Multimorbidity in Community-Dwelling Older Adults in Beijing: Prevalence and Trends, 2004-2017

Age-specific Multimorbidity Patterns and Burden on All-Cause Mortality and Public Direct Medical Expenditure: A Retrospective Cohort Study

OBJECTIVE

To evaluate age-specific multimorbidity patterns and morbidity burden on mortality and healthcare expenditure across age groups.

PATIENTS AND METHODS

Retrospective observational study between January 1, 2009 to December 31, 2017 using electronic health records in Hong Kong: Individuals were stratified by age (< 50, 50-64, 65-79, ≥ 80), and sub-classified by number of morbidities (0, 1, 2, 3, ≥ 4) out of 21 common chronic conditions. Clustering analyses were conducted to identify specific patterns of multimorbidity. Association between the number as well as combinations of morbidities and all-cause mortality and public expenditure was examined.

RESULTS

4,562,832 individuals with a median follow-up of 7 years were included. Mental disorders were the top morbidities among young individuals, while cardiovascular diseases were prevalent in the elderly. An increased number of morbidities was associated with a greater relative risk for mortality and medical expenditure, and this relationship was stronger among younger patients. Compared to individuals in the same age group without morbidity, the hazard ratios (HR; 95% CI) of all-cause mortality in patients aged < 50 and ≥ 80 with two comorbidities 3.81 (3.60-4.03) and 1.38 (1.36-1.40), respectively, which increased to 14.22 (9.87-20.47) and 2.20 (2.13-2.26), respectively, as the number of morbidities increased to ≥ 4. The stroke-hypertension cluster was shown to be associated with the highest HR of mortality 2.48 (2.43-2.53) among all identified clusters arising from the clustering analysis.

CONCLUSION

Given the stronger association between multimorbidity and all-cause mortality and greater opportunity costs in younger populations, prevention and management of early-onset multimorbidity are warranted. (248 words).

Prevalence and patterns of multimorbidity in China during 2002-2022: A systematic review and meta-analysis

BACKGROUND

Multimorbidity is common, particularly among elderly people. Restructuring health service systems to better manage this public health issue requires knowledge regarding disease prevalence and patterns. We quantified the epidemiology characteristics of multimorbidity among adults in China to inform policy-making and resource allocation.

METHODS

We searched 10 databases for studies (January 2000-October 2023) reporting primary epidemiological multimorbidity data for adults in China. We included observational studies; we excluded duplicate publications and studies investigating a single comorbidity pattern, focused on specific population categories, using medical insurance reimbursement data, and with unclear/incomplete data. We assessed risk of bias using the STROBE checklist and estimated heterogeneity among studies. The prevalence was pooled using the random-effects method and sample size as weight.

FINDINGS

Of 13,998 records retrieved, 67 studies (30 in English, 37 in Chinese) were included. The prevalence (95% confidence interval) of multimorbidity was 25.4% (15.1%, 35.7%) among Chinese adults. Among 42 studies reporting age-specific prevalence, multimorbidity prevalence increased rapidly with age: 3.3% (0%, 15.2%) for age 18-29 years, 5.9% (0%, 12.9%) for 30-44 years, 17.6% (6.1%, 29.1%) for 45-59 years, 32.4% (16.1%, 48.7%) for 60-69 years, 38.5% (23.6%, 53.4%) for 70-79 years, and 40.2% (20.8%, 59.6%) for age ≥ 80 years. Overall prevalence of multimorbidity has increased in recent years, with regional disparity. The most common patterns included hypertension with hearing impairment (10.4% [95% CI: 4.3%, 16.5%]), dyslipidemia (8.9% [4.1%, 13.6%]), and diabetes (8.7% [3.7%, 13.8%]).

CONCLUSION

Multimorbidity was present nearly one in four Chinese adults, with hypertensive diseases and other comorbidities being the most-observed pattern; the prevalence increased rapidly with increased age. There is huge variation in the prevalence of multimorbidity across China. Coordinated, comprehensive strategies are urgently needed to control the ongoing impact of multimorbidity.

Incidence, prevalence and characteristics of multimorbidity in different age groups among urban hospitalized patients in China

The aim of the study was to investigate the incidence, prevalence and characteristics of multimorbidity in urban inpatients of different age groups. This study used data from the National Insurance Claim for Epidemiology Research (NICER) to calculate the overall incidence, prevalence, geographic and age distribution patterns, health care burden, and multimorbidity patterns for multimorbidity in 2017. According to our study, the overall prevalence of multimorbidity was 6.68%, and the overall prevalence was 14.87% in 2017. The prevalence of multimorbidity increases with age. The pattern of the geographic distribution of multimorbidity shows that the prevalence of multimorbidity is relatively high in South East China. The average annual health care expenditure of patients with multimorbidity increased with age and rose rapidly, especially among older patients. Patients with cancer and chronic kidney disease have higher treatment costs. Patients with hypertension or ischemic heart disease had a significantly higher relative risk of multimorbidity than other included noncommunicable diseases (NCDs). Hyperlipidemia has generated the highest number of association rules, which may suggest that hyperlipidemia may be both a risk factor for other NCDs and an outcome of them.

Healthcare for Older Adults with Multimorbidity: A Scoping Review of Reviews

Purpose

To summarize adverse healthcare outcomes experienced by older adults with multimorbidity and barriers perceived by stakeholders regarding the healthcare systems primarily designed to address individual health conditions. Healthcare elements that aim to provide coordinated, continuous, and comprehensive services for this population were also identified.

Patients and Methods

We applied the methodology framework developed by Arksey and O'Malley to guide the review. The three-step search strategy was used to identify relevant English reviews that focused on adverse healthcare outcomes and barriers encountered by older adults with multimorbidity and other stakeholders regarding the single-disease-focused healthcare systems, as well as those concentrated on healthcare elements that aim to provide coordinated, continuous, and comprehensive services for older adults with multimorbidity. Five electronic databases, including PubMed/Medline, CINAHL, Web of Science Core Collection, Cochrane Library, and Embase, were systematically searched from database inception to February 2022. A standardized table was used to extract data. Thematic analysis was then conducted under the guidance of the Rainbow Model of Integrated Care and the Chronic Care Model.

Results

Twenty reviews were included in this study. Therapeutic competitions, high healthcare service utilization, and high healthcare costs were three adverse healthcare outcomes experienced by patients. Both patients and healthcare professionals faced various barriers. Other stakeholders, including informal caregivers, healthcare managers, and policymakers, also perceived several barriers. Numerous healthcare elements were identified that may contribute to optimized services. The elements most frequently mentioned included the implementation of shared decision-making, comprehensive geriatric assessments, and individual care plans.

Conclusion

This study conducted a comprehensive overview of the current knowledge related to healthcare for older adults with multimorbidity. In the future, it is necessary to develop more coordinated, continuous, and comprehensive healthcare service delivery models based on the healthcare needs of older adults with multimorbidity and the specific characteristics of different countries.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

None.

Multimorbidity prevalence and patterns at the baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

Background

To identify multimorbidity patterns, by sex, according to sociodemographic and lifestyle in ELSA-Brasil.

Methods

Cross-sectional study with 14,516 participants from ELSA-Brasil (2008-2010). Fuzzy c-means was used to identify multimorbidity patterns of 2+ chronic morbidities, where the consequent morbidity had to occur in at least 5% of all cases. Association rule (O/E≥1.5) was used to identify co-occurrence of morbidities, in each cluster, by sociodemographic and lifestyle factors.

Results

The prevalence of multimorbidity was higher in women (73.7%) compared to men (65.3%). Among women, cluster 1 was characterized by hypertension/diabetes (13.2%); cluster 2 had no overrepresented morbidity; and cluster 3 all participants had kidney disease. Among men, cluster 1 was characterized by cirrhosis/hepatitis/obesity; cluster 2, most combinations included kidney disease/migraine (6.6%); cluster 3, no pattern reached association ratio; cluster 4 predominated co-occurrence of hypertension/rheumatic fever, and hypertension/dyslipidemia; cluster 5 predominated diabetes and obesity, and combinations with hypertension (8.8%); and cluster 6 presented combinations of diabetes/hypertension/heart attack/angina/heart failure. Clusters were characterized by higher prevalence of adults, married and participants with university degrees.

Conclusion

Hypertension/diabetes/obesity were highly co-occurred, in both sexes. Yet, for men, morbidities like cirrhosis/hepatitis were commonly clustered with obesity and diabetes; and kidney disease was commonly clustered with migraine and common mental disorders. The study advances in understanding multimorbidity patterns, benefiting simultaneously or gradually prevention of diseases and multidisciplinary care responses.

Prevalence of Non-Communicable Diseases and Its Associated Factors Among Urban Elderly of Six Indian States

Aims The aim of this study is to investigate the prevalence, impact of health determinants on non-communicable diseases (NCDs), and multimorbidity among urban elderly in India. Methods This is a cross-sectional study involving a total of 1,671 (870 male and 801 female) respondents aged 60-80 years. Multistage sampling was used for the recruitment of the participants. A total of 12 sample areas from 12 cities of six southern states of south India were selected. Through survey form, information regarding demographic characteristics, health-influencing lifestyle factors, and history of nine NCDs was collected. Results The mean age of participants was 68.5 ± 6.01 years.. The prevalence of hypertension was 40.4%, followed by diabetes (31.2%), arthritis (22.1%), sensory impairment (10.1%), heart diseases (7.8%), and dyslipidemia (7.0%). 74.1% of participants had at least one morbidity, and 40.0% of people had multimorbidity. Being overweight is the highest risk health determinant for hypertension, diabetes, heart disease, high cholesterol, stroke, and joint pain. Obese people have 64% more risk of hypertension than people with normal BMI. People with disturbed sleep have increased risk of hypertension, high cholesterol, and joint pain by more than 80% compared to people with proper sleep. Among the modifiable health determinants of obesity, disturbed sleep, constipation, and physical activity up to 30 minutes were positively associated with multimorbidity. Those in the age group of 70 to 80 years have a high risk for NCDs and multimorbidity compared to those in the age group of 60 to 70 years. Conclusions A healthy lifestyle is necessary to reduce the burden of NCDs among the elderly. Developing holistic health policies seems an urgent need.

Differences by Sex in the Presentation of Multimorbidity: Longitudinal Study in Mexican Adults Living in the Community, 2001-2018

Background: Multimorbidity represents a challenge for public health because as populations age, its prevalence increases. The objectives were to describe by sex the multimorbidity patterns from 2001 to 2018 in a cohort of people ≥50 years and in a subcohort with multimorbidity to describe the trajectories and transitions. Materials and Methods: Secondary analysis of the cohort of adults ≥50 years in the Mexican Health and Aging Study. Sociodemographic, health, functionality, and mortality were analyzed. Descriptive analysis was performed, estimation of prevalence by sex and trajectories, and transitions of the multimorbidity patterns with alluvial diagrams. Results: In the full cohort, 53.3% were women and in the subcohort with multimorbidity 66.1%. In both sexes, more cases with multimorbidity were observed among people without schooling, without a job, with a fair or bad economic situation, and with fair or bad self-perception of their health. The chronic diseases (CDs) with the highest prevalence were diabetes mellitus (DM), hypertension (HT), and arthritis and the most prevalent multimorbidity patterns were HT+arthritis and DM+HT. Higher proportion of men transited early to death and the women to other patterns more complex. Conclusion: Women always had higher prevalence of multimorbidity from an early age and with more complex combinations of CDs, but men with multimorbidity died prematurely. It is important to analyze multimorbidity not only from a biological approach but also from a perspective that considers sex inequalities and allows for the development of specific interventions adapted to the particular needs of men and women.

Physical multimorbidity and psychological distress among Chinese older adults: Findings from Chinese Longitudinal Healthy Longevity Survey

BACKGROUND

Research has linked multimorbidity with psychological distress among people with multimorbidity but the available findings are inconsistent. This study was to investigate the prevalence of multimorbidity and incidence of psychological distress in a nationally representative sample of Chinese older adults and examine the association between multimorbidity and psychological distress in this population.

METHODS

This study was a cross-sectional, secondary analysis using data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Participants' socio-demographic characteristics and clinical information were obtained. Psychological distress including anxiety and depression were assessed by the Generalized Anxiety Disorder-7 (GAD-7) and the Center for Epidemiologic Studies Depression Scale (10-item CES-D). Binary logistic regression was used to ascertain the association between multimorbidity and psychological distress with covariates adjustment.

RESULTS

Compared with those without physical chronic conditions, having five or more physical chronic conditions was associated with the likelihood of depression after covariates adjustment.

CONCLUSION

Psychological distress is a common health issue among Chinese older adults with multimorbidity. Having multimorbidity might not be associated with psychological distress represented by anxiety and depression. Management of multimorbidity among this population would benefit from more attention on the mental health domain.

Developing and validating a Chinese multimorbidity-weighted index for middle-aged and older community-dwelling individuals

OBJECTIVE

To develop and validate an index to quantify the multimorbidity burden in Chinese middle-aged and older community-dwelling individuals.

METHODS

We included 20,035 individuals aged 45 and older from the China Health and Retirement Longitudinal Study (CHARLS) and 19,297 individuals aged 65 and older from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Health outcomes of physical functioning (PF), basic and instrumental activities of daily living (ADL and IADL) and mortality were obtained. Based on self-reported disease status, we calculated five commonly used western multimorbidity indexes for CHARLS baseline participants. The one that predicted the health outcomes the best was selected and then modified through a linear mixed model using the repeated individual data in CHARLS. The performance of the modified index was internally and externally evaluated with CHARLS and CLHLS data.

RESULTS

The multimorbidity-weighted index (MWI) performed the best among the five indexes. In the modified Chinese multimorbidity-weighted index (CMWI), the weights of the diseases varied greatly (range 0.2-5.1). The top three diseases with the highest impact were stroke, memory-related diseases and cancer, corresponding to weights of 5.1, 4.3 and 3.4, respectively. Compared with the MWI, the CMWI showed better model fits for PF and IADL with larger R2 and smaller Akaike information criterion, and comparable prediction performances for ADL, IADL and mortality (e.g. the same predictive accuracy of 0.80 for ADL disability).

CONCLUSION

The CMWI is an adequate index to quantify the multimorbidity burden for Chinese middle-aged and older community-dwelling individuals. It can be directly computed via disease status examined in regular community health check-ups to facilitate health management.

Spatiotemporal Analysis of the Prevalence and Pattern of Multimorbidity in Older Chinese Adults

Background

Multimorbidity presents an enormous problem to societal and healthcare utilization under the context of aging population in low- and middle-income countries (LMICs). Currently, systematic studies on the profile of multimorbidity and its characteristics among Chinese elderly are lacking. We described the temporal and spatial trends in the prevalence of multimorbidity and explored chronological changes of comorbidity patterns in a large elderly population survey.

Methods

Data were extracted from the Chinese Longitudinal Healthy Longevity Study (CLHLS) conducted between 1998 and 2018 in a random selection of half of the counties and city districts. All the elderly aged 65 and older were included in the survey of eight waves. We used 13 investigated chronic diseases to measure the prevalence of multimorbidity by means of geography, subpopulation, and chronological changes. The patterns of multimorbidity were assessed by computing the value of relative risk (RR indicates the likelihood of certain diseases to be associated with multimorbidity) and the observed-to-expected ratio (O/E indicates the likelihood of the coexistence of a multimorbidity combination).

Results

From 1998 to 2018, the prevalence of multimorbidity went from 15.60 to 30.76%, increasing in the fluctuation across the survey of eight waves (p_{for trend} = 0.020). Increasing trends were observed similarly in a different gender group (p_male = 0.009; p_female = 0.004) and age groups among female participants (p_~80 = 0.009; p₈₁₋₉₀ = 0.004; p₉₁₋₁₀₀ = 0.035; p_101~ = 0.018). The gap in the prevalence of multimorbidity between the north and the south was getting narrow across the survey of eight waves. Hypertension was the highest prevalent chronic condition while diabetes was most likely to coexist with other chronic conditions in the CLHLS survey. The most frequently occurring clusters were hypertension and heart disease, hypertension and cataract, and hypertension and chronic lung disease. And, the cancer, TB, and Parkinson's disease cluster took the domination of O/E rankings over time, which had a higher probability of coexistence in all the multimorbidity combinations.

Conclusions

The prevalence of multimorbidity has been increasing nationwide, and more attention should be paid to a rapid growth in the southern part of China. It demands the effective diagnosis and treatment adopted to the highly prevalent comorbidities, and strategies and measures were adjusted to strongly relevant clusters.

Intrinsic Capacity vs. Multimorbidity: A Function-Centered Construct Predicts Disability Better Than a Disease-Based Approach in a Community-Dwelling Older Population Cohort

Objective: This study aimed to assess the status of intrinsic capacity (IC)—a novel function-centered construct proposed by the WHO and examine whether impairment in IC predicts subsequent 1-year activities of daily living (ADL) disability better than a disease-based approach, i. e., multimorbidity status.

Methods: This study included data of community-dwelling older adults from the Beijing Longitudinal Study on Aging II aged 65 years or older who were followed up at 1 year. Multivariate logistic regressions were performed to estimate the odds of ADL disability at baseline and 1-year follow-up.

Results: A total of 7,298 older participants aged 65 years or older were included in the current study. About 4,742 older adults were followed up at 1 year. At baseline, subjects with a higher impairment in IC domains showed higher odds of ADL disability [adj. odds ratio (OR) = 9.51 for impairment in ≥3 domains, area under the curve (AUC) = 0.751] compared to much lower odds of ADL disability in subjects with a higher number (≥3) of chronic diseases (adj. OR 3.92, AUC = 0.712). At 1-year follow-up, the overall incidence of ADL disability increased with the impairment in IC domains higher than the increase in multimorbidity status. A higher impairment in IC domains showed higher odds of incidence ADL disability for impairment in 2 or ≥3 IC domains (adj. OR 2.32 for impairment in ≥3 domains, adj. OR 1.43 for impairment in two domains, AUC = 0.685). Only subjects who had ≥3 chronic diseases had higher odds of 1-year incident ADL disability (adj. OR 1.73, AUC = 0.681) that was statistically significant.

Conclusion: Our results imply that a function-centered construct could have higher predictability of disability compared to the multimorbidity status in community older people. Our results need to be confirmed by studies with longer follow-up.