Multimorbidity patterns and associations with functional limitations among an aging population in prison

Interactions between patterns of multimorbidity and functional status among hospitalized older patients: a novel approach using cluster analysis and association rule mining

BACKGROUND

Multimorbidity (MM) is generally defined as the presence of 2 or more chronic diseases in the same patient and seems to be frequently associated with frailty and poor quality of life. However, the complex interplay between MM and functional status in hospitalized older patients has not been fully elucidated so far. Here, we implemented a 2-step approach, combining cluster analysis and association rule mining to explore how patterns of MM and disease associations change as a function of disability.

METHODS

This retrospective cohort study included 3366 hospitalized older patients discharged from acute care units of Ancona and Cosenza sites of Italian National Institute on Aging (INRCA-IRCCS) between 2011 and 2017. Cluster analysis and association rule mining (ARM) were used to explore patterns of MM and disease associations in the whole population and after stratifying by dependency in activities of daily living (ADL) at discharge. Sensitivity analyses in men and women were conducted to test for robustness of study findings.

RESULTS

Out of 3366 included patients, 78% were multimorbid. According to functional status, 22.2% of patients had no disability in ADL (functionally independent group), 22.7% had 1 ADL dependency (mildly dependent group), and 57.4% 2 or more ADL impaired (moderately-severely dependent group). Two main MM clusters were identified in the whole general population and in single ADL groups. ARM revealed interesting within-cluster disease associations, characterized by high lift and confidence. Specifically, in the functionally independent group, the most significant ones involved atrial fibrillation (AF)-anemia and chronic kidney disease (CKD) (lift = 2.32), followed by coronary artery disease (CAD)-AF and heart failure (HF) (lift = 2.29); in patients with moderate-severe ADL disability, the most significant ARM involved CAD-HF and AF (lift = 1.97), thyroid dysfunction and AF (lift = 1.75), cerebrovascular disease (CVD)-CAD and AF (lift = 1.55), and hypertension-anemia and CKD (lift = 1.43).

CONCLUSIONS

Hospitalized older patients have high rates of MM and functional impairment. Combining cluster analysis to ARM may assist physicians in discovering unexpected disease associations in patients with different ADL status. This could be relevant in the view of individuating personalized diagnostic and therapeutic approaches, according to the modern principles of precision medicine.

A scoping review finds a growing trend in studies validating multimorbidity patterns and identifies five broad types of validation methods

OBJECTIVES

Multimorbidity, the presence of two or more long-term conditions, is a growing public health concern. Many studies use analytical methods to discover multimorbidity patterns from data. We aimed to review approaches used in published literature to validate these patterns.

STUDY DESIGN AND SETTING

We systematically searched PubMed and Web of Science for studies published between July 2017 and July 2023 that used analytical methods to discover multimorbidity patterns.

RESULTS

Out of 31,617 studies returned by the searches, 172 were included. Of these, 111 studies (64%) conducted validation, the number of studies with validation increased from 53.13% (17 out of 32 studies) to 71.25% (57 out of 80 studies) in 2017-2019 to 2022-2023, respectively. Five types of validation were identified: assessing the association of multimorbidity patterns with clinical outcomes (n = 79), stability across subsamples (n = 26), clinical plausibility (n = 22), stability across methods (n = 7) and exploring common determinants (n = 2). Some studies used multiple types of validation.

CONCLUSION

The number of studies conducting a validation of multimorbidity patterns is clearly increasing. The most popular validation approach is assessing the association of multimorbidity patterns with clinical outcomes. Methodological guidance on the validation of multimorbidity patterns is needed.

Experience of living with multimorbidity and health workers perspectives on the organization of health services for people living with multiple chronic conditions in Bahir Dar, northwest Ethiopia: a qualitative study

BACKGROUND

Multimorbidity-the simultaneous occurrence of two or more chronic Non-Communicable Diseases) in an individual is increasing globally and challenging health systems. Although individuals living with multimorbidity face a range of adverse consequences and difficulty in getting optimal health care, the evidence base in understanding the burden and capacity of the health system in managing multimorbidity is sparse in low-and middle-income countries (LMICs). This study aimed at understanding the lived experiences of patients with multimorbidity and perspective of service providers on multimorbidity and its care provision, and perceived capacity of the health system for managing multimorbidity in Bahir Dar City, northwest Ethiopia.

METHODS

A facility-based phenomenological study design was conducted in three public and three private health facilities rendering chronic outpatient Non-Communicable Diseases (NCDs) care in Bahir Dar City, Ethiopia. Nineteen patient participants with two or more chronic NCDs and nine health care providers (six medical doctors and three nurses) were purposively selected and interviewed using semi-structured in-depth interview guides. Data were collected by trained researchers. Interviews were audio-recorded using digital recorders, stored and transferred to computers, transcribed verbatim by the data collectors, translated into English and then imported into NVivo V.12 software for data analysis. We employed a six-step inductive thematic framework analysis approach to construct meaning and interpret experiences and perceptions of individual patients and service providers. Codes were identified and categorized into sub-themes, organizing themes and main themes iteratively to identify similarities and differences across themes, and to interpret them accordingly.

RESULTS

A total of 19 patient participants (5 Females) and nine health workers (2 females) responded to the interviews. Participants' age ranged from 39 to 79 years for patients and 30 to 50 years for health professionals. About half (n = 9) of the participants had three or more chronic conditions. The key themes produced were feeling dependency, social rejection, psychological distress, poor medication adherence and poor quality of care. Living with multimorbidity poses a huge burden on the physical, psychological, social and sexual health of patients. In addition, patients with multimorbidity are facing financial hardship to access optimal multimorbidity care. On the other hand, the health system is not appropriately prepared to provide integrated, person-centered and coordinated care for people living with multiple chronic conditions.

CONCLUSION AND RECOMMENDATIONS

Living with multimorbidity poses huge impact on physical, psychological, social and sexual health of patients. Patients seeking multimorbidity care are facing challenges to access care attributable to either financial constraints or the lack of integrated, respectful and compassionate health care. It is recommended that the health system must understand and respond to the complex care needs of the patients with multimorbidity.

The case for transitional services and programs for older adults reentering society: a narrative review of US departments of correction and recommendations

PURPOSE

Older adults who are or have been incarcerated constitute a growing population in the USA. The complex health needs of this group are often inadequately addressed during incarceration and equally so when transitioning back to the community. The purpose of this paper is to discuss the literature on challenges older adults (age 50 and over) face in maintaining health and accessing social services to support health after an incarceration and to outline recommendations to address the most urgent of these needs.

DESIGN/METHODOLOGY/APPROACH

This study conducted a narrative literature review to identify the complex health conditions and health services needs of incarcerated older adults in the USA and outline three primary barriers they face in accessing health care and social services during reentry.

FINDINGS

Challenges to healthy reentry of older adults include continuity of health care; housing availability; and access to health insurance, disability and other support. The authors recommend policy changes to improve uniformity of care, development of support networks and increased funding to ensure that older adults reentering communities have access to resources necessary to safeguard their health and safety.

ORIGINALITY/VALUE

This review presents a broad perspective of the current literature on barriers to healthy reentry for older adults in the USA and offers valuable system, program and policy recommendations to address those barriers.

Number of chronic conditions and associated functional limitations among older adults: cross-sectional findings from the longitudinal aging study in India

Background

Chronic conditions reduce the likelihood of physical functioning among older adults. However, the contribution of most prevalent diseases and multimorbidity to different measures of functional limitations is relatively underexplored among Indian older adults. The present study explores the prospective association between number of chronic conditions and limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL) among older adults in India.

Methods

This study utilized data from the nationally representative Longitudinal Ageing Study in India (LASI-2017-18). The effective sample size was 31,464 older adults aged 60 years and above. Descriptive statistics along with cross-tabulation were presented in the study. Additionally, binary logistic regression analysis was used to fulfil the objectives. The outcome variables were dichotomized; high representing no difficulty in ADL/IADL and low representing a difficulty in at least one ADL/IADL. The chronic conditions included hypertension, diabetes, neurological/psychiatric disease, lung disease, heart diseases, stroke, and bone-related disease. The number of chronic diseases was categorized into no disease, single, two and three plus based on number of reported disease.

Results

26.36% of older women and 20.87% of older men had low ADL and the figures for low IADL were 56.86 and 38.84% for older men and women respectively. The likelihood of low ADL (AOR: 1.698, CI:1.544, 1.868) and low IADL (AOR: 1.197; CI: 1.064, 1.346) was higher among womenthan men. With increasing age, the prevalence of low ADL increased among older adults. Respondents with pre-existing chronic conditions had higher likelihood of low ADL and IADL. Older adults with hypertension, psychiatric disease, heart disease, stroke and bone-related disease had significantly higher odds of reporting low IADL. The chances of low ADL and IADL were 2.156 (CI: 1.709, 2.719) and 2.892 (CI: 2.067, 4.047) times respectively higher among older adults with more than three chronic conditions. After controlling for socio-economic and health-related covariates, it was found that men with more than three pre-existing chronic conditions had higher odds of low ADL than women. On the other hand, low IADL were found higher among women with more than three pre-existing chronic conditions.

Conclusions

The present study demonstrates a significant burden of functional limitations among older individuals and that there is a strong association between pre-existing chronic conditions and functional disability. Those with hypertension, diabetes, psychiatric disorders, heart disease, stroke, lung disease or bone-related diseases should be effectively monitored to predict future functional limitations, which may lead to worsening health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02620-0.

Spousal Concordance in the Development of Functional Limitations Among Married Adults in China

IMPORTANCE

Functional limitation is increasingly common as people age and is often associated with negative consequences. Evidence of the dynamics of functional limitation within couples in China is still inadequate.

OBJECTIVES

To examine whether functional limitation was associated within middle-aged and older couples and to explore sex differences in spousal associations.

DESIGN, SETTING, AND PARTICIPANTS

In this nationwide, population-based cohort study performed from January 1, 2011, to December 31, 2018, participants were selected using multistage probability sampling, and 5207 community-dwelling couples (10 414 individuals) 45 years or older were included in the nationally representative China Health and Retirement Longitudinal Study. Data analysis was performed from January 1 to February 28, 2021.

EXPOSURES

The exposure variable was the presence of functional limitation in spouses. Functional limitation was measured by the activities of daily living (ADLs) and instrumental activities‎ of daily ‎living (IADLs) scales and was defined as having difficulty in independently performing at least 1 ADL or IADL item.

MAIN OUTCOMES AND MEASURES

The main outcome was functional limitation in index participants. Multivariable logistic regression with generalized estimating equations was used to estimate the reciprocal association of functional limitation within couples over time.

RESULTS

A total of 5207 married, different-sex couples (mean [SD] age, 59.1 [8.8] years for husbands and 57.0 [8.2] years for wives) were included in the study. For husbands, the number (percentage) of participants classified with baseline functional limitation was 1140 (21.9%), the number (percentage) with ADL limitation was 684 (13.1%), and the number (percentage) with IADL limitation was 834 (16.0%). For wives, the number (percentage) of participants classified with baseline functional limitation was 1502 (28.8%), the number (percentage) with ADL limitation was 887 (17.0%), and the number (percentage) with IADL limitation was 1183 (22.7%). Longitudinal results demonstrated an association in spouses developing functional limitation (adjusted odds ratio [OR], 2.55; 95% CI, 2.41-2.69; P < .001), ADL limitation (adjusted OR, 2.26; 95% CI, 2.11-2.41; P < .001), and IADL limitation (adjusted OR, 2.58; 95% CI, 2.43-2.73; P < .001). Subgroup analyses by sex revealed similar patterns of spousal health concordance in terms of all studied outcomes, indicating no sex specificity.

CONCLUSIONS AND RELEVANCE

This population-based cohort study suggests that among Chinese middle-aged and older couples there is significant concordance in the development of functional limitation. This study of spousal functional ability from a dyadic perspective may help in the understanding of health risks within a wider familial context and offers novel insights for prioritizing policy focus from individual centered to couple based.

Multimorbidity patterns in people with HIV

PURPOSE OF REVIEW

With the progressive aging of populations of people with HIV (PWH), multimorbidity is increasing. Multimorbidity patterns, that is groups of comorbidities that are likely to co-occur, may suggest shared causes or common risk factors. We review the literature regarding multimorbidity patterns identified with data-driven approaches and discuss the methodology and potential implications of the findings.

RECENT FINDINGS

Despite the substantial heterogeneity in the methods used to identify multimorbidity patterns, patterns of mental health problems, cardiovascular diseases, metabolic disorders and musculoskeletal problems are consistently reported in the general population, with patterns of mental health problems, cardiovascular diseases or metabolic disorders commonly reported in PWH. In addition to these, patterns of lifestyle-related comorbidities, such as sexually transmitted diseases, substance use (alcohol, recreational drugs and tobacco smoking) or their complications, seem to occur among PWH.

SUMMARY

Multimorbidity patterns could inform the development of appropriate guidelines for the prevention, monitoring and management of multiple comorbidities in PWH. They can also help to generate new hypotheses on the causes underlying previously known and unknown associations between comorbidities and facilitate the identification of risk factors and biomarkers for specific patterns.

The characteristics of older homicide offenders: a systematic review

This systematic review was conducted to develop a broader understanding of the characteristics of older people who commit homicide. PubMed, Embase and PsycINFO were searched on 28 November 2018 for studies on homicides committed by people aged 55 years and over. Only articles published in English were included. Studies focusing on euthanasia and palliation were excluded. Fifteen articles met the inclusion criteria, with studies from the United States (n = 6), United Kingdom (n = 2), Australia, Canada, Finland, Italy, New Zealand, Switzerland and Turkey. The age range for 'older offenders' varied across the studies. Some studies examined the phenomena of sexual homicide and homicide-suicide. Offenders were more likely to be male, and the domestic setting for the offence was common. Social maladjustment, a care-giver role, personal physical and mental health problems and/or substance misuse issues were relevant to the offenders. Firearms-related homicides were common. Homicide committed by older people is rare but there may be a constellation of risk factors specific to this age group that needs further understanding. Our findings suggest that there is an increasing need for care of older offenders and a need for specialist forensic services for elderly offenders.

The mental and physical health of older offenders: A systematic review and meta-analysis

A systematic review with meta-analysis was performed to: 1) estimate the prevalence of both mental and physical health problems in older offenders; 2) calculate relative risks for the health conditions in relation to non-offender older adults and; 3) explore the potential confounding role of several variables. We searched five databases up to August 2019. Studies involving offenders older than 50 years old were included. Fifty-five publications met criteria. The pooled prevalence for 18 mental and 28 physical health problems was calculated. In comparison with non-offender older adults, older offenders showed significantly higher risk for Hypertension (RR = 1.16, CI = 1.1, 1.2), Cardiovascular Diseases (RR = 1.24, CI = 1.09, 1.41), Respiratory diseases (RR = 1.75, CI = 1.29, 2.35), and Arthritis (RR = 1.19, CI = 1.12, 1.25). Heterogeneity was significant for all meta-analyses and partially explained by the confounding effect of country, the diagnosis assessment method, and the sample characteristics. Future research should include comparison groups of non-offender older adults and use longitudinal study designs to identify risk factors that can be targeted in preventive programmes.

Challenges and opportunities for the management of infectious diseases in Europes' prisons: evidence-based guidance

People in prison have multiple complex health and social care needs. These are likely to be the result of a combination of overlapping, and sometimes interlinked, risk factors for infection, ill-health, and incarceration, such as problem drug use. Incarceration can represent a unique opportunity to make high-quality health care available to people in prison and to target socially deprived groups who are often medically underserved when living in the community they originate from. In recent years, international and European institutions have increasingly acknowledged the importance of treating prison health as an inseparable component of public health. However, numerous challenges hamper the successful implementation of such a concept, including the need for evidence-based decision making, intersectoral partnerships, and better monitoring systems. New initiatives are ongoing in the EU that might contribute to bring about positive changes, such as the publication of the first evidence-based public health guidance on prevention and control of communicable diseases in prison settings.