Multimorbidity, health and aging in Canada and Australia: a tale of two countries

Multimorbidity and health-related quality of life amongst Indigenous Australians: A longitudinal analysis

BACKGROUND

The burden of multimorbidity has been observed worldwide and it has significant consequences on health outcomes. In Australia, health-related quality of life (HRQoL) is comparatively low amongst Aboriginal and/or Torres Strait Islanders, yet no studies have examined the effect of multimorbidity on HRQoL within this at-risk population. This study seeks to fill that gap by employing a longitudinal research design.

METHODS

Longitudinal data were derived from three waves (9, 13, and 17) of the household, income and labour dynamics in Australia (HILDA) Survey. A total of 1007 person-year observations from 592 Aboriginal and/or Torres Strait Islander individuals aged 15 years and above were included. HRQoL was captured using the 36-item Short-Form Health Survey (SF-36), and multimorbidity was defined using self-reports of having been diagnosed with two or more chronic health conditions. Symmetric fixed-effects linear regression models were used to assess how intraindividual changes in multimorbidity were associated with intraindividual changes in HRQoL.

RESULTS

Approximately 21% of Indigenous Australians were classified as experiencing multimorbidity. Respondents had statistically significantly lower HRQoL on the SF-36 sub-scales, summary measures, and health-utility index in those observations in which they experienced multimorbidity. Among others, multimorbidity was associated with lower scores on the SF-36 physical-component scale (β =  - 6.527; Standard Error [SE] = 1.579), mental-component scale (β =  - 3.765; SE = 1.590) and short-form six-dimension utility index (β =  - 0.075; SE = 0.017).

CONCLUSION

This study demonstrates that having multiple chronic conditions is statistically significantly associated with lower HRQoL amongst Indigenous Australians. These findings suggest that comprehensive and culturally sensitive health strategies addressing the complex needs of individuals with multimorbidity should be implemented to improve the HRQoL of Indigenous Australians.

The role of life satisfaction and living arrangements in the association between chronic disease and depression: a national cross-sectional survey

Introduction

For middle-aged and older people, depression is a frequent and prevalent illness. The purpose of this study was to examine the moderating function of living arrangements in the mediating model as well as the mediating role of life satisfaction in the association between chronic diseases and depressive symptoms.

Methods

The China Health and Retirement Longitudinal Study (CHARLS) provided the data for this investigation (2018). Respondents were grouped according to depression status to compare the differences between middle-aged and older people with different depression statuses. The moderating effect of living arrangements and the mediating effect of life satisfaction were tested using the Bootstrap program and the simple slope approach.

Results

The population's total prevalence of depressive symptoms was 30.3%. According to the mediating effect research, middle-aged and older people with chronic diseases experienced substantial direct effects on depressive symptoms (β = 1.011, p < 0.001). It has been established that life satisfaction has an 18.6% mediation effect between depressive symptoms and chronic diseases. Regarding the further moderating influence, it was discovered that chronic diseases had a more significant impact on the life satisfaction of middle-aged and older people who are in live alone than those who are living with others (β = 0.037, p < 0.05).

Conclusion

In middle-aged and older people, chronic diseases have a major influence on depressive symptoms. Life satisfaction mediated the relationship between chronic diseases and depressive symptoms, and living arrangements moderated the first part of the route in the mediation model. Therefore, life satisfaction and living arrangements should be important considerations to decrease the prevalence of depressive symptoms in middle-aged and older people.

Could an optimally fitted categorization of difference between multi-disease score and multi-symptom score be a practical indicator aiding in improving the cost-effectiveness of healthcare delivery for older adults in developing countries?

BACKGROUND

Physio-psycho-socioeconomical health comprehensively declines during aging, the complexity of which is challenging to measure. Among the complexity, multiple chronic disorders continuously cumulated during aging, further aggravating the challenge.

METHODS

A population-based survey on Comprehensive Ageing Health Assessment was conducted in older adults (age >  = 60) enrolled from hospital settings and community settings in 13 working centers in six subnational regions in China. Cross-sectional datasets of 8,093 older participants with approximately complete assessment results were collected for the present analysis. Individual's multi-disease or multi-symptom was respectively scored by summing coexistent multiple diseases or multiple symptoms by respective weighting efficient for Self-Rated Health (SRH). Individual's age-dependent health decline was further summed of four SRH-weighted scores for daily function (activity of daily life, ADL), physical mobility (an average of three metrics), cognitive function (mini mental state examination, MMSE) and mental being (geriatric depression scale, GDS) plus multi-disease score (MDS) and multi-symptom score (MSS).Multi-disease patten among 18 diseases or multi-symptom pattern among 15 symptoms was latent-clustered in the older adults, the optimal outcome of which was categorized into high, moderate or low aging-associated clusters, respectively. Percentage distribution was compared between overall health decline score and multi-disease pattern cluster or multi-symptom patten cluster. A new variable of difference between MDS and MSS (hereinafter terming DMM) that displayed linear variation with socioeconomic factors was further fitted using multilevel regression analyses by substantial adjustments on individual confounders (level-1) and subnational region variation (level-2).

RESULTS

Consistent gradient distribution was shown between health decline and multimorbidity pattern cluster in the older adults. DMM was found linearly varied with personal education attainment and regional socioeconomic status. Using optimally fitted stratification of DMM (DMM interval = 0.02), an independent U-shaped interrelated tendency was shown between health decline, multi-disease and multi-symptom, which could be well explained by regional disparities in socioeconomic status.

CONCLUSION

Newly developed metrics for age-dependent health decline and aging-associated multimorbidity patten were preliminarily validated from within. The new variable of optimally fitted categorization of DMM might function as a practical indicator aiding in improving the cost-effectiveness and reduce inequity of healthcare delivery for older adults in developing countries.

Associations of hospitalisation - admission, readmission and length to stay - with multimorbidity patterns by age and sex in adults and older adults: the ELSI-Brazil study

BACKGROUND

Although the association between multimorbidity (MM) and hospitalisation is known, the different effects of MM patterns by age and sex in this outcome needs to be elucidated. Our study aimed to analyse the association of hospitalisations' variables (occurrence, readmission, length of stay) and patterns of multimorbidity (MM) according to sex and age.

METHODS

Data from 8.807 participants aged ≥ 50 years sourced from the baseline of the Brazilian Longitudinal Study of Ageing (ELSI-Brazil) were analysed. Multimorbidity was defined as ≥ 2 (MM2) and ≥ 3 (MM3) chronic conditions. Poisson regression was used to verify the association between the independent variables and hospitalisation according to sex and age group. Multiple linear regression models were constructed for the outcomes of readmission and length of stay. Ising models were used to estimate the networks of diseases and MM patterns.

RESULTS

Regarding the risk of hospitalisation among those with MM2, we observed a positive association with male sex, age ≥ 75 years and women aged ≥ 75 years. For MM3, there was a positive association with hospitalisation among males. For the outcomes hospital readmission and length of stay, we observed a positive association with male sex and women aged ≥ 75 years. Network analysis identified two groups that are more strongly associated with occurrence of hospitalisation: the cardiovascular-cancer-glaucoma-cataract group stratified by sex and the neurodegenerative diseases-renal failure-haemorrhagic stroke group stratified by age group.

CONCLUSION

We conclude that the association between hospitalisation, readmission, length of stay, and MM changes when sex and age group are considered. Differences were identified in the MM patterns associated with hospitalisation according to sex and age group.

Health and well-being of Hutterite farmers in Alberta: Results from the Sustainable Farm Families Alberta program

Introduction

This article describes the health and lifestyle profile of Hutterite farmers in Alberta who participated in a health literacy education program.

Methods

Longitudinal quantitative and qualitative data from the sustainable farm families (SFF) Alberta program (2014-2017) were used to describe the health and lifestyle profile of Hutterites. Data were analysed using descriptive statistics and conventional and summative content analysis.

Results

Four hundred and twenty-seven Hutterite men and women aged 18-75 years participated in a health literacy education program. About 50%-80% of Hutterites reported good health status, no hearing or sleeping problems, little to no body pain, fewer breathing and bladder difficulties and no constipation/diarrhoea. On average, the risk of diabetes was low (mean = 3.4) with total glucose (mean = 5.2) and cholesterol (mean = 3.5) within normal levels. Mental health outcomes such as anxiety (mean = 4.1), stress (mean = 6.7) and depression (mean = 3.1) were also within normal to mild ranges. Qualitative data showed that Hutterite farmers are committed to maintaining physical health and adopting strategies to improve mental health and lifestyle behaviours.

Conclusion

Hutterites have recognisable health challenges like other rural farming communities but are aware of their physical and mental health challenges and engage in healthy lifestyle behaviours. The Hutterite tenets of living present a perfect ecological setting for sustainable health promotion intervention.

Multimorbidity and loneliness. Longitudinal analysis based on the GSOEP

BACKGROUND

Our aim was to examine the longitudinal association between multimorbidity and loneliness in the general adult population (and in different age groups) in Germany.

METHODS

Longitudinal data were used from the German Socio-Economic Panel (n= 44,385 observations in the years 2013 and 2017) - a nationally representative sample including adults aged 18 years and above. Respondents are re-surveyed annually. Loneliness was quantified using the established UCLA-3. Multimorbidity was defined as the coexistence of two or more conditions and was indicated by a list containing 13 somatic and mental diseases. Asymmetric linear fixed effects regressions (also stratified by three age groups: 18 to 44 years; 45 to 64 years, 65 years and older) were used to examine the association between the onset and end of multimorbidity as well as loneliness.

RESULTS

After adjusting for possible confounders, regression analysis revealed that the onset of multimorbidity is associated with an increase in loneliness in the total sample (β = 0.07, p < 0.001) and among individuals aged 65 years and older (β = 0.13, p < 0.001), whereas no significant association was found in the other age groups. The end of multimorbidity was not associated with loneliness neither in the total group nor in the individual age groups.

CONCLUSION

This study revealed an association between the onset of multimorbidity and higher loneliness particularly among individuals in late life. Thus, preventing or delaying multimorbidity may be beneficial to avoid loneliness among older adults.

Multimorbidity, COVID-19 and Mental Health: Canadian Longitudinal Study on Aging (CLSA) Longitudinal Analyses

OBJECTIVES

This paper examines the longitudinal effects of the COVID-19 pandemic on older adults (65+) with multimorbidity on levels of depression, anxiety, and perceived global impact on their lives.

METHODS

Baseline (2011-2015) and Follow-up 1 (2015-2018) data from the Canadian Longitudinal Study on Aging (CLSA), and the Baseline and Exit waves of the CLSA COVID-19 study (April-December, 2020) (n = 18,099). Multimorbidity was measured using: a) an additive scale of chronic conditions; and b) six chronic disease clusters. Linear Mixed Models were employed to test hypotheses.

RESULTS

Number of chronic conditions pre-pandemic was associated with pandemic levels of depression (estimate = 0.40, 95% CI: [0.37,0.44]); anxiety (estimate = 0.20, 95% CI: [0.18, 0.23]); and perceived negative impact of the pandemic (OR = 1.04, 95% CI: [1.02, 1.06]). The associations between multimorbidity and anxiety decreased during the period of the COVID-19 surveys (estimate = -0.02, 95% CI: [-0.05, -0.01]); whereas the multimorbidity association with perceived impact increased (OR = 1.03, 95% CI: [1.01, 1.05]).

CONCLUSIONS

This study demonstrates that pre-pandemic multimorbidity conditions are associated with worsening mental health.

CLINICAL IMPLICATIONS

Clinicians treating mental health of older adults need to consider the joint effects of multimorbidity conditions and pandemic experiences to tailor counseling and other treatment protocols.

Multimorbidity resilience and health behaviors among older adults: A longitudinal study using the Canadian Longitudinal Study on Aging

Objective

There has been a growing interest in examining why some individuals adapt and bounce back from multimorbidity (resilience) better than others. This paper investigates the positive role of protective health behaviors on multimorbidity resilience (MR) among older adults focusing on older persons with two or more concurrent chronic conditions, and separately for three multimorbidity chronic illness clusters.

Methods

Using Baseline and Follow-up One data from the Comprehensive Cohort of the Canadian Longitudinal Study on Aging, we studied 10,628 participants aged 65 years and older who reported two or more of 27 chronic conditions, and three multimorbidity clusters: Cardiovascular/metabolic, Musculoskeletal, and Mental health. Associations between health behaviors and MR were evaluated using Linear Mixed Models, adjusting for socio-demographic, social/environmental, and illness context social determinants of health.

Results

Among older adults with two or more illnesses, smoking, satisfaction with sleep, appetite, and skipping meals were associated with MR in the expected direction. Also, obesity (compared to normal weight) and skipping meals showed longitudinal interaction effects with survey wave. Most of the results were replicated for the physical multimorbidity clusters (Cardiovascular/metabolic and Musculoskeletal) compared to the full 2+ multimorbidity analyses; however, for the Mental health cluster, only satisfaction with sleep was supported as a lifestyle predictor of MR.

Discussion

Several modifiable health behaviors identified in the broader health and aging literature are important in affecting levels of multimorbidity resilience in older age. These factors are important strength-based areas to target. Additionally, several social determinants of health are also supported and parallel research on multimorbidity risk. The effects of lifestyle factors for resilience among older adults is dependent on the type of multimorbidity measured. We conclude that the results have significant public health, program intervention, and clinical implications for healthy aging among persons coping with multimorbidity.

Association between physical activity and life satisfaction among adults with multimorbidity in Canada

OBJECTIVE

Maintaining life satisfaction may aid in multimorbidity resilience. As the prevalence of multimorbidity continues to rise in Canada, understanding modifiable factors that can influence life satisfaction among people with multimorbidity is warranted. This study aimed to examine the relationship between physical activity and life satisfaction among adults affected by multimorbidity.

METHODS

Cross-sectional data from the 2015-2018 cycles of the Canadian Community Health Survey were used; 22,851 respondents with multimorbidity aged 20 years and older were included. Multiple linear regression models were used to investigate the relationship between physical activity (sedentary, somewhat active, moderately active, active) and life satisfaction for the whole population and for those having specific types of chronic conditions, controlling for self-perceived health status and sociodemographic factors.

RESULTS

Respondents affected by multimorbidity who were somewhat active (β = 0.20, 95% CI: 0.08, 0.32), moderately active (β = 0.28, 95% CI: 0.13, 0.44), and active (β = 0.29, 95% CI: 0.17, 0.41) were more satisfied with life than respondents who had a sedentary lifestyle. The relationship between physical activity and life satisfaction was also found to be statistically significant in sub-populations of respondents affected by cancer, diabetes, chronic respiratory diseases, and mental health disorders but not cardiovascular diseases.

CONCLUSION

Physical activity may contribute to better life satisfaction among adults with multimorbidity. As multimorbidity increases in Canada, further investigation on the relationship between physical activity and life satisfaction is warranted to help improve interventions to cope with the effects of multimorbidity.

Association between multimorbidity and hospitalization in older adults: systematic review and meta-analysis

Background

Multimorbidity is defined as the presence of multiple chronic conditions in the same individual. Multimorbidity is more prevalent in older adults and can lead to several adverse health outcomes.

Methods

We systematically reviewed evidence from observational studies to verify the association between multimorbidity and hospitalization in older adults. Furthermore, we also aimed to identify whether it changes according to gender, advanced age, institutionalization, and wealth of the country of residence. We searched the PubMed, Embase and Scopus databases from December 2020 to April 2021. The analysed outcomes were as follows: hospitalization, length of stay and hospital readmission.

Results

Of the 6,948 studies identified in the databases, 33 were included in this review. From the meta-analysis results, it was found that multimorbidity, regardless of the country’s wealth, was linked to hospitalization in older adults (OR = 2.52, CI 95% = 1.87–3.38). Both definitions of multimorbidity, ≥2 (OR = 2.35, 95% CI = 1.34–4.12) and ≥3 morbidities (OR = 2.52, 95% CI = 1.87–3.38), were associated with hospitalization. Regardless of gender, multimorbidity was associated with hospitalization (OR = 1.98, 95% CI = 1.67–2.34) and with readmission (OR = 1.07, 95% CI = 1.04–1.09). However, it was not possible to verify the association between multimorbidity and length of stay.

Conclusions

Multimorbidity was linked to a higher hospitalization risk, and this risk was not affected by the country’s wealth and patient’s gender. Multimorbidity was also linked to a higher hospital readmission rate in older adults. PROSPERO Registration (Registration number: CRD42021229328).

The age-invariant role of resilience resources in emotional symptomatology

Objectives 1) To study the relationship between resilience resources (both social and individual) and emotional symptomatology (depression and anxiety symptoms), taking into account the potential indirect effects through perceived stress; 2) to investigate whether this network of relationships varies in different age groups.

METHOD

A sample of 718 Brazilians completed self-reports on perceived stress, depressive and anxious symptomatology, social support and individual resilience. The sample comprised two age groups: a sample of adults aged 60 or older (n = 361; 38.78% men; M_age = 67.32 years, SD_age = 5.76, range = 60-86), and a sample of younger adults (n = 357; 29.41% men; M_age = 41.37 years, SD_age = 7.23, range = 18-59). Multigroup multiple indicator, multiple cause (MIMIC) modelling was used to test for the direct and indirect effects of resilience resources on emotional symptom development, considering the age groups.

RESULTS

The relationship between individual resilience resources and depressive or anxiety symptomatology was found to take place exclusively through stressfulness appraisal. On the other hand, social resilience resources showed a direct and indirect effect on emotional symptoms. This pattern of relationships was found to be invariant across age groups.

CONCLUSION

Our findings suggest that both individual and social resilience resources are negatively related to both depressive and anxiety symptoms in adults regardless of age, thus opening the way to future research analysing how interventions may build resilience resources to minimise the influence of stressful and traumatic events across the lifespan.

Relationships between non-communicable disease, social isolation and frailty in community dwelling adults in later life: findings from the Hertfordshire Cohort Study

BACKGROUND

Social relationships play a fundamental role in individuals' lives and health, and social isolation is prevalent among older people. Chronic non-communicable diseases (NCDs) and frailty are also common in older adults.

AIMS

To examine the association between number of NCDs and social isolation in a cohort of community-dwelling older adults in the UK, and to consider whether any potential association is mediated by frailty.

METHODS

NCDs were self-reported by 176 older community-dwelling UK adults via questionnaire. Social isolation was assessed using the six-item Lubben Social Network Scale. Frailty was assessed by the Fried phenotype of physical frailty.

RESULTS

The median (IQR) age of participants in this study was 83.1 (81.5-85.5) years for men and 83.8 (81.5-85.9) years for women. The proportion of socially isolated individuals was 19% in men and 20% in women. More women (18%) than men (13%) were identified as frail. The number of NCDs was associated with higher odds of being isolated in women (unadjusted odds ratio per additional NCD: 1.65, 95% CI 1.08, 2.52, p = 0.021), but not in men, and the association remained robust to adjustment, even when accounting for frailty (OR 1.85, 95% CI 1.06, 3.22, p = 0.031).

DISCUSSION

Number of self-reported NCDs was associated with higher odds of social isolation in women but not in men, and the association remained after considering frailty status.

CONCLUSIONS

Our observations may be considered by healthcare professionals caring for community-dwelling older adults with multiple NCDs, where enquiring about social isolation as part of a comprehensive assessment may be important.

Age and sex trends in depressive symptoms across middle and older adulthood: Comparison of the Canadian Longitudinal Study on Aging to American and European cohorts

BACKGROUND

The literature suggests depressive symptoms differ in a non-linear fashion across adulthood and are more commonly reported in women as compared to men. Whether these trends are observed across countries in population-based cohorts is unclear.

METHODS

Cross-sectional observational study of approximately 138,000 women and men between the ages of 45 and 95 from three population-based cohorts representing Canadian, European, and American populations. Age, gender, educational attainment and annual income were assessed in each cohort. Depressive symptoms were assessed by the Center for Epidemiological Studies Depression Scale in the US and Canadian cohorts, and by the EURO-D in the European cohort.

RESULTS

Across all three cohorts, non-linear age trends and gender differences were observed in the report of depressive symptoms, independent from educational attainment and annual income effects. The non-linear age trends reflected a negative association between depressive symptoms and age during midlife and then a positive association in late life. Females reported greater depressive symptoms than males; however, an interaction between gender and age was also observed in the Canadian and European cohorts. Among Canadians, the gender differences were largest after age 70, whereas among Europeans, gender differences where largest among those approximately aged 60.

LIMITATIONS

Limitations include: 1) the cross-sectional nature of the study, resulting in age differences potentially reflecting cohort effects rather than a developmental process; and 2) the use of different depressive symptoms measures across cohorts.

CONCLUSIONS

Characterization of depressive symptoms over mid and late adulthood in women and men provides insights into potential focal points for intervention and allocation of resources.

A Study of Social Isolation, Multimorbidity and Multiple Role Demands Among Middle-Age Adults Based on the Canadian Longitudinal Study on Aging

Given the increasing complexity and fluidity of parenting, caregiving, and paid work patterns, in tandem with an increased risk of multimorbidity in mid-life, this study examines the relationship between these three concurrent roles and social isolation among middle-aged persons across multimorbidity statuses. Drawing upon life course theory, we applied linear mixed models to analyze 29,847 middle-aged participants from two waves of the Canadian Longitudinal Study on Aging. Findings reveal that participants experience greater social isolation over time, albeit the difference is extremely small. Among participants without multimorbidity, holding multiple roles is associated with lower social isolation. For those with multimorbidity, being employed full-time and providing intensive care are associated with social isolation. The occurrence of multiple roles demonstrates unique associations with social isolation among those with and without multimorbidity over time. Future research should study multimorbidity as a salient contextual variable. Moreover, enhanced support is needed for multimorbid middle-aged individuals with different role demands.

How do multimorbidity and lifestyle factors impact the perceived health of adults with intellectual disabilities?

BACKGROUND

Adults with intellectual disability (ID) have poorer physical and perceived health than the general population. Knowledge of perceived health predictors is both limited and important for guiding the development of preventive actions. The aims of this study were to investigate (1) the associations between perceived health and demographics, degree of ID, physical health conditions, and weight and physical activity level and (2) lifestyle factors and multimorbidity as predictors for perceived health adjusted for age, gender, and level of ID.

METHOD

The North Health in Intellectual Disability study is a community based cross-sectional survey. The POMONA-15 health indicators were used. Univariate and multivariate logistic regression analyses with poor versus good health as the dependent variable were applied.

RESULTS

The sample included 214 adults with a mean age 36.1 (SD 13.8) years; 56% were men, and 27% reported perceiving their health as poor. In univariate analyses, there were significant associations between poor health ratings and female gender, lower motor function, number of physical health conditions and several indicators of levels of physical activity. In the final adjusted model, female gender [odds ratio (OR) 2.4, P < 0.05], level of ID (OR 0.65, P < 0.05), numbers of physical health conditions (OR 1.6, P < 0.001) and lower motor function (OR 1.5 P < 0.05) were significant explanatory variables for poor perceived health, with a tendency to independently impact failure to achieve 30 min of physical activity daily (OR 2.0, P = 0.07).

CONCLUSION

Adults with ID with female gender, reduced motor function and more physical health conditions are at increased risk of lower perceived health and should be given attention in health promoting interventions. A lack of physical activity tends to negatively influence perceived health.

Examine the association between key determinants identified by the chronic disease indicator framework and multimorbidity by rural and urban settings

Background

Multimorbidity, often defined as having two or more chronic conditions is a global phenomenon. This study examined the association between key determinants identified by the chronic disease indicator framework and multimorbidity by rural and urban settings. The prevalence of individual diseases was also investigated by age and sex.

Methods

The Canada Community Health Survey and linked health administrative databases were used to examine the association between multimorbidity, sociodemographic, behavioral, and other risk factors in the province of Ontario. A multivariable logistic regression model was used to conduct the main analysis.

Results

Analyses were stratified by age (20-64 and 65-95) and area of residence (rural and urban). A total sample of n = 174,938 residents between the ages of 20-95 were examined in the Ontario province, of which 18.2% (n = 31,896) were multimorbid with 2 chronic conditions, and 23.4% (n = 40,883) with 3+ chronic conditions. Females had a higher prevalence of 2 conditions (17.9% versus 14.6%) and 3+ conditions (19.7% vs. 15.6%) relative to males. Out of all examined variables, poor self-perception of health, age, Body Mass Index, and income were most significantly associated with multimorbidity. Smoking was a significant risk factor in urban settings but not rural, while drinking was significant in rural and not urban settings. Income inequality was associated with multimorbidity with greater magnitude in rural areas. Prevalence of multimorbidity and having three or more chronic conditions were highest among low-income populations.

Conclusion

Interventions targeting population weight, age/sex specific disease burdens, and additional focus on stable income are encouraged.

Impact of neighbourhood walkability on the onset of multimorbidity: a cohort study

Multimorbidity has become highly prevalent around the globe and been associated with adverse health outcomes and cost of care. The built environment has become an important dimension in response to obesity and associated chronic diseases by addressing population sedentariness and low physical activity.

OBJECTIVE

The aim of the following study was to examine whether there was an increased risk for multimorbidity for those living in less walkable neighbourhoods. It was hypothesised that participants residing in less walkable neighbourhoods would have a higher risk for multimorbidity.

SETTING

City of Toronto and 14 neighbouring regions/municipalities within Ontario, Canada.

PARTICIPANTS

Study participants who had completed the Canadian Community Health Survey between the year 2000 and 2012, between 20 and 64 and 65 and 95 years of age, residing within a neighbourhood captured in the Walkability Index, and who were not multimorbid at the time of interview, were selected.

INTERVENTION

The Walkability Index was the key exposure in the study, which is divided into quintiles (1-least, 5-most walkable neighbourhoods). Participants were retrospectively allocated to one of five quintiles based on their area of residency (at the time of interview) and followed for a maximum of 16 years.

PRIMARY OUTCOME MEASURE

Becoming multimorbid with two chronic conditions.

SECONDARY OUTCOME MEASURE

Becoming multimorbid with three chronic conditions.

RESULTS

Risk for multimorbidity (two chronic conditions) was highest in least compared with most walkable neighbourhoods with an HR of 1.14 (95% CI: 1.02 to 1.28, p=0.0230). While results showed an overall gradient response between decreased walkability and increased risk for multimorbidity, they were not statistically significant across all quintiles or in the older-adult cohort (65-95 years of age).

CONCLUSION

Study results seem to suggest that low neighbourhood walkability may be a risk factor for multimorbidity over time. More studies are needed to examine whether neighbourhood walkability is a potential solution for multimorbidity prevention at the population level.

Utilization Rates of Pancreatectomy, Radical Prostatectomy, and Nephrectomy in New York, Ontario, and New South Wales, 2011 to 2018

Importance

Few studies have compared surgical utilization between countries or how rates may differ according to patients' socioeconomic status.

Objective

To compare population-level utilization of 3 common nonemergent surgical procedures in New York State (US), Ontario (Canada), and New South Wales (Australia) and how utilization differs for residents of lower- and higher-income neighborhoods.

Design, Setting, and Participants

This cohort study included all adults aged 18 years and older who were hospitalized for pancreatectomy, radical prostatectomy, or nephrectomy between 2011 and 2016 in New York, between 2011 and 2018 in Ontario, and between 2013 and 2018 in New South Wales. Each patient's address of residence was linked to 2016 census data to ascertain neighborhood income. Data were analyzed from August 2019 to November 2020.

Main Outcomes and Measures

Primary outcomes were (1) each jurisdiction's per capita age- and sex-standardized utilization rates (procedures per 100 000 residents per year) for each surgery and (2) utilization rates among residents of lower- and higher-income neighborhoods.

Results

This study included 115 428 surgical patients (25 780 [22.3%] women); 5717, 21 752, and 24 617 patients in New York were hospitalized for pancreatectomy, radical prostatectomy, and nephrectomy, respectively; 4929, 19 125, and 16 916 patients in Ontario, respectively; and 2069, 13 499, and 6804 patients in New South Wales, respectively. Patients in New South Wales were older for all procedures (eg, radical prostatectomy, mean [SD] age in New South Wales, 64.8 [7.3] years; in New York, 62.7 [8.4] years; in Ontario, 62.8 [6.7] years; P < .001); patients in New York were more likely than those in other locations to be women for pancreatectomy (New York: 2926 [51.2%]; Ontario: 2372 [48.1%]; New South Wales, 1003 [48.5%]; P = .004) and nephrectomy (New York: 10 645 [43.2%]; Ontario: 6529 [38.6%]; 2605 [38.3%]; P < .001). With the exception of nephrectomy in Ontario, there was a higher annual utilization rate for all procedures in all jurisdictions among patients residing in affluent neighborhoods (quintile 5) compared with poorer neighborhoods (quintile 1). This difference was largest in New South Wales for pancreatectomy (4.65 additional procedures per 100 000 residents [SE, 0.28]; P < .001) and radical prostatectomy (73.46 additional procedures per 100 000 residents [SE, 1.20]; P < .001); largest in New York for nephrectomy (8.43 additional procedures per 100 000 residents [SE, 0.85]; P < .001) and smallest in New York for radical prostatectomy (19.70 additional procedures per 100 000 residents [SE, 2.63]; P < .001); and smallest in Ontario for pancreatectomy (1.15 additional procedures per 100 000 residents [SE, 0.28]; P < .001) and nephrectomy (-1.10 additional procedures per 100 000 residents [SE, 0.52]; P < .001). New York had the highest utilization of nephrectomy (28.93 procedures per 100 000 residents per year [SE, 0.18]) and New South Wales for had the highest utilization of pancreatectomy and radical prostatectomy (6.94 procedures per 100 000 residents per year [SE, 0.15] and 94.37 procedures per 100 000 residents per year [SE, 0.81], respectively; all P < .001). Utilization was lowest in Ontario for all procedures (pancreatectomy, 6.18 procedures per 100 000 residents per year [SE, 0.09]; radical prostatectomy, 49.24 procedures per 100 000 residents per year [SE, 0.36]; nephrectomy, 21.40 procedures per 100 000 residents per year [SE, 0.16]; all P < .001).

Conclusions and Relevance

In this study, New York and New South Wales had higher per capita surgical utilization and larger neighborhood income-utilization gradients than Ontario. These findings suggest that income-based disparities are larger in the United States and Australia and smaller in Canada and highlight trade-offs inherent in the health care systems of different countries.

Multimorbidity, Loneliness, and Social Isolation. A Systematic Review

No systematic review has appeared so far synthesizing the evidence regarding multimorbidity and loneliness, social isolation, or social frailty. Consequently, our aim was to fill this gap. Three electronic databases (PubMed, PsycINFO, and CINAHL) were searched in our study. Observational studies examining the link between multimorbidity and loneliness, social isolation, and social frailty were included, whereas disease-specific samples were excluded. Data extraction included methods, characteristics of the sample, and the main results. A quality assessment was conducted. Two reviewers performed the study selection, data extraction, and quality assessment. In sum, eight studies were included in the final synthesis. Some cross-sectional and longitudinal studies point to an association between multimorbidity and increased levels of loneliness. However, the associations between multimorbidity and social isolation as well as social frailty remain largely underexplored. The quality of the studies included was rather high. In conclusion, most of the included studies showed a link between multimorbidity and increased loneliness. However, there is a lack of studies examining the association between multimorbidity and social isolation as well as social frailty. Future studies are required to shed light on these important associations. This is particularly important in times of the COVID-19 pandemic.

Patterns of Service Provision in Older People's Mental Health Care in Australia

Australia has a population of around 4 million people aged 65 years and over, many of whom are at risk of developing cognitive decline, mental illness, and/or psychological problems associated with physical illnesses. The aim of this study was to describe the pattern of specialised mental healthcare provision (availability, placement capacity, balance of care and diversity) for this age group in urban and rural health districts in Australia. The Description and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC) tool was used in nine urban and two rural health districts of the thirty-one Primary Health Networks across Australia. For the most part service provision was limited to hospital and outpatient care across all study areas. The latter was mainly restricted to health-related outpatient care, and there was a relative lack of social outpatient care. While both acute and non-acute hospital care were available in urban areas, in rural areas hospital care was limited to acute care. Limited access to comprehensive mental health care, and the uniformity in provision across areas in spite of differences in demographic, socioeconomic and health characteristics raises issues of equity in regard to psychogeriatric care in this country. Comparing patterns of mental health service provision across the age span using the same classification method allows for a better understanding of care provision and gap analysis for evidence-informed policy.

Validation of the SPF-Q, an instrument to assess the quality of production functions to achieve well-being, among multimorbid patients

BACKGROUND

In a time of ageing populations, examination of the ability of multimorbid patients to achieve well-being has become increasingly important. Social production function theory is used to characterise people's ability to achieve well-being. Whereas much research has examined the fulfilment of substantive needs, far less research has investigated the quality of production functions (being in control, avoiding a loss frame, and efficiency) to achieve well-being. Therefore, this study involved the development and validation of the Social Production Function-Quality of production functions (SPF-Q) instrument to assess the quality of production functions via the fulfilment of production needs to achieve well-being.

METHODS

The 12-item SPF-Q was used to assess the quality of production functions via the fulfilment of production needs to achieve well-being among patients with multimorbidity from seven health care practices in the region of Tilburg, the Netherlands. A total of 216 patients filled in the questionnaire (55% response rate). To test the validity of the SPF-Q, we used structural equation modelling to specify a measurement model by loading each item on its respective latent factor, and we examined associations between production needs and other measures.

RESULTS

Psychometric results clearly showed that the SPF-Q is a valid and reliable instrument for the assessment of the quality of production functions among multimorbid patients. Confirmatory factor analyses revealed good indices of fit for the instrument. As indicated by the high reliability coefficient, the scale also showed good internal consistency. We found support for construct validity through significant positive correlations between substantive and production well-being needs, as well as with overall well-being and life satisfaction. Moreover, production needs added to multimorbid patients' overall level of well-being in addition to the substantive needs.

CONCLUSION

This study clearly showed that the SPF-Q is a valid and reliable instrument for the assessment of production needs among multimorbid patients. Given that multimorbidity is becoming the leading threat to population health, such an instrument can help to improve the ability to achieve well-being in this vulnerable population.

Morbidades e associações com autoavaliação de saúde e capacidade funcional em idosos

Resumo Objetivos investigar a relação entre número de doenças crônicas e autoavaliação de saúde/capacidade funcional em relação a sexo e diferentes níveis educacionais. Métodos foi realizado um estudo transversal com 419 idosos que haviam participado do estudo FIBRA, o qual investiga fragilidade em indivíduos idosos. Foram avaliadas variáveis sociodemográficas, doenças crônicas não transmissíveis, autoavaliação de saúde e capacidade funcional. Foi utilizado o teste qui-quadrado ou exato de Fisher para testar as associações entre número de doenças e autoavaliação de saúde e capacidade funcional, com nível de significância de 5%. Resultados A autoavaliação de saúde negativa foi significativamente associada com número de doenças crônicas na amostra geral, no sexo feminino e em ambas as categorias de escolaridade. Por outro lado, relatar dependência parcial ou total para realizar uma ou mais atividades instrumentais de vida diária (AIVDs) apresentou associação significativa para número de doenças crônicas na amostra completa, sexo feminino e 0 a 4 anos de escolaridade. Conclusão as doenças crônicas possuem um impacto negativo na autoavaliação de saúde, especialmente em mulheres e em relação aos anos de escolaridade; e na dependência funcional para AIVDs, especialmente em mulheres e pessoas com 0 a 4 anos de escolaridade.

The association of multimorbidity, loneliness, social exclusion and network size: findings from the population-based German Ageing Survey

BACKGROUND

The aim of this study was to examine the association between multimorbidity and (i) loneliness, (ii) social exclusion and (iii) network size, respectively.

METHODS

Cross-sectional data from a German representative sample of community-dwelling adults aged 40 and over was used (N = 7604). Multimorbidity was indicated with the presence of two or more diseases. Self-rated loneliness was assessed with a short form of the validated De Jong Gierveld Loneliness Scale and social exclusion was measured with a validated scale developed by Bude and Lantermann. Counts of important people in regular contact represented the network size of respondents.

RESULTS

Multimorbidity was present in 68% of the sample. While controlling for potential confounders, multiple linear regression analysis yielded that multimorbidity was associated with increased loneliness (b = 0.08; p < 0.001) and increased social exclusion (b = 0.10; p < 0.01). Multimorbidity was also associated with an increased network size (b = 0.27; p < 0.001).

CONCLUSION

While there was an association between multimorbidity and increased social exclusion as well as increased loneliness, regressions also revealed an association between multimorbidity and an increased network size. Although the association between multimorbidity and our outcome measures is weak, its complex nature should be investigated further using a longitudinal approach.

The longitudinal association of multimorbidity on loneliness and network size: Findings from a population-based study

OBJECTIVE

The aim of this study was to investigate the association between the onset of multimorbidity with loneliness and social network size longitudinally.

METHODS

Longitudinal data was used from the German Ageing Survey, a representative sample of adults aged 40 and over, residing in private households. The presence of two or more illnesses indicated multimorbidity. A 6-item version of the validated De Jong Gierveld Loneliness scale was used to assess perceived loneliness. The network size of respondents was represented by counts of important people in regular contact. Fixed-effects regressions adjusted for time-varying socio-demographic, life style, and health-related variables were used.

RESULTS

The regression analysis yielded, when controlling for possible confounders, that the onset of multimorbidity led to increased loneliness (β = .06, p < .001). However, the results revealed as well that the onset of multimorbidity was associated with an increased network size (β = .29, p < .001).

CONCLUSION

Results demonstrate a complex relationship of the variables examined. Efforts to target multimorbidity, eg, to postpone or prevent it, could be helpful to decrease loneliness.

Tramadol prescribed use in general and chronic noncancer pain: a nationwide register-based cohort study of all patients above 16 years

Background and aims

In the Western world, it has become clear that we are facing a crisis of overuse, abuse and improperly prescribed use of opioids. As part of the ongoing discussion on opioid use, the use and prescription of tramadol have been addressed in recent years. A significant portion of this discussion should adequately address the risk factors for the use of weak opioid products such as tramadol. The risk factors which characterise the long-term tramadol use are still incompletely understood. Thus, we aimed to describe the characteristics of Danish patients using tramadol in more detail, under different scenarios and determinants of subsequent usage patterns.

Methods

We conducted a nationwide cohort study to identify individuals purchasing tramadol from 01/01/2004 to 31/12/2015 who are age 16 +  years old by using data from The Danish National Databases; these databases consist of unique information for all citizens in Denmark. Logistic regression analyses were used to assess the potential risk factors for repeated tramadol use.

Results

The final cancer-free cohort consisted of N = 941,839 tramadol users: 54.4% women, with a mean age of 53.2 years. The number of chronic noncancer pain (CNCP) was 430,641 individuals, and 56% of the total third who repeated the use of tramadol with two +  purchased prescriptions were CNCP patients. The increased risk of repeated use for CNCP was, among others, associated with: male sex (HR 1.21), age 69–110 (HR 1.72), back/spine pain men (HR 1.47), women (HR 1.46), spondylopathies (HR 1.24), male osteoporosis (HR 1.22), multimorbid ulcer/skin (HR 1.28), region of municipality Northern Jutland (HR 1.74), Central Jutland (HR 1.75), number of co-medication 4–9 (HR 1.33), dementia (HR 1.27). Factors associated with decreased risk: co-medication ischemic heart disease (HR 0.85), diagnosis headache (HR 0.70), household income highest tertile (HR 0.81), unknown (HR 0.70), single women (HR 0.96).

Conclusions

This study proved a widespread prescribed use of tramadol in Denmark, and, as know from the literature, weak opioid use may lead to long-term use of high potent opioids, this usage is inappropriate, in general, but especially for the treatment of CNCP.

Implications

When striving to reduce the overuse of opioids, focus on the extensive use of tramadol may be essential. The current study indicates an excessive and not appropriately prescribed use of tramadol among Danish CNCP patients. In addition to being inappropriate, such use may also have an impact on the growing problem of an illicit Internet market for this drug. Thus, the situation must be taken seriously. The current study confirms the recent clinical guideline and the National Recommendations in Denmark, which emphasises the risks of problematic use of tramadol. The research may also be relevant in other comparable countries. Caution must especially be taken with CNCP patients with comorbidities like diabetes, lung disease, dementia, and osteoporosis.

Prevalence and patterns of multimorbidity among the elderly in China: a cross-sectional study using national survey data

OBJECTIVES

Examination of the prevalence and patterns of multimorbidity among the elderly in China.

DESIGN

Cross-sectional study.

SETTING

More than 10 000 households in 28 of the 34 provinces of mainland China.

PARTICIPANTS

11 707 Chinese adults aged 60 and over.

PRIMARY OUTCOME MEASURES

Prevalence and patterns of multimorbidity among the participants. Relative risks were calculated to estimate the probability of up to 14 chronic conditions coexisting with each other. Observed-to-expected (O/E) ratios were used to analyse the patterns of multimorbidity.

RESULTS

Multimorbidity was present in 43.6% of respondents from the sample population, with women having the greater prevalence compared with men. There were 804 different comorbidity combinations identified, including 76 dyad combinations and 169 triad combinations. The top 10 morbidity dyads and triads accounted for 69.01% and 47.05% of the total dyad and triad combinations observed, respectively. Among the 14 chronic conditions included in the study, asthma, stroke, heart attack and six other chronic conditions were the main components of multimorbidity due to their high relative risk ratios. The most frequently occurring clusters with higher O/E ratios were stroke along with emotional, nervous, or psychiatric problems; memory-related diseases together emotional, nervous, or psychiatric problems; and memory-related diseases and asthma accompanied by chronic lung diseases and asthma.

CONCLUSIONS

The results of this study highlight the high prevalence of multimorbidity in the elderly population in China. Further studies are required to understand the aetiology of multimorbidity, and future primary healthcare policies should be made while taking multimorbidity into consideration.

Measurement instruments for quantifying physical resilience in aging: a scoping review protocol

BACKGROUND

Physical resilience is the ability to optimize or recover motor function in the face of disease, injury, or aging-related decline. Greater knowledge of how some individuals regain or maintain function despite pathology may help identify protective factors and approaches that promote healthy aging. To date, a scoping review on physical resilience has not been conducted. The aims are to (1) identify measurement instruments for physical resilience, (2) synthesize and map the key concepts of physical resilience, and (3) identify gaps and make recommendations for future research.

METHODS

A scoping review of Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Medline Ovid, PsycINFO, and AgeLine databases will take place using the search strategy "resilience" AND (aging OR elderly OR older adult). The initial electronic search will be supplemented by hand searching the reference lists and review articles to identify any missing studies. Two parallel independent assessments of study eligibility will be conducted for the title, abstract, and full-text screens. To meet study inclusion criteria, the term "resilience" must be applied in relation to the physical health of older adults. Any disagreement will be resolved by consensus and a third reviewer consulted to make a decision if consensus is not achieved initially. Physical resilience information to be extracted are measurement instruments that describe the core domains of (1) body function or structure (signs or symptoms, etc.), (2) activity and participation (quality of life, etc.), and (3) societal impact. Tables and/or charts will map the data with distribution of studies by core domains. Finally, the amalgamation of results will be an iterative process whereby reviewers will refine the plan for presenting results after data extraction is completed so that all of the contents of the extraction may be included in the results.

DISCUSSION

The information gleaned in this scoping review will be essential to understand how physical resilience is currently measured and identify gaps for further research.

Development and validation of a multi-domain multimorbidity resilience index for an older population: results from the baseline Canadian Longitudinal Study on Aging

Background

Multimorbidity is recognized as a major public health issue that increases with age and affects approximately two-thirds of older people in Canada, the US, Australia and many European countries. This study develops and tests a three domain (functional, social and psychological) multimorbidity resilience composite index based on a previously developed lifecourse model of multimorbidity resilience, incorporating measures of adversity and positive adaptation. The criterion validity of the measure is demonstrated by means of an analysis of key outcome variables drawn from the literature.

Methods

We used the baseline data from the Comprehensive Cohort of the Canadian Longitudinal Study on Aging. Associations of functional, social, psychological as well as total resilience with two health utilization and three illness context outcome variables were examined using logistic regression analyses, adjusted for age, gender, marital status, income, education, region, and number of chronic conditions.

Results

The sample included all 6771 Canadian adults aged 65 or older (mean age 73.0, 57% women) who reported two or more of 27 possible chronic conditions. Total resilience was associated with: perceived health (OR = 1.68, CI 1.59–1.77); sleep quality (OR = 1.34, CI 1.30–1.38); perceived pain (OR = 0.80, CI 0.77–0.83); hospital overnight stays (OR = 0.87, CI 0.83–0.91); and emergency department visits (OR = 0.90, CI 0.87–0.94)., after adjusting for socio-demographic factors, and number of chronic conditions. These associations were similar for the unadjusted models, as well as for the functional, social and psychological resilience sub-indices.

Conclusions

Combining components of adversity and positive adaptation within functional, social and psychological domains produces a measure of multimorbidity resilience that is associated with more positive health outcomes. Several implications of a composite multimorbidity resilience measure for clinical practice are identified. This measure can be replicated using measures found in other secondary health data sets. Future validation using longitudinal data is warranted.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0851-y) contains supplementary material, which is available to authorized users.

Physical multimorbidity and loneliness: A population-based study

Multimorbidity has been linked to a variety of negative outcomes although as yet, there has been little research on its association with loneliness. This study examined the association between physical multimorbidity (≥ 2 physical diseases) and loneliness in the general population and its potential mediators. Data came from the Adult Psychiatric Morbidity Survey 2007 (N = 7403, aged ≥16 years). Information was obtained on 20 doctor diagnosed physical conditions that were present in the previous year. An item from the Social Functioning Questionnaire (SFQ) was used to obtain information on loneliness. Multivariable logistic regression analysis was used to examine associations. An increasing number of physical diseases was associated with higher odds for loneliness. Compared to no physical diseases, the odds ratio (OR) (95% confidence interval: CI) for loneliness increased from 1.34 (1.13–1.59) to 2.82 (2.11–3.78) between one and ≥5 physical diseases. This association was particularly strong in the youngest age group (i.e. 16–44 years). The loneliness-physical multimorbidity association was significantly mediated by stressful life events (% mediated 11.1%-30.5%), anxiety (30.2%), and depression (15.4%). Physical multimorbidity is associated with increased odds for loneliness. Prospective research is now needed to further elucidate this association and the factors that underlie it.