate the potential implications for improved prediction of functional decline.

Studying trajectories of multimorbidity: a systematic scoping review of longitudinal approaches and evidence

OBJECTIVES

Multimorbidity-the co-occurrence of at least two chronic diseases in an individual-is an important public health challenge in ageing societies. The vast majority of multimorbidity research takes a cross-sectional approach, but longitudinal approaches to understanding multimorbidity are an emerging research area, being encouraged by multiple funders. To support development in this research area, the aim of this study is to scope the methodological approaches and substantive findings of studies that have investigated longitudinal multimorbidity trajectories.

DESIGN

We conducted a systematic search for relevant studies in four online databases (Medline, Scopus, Web of Science and Embase) in May 2020 using predefined search terms and inclusion and exclusion criteria. The search was complemented by searching reference lists of relevant papers. From the selected studies, we systematically extracted data on study methodology and findings and summarised them in a narrative synthesis.

RESULTS

We identified 35 studies investigating multimorbidity longitudinally, all published in the last decade, and predominantly in high-income countries from the Global North. Longitudinal approaches employed included constructing change variables, multilevel regression analysis (eg, growth curve modelling), longitudinal group-based methodologies (eg, latent class modelling), analysing disease transitions and visualisation techniques. Commonly identified risk factors for multimorbidity onset and progression were older age, higher socioeconomic and area-level deprivation, overweight and poorer health behaviours.

CONCLUSION

The nascent research area employs a diverse range of longitudinal approaches that characterise accumulation and disease combinations and to a lesser extent disease sequencing and progression. Gaps include understanding the long-term, life course determinants of different multimorbidity trajectories, and doing so across diverse populations, including those from low-income and middle-income countries. This can provide a detailed picture of morbidity development, with important implications from a clinical and intervention perspective.

Not Seeing Double: Discordance in Disease, Function, and Their Longitudinal Associations in Monozygotic Twins

OBJECTIVE

Prior research on the causality and directionality between disease and functional limitations is ambiguous. The current study used longitudinal monozygotic twin data to test both directions linking disease burden and functional limitations in middle-aged and older adults, controlling for genetic and familial factors. We also examined potential moderation by psychological well-being.

METHODS

The twin subsample from the first two waves of the longitudinal Midlife in the United States (MIDUS) study was used (wave 1, 1995-1996; wave 2, 2004-2006). Only monozygotic twins (n = 713) were included in analyses. In separate multilevel models, we examined disease burden at MIDUS 2 predicted by functional limitations at MIDUS 1 and MIDUS 2 functional limitations predicted by disease burden at MIDUS 1.

RESULTS

Disease burden and functional limitations at MIDUS 2 varied substantially within families. There was no within-family association of earlier functional limitations with change in later disease burden (b = 0.40, p = .39), but there was a within-family association such that the twin with higher baseline disease burden had a greater increase in functional limitations than his/her co-twin (b = 0.06, p = .02). Well-being was not a moderator in either model.

CONCLUSIONS

We found support for a potentially causal association between earlier disease burden and later increases in functional limitations, consistent with the Disablement Process Model. Sensitivity analyses confirm the detected within-family effect. Possible mechanisms linking disease burden and functional limitations are discussed as potential targets for future research.

Health trajectories after age 60: the role of individual behaviors and the social context

Background: This study aimed to detect health trajectories after age 60, and to explore to what extent individual and social factors may contribute to healthier aging.

Methods: Twelve-year health trajectories were identified in subjects from the Swedish National Study on Aging and Care in Kungsholmen (N=3108), integrating five indicators of disease, physical and cognitive function, and disability through nominal response models. Growth mixture models were applied to explore health trajectories in terms of rate and pattern of change. Baseline information about health-related behaviors and the social context was collected through standardized questionnaires. The strength of the associations was estimated using logistic regression, and their impact through population attributable fractions (PAF).

Results: Three trajectories were identified grouping 78%, 18%, and 4% of people with respectively increasing rates of health decline. Compared to the best trajectory, subjects in the middle and worst trajectories became functionally dependent 12.0 (95% CI: 11.4-12.6) and 12.1 (95% CI: 11.5-12.7) years earlier, respectively. Insufficient physical activity (OR: 3.38, 95% CI: 2.58-4.42), financial strain (OR: 2.76, 95% CI: 1.77-4.30), <12 years education (OR: 1.53, 95% CI: 1.14-2.04), low social connections (OR: 1.45, 95% CI: 1.09-1.94), low social participation (OR: 1.39, 95% CI: 1.06-1.83) and a body mass index ≥25 (OR: 1.34, 95% CI: 1.03-1.75) were associated with belonging to the middle/worst trajectories. The highest PAFs were observed for insufficient physical activity (27.1%), low education (19.3%) and low social participation (15.9%); a total PAF of 66.1% was obtained.

Conclusions: Addressing the social determinants of health in its broadest sense, complementarily considering life-long factors belonging to the socioeconomic, psychosocial, and behavioral dimensions, should be central to any strategy aimed at fostering health in older age.

Health status and health care utilization after discharge from geriatric in-hospital stay - description of a register-based study

Background

This study is the first part of a register-based research program with the overall aim to increase the knowledge of the health status among geriatric patients and to identify risk factors for readmission in this population. The aim of this study was two-fold: 1) to evaluate the validity of the study cohorts in terms of health care utilization in relation to regional cohorts; 2) to describe the study cohorts in terms of health status and health care utilization after discharge.

Methods

The project consist of two cohorts with data from patient records of geriatric in-hospital stays, health care utilization data from Stockholm Regional Healthcare Data Warehouse 6 months after discharge, socioeconomic data from Statistics Sweden. The 2012 cohort include 6710 patients and the 2016 cohort, 8091 patients; 64% are women, mean age is 84 (SD 8).

Results

Mean days to first visit in primary care was 12 (23) and 10 (19) in the 2012 and 2016 cohort, respectively. Readmissions to hospital was 38% in 2012 and 39% in 2016. The validity of the study cohorts was evaluated by comparing them with regional cohorts. The study cohorts were comparable in most cases but there were some significant differences between the study cohorts and the regional cohorts, especially regarding amount and type of primary care.

Conclusion

The study cohorts seem valid in terms of health care utilization compared to the regional cohorts regarding hospital care, but less so regarding primary care. This will be considered in the analyses and when interpreting data in future studies based on these study cohorts. Future studies will explore factors associated with health status and re-admissions in a population with multi-morbidity and disability.

Estimage: a webserver hub for the computation of methylation age

Methylage is an epigenetic marker of biological age that exploits the correlation between the methylation state of specific CG dinucleotides (CpGs) and chronological age (in years), gestational age (in weeks), cellular age (in cell cycles or as telomere length, in kilobases). Using DNA methylation data, methylage is measurable via the so called epigenetic clocks. Importantly, alterations of the correlation between methylage and age (age acceleration or deceleration) have been stably associated with pathological states and occur long before clinical signs of diseases become overt, making epigenetic clocks a potentially disruptive tool in preventive, diagnostic and also in forensic applications. Nevertheless, methylage dependency from CpGs selection, mathematical modelling, tissue specificity and age range, still makes the potential of this biomarker limited. In order to enhance model comparisons, interchange, availability, robustness and standardization, we organized a selected set of clocks within a hub webservice, EstimAge (Estimate of methylation Age, http://estimage.iac.rm.cnr.it), which intuitively and informatively enables quick identification, computation and comparison of available clocks, with the support of standard statistics.

Barriers, facilitators, and opportunities to optimize care engagement in a diverse sample of older low-income women: A qualitative study

The growing population of aging women in the United States is disproportionately at-risk for adverse physical, behavioral, mental, and psychosocial health conditions. Engagement with preventive care is critical to address these risk factors. A qualitative descriptive approach was used to explore patterns of healthcare use, facilitators, barriers, and opportunities to optimize primary/preventive care engagement among low-income midlife and older women. Themes were deductively derived from the Behavioral Model for Vulnerable Populations. Categories were inductively determined: barriers to care engagement; facilitators of care engagement; opportunities to optimize primary/preventive care engagement. Themes emerging from this study suggest that experiences related to discrimination, psychological health, trauma, and prioritizing care of others negatively influence care engagement; while respect, continuity, and clinician gender and racial/ethnic concordance enhance care participation. Efforts aiming to engage low-income aging women in care should focus on addressing barriers, building on facilitators, and leveraging contemporary telehealth-outreach solutions.

Common Mental Disorders, Functional Limitation and Diet Quality Trends and Related Factors among COPD Patients in Spain, 2006-2017: Evidence from Spanish National Health Surveys

Certain conditions such as common mental disorders (CMDs), functional limitation (FL) and poor diet quality may affect the lives of individuals who suffer from chronic obstructive pulmonary disease (COPD). This study sought to examine time trends in the prevalence of CMDs, FL and diet quality among male and female COPD patients living in Spain from 2006 to 2017 and to identify which factors were related to CMDs, FL and a poor/improvable diet quality in these patients. We performed a cross-sectional study among COPD patients aged ≥ 40 years old using data from the Spanish National Health Surveys conducted in 2006, 2011 and 2017, identifying a total of 2572 COPD patients. Binary logistic regressions were performed to determine the characteristics related to CMDs, FL and poor/improvable diet quality. Over the years of the study, the prevalence of FL among female COPD patients increased (p for trend <0.001). In addition, CMDs were associated to body mass index (BMI), educational level, physical activity, smoking status, occupation, chronic conditions and alcohol consumption; FL was related to age, living with a partner, educational level, physical activity and chronic conditions; and poor/improvable diet quality was associated to age, smoking status, BMI and physical activity.

Patterns of multimorbidity and pharmacotherapy: a total population cross-sectional study

BACKGROUND

Treatment of multimorbid patients can be improved. Development of patient-centred care of high-quality requires context-bound understanding of the multimorbid population's patterns of demographics, co-morbidities and medication use.

OBJECTIVE

The aim of this study was to identify patterns of multimorbidity in the total population of Region Stockholm, Sweden, by exploring demographics, claimed prescription drugs, risk of mortality and non-random association of conditions.

METHODS

In this cross-sectional descriptive population-based cohort study, we extracted data from the Swedish VAL database (N = 2 323 667) including all consultations in primary and specialized outpatient care, all inpatient care and all prescriptions claimed during 2017. We report number of chronic conditions and claimed prescription drugs, physical and mental co-morbidity, and 1-year mortality. We stratified the analyses by sex. We examined non-random associations between diseases using cluster analysis.

RESULTS

In total, 21.6% had multimorbidity (two or more chronic conditions) and 24.1% had polypharmacy (more than five claimed prescription drugs). Number of claimed drugs, co-occurrence of mental and physical conditions, and 1-year mortality increased as multimorbidity increased. We identified seven multimorbidity clusters with clinically distinct characteristics. The smallest cluster (7% of individuals) had prominent cardiovascular disease, the highest 1-year mortality rate, high levels of multimorbidity and polypharmacy, and was much older. The largest cluster (27% of individuals) was younger and heterogenous, with primarily mental health problems.

CONCLUSIONS

Individuals with chronic conditions often show clinical complexity with both concordant and discordant conditions and polypharmacy. This study indicates that clinical guidelines addressing clustering of conditions may be one strategy for managing complexity.

Not Only Diabetes but Also Prediabetes Leads to Functional Decline and Disability in Older Adults

OBJECTIVE

Diabetes is linked to functional decline, but the impact of prediabetes on physical function is unknown. We aimed to examine and compare the impact of prediabetes and diabetes on physical function and disability progression and to explore whether cardiovascular diseases (CVDs) mediate these associations.

RESEARCH DESIGN AND METHODS

A cohort of 2,013 participants aged ≥60 from the Swedish National Study on Aging and Care in Kungsholmen, an ongoing population-based longitudinal study, was monitored for up to 12 years. Physical function was measured with chair stand (s) and walking speed (m/s) tests, and disability was measured by summing the numbers of impaired basic and instrumental activities of daily living. Diabetes was identified through medical examinations or clinical records, medication use, or glycated hemoglobin (HbA_1c) ≥6.5%. Prediabetes was defined as HbA_1c ≥5.7-6.4% in participants free of diabetes. CVDs were ascertained through clinical examinations and the National Patient Register. Data were analyzed using mixed-effect models and mediation models.

RESULTS

At baseline, 650 (32.3%) had prediabetes and 151 had diabetes (7.5%). In multiadjusted mixed-effect models, prediabetes was associated with an increased chair stand time (β 0.33, 95% CI 0.05-0.61), a decreased walking speed (β -0.006, 95% CI -0.010 to -0.002), and an accelerated disability progression (β 0.05, 95% CI 0.01-0.08), even after controlling for the future development of diabetes. Diabetes led to faster functional decline than prediabetes. In mediation analyses, CVDs mediated 7.1%, 7.8%, and 20.9% of the associations between prediabetes and chair stand, walking speed, and disability progression, respectively.

CONCLUSIONS

Prediabetes, in addition to diabetes, is associated with faster functional decline and disability, independent of the future development of diabetes. This association may be in part mediated by CVDs.

Glutathione Serum Levels and Rate of Multimorbidity Development in Older Adults

We aimed to investigate the association between baseline levels of total serum glutathione (tGSH) and rate of chronic disease accumulation over time. The study population (n = 2,596) was derived from a population-based longitudinal study on ≥60-year-olds living in Stockholm. Participants were clinically assessed at baseline, 3- and 6-year follow-ups. Multimorbidity was measured as the number of chronic conditions from a previously built list of 60 diseases. Linear mixed models were applied to analyze the association between baseline tGSH levels and the rate of multimorbidity development over 6 years. We found that at baseline, participants with ≥4 diseases had lower tGSH levels than participants with no chronic conditions (3.3 vs 3.6 µmol/L; p < .001). At follow-up, baseline levels of tGSH were inversely associated with the rate of multimorbidity development (β * time: -0.044, p < .001) after adjusting for age, sex, education, levels of serum creatinine, C-reactive protein, albumin, body mass index, smoking, and time of dropout or death. In conclusion, serum levels of tGSH are inversely associated with multimorbidity development; the association exists above and beyond the link between tGSH and specific chronic conditions. Our findings support the hypothesis that tGSH is a biomarker of multisystem dysregulation that eventually leads to multimorbidity.

Patterns of Multimorbidity in a Population-Based Cohort of Older People: Sociodemographic, Lifestyle, Clinical, and Functional Differences

BACKGROUND

The aim of this study is to identify clusters of older persons based on their multimorbidity patterns and to analyze differences among clusters according to sociodemographic, lifestyle, clinical, and functional characteristics.

METHODS

We analyzed data from the Swedish National Study on Aging and Care in Kungsholmen on 2,931 participants aged 60 years and older who had at least two chronic diseases. Participants were clustered by the fuzzy c-means cluster algorithm. A disease was considered to be associated with a given cluster when the observed/expected ratio was ≥2 or the exclusivity was ≥25%.

RESULTS

Around half of the participants could be classified into five clinically meaningful clusters: respiratory and musculoskeletal diseases (RESP-MSK) 15.7%, eye diseases and cancer (EYE-CANCER) 10.7%, cognitive and sensory impairment (CNS-IMP) 10.6%, heart diseases (HEART) 9.3%, and psychiatric and respiratory diseases (PSY-RESP) 5.4%. Individuals in the CNS-IMP cluster were the oldest, with the worst function and more likely to live in a nursing home; those in the HEART cluster had the highest number of co-occurring diseases and drugs, and they exhibited the highest mean values of serum creatinine and C-reactive protein. The PSY-RESP cluster was associated with higher levels of alcoholism and neuroticism. The other half of the cohort was grouped in an unspecific cluster, which was characterized by gathering the youngest individuals, with the lowest number of co-occurring diseases, and the best functional and cognitive status.

CONCLUSIONS

The identified multimorbidity patterns provide insight for setting targets for secondary and tertiary preventative interventions and for designing care pathways for multimorbid older people.

The incidence of multimorbidity and patterns in accumulation of chronic conditions: A systematic review

Multimorbidity, the presence of 1+ chronic condition in an individual, remains one of the greatest challenges to health on a global scale. Although the prevalence of multimorbidity has been well-established, its incidence is not fully understood. This systematic review determined the incidence of multimorbidity across the lifespan; the order in which chronic conditions accumulate to result in multimorbidity; and cataloged methods used to determine and report accumulation of chronic conditions resulting in multimorbidity. Studies were identified by searching MEDLINE, Embase, CINAHL, and Cochrane electronic databases. Two independent reviewers evaluated studies for inclusion and performed quality assessments. Of 36 included studies, there was high heterogeneity in study design and operational definitions of multimorbidity. Studies reporting incidence (n = 32) reported a median incidence rate of 30.7 per 1,000 person-years (IQR 39.5 per 1,000 person-years) and a median cumulative incidence of 2.8% (IQR 28.7%). Incidence was notably higher for persons with older age and 1+ chronic conditions at baseline. Studies reporting patterns in accumulation of chronic conditions (n = 5) reported hypertensive and heart diseases, and diabetes, as among the common starting conditions resulting in later multimorbidity. Methods used to discern patterns were highly heterogenous, ranging from the use of latent growth trajectories to divisive cluster analyses, and presentation using alluvial plots to cluster trajectories. Studies reporting the incidence of multimorbidity and patterns in accumulation of chronic conditions vary greatly in study designs and definitions used. To allow for more accurate estimations and comparison, studies must be transparent and consistent in operational definitions of multimorbidity applied.

Beyond the social gradient: the role of lifelong socioeconomic status in older adults' health trajectories

Inequalities in older adults' health rarely consider life-course aspects of socioeconomic status (SES). We examined the association between lifelong SES and old-age health trajectories, and explored the role of lifestyle factors and depressive symptoms in this association. We followed 2760 adults aged 60+ from the Swedish National Study on Care and Aging, Kungsholmen. SES groups were derived using latent class analysis incorporating seven socioeconomic measures spanning childhood, midlife, and late life. We measured health using the Health Assessment Tool, which combines gait speed, cognition, multimorbidity, and disability. Linear mixed models were used to estimate health trajectories. Four SES groups were identified: High (34.9%), Middle (40.2%), Low (21.2%), and Mixed (3.8%). The Mixed group reported greater financial difficulties in childhood and older age, but varying SES attainment in midlife. Baseline health scores indicated that Mixed SES experienced substantial cognitive and physical deficits 12 years earlier than the High SES group. Compared to the High SES group, the Mixed SES group had the fastest health deterioration (β×time=-0.07, 95% CI:-0.11,-0.02); other groups followed a gradient (High>Middle>Low). Lifestyle factors and depressive symptoms attenuated the gradient but did not explain Mixed group's health disadvantage. Life-long SES measures are crucial for understanding older adults' health inequalities.

A Prospective Study on Risk Factors for Olfactory Dysfunction in Aging

Background

Olfactory dysfunction (OD) refers to a reduced or absent ability to smell. OD negatively impacts health and quality of life and its prevalence increases with advancing age. Since OD may be an early marker of dementia and impending death, more knowledge regarding risk factors of OD in aging is warranted. The objective was therefore to explore longitudinally which demographic, genetic, clinical, lifestyle, and cognitive factors predict the development of OD.

Methods

The study included participants aged 60–90 years from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K), who did not have OD at baseline and were reassessed with an odor identification task at a 6-year follow-up (n = 1,004). Risk factors of OD were assessed with multivariable logistic regression analyses.

Results

The percentage of incident OD cases was 14.2% over 6 years in the total sample and this number increased monotonically with age. Increasing age, carrying the ε4 allele of the APOE gene, atrial fibrillation, cerebrovascular disease, and current smoking were found to be risk factors for the development of OD, whereas better olfactory identification and verbal episodic memory proficiency at baseline were identified as protective factors.

Conclusions

In addition to nonmodifiable factors (age and genetic risk), several modifiable risk factors of OD were identified. This suggests that it might be possible to reduce OD incidence through the management of vascular risk factors and maintenance of a healthy lifestyle.

Moderation of the Association Between Chronic Medical Conditions and Functional Limitations Over Time by Physical Activity: Effects of Age

Background

Age-related accumulation of chronic medical conditions increases disability in older adults. Physical activity potently combats chronic conditions and disability. However, it is unclear whether activity maintenance alleviates the effects of chronic conditions on disability and if this buffering effect differs with age. This study examined whether long-term physical activity can forestall functional limitations in the face of accumulating chronic conditions among middle-aged and older adults.

Methods

Participants (n = 2,119; 54.7% female) were from the Survey of Midlife Development in the United States. Self-reported physical activity, number of chronic conditions, and functional limitations were obtained across 18–20 years. Functional limitations were regressed against the change in chronic conditions, physical activity, and their interaction over time in a multilevel model of change. Baseline age was added as an additional moderator.

Results

Faster accumulation of chronic conditions [B(SE) = 2.08(0.32), p < .001] and steeper declines in activity [B(SE) = −2.29(0.41), p < .001] were associated with greater increases in functional limitations over time. Among those with faster-than-average increases in conditions, those who maintained activity had a slower progression of functional limitations, compared to those whose activity declined more rapidly [B(SE) = −11.18(3.96), p = .005]. Baseline age moderated the buffering effect of activity maintenance; older adults were protected against functional limitations only when conditions accumulated slowly [B(SE) = 0.23(0.08), p = .005].

Conclusion

This study provides evidence for an age-dependent buffering effect of activity maintenance on the longitudinal relationship between chronic conditions and functional limitations. Intervention strategies using physical activity to forestall disability should target midlife adults and consider the rate of condition accumulation.

Social vulnerability underlying disability amongst older adults: A systematic review

BACKGROUND

Older adults face radical changes in their social life during ageing, dealing with several age-related social adaptations. The aim of this review is to systematically explore the literature on social vulnerability (SV) and its association with functional decline activity of daily living (ADL)/instrumental activities of daily living (IADL) as an endpoint in older adults.

METHODS

We searched for relevant studies in three different databases: PubMed, Ovid Medline and PsychInfo. Inclusion criteria included: prospective cohort studies assessing SV correlation; studies in English, Italian, French and Spanish to the end of March 2018; a general population aged >65 years living in a community setting and/or studies including younger participants if the mean age was >65 years; and basic ADL and/or IADL by Katz and Lawton, respectively, as functional decline and clinical outcomes.

RESULTS

We identified 65 manuscripts that assessed the role of SV in functional decline. Our systematic analysis showed that 26, 36 and 19 studies observed a correlation between Basic Social Needs, Social Resources and Social Behaviour and Activity, respectively, and the onset of ADL/IADL functional decline. Twenty-six studies explored the correlation between General Social Resources and the onset of ADL/IADL functional decline.

CONCLUSIONS

When examining a wide set of social variables, the "quality," rather than just structure, and "type" of social relationship represents the core feature of SV that predicts functional decline in older adults. By defining individual SV, its measurement and evaluation, we can plan effective social interventions aimed at preventing or delaying functional decline or death.

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.

Leisure activity and social integration mitigate the risk of dementia related to cardiometabolic diseases: A population-based longitudinal study

INTRODUCTION

The effect of comorbid cardiometabolic diseases (CMDs), including diabetes, heart diseases, and stroke, on dementia remains unclear.

METHODS

A cohort of 2648 dementia-free adults aged ≥60 years was followed up for 12 years. An active lifestyle was defined in accordance with the engagement in leisure activities and/or a social network. Cox models were used in data analysis.

RESULTS

The multiadjusted hazard ratio (HR, 95% confidence interval) of dementia was 1.41 (1.07-1.86) for one, 2.38 (1.58-3.59) for two, and 4.76 (2.04-11.13) for three CMDs. In joint exposure analysis, the HR of dementia was 3.36 (2.14-5.30) for participants with CMDs plus an inactive lifestyle and 1.32 (0.95-1.84) for those with CMDs plus an active lifestyle (reference: no CMDs plus active lifestyle). An active lifestyle delayed dementia onset by 3.50 years in people with CMDs.

DISCUSSION

CMDs, especially when comorbid, are associated with increased dementia risk; however, leisure activities and social integration mitigate this risk.

Comparing the prognostic value of geriatric health indicators: a population-based study

BACKGROUND

The identification of individuals at increased risk of poor health-related outcomes is a priority. Geriatric research has proposed several indicators shown to be associated with these outcomes, but a head-to-head comparison of their predictive accuracy is still lacking. We therefore aimed to compare the accuracy of five geriatric health indicators in predicting different outcomes among older persons: frailty index (FI), frailty phenotype (FP), walking speed (WS), multimorbidity, and a summary score including clinical diagnoses, functioning, and disability (the Health Assessment Tool; HAT).

METHODS

Data were retrieved from the Swedish National Study on Aging and Care in Kungsholmen, an ongoing longitudinal study including 3363 people aged 60+. To inspect the accuracy of geriatric health indicators, we employed areas under the receiver operating characteristic curve (AUC) for the prediction of 3-year and 5-year mortality, 1-year and 3-year unplanned hospitalizations (1+), and contacts with healthcare providers in the 6 months before and after baseline evaluation (2+).

RESULTS

FI, WS, and HAT showed the best accuracy in the prediction of mortality [AUC(95%CI) for 3-year mortality 0.84 (0.82-0.86), 0.85 (0.83-0.87), 0.87 (0.85-0.88) and AUC(95%CI) for 5-year mortality 0.84 (0.82-0.86), 0.85 (0.83-0.86), 0.86 (0.85-0.88), respectively]. Unplanned hospitalizations were better predicted by the FI [AUC(95%CI) 1-year 0.73 (0.71-0.76); 3-year 0.72 (0.70-0.73)] and HAT [AUC(95%CI) 1-year 0.73 (0.71-0.75); 3-year 0.71 (0.69-0.73)]. The most accurate predictor of multiple contacts with healthcare providers was multimorbidity [AUC(95%CI) 0.67 (0.65-0.68)]. Predictions were generally less accurate among younger individuals (< 78 years old).

CONCLUSION

Specific geriatric health indicators predict clinical outcomes with different accuracy. Comprehensive indicators (HAT, FI, WS) perform better in predicting mortality and hospitalization. Multimorbidity exhibits the best accuracy in the prediction of multiple contacts with providers.

Trends in multimorbidity, complex multimorbidity and multiple functional limitations in the ageing population of England, 2002-2015

This study aimed to estimate the prevalence of three measures of multimorbidity among people aged 50 years or older in England. Beside the basic measure of two or more diseases within a person, we added a measure of three or more affected body systems (complex multimorbidity) and a measure of 10 or more functional limitations. We found that the three health outcomes became more prevalent between 2002 and 2015. They were more common among females than males and were becoming more common among younger age groups. While in 2002, the prevalence of basic multimorbidity overcame 50% from the 70–74 age group upwards, in 2015 it crossed the same threshold in the 65–69 age group. The distribution of multimorbidity and multiple functional limitations were stratified by the amount of household wealth. Multiple functional limitations reflected the largest differences between the most and the least affluent groups (5.9-fold in 2014/2015), followed by the measure of complex multimorbidity (2.8-fold in 2014/2015) and basic multimorbidity (1.9-fold) in 2014/2015.While age acted as a levelling factor for the wealth differences in basic multimorbidity, it had no such effect on the two other outcomes. Our study observed social polarization among multimorbid ageing population in England where complex multimorbidity and multiple functional limitations increase faster and reflect stronger inequality than basic multimorbidity.

Association Between Speed of Multimorbidity Accumulation in Old Age and Life Experiences: A Cohort Study

Rapidly accumulating multiple chronic conditions (multimorbidity) during aging are associated with many adverse outcomes. We explored the association between 4 experiences throughout life-childhood socioeconomic circumstances, early-adulthood education, midlife occupational stress, and late-life social network-and the speed of chronic disease accumulation. We followed 2,589 individuals aged ≥60 years from the Swedish National Study on Aging and Care in Kungsholmen for 9 years (2001-2013). Information on life experiences was collected from detailed life-history interviews. Speed of disease accumulation was operationalized as the change in the count of chronic conditions obtained from clinical examinations, medical histories, laboratory data, drug use, and register linkages over 9 years. Linear mixed models were used to analyze the data. Speed of disease accumulation was lower in individuals with more than elementary education (for secondary, β × time = -0.065, 95% CI: -0.126, -0.004; for university, β × time = -0.118, 95% CI: -0.185, -0.050); for active occupations compared with high-strain jobs (β × time = -0.078, 95% CI: -0.138, -0.017); and for richer social networks (for moderate tertile, β × time = -0.102, 95% CI: -0.149, -0.055; for highest tertile, β × time = -0.135, 95% CI: -0.182, -0.088). The association between childhood circumstances and speed of disease accumulation was attenuated by later-life experiences. Diverse experiences throughout life might decelerate chronic disease accumulation during aging.

Inflammation in multimorbidity and disability: An integrative review

OBJECTIVE

Multimorbidity is a robust predictor of disability in aging adults, but the mechanisms by which multimorbidity is disabling are not clear. Most existing research focuses on disease-specific phenomena, such as diminished lung capacity in chronic obstructive pulmonary disease, which can result in functional limitations. This review takes a different approach by highlighting the potential role of a biological process-inflammation-that is common to many chronic medical conditions and thus, from a medical perspective, relatively disease nonspecific.

METHOD

Beginning with a description of inflammation and its measurement, this paper will provide an overview of research on inflammation as a predictor of disease risk in healthy adults and of adverse outcomes (e.g., disability) in those with multimorbidity.

RESULTS

The discussion of inflammation is then situated in the context of biopsychosocial influences on health, as inflammation has been shown to be sensitive to a wide range of social and psychological processes that are thought to contribute to healthy aging, including successful adaptation to multimorbidity and reduced risk of disability.

CONCLUSIONS

Finally, implications of this broader perspective for interventions to improve outcomes in aging adults with multimorbidity are briefly considered. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Psychosocial working conditions, trajectories of disability, and the mediating role of cognitive decline and chronic diseases: A population-based cohort study

BACKGROUND

Unfavorable psychosocial working conditions have been associated with cognitive decline and chronic diseases, both of which may subsequently accelerate functional dependence. This study aimed to investigate the association between job demand-control-support combinations and trajectories of disability in later life and to further explore the role of cognitive decline and the co-occurrence of chronic diseases in mediating this association.

METHODS AND FINDINGS

In this cohort study, 2,937 community dwellers aged 60+ years (mean age 73 ± 10.6; 62.9% female) residing in the Kungsholmen District of Stockholm, Sweden, participated in the baseline survey (2001-2004) and were followed up to 12 years. Lifelong occupational history was obtained through a standardized interview; job demands, job control, and social support at work in the longest-held occupation were graded with a psychosocial job-exposure matrix. Job control, demands, and social support were dichotomized using the median values from the matrix, respectively, to further generate demand-control-support combinations. Disability was measured by summing the number of impaired basic and instrumental activities of daily living. Global cognitive function was assessed by Mini-Mental State Examination. Chronic conditions were ascertained by clinical examinations, medical history, and patient clinical records; the total number of chronic diseases was summed. Data were analyzed using linear mixed-effects models and mediation analysis. Age, sex, education, alcohol consumption, smoking, leisure activity engagement, early-life socioeconomic status, occupational characteristic and physical demands, and baseline cognitive function and number of chronic diseases were adjusted for in the analyses. Compared with active jobs (high control/high demands; n = 1,807), high strain (low control/high demands; n = 328), low strain (high control/low demands; n = 495), and passive jobs (low control/low demands; n = 307) were all associated with a faster rate of disability progression (β = 0.07, 95% CI 0.02-0.13, p = 0.01; β = 0.10, 95% CI 0.06-0.15, p < 0.001; β = 0.11, 95% CI 0.05-0.18, p < 0.001). The association between high strain and disability progression was only shown in people with low social support at work (β = 0.13, 95% CI 0.07-0.19, p < 0.001), but not in those with high social support (β = 0.004, 95% CI -0.09 to 0.10, p = 0.93). Moreover, we estimated that the association between demand-control status and disability trajectories was mediated 38.5% by cognitive decline and 18.4% by accumulation of chronic diseases during the follow-up period. The limitations of this study include unmeasured confounding, self-reported work experience, and the reliance on a psychosocial job-exposure matrix that does not consider variabilities in individuals' perception on working conditions or job characteristics within occupations.

CONCLUSIONS

Our findings suggest that negative psychosocial working conditions during working life may accelerate disability progression in later life. Notably, social support at work may buffer the detrimental effect of high strain on disability progression. Cognitive decline and chronic-disease accumulation, and especially the former, partially mediate the association of psychosocial working conditions with trajectories of disability. Further studies are required to explore more mechanisms that underlie the association between psychosocial working conditions and disability trajectories.

Association between frailty and incident risk of disability in community-dwelling elder people: evidence from a meta-analysis

OBJECTIVE

Frailty is considered to be one of the risk factors of disability. However, the results of original reported studies are not consistent with respect to the frailty and incidence of disability, and previously published meta-analyses have also shown inconsistent results. This meta-analysis was conducted to investigate the relationship between the different stages of frailty and the incidence of disability by examining updated overall trends in community-dwelling elders.

STUDY DESIGN

Cohort studies in English or Chinese based on associations between frailty and incident disability risks that were published from 2000 until the current date were researched using PubMed, Embase, Web of Science, and CENTRAL databases.

METHODS

The Q test and I² statistic were used to examine between-study heterogeneity. Random-effect models were adopted to synthesize the results based on the study heterogeneity. Subgroup analyses were also conducted to explore the possible sources of between-study heterogeneity based on the characteristics of participants.

RESULTS

Eighteen cohort studies with 88,906 participants were included in our meta-analyses. Compared with the non-frailty category, the combined relative risks (RRs) (95% confidence interval [CI]) of the disability were 1.66 (1.49-1.85) and 2.53 (2.01-3.14) for the category of prefrailty and frailty, respectively. Results suggested that the incident risk of disability at follow-up times <5 (RR = 3.19, 95% CI = 2.25-4.53) was significantly higher than for follow-up times ≥5 in the frailty category (RR = 2.00, 95% CI = 1.55-2.56). The risk in a sample size of ≥1000 (RR = 2.78, 95% CI = 2.04-3.14) was significantly higher than that when the sample size was <1000 (RR = 1.91, 95% CI = 1.53-2.37) in the frailty group. Compared with a value adjusted for comorbidity, the unadjusted comorbidity was significantly higher in the prefrailty category (1.90 vs. 1.52). Compared with a value adjusted for education, the unadjusted education was significantly higher in the prefrailty category (1.81 vs. 1.46). No publication bias was observed.

CONCLUSION

The overall meta-analysis confirms that frailty has significantly increased the incident risk of disability. Frail, elderly people are at the highest risk of future disability and may be adequate candidates for taking part in prevention and intervention programs.

Profiling the hospital-dependent patient in a large academic hospital: Observational study

BACKGROUND

In older patients with acute illness, a condition of "hospital-dependence" may arise: patients get adapted to the hospital care and, once discharged, may experience health status decline, requiring repeated readmissions despite appropriate treatments.

AIMS

The objective of this case-series study was to describe the characteristics of 118 patients (72 F) aged ≥75 (mean 83.7 ± 4.9) who were urgently admitted to our institution at least 4 times in 2015.

METHODS

For each patient and admission, data on multimorbidity (Cumulative Illness Rating Scale Comorbidity Score and Severity Index), frailty (Rockwood Clinical Frailty Scale), functional dependence, functional status, polypharmacy, length of stay and interval between admissions were extrapolated from clinical records. Mortality during the years 2015 and 2016 was assessed on the institutional database.

RESULTS

At the first admission, patients had a high burden of polypharmacy (median number of drugs 8.5, IQR 6-11) and multimorbidity (Comorbidity Score 15.8 ± 4.1, Severity Index 2.9 ± 1.1). However, most (55.5%) were fit or pre-frail according to Clinical Frailty Scale (score 1-4). At multivariate models, Severity Index was significantly correlated with the length of stay (β ± SE 2.23 ± 0.89, p = .01) and readmission interval (β ± SE -22.49 ± 9.27, p = .02). Significantly increasing trends of multimorbidity and disability occurred across admissions. By the end of 2016, 66% of patients had died. Frailty (RR 2.005, 95%CI 1.054-3.814, p = .007) and cancer were the only predictors of mortality.

CONCLUSIONS

Hospital-dependent patients had severe multimorbidity, but exhibited an unexpectedly low prevalence of frailty/disability at baseline, though increasing across admissions. Trends of frailty and multimorbidity are paramount for profiling the hospital-dependence risk.