Abbreviated guidelines for scoring the Cumulative Illness Rating Scale (CIRS) in family practice

Higher blood biochemistry-based biological age developed by advanced deep learning techniques is associated with frailty in geriatric rehabilitation inpatients: RESORT

BACKGROUND

Accelerated biological ageing is a major underlying mechanism of frailty development. This study aimed to investigate if the biological age measured by a blood biochemistry-based ageing clock is associated with frailty in geriatric rehabilitation inpatients.

METHODS

Within the REStORing health of acutely unwell adulTs (RESORT) cohort, patients' biological age was measured by an ageing clock based on completed data of 30 routine blood test variables measured at rehabilitation admission. The delta of biological age minus chronological age (years) was calculated. Ordinal logistic regression and multinomial logistic regression were performed to evaluate the association of the delta of ages with frailty assessed by the Clinical Frailty Scale. Effect modification of Cumulative Illness Rating Scale (CIRS) score was tested.

RESULTS

A total of 1187 geriatric rehabilitation patients were included (median age: 83.4 years, IQR: 77.7-88.5; 57.4 % female). The biochemistry-based biological age was strongly correlated with chronological age (Spearman r = 0.883). After adjustment for age, sex and primary reasons for acute admission, higher biological age (per 1 year higher in delta of ages) was associated with more severe frailty at admission (OR: 1.053, 95 % CI:1.012-1.096) in patients who had a CIRS score of <12 not in patients with a CIRS score >12. The delta of ages was not associated with frailty change from admission to discharge. The specific frailty manifestations as cardiac, hematological, respiratory, renal, and endocrine conditions were associated with higher biological age.

CONCLUSION

Higher biological age was associated with severe frailty in geriatric rehabilitation inpatients with less comorbidity burden.

Patterns and predictors of ten-year mortality after discharge from community-based post-acute care for acquired brain injury: A retrospective cohort study (ABI-RESTaRT), Western Australia, 1991-2017

BACKGROUND

Survivors of acquired brain injury (ABI) are left with long-term disability and an increased risk of mortality years post-injury.

OBJECTIVE

To examine 10-year mortality in adults with ABI after discharge from post-acute care and identify modifiable risk factors to reduce long-term mortality risk.

METHODS

Retrospective cohort study of 586 adults with traumatic (TBI) or non-traumatic brain injury (NTBI), or neurologic condition, consecutively discharged from a post-acute rehabilitation service in Western Australia from 1-Mar-1991 to 31-Dec-2017. Data sources included rehabilitation records, and linked mortality, hospital, and emergency department data. Survival status at 10 years post-discharge was determined. All-cause and cause-specific age- and sex-adjusted standardised mortality ratios (SMR) by ABI diagnosis were calculated using Australian population reference data. Risk factors were examined using multilevel cox proportional hazards regression.

RESULTS

Compared with the Australian population, 10-year all-cause mortality was significantly elevated for all diagnosis cohorts, with the first 12 months the highest risk period. Accidents or intentional self-harm deaths were elevated in TBI (13.2, 95%CI 5.4; 12.1). Neurodegenerative disease deaths were elevated in Neurologic (21.9, 95%CI 13.0; 30.9) and Stroke (19.8; 95%CI 2.4; 27.2) cohorts. Stroke (20.8; 95%CI 7.9; 33.8) and circulatory disease deaths (6.2; 95%CI 2.3; 9.9) were also elevated in Stroke. Psychiatric comorbidity was the strongest risk factor followed by older age, geographical remoteness, and cardiac, vascular, genitourinary and renal comorbidity. Clinically significant improvement in functional independence and psychosocial functioning significantly reduced mortality risk.

CONCLUSIONS

Individuals with ABI have an elevated risk of mortality years post-injury. Comorbidity management, continuity of care, and rehabilitation are important to reduce long-term mortality risk.

Characterizing end-of-life communication in families

Background

The chronic disease course can be uncertain, contributing to delayed end-of-life discussion within families resulting in missed opportunity to articulate wishes, increased decisional uncertainty, and delayed hospice care. Consistent with the Family Communication Patterns Theory (FCPT), family communication patterns may affect the quality and timing of end-of-life discussion, hospice utilization, and the experience of 'a good death.'

Objective

To assess how families' conversation and conformity orientation (spontaneity of conversation and hierarchical rigidity) form four family communication patterns (consensual, pluralistic, protective, and laissez-faire) and may be associated with the number and timing of end-of-life discussions.

Design

A cross-sectional study.

Methods

Family members of loved ones who died from chronic illnesses while in hospice (n = 56) completed online surveys including a modified Revised Family Communication Pattern instrument (RFCP) and the Chronic Illness Rating Scale (CIRS). Additional survey questions assessed the number and timing of end-of-life discussions and timing of hospice enrollment. IBM SPSS version 26 was used for descriptive analysis.

Results

Most families (42.9%) were pluralistic, reporting communication styles with high conversation and low conformity orientation; (39.29%) were protective, reporting low conversation and high conformity orientation. Pluralistic families had more end-of-life conversations than did protective families.

Conclusion

Study findings suggest that there may be a relationship between family communication pattern type and inclination toward end-of-life discussion. This first step supports future research regarding whether the FCPT can be used to predict which families may be at increased risk for ineffective or delayed end-of-life discussion. Additional variables to consider include the timing of hospice enrollment and the quality of the dying experience. Clinicians may ultimately use findings to facilitate earlier identification of and intervention for families who are at risk for poor end-of-life communication and outcomes.

What are the predictors of change in multimorbidity among people with HIV? A longitudinal observational cohort study

INTRODUCTION

Multimorbidity is common among people living with HIV (PLWH), with numerous cross-sectional studies demonstrating associations with older age and past immunosuppression. Little is known about the progression of multimorbidity, particularly in the setting of long-term access to antiretrovirals. This study aims to determine factors predictive of change in multimorbidity in PLWH.

METHODS

People living with HIV who attended a regional HIV service were recruited to a consented observational cohort between September 2016 and March 2020. Demographic data, laboratory results and a Cumulative Illness Rating Scale (CIRS) were collected at enrolment and first clinical review of every subsequent year. Change in CIRS score was calculated from enrolment to February 2021. Associations with change were determined through univariate and multivariate linear regression.

RESULTS

Of 253 people, median age was 58.9 [interquartile range (IQR): 51.9-64.4] years, 91.3% were male, and HIV was diagnosed a median of 22.16 years (IQR: 12.1-30.9) beforehand. Length of time in the study was a median of 134 weeks (IQR: 89.0-179.0), in which a mean CIRS score change of 1.21 (SD 2.60) was observed. Being older (p < 0.001) and having a higher body mass index (p = 0.008) and diabetes (p = 0.014) were associated with an increased likelihood of worsening multimorbidity. PLWH with a higher level of multimorbidity at baseline were less likely to worsen over time (p < 0.001).

CONCLUSION

As diabetes and weight predict worsening multimorbidity, routine diabetes screening, body mass index measurement, and multimorbidity status awareness are recommended.

Treatment with COLchicine in hospitalized patients affected by COVID-19: The COLVID-19 trial

OBJECTIVE

To evaluate whether the addition of colchicine to standard of care (SOC) results in better outcomes in hospitalized patients with COVID-19.

DESIGN

This interventional, multicenter, randomized, phase 2 study, evaluated colchicine 1.5 mg/day added to SOC in hospitalized COVID-19 patients (COLVID-19 trial) and 227 patients were recruited. The primary outcome was the rate of critical disease in 30 days defined as need of mechanical ventilation, intensive care unit (ICU), or death.

RESULTS

152 non-anti-SARS-CoV-2-vaccinated patients (colchicine vs controls: 77vs75, mean age 69.1±13.1 vs 67.9±15 years, 39% vs 33.3% females, respectively) were analyzed. There was no difference in co-primary end-points between patients treated with colchicine compared to controls (mechanical ventilation 5.2% vs 4%, ICU 1.3% vs 5.3%, death 9.1% vs 6.7%, overall 11 (14.3%) vs 10 (13.3%) patients, P=ns, respectively). Mean time to discharge was similar (colchicine vs controls 14.1±10.4 vs 14.7±8.1 days). Older age (>60 years, P=0.025), P/F<275 mmHg (P=0.005), AST>40 U/L (P<0.001), pre-existent heart (P=0.02), lung (P=0.003), upper-gastrointestinal (P=0.014), lower-gastrointestinal diseases (P=0.009) and cancer (P=0.008) were predictive of achieving the primary outcome. Diarrhoea (9.1% vs 0%, p=0.0031) and increased levels of AST at 6 days (76.9±91.8 vs 33.5±20.7 U/l, P=0.016) were more frequent in the colchicine group.

CONCLUSION

Colchicine did not reduce the rate and the time to the critical stage. Colchicine was relatively safe although adverse hepatic effects require caution. We confirm that older (>60 years) patients with comorbidities are characterized by worse outcome.

A blended e-health intervention for improving functional capacity in elderly patients on haemodialysis: A feasibility study

Introduction

Physical exercise showed to be beneficial for frail older adults on haemodialysis (HD). However, there are several obstacles hindering the regular practice of exercise, such as transportation difficulties, lack of time, fatigue and comorbidities. E-health in this regard has many potential advantages and could be useful for motivating HD patients to increase their level of physical activity. The aim of this study was to evaluate the feasibility of a blended e-health intervention for elderly HD patients who individually exercise at home while under remote supervision of a physiotherapist.

Material and methods

Patients over 60 years of age with sufficient cognitive and motoric resources to perform a simple physical test battery and to use a tablet-computer were recruited from four HD outpatient facilities. Following baseline assessment at home, the participants were visited by a physiotherapist (PT). The PT set an individual exercise programme and explained how to use the web-based interface. During the 12 weeks of training, the PTs remotely supervised the patients' progress. At 12 weeks follow-up a second assessment took place.

Results

Twenty-two patients were recruited to participate in the study. Seven patients dropped out of the blended programme and 15 patients concluded the programme. The average training frequency of the 15 participants concluding the study was 1.5 times a week [range 0.2-5.8]. The duration of a training session was between 20 and 40 min. The usability of the system was deemed positive. Regarding the efficacy of the intervention, no significant improvement of any measured parameter was found, and effect sizes were small to medium.

Conclusion

A blended e-health intervention supported by a web-based application for exercising at home under remote supervision of a PT is feasible in a HD population including older patients. However, before planning a randomized controlled trial, strategies to increase the recruitment rate and the adherence to such a blended intervention should be further developed, e.g., to improve the recruitment procedures and lower the expectable drop-out rate. Furthermore, the dosage of the blended programme should be adapted to the patients' physical performance levels in future trials.The study was registered on the website clinicaltrials.gov with ID NCT04076488.

Effects of comorbidity on post-acute outcomes in acquired brain injury: ABI-RESTaRT 1991-2020

BACKGROUND

Current understanding of comorbidities associated with acquired brain injury (ABI) and the effects on post-acute ABI outcomes is poor.

OBJECTIVE

To describe the prevalence, severity and patterns of comorbidity for the pre-injury, acute and post-acute phases, and to examine the effects of post-acute comorbidities on functional independence and length of stay (LOS) at discharge from post-acute care.

METHODS

Retrospective whole-population cohort study of n = 1,011 individuals with traumatic (TBI) or non-traumatic brain injury (NTBI), or eligible neurologic conditions admitted to a post-acute neurorehabilitation and disability support service in Western Australia (WA) between 1991 and 2020. Comorbidities were ascertained from internal electronic medical records and linked hospital and emergency department data from the WA Data Linkage System. We measured comorbidities across 14 body systems using the Cumulative Illness Rating Scale (CIRS) and Elixhauser Comorbidity Index (ECI), and functional independence with the UK Functional Independence Measure and Functional Assessment Measure (UK FIM+FAM). We used multilevel mixed-effect regression models to determine the effects of comorbidity on post-acute outcomes.

RESULTS

NTBI was the most common diagnosis (54%), followed by TBI (34%) and neurologic conditions (10%). Pre-injury comorbidities were present in over half the cohort. Comorbidity prevalence increased significantly from 57% to 84% (∆+27%) and severity (mean ECI score) increased significantly from 2.1 to 13.8 (∆+11.7) between pre-injury and the acute phase and remained elevated at admission to post-acute services (82%, mean ECI score 7.3). Psychiatric comorbidity was the most prevalent (56%) and was associated with significantly poorer functional outcomes at discharge and an increase in LOS of 6.5 months. Genitourinary, musculoskeletal, eye, ear nose and throat, and renal comorbidities also had significant effects on post-acute outcomes.

CONCLUSIONS

ABI has a long-term impact on multiple body systems. Identification and management of comorbidities is critical to maximize functional outcomes and reduce the cost of post-acute care.

A Pilot Observational Study Assessing Long-Term Changes in Clinical Parameters, Functional Capacity and Fall Risk of Patients With Chronic Renal Disease Scheduled for Hemodialysis

Background

Patients with end-stage renal disease are known to be particularly frail, and the cause is still widely seen as being directly related to specific factors in renal replacement therapy. However, a closer examination of the transitional phase from predialysis to long-term hemodialysis leads to controversial explanations, considering that the frailty process is already well-described in the early stages of renal insufficiency. This study aims to describe longitudinally and multifactorially changes in the period extending from the decision to start the replacement therapy through to the end of 2 years of hemodialysis. We hypothesized that frailty is pre-existent in the predialysis phase and does not worsen with the beginning of the replacement therapy. Between 2015 and 2018 we recruited 25 patients (72.3 ± 5.7 years old) in a predialysis program, with the expectation that replacement therapy would begin within the coming few months.

Methods

The patients underwent a baseline visit before starting hemodialysis, with 4 follow-up visits in the first 2 years of treatment. Health status, physical performance, cognitive functioning, hematology parameters, and adverse events were monitored during the study period.

Results

At baseline, our sample had a high variability with patients ranging from extremely frail to very fit. In the 14 participants that did not drop out of the study, out of 32 clinical and functional measures, a statistically significant worsening was only observed in the Short Physical Performance Battery (SPPB) score (p &lt; 0.01, F = 8.50) and the number of comorbidities (p = 0.01, F = 3.94). A careful analysis, however, reveals a quite stable situation in the first year of replacement therapy, for both frail and fit participants and a deterioration in the second year that in frail participants could lead to death.

Conclusion

Our results should stimulate a reassessment about the role of a predialysis program in reducing complications during the transitional phase, but also about frailty prevention programs once hemodialysis has begun, for both frail and fit patients, to maintain satisfactory health status.

Patient characteristics as predictors of sleep disturbances in multimorbid primary care patients - A secondary analysis

OBJECTIVE

The aim of the study was to identify patient characteristics (adult attachment, health status, number and severity of chronic conditions, social support) predictive sleep disturbances after 12 months.

METHODS

In a secondary analysis of a prospective longitudinal study dealing with adult attachment and self-management, attachment- and health-related characteristics, socio-demographic data at baseline and symptoms of insomnia at the follow up (12 month later) was recorded by 219 patients between the ages of 50 and 85 years with multimorbidity in primary care. Adult attachment was measured by the ECR-RD12. The overall health status was measured using a visual analogue scale (VAS) and a standardized list of chronic conditions. The number and severity of chronic diseases (CIRS-G) was assessed by general practitioners (GPs). Sleep disturbances was measured by the ISI 12 month later.

RESULTS

Approximately 19% of the respondents were found to have clinically relevant symptoms of insomnia, and a further 34% to be subclinical insomnia. Attachment-related anxiety, a poorer perceived social support, the number of chronic conditions and a better general health status could predict higher levels of sleep disturbance after 12 month.

CONCLUSION

Sleep disorders can play a major role in patients with multimorbidity. Attachment anxiety and lack of social support may also be possible risk factors for the development of sleep disturbances.

Feasibility of Diagnosing Initial Orthostatic Hypotension Using a Continuous Blood Pressure Device in Geriatric Rehabilitation Inpatients: RESORT

Background

Initial orthostatic hypotension (IOH) is highly prevalent in older adults and may interfere with the ability to regain function after acute hospitalization. IOH assessment requires a non-invasive, beat-to-beat continuous blood pressure device, which is not widely used in geriatric rehabilitation. Our aim was to test the feasibility of diagnosing IOH using a continuous blood pressure device in geriatric rehabilitation inpatients.

Methods

Geriatric rehabilitation inpatients of the REStORing Health of Acutely Unwell AdulTs (RESORT) cohort admitted to a tertiary hospital were randomly selected to undergo continuous blood pressure monitoring (Finapres) for 5 min in the supine position and 3 min of standing or sitting when unable to stand. Interventions to warm hands and adjusting the cuff pressure sizes were attempted if no signal was obtained or an error message occurred.

Results

Of 37 randomly selected inpatients, 29 {55.2% female; mean age 82.8 (standard deviation [SD]) 6.6 years} agreed to the continuous blood pressure measurement. Successful measurements were achieved in 20 out of 29 inpatients, two after hand warming. Patients with unsuccessful measurements were likely to be older (mean age 87.2 [SD] 4.4 years, p = 0.03), have cerebrovascular disease (p = 0.006), lower body mass index (p = 0.012), and a lower short physical performance battery score (p = 0.039). Eight out of 20 patients had IOH.

Conclusion

The number of unsuccessful continuous blood pressure measurements was high in a population with high IOH prevalence despite multiple interventions to establish a signal. Future research should focus on improving the efficiency of continuous blood pressure devices in hospitalized patients with unsuccessful signals.

Sarcopenia in patients following stroke: an overlooked problem

Our aim was to investigate the prevalence of sarcopenia in stroke patients, the relationship between sarcopenia detected with different low muscle mass (LMM) adjustment methods, and between stroke-related parameters. Eighty-one patients with chronic stroke who underwent inpatient rehabilitation were included. Spasticity was evaluated by modified Ashworth scale, Brunnstrom staging approach was used for motor function evaluation, physical independence was evaluated using Barthel Index, quality-of-life was evaluated by EQ-5D-3L, and the Cumulative Illness Rating Scale was used to measure multimorbidity. Muscle strength was evaluated by handgrip strength, muscle quantity through a bioelectric impedance analysis, and physical performance by gait speed and short physical performance battery. LMM was calculated through two different methods: Skeletal muscle mass (SMM)/height2, and SMM/BMI. For the definition of sarcopenia, we followed the EWGSOP2 recommendation. Associated sarcopenia factors were predicted by multivariate binary logistic regression analysis. The prevalence of probable sarcopenia was 32.1%. The prevalence of confirmed/sarcopenia when LMM was adjusted for BMI was higher than when adjusted for height2 (16 and 1.2%, respectively). Age was significantly higher in those with probable sarcopenia (P = 0.006). Stroke duration was shorter in those with probable or confirmed sarcopenia (P = 0.004, P < 0.001, respectively). EQ-5D-3L scores were significantly lower in those with confirmed sarcopenia (P = 0.050). The strongest associated factor with confirmed sarcopenia was stroke duration (OR: 0.77; 95% CI, 0.618-0.965). This study suggests that prevalence of sarcopenia after a stroke is significantly high. LMM adjusted for BMI comes in front as the adjustment method for LMM after a stroke.

Interleukin-1 Beta in Peripheral Blood Mononuclear Cell Lysates as a Longitudinal Biomarker of Response to Antidepressants: A Pilot Study

Interleukin-1 beta (IL1β) is primarily produced by monocytes in the periphery and the brain. Yet, IL1β protein levels have to date been investigated in major depressive disorder (MDD) and antidepressant response using either plasma or serum assays although with contradictory results, while mononuclear cell assays are lacking despite their extensive use in other contexts. In this pilot study, we comparatively assessed IL1β in mononuclear lysates and plasma in depressed MDD patients over treatment and healthy controls (HC). We recruited 31 consecutive adult MDD inpatients and 25 HC matched on age, sex, and BMI. Twenty-six patients completed an 8-week follow-up under treatment. IL1β was measured in both lysates and plasma in patients at baseline (T0) and at study end (T1) as well as in HC. We calculated ΔIL1β(%) for both lysates and plasma as IL1β percent changes from T0 to T1. Seventeen patients (65.4% of completers) were responders at T1 and had lower baseline BMI than non-responders (p = 0.029). Baseline IL1β from either plasma or lysates could not efficiently discriminate between depressed patients and HC, or between responders and non-responders. However, the two response groups displayed contrasting IL1β trajectories in lysates but not in plasma assays (response group by time interactions, p = 0.005 and 0.96, respectively). ΔIL1β(%) in lysates predicted response (p = 0.025, AUC = 0.81; accuracy = 84.6%) outperforming ΔIL1β(%) in plasma (p = 0.77, AUC=0.52) and was robust to adjusting for BMI. In conclusion, ΔIL1β(%) in mononuclear lysates may be a longitudinal biomarker of antidepressant response, potentially helpful in avoiding untimely switching of antidepressants, thereby warranting further investigation.

Development and internal validation of prognostic models to predict negative health outcomes in older patients with multimorbidity and polypharmacy in general practice

BACKGROUND

Polypharmacy interventions are resource-intensive and should be targeted to those at risk of negative health outcomes. Our aim was to develop and internally validate prognostic models to predict health-related quality of life (HRQoL) and the combined outcome of falls, hospitalisation, institutionalisation and nursing care needs, in older patients with multimorbidity and polypharmacy in general practices.

METHODS

Design: two independent data sets, one comprising health insurance claims data (n=592 456), the other data from the PRIoritising MUltimedication in Multimorbidity (PRIMUM) cluster randomised controlled trial (n=502). Population: ≥60 years, ≥5 drugs, ≥3 chronic diseases, excluding dementia. Outcomes: combined outcome of falls, hospitalisation, institutionalisation and nursing care needs (after 6, 9 and 24 months) (claims data); and HRQoL (after 6 and 9 months) (trial data). Predictor variables in both data sets: age, sex, morbidity-related variables (disease count), medication-related variables (European Union-Potentially Inappropriate Medication list (EU-PIM list)) and health service utilisation. Predictor variables exclusively in trial data: additional socio-demographics, morbidity-related variables (Cumulative Illness Rating Scale, depression), Medication Appropriateness Index (MAI), lifestyle, functional status and HRQoL (EuroQol EQ-5D-3L). Analysis: mixed regression models, combined with stepwise variable selection, 10-fold cross validation and sensitivity analyses.

RESULTS

Most important predictors of EQ-5D-3L at 6 months in best model (Nagelkerke's R² 0.507) were depressive symptoms (-2.73 (95% CI: -3.56 to -1.91)), MAI (-0.39 (95% CI: -0.7 to -0.08)), baseline EQ-5D-3L (0.55 (95% CI: 0.47 to 0.64)). Models based on claims data and those predicting long-term outcomes based on both data sets produced low R² values. In claims data-based model with highest explanatory power (R²=0.16), previous falls/fall-related injuries, previous hospitalisations, age, number of involved physicians and disease count were most important predictor variables.

CONCLUSIONS

Best trial data-based model predicted HRQoL after 6 months well and included parameters of well-being not found in claims. Performance of claims data-based models and models predicting long-term outcomes was relatively weak. For generalisability, future studies should refit models by considering parameters representing well-being and functional status.

Changes in older drivers' self-awareness of driving ability over one year

Older drivers' self-awareness of driving ability can prompt self-regulatory behaviors and modifications of their everyday driving performance. To date, studies have yet to examine how older drivers' self-awareness of changes in driving ability over time or identify the characteristics of those who can accurately monitor such changes. 64 older drivers (Age: Mean = 80.0 years, SD = 5.4; male: 70 %) were recruited and categorized into four groups based on the correspondence of changes in their perceived and actual driving ability over one year: 40 % of the participants were accurate in their stable or better driving ability over time, 30 % did not detect their driving performance had worsened and over-estimated their driving ability, and the remainder either accurately detected their performance had worsened or under-estimated their driving performance. No demographic or clinical factors were associated with older drivers' self-awareness of changes in driving ability over time, except the mental processing and executive functioning measured using the Trail Making Tests Part B, showed a marginal effect. Implications for clinical importance are discussed.

Personal and Clinical Factors Associated with Older Drivers' Self-Awareness of Driving Performance

Most older adults perceive themselves as good drivers; however, their perception may not be accurate, and could negatively affect their driving safety. This study examined the accuracy of older drivers' self-awareness of driving ability in their everyday driving environment by determining the concordance between the perceived (assessed by the Perceived Driving Ability [PDA] questionnaire) and actual (assessed by electronic Driving Observation Schedule [eDOS]) driving performance. One hundred and eight older drivers (male: 67.6%; age: mean = 80.6 years, standard deviation [SD] = 4.9 years) who participated in the study were classified into three groups: underestimation (19%), accurate estimation (29%), and overestimation (53%). Using the demographic and clinical functioning information collected in the Candrive annual assessments, an ordinal regression showed that two factors were related to the accuracy of self-awareness: older drivers with better visuo-motor processing speed measured by the Trail Making Test (TMT)-A and fewer self-reported comorbid conditions tended to overestimate their driving ability, and vice versa.

Evaluation of an educational course for primary care physiotherapists on comorbidity-adapted exercise therapy in knee osteoarthritis: an observational study

Objective

The objectives of the present study were to: (1) evaluate the effect of an educational course on competence (knowledge and clinical reasoning) of primary care physical therapists (PTs) in treating patients with knee osteoarthritis (KOA) and comorbidity according to the developed strategy; and (2) identify facilitators and barriers for usage.

Method

The present research was an observational study with a pretest‐posttest design using mixed methods. PTs were offered a postgraduate course consisting of e‐learning and two workshops (blended education) on the application of a strategy for exercise prescription in patients with KOA and comorbidity. Competences were measured by questionnaire on knowledge (administered before and 2 weeks after the course), and a patient vignette to measure clinical reasoning (administered before the course and after a 6 month period of treating patients). Facilitators and barriers for using the strategy were assessed by a questionnaire and semi‐structured interviews.

Results

Thirty‐four PTs were included. Competence (knowledge and clinical reasoning) improved significantly (p < 0.01). Fourteen out of 34 PTs had actually treated patients with KOA and comorbidity, during a 6‐month period. The strategy was found to be feasible in daily practice. The main barriers included the limited number of (self‐) referrals of patients, limited number of reimbursed treatment sessions by insurance companies and a suboptimal collaboration with (referring) physicians.

Conclusion

A blended course on exercise therapy for patients with KOA and comorbidity seems to improve PTs' competence through increasing knowledge and clinical reasoning skills. Identified barriers should be solved before large‐scale implementation of exercise therapy can take place in these complex patients.

THE ASSESSMENT OF COMORBID PATHOLOGY IN CLEAN-UP WORKERS OF THE ACCIDENT CONSEQUENCES AT THE CHORNOBYL NPP HAVING CARDIOVASCULAR DISEASES

OBJECTIVE

Analysis of comorbid pathology based on the use of methods for its quantitative assessment in personswho were exposed to radiation because of the Chornobyl accident.

MATERIALS AND METHODS

Comorbid pathology was studied in 608 men, including 420 clean-up workers (CW) of theaccident consequences at the Chornobyl NPP (main group) and 188 non-irradiated persons (control group - CG). Allpatients had cardiovascular diseases as their main pathology and were examined in the cardiology department ofthe NRCRM hospital during 2011-2019. The groups did not differ by age, either at the beginning of the accident orat the time of their last examination. Patients of both groups before the accident were practically healthy peopleand were not registered at the dispensary. The Cumulative Illness Rating Scale (CIRS) was used to quantify comorbid pathology.

RESULTS

Comorbid pathology was detected in 418 CW (99.5 %) and 183 patients of CG (99.3 %). The total score inCW (10.3 ± 2.9) units significantly (р = 0.000) exceeded the same index in non-irradiated patients (8.8 ± 3.0) units,as well as the mean number of CIRS categories, whose level severity was 1 point (3.3 ± 1.7 vs. 2.6 ± 1.5, р = 0.000),2 points (1.8 ± 1.0 vs. 1.6 ± 1.0, p = 0.032) and 3-4 points (1.2 ± 0.8 vs. 1.0 ± 0.9, р = 0.062). In contrast, the meanvalue of the categories with zero score, i.e. without diseases, was more common in CG (7.8 ± 1.8 vs. 8.8 ± 1.7,р = 0.000). The most common pathology in CW and CG were heart (98.3 % vs. 94.7 %, р < 0.05) and vascular diseases(92.9 % vs. 87.8 %, р > 0.05), followed by diseases of nervous system (79.0 % vs. 57.4 %, р <0.001), musculoskeletal system and skin (69.8 % vs. 56.9 %, р < 0.01), endocrine (56.0 % vs. 49,5 %, р > 0.05) and the respiratory system (53.8 % vs. 53.7 %, р > 0.05) and liver (51.2 % vs. 36.2 %, р < 0.001), which were detected more than in halfpatients of the main group. Diseases of the kidneys (3.3 % vs. 4.8 %, р > 0.05) and lower gastrointestinal tract(3.3 % vs. 0.5 %, р < 0.01) were quite rare. The incidence of the other four CIRS categories was 18.6-34 %. The totalscore in subgroups with different ages varied in descending order of mean values as follows: CW > 65 years (10.5 ± 2.9)units, CW < 65 years (9.9 ± 2.8) units, CG > 65 years (9.5 ± 2.8) units and CG < 65 years (7.8 ± 2.9) units with significant differences both between age subgroups in each of the groups and between CW and CG older subgroups.

CONCLUSIONS

Quantitative assessment of comorbidity by CIRS showed that in persons irradiated during their emergency work due to the Chornobyl accident, the incidence of combined pathology of such organ systems as cardiovascular, nervous, endocrine, hematopoietic, urogenital, musculoskeletal, gastrointestinal, liver and kidneys wassignificantly higher than in non-irradiated patients. In irradiated patients, the course of comorbid pathology wasmore severe for each system and in general, reflecting higher values of the total CIRS score. Both among CW andnon-irradiated controls, higher values of the total comorbidity score were observed in patients 65 years and older,compared with younger individuals. In both age subgroups of CW the total score was higher than in patients of thecontrol group.

Couples Adjusting to Multimorbidity: A Dyadic Study on Disclosure and Adjustment Disorder Symptoms

Background

Multimorbidity is challenging not only for the patient but also for the romantic partner. Strategies for interpersonal emotion regulation like disclosing to the partner are supposed to play a major role in the psychosocial adjustment to multimorbidity. Research has often focused on disease-related disclosure, even though disclosing thoughts and feelings related to mundane, everyday life occurrences might also play a role in coadjustment. The current dyadic study aimed at investigating the association between these two types of interpersonal regulation strategies and adjustment disorder symptoms, following the new ICD 11 criteria in multimorbid patients and their partners.

Methods

Shortly after being hospitalized due to an acute health crisis, N = 28 multimorbid patients (average age 70 years) and their partners filled in questionnaires on disclosure in the couple, adjustment disorder criteria of the ICD 11 (“preoccupation,” “failure to adapt”), and sleep problems.

Results

Both patients and their partners did show similarly high levels of preoccupation and failure to adapt indicating adjustment problems to the complex health situation. The adjustment symptoms of both partners correlated between r = 0.22 and 0.45. Regression based on Actor-Partner Interdependence-Models revealed that own mundane disclosure was related to less adjustment symptoms in the patients. Beyond that, a partner effect was observed, revealing a negative association between partners’ illness-related disclosure and the patients’ level of preoccupation. For the partners, mundane disclosure of the partner was associated with less preoccupation, failure to adapt, and reported sleep problems above and beyond own disclosure reports. Furthermore, there was an actor effect of disease-related disclosure on less sleep problems for the partners.

Conclusion

These results support an interpersonal view on adjustment processes to physical disease. Disclosure as a way of regulating the relationship and emotional responses might play a relevant role here, which seems to be different for patients and their partners. Further research is needed to shed more light on the differential role of disease-related and mundane everyday disclosure for psychosocial adjustment in couples confronted with health challenges.

Predicting patient use of general practice services in Australia: models developed using national cross-sectional survey data

Background

The ageing population and increasing prevalence of multimorbidity place greater resource demands on the health systems internationally. Accurate prediction of general practice (GP) services is important for health workforce planning. The aim of this research was to develop a parsimonious model that predicts patient visit rates to general practice.

Methods

Between 2012 and 2016, 1449 randomly selected Australian GPs recorded GP-patient encounter details for 43,501 patients in sub-studies of the Bettering the Evaluation and Care of Health (BEACH) program. Details included patient characteristics, all diagnosed chronic conditions per patient and the number of GP visits for each patient in previous 12 months. BEACH has a single stage cluster design. Survey procedures in SAS version 9.3 (SAS Inc., Cary, NC, USA) were used to account for the effect of this clustering. Models predicting patient GP visit rates were tested. R-square value was used to measure how well each model predicts GP attendance. An adjusted R-square was calculated for all models with more than one explanatory variable. Statistically insignificant variables were removed through backwards elimination. Due to the large sample size, p < 0.01 rather than p < 0.05 was used as level of significance.

Results

Number of diagnosed chronic conditions alone accounted for 25.48% of variance (R-square) in number of visits in previous year. The final parsimonious model accounted for 27.58% of variance and estimated that each year: female patients had 0.52 more visits; Commonwealth Concessional Health Care Card holders had 1.06 more visits; for each chronic condition patients made 1.06 more visits; and visit rate initially decreased with age before increasing exponentially.

Conclusions

Number of diagnosed chronic conditions was the best individual predictor of the number of GP visits. Adding patient age, sex and concession card status explained significantly more variance. This model will assist health care planning by providing an accurate prediction of patient use of GP services.

Multimorbidity among elderly in Bangladesh

BACKGROUND

Multimorbidity among the elderly is a major public health problem in most of the developing countries, including Bangladesh, where the population is moving towards aging. Multimorbidity was defined as the co-occurrence of at least two chronic diseases in a person whether as a coincidence or not. Little attention has been paid to the study of the prevalence of multimorbidity among the elderly in Bangladesh.

OBJECTIVE

The objectives of this study were to estimate the prevalence of multimorbidity among hospitalized elderly.

METHODS

A cross-sectional study was conducted in two tertiary level hospitals with a sample of 566 adults aged 60 years or more. Data were collected from medical examination reports at the hospital and using a semi-structured interview schedule through an in-person interview. Descriptive statistics were used to measure the prevalence of multimorbidity.

RESULTS

The overall prevalence of multimorbidity among the elderly was 56.4% and the prevalence was higher among females (64.18%) than males (54.17%). The most prevalent conditions were hypertension (33.0%), diabetes (27.6%), ischemic heart disease (12.0%), and chronic obstructive pulmonary disease (9%).

CONCLUSION

A high prevalence of multimorbidity suggests that there is an urgent need to develop geriatric health-care services. Policymakers should pay attention to developing effective intervention strategies and programs to reduce the burden of multimorbidity.

Decomposing the within-person and between-person sources of variation in physical activity-cognition associations for low-active older adults

OBJECTIVES

To examine within-person and between-person sources of variation in the relationship between physical activity and cognition in older adults participating in a walking program. To explore whether demographic, health and fitness variables, and their interactions with activity, are significant predictors of cognition.

DESIGN

Brief longitudinal burst design.

PARTICIPANTS

118 participants (91 females, mean age = 72.81 + 5.24 years).

MAIN OUTCOME MEASURES

Cognition, self-reported moderate-to-vigorous walking and self-reported moderate-to-vigorous physical activity were assessed at baseline and 6, 9, 12 and 16 weeks follow-up. Attendance at weekly walks was also recorded.

RESULTS

Within-persons, changes in physical activity were related to select measures of executive functioning, with increased activity predictive of better cognition (three of four cognitive functions, p<.05). Between-persons, activity was also associated with cognition (two of four cognitive functions, p<.05). Younger age and higher education were related to better cognition. Interactions of demographic, health, and fitness variables with changes in within-person activity were generally non-significant.

CONCLUSION

The results highlight the importance of distinguishing within- from between-person effects in longitudinal analyses of the association between physical activity and cognition. This stringent within-person test of association underscores the potential value of simple physical activity interventions for improving cognitive function.

Multimorbidity, not human immunodeficiency virus (HIV) markers predicts unplanned admission among people with HIV in regional New South Wales

BACKGROUND

Multimorbidity and unplanned admissions are common among people with human immunodeficiency virus (PWH).

AIMS

To determine factors predictive of unplanned admission among PWH in regional New South Wales and compare care coordination between people with and without unplanned admissions.

METHODS

A prospective cohort study of PWH attending a regional human immunodeficiency virus (HIV) service was conducted. Baseline HIV-specific results and multimorbidity markers including Cumulative Illness Rating Scale (CIRS) were assessed as predictors of time to first unplanned admission using Cox regression analysis. Care coordination markers were compared between people with and without unplanned admission, using χ² statistic for proportions and t-test for means.

RESULTS

A cohort of 181 PWH was followed for a maximum of 5 years. During a total of 739 person-years of follow up, 39 (20.6%) patients reached the endpoint of unplanned admission. In multivariate analysis, the baseline CIRS score was predictive of unplanned admission (P < 0.001). Age, HIV-specific markers and missed visits were not predictive of unplanned admission. For patients with an unplanned admission, discharge summaries were documented for 22/39 (56.4%). Of 180 PWH with a visit after baseline, 131 (72.8%) had a letter to a general practitioner and 79 (43.7%) had two or more prescribers. Having two or more prescribers was more common in people with an unplanned admission than in those without (64.1% vs 38.0%, P = 0.004).

CONCLUSION

Unplanned admission among PWH is predicted by multimorbidity. Care for PWH should include coordinated management of other health conditions in order to reduce their severity and prevent unplanned admissions.

Changes in prescribed medicines in older patients with multimorbidity and polypharmacy in general practice

Background

Treatment complexity rises in line with the number of drugs, single doses, and administration methods, thereby threatening patient adherence. Patients with multimorbidity often need flexible, individualised treatment regimens, but alterations during the course of treatment may further increase complexity. The objective of our study was to explore medication changes in older patients with multimorbidity and polypharmacy in general practice.

Methods

We retrospectively analysed data from the cluster-randomised PRIMUM trial (PRIoritisation of MUltimedication in Multimorbidity) conducted in 72 general practices. We developed an algorithm for active pharmaceutical ingredients (API), strength, dosage, and administration method to assess changes in physician-reported medication data during two intervals (baseline to six-months: ∆₁; six- to nine-months: ∆₂), analysed them descriptively at prescription and patient levels, and checked for intervention effects.

Results

Of 502 patients (median age 72 years, 52% female), 464 completed the study. Changes occurred in 98.6% of patients (changes were 19% more likely in the intervention group): API changes during ∆₁ and ∆₂ occurred in 414 (82.5%) and 338 (67.3%) of patients, dosage alterations in 372 (74.1%) and 296 (59.2%), and changes in API strength in 158 (31.5%) and 138 (27.5%) respectively. Administration method changed in 79 (16%) of patients in both ∆₁ and ∆₂. Simvastatin, metformin and aspirin were most frequently subject to alterations.

Conclusion

Medication regimens in older patients with multimorbidity and polypharmacy changed frequently. These are mostly due to discontinuations and dosage alterations, followed by additions and restarts. These findings cast doubt on the effectiveness of cross-sectional assessments of medication and support longitudinal assessments where possible.

Trial registration.

1. Prospective registration: Trial registration number: NCT01171339; Name of registry: ClinicalTrials.gov; Date of registration: July 27, 2010; Date of enrolment of the first participant to the trial: August 12, 2010.

2. Peer reviewed trial registration: Trial registration number: ISRCTN99526053; Name of registry: Controlled Trials; Date of registration: August 31, 2010; Date of enrolment of the first participant to the trial: August 12, 2010.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0825-3) contains supplementary material, which is available to authorized users.

Quality of life and its contributing factors in an elderly community-dwelling population in Shanghai, China

BACKGROUND

We aimed to investigate the relationship between quality of life and the factors that may influence it in an elderly community-dwelling population in Shanghai.

METHODS

From August to October 2014, elderly individuals were enrolled from three randomly selected communities in Shanghai. Participant information was collected from responses to a general questionnaire and to the Lubben Social Network Scale-6, Cumulative Illness Rating Scale for Geriatrics, Patient Health Questionnaire, and the 12-item Short Form Health Survey. The factors influencing quality of life were explored in a multivariate stepwise linear regression model.

RESULTS

Physical and mental component summary scores for the elderly in Shanghai communities were 50.1 ± 10.1 and 47.3 ± 7.9, respectively. Physical component summary scores in the rural area were higher than those in the urban-rural intersection area (a place where urban and rural transitions are taking place) (52.32 ± 9.81 vs 49.63 ± 9.33, P < 0.05) and the urban area (52.32 ± 9.81 vs 47.34 ± 10.18, P < 0.05). Additionally, mental component summary scores in the rural area were higher than those in the urban-rural intersection area (52.63 ± 9.28 vs 48.43 ± 9.42, P < 0.05) and the urban area (52.63 ± 9.28 vs 48.13 ± 10.69, P < 0.05).

CONCLUSIONS

Depression, self-care ability, and medical care burden were found to be significantly associated with the quality of life of elderly individuals in Shanghai, China. Therefore, more attention should be paid to the mental health of this elderly population.

Effectiveness of a complex intervention on Prioritising Multimedication in Multimorbidity (PRIMUM) in primary care: results of a pragmatic cluster randomised controlled trial

OBJECTIVES

Investigate the effectiveness of a complex intervention aimed at improving the appropriateness of medication in older patients with multimorbidity in general practice.

DESIGN

Pragmatic, cluster randomised controlled trial with general practice as unit of randomisation.

SETTING

72 general practices in Hesse, Germany.

PARTICIPANTS

505 randomly sampled, cognitively intact patients (≥60 years, ≥3 chronic conditions under pharmacological treatment, ≥5 long-term drug prescriptions with systemic effects); 465 patients and 71 practices completed the study.

INTERVENTIONS

Intervention group (IG): The healthcare assistant conducted a checklist-based interview with patients on medication-related problems and reconciled their medications. Assisted by a computerised decision support system, the general practitioner optimised medication, discussed it with patients and adjusted it accordingly. The control group (CG) continued with usual care.

OUTCOME MEASURES

The primary outcome was a modified Medication Appropriateness Index (MAI, excluding item 10 on cost-effectiveness), assessed in blinded medication reviews and calculated as the difference between baseline and after 6 months; secondary outcomes after 6 and 9 months' follow-up: quality of life, functioning, medication adherence, and so on.

RESULTS

At baseline, a high proportion of patients had appropriate to mildly inappropriate prescriptions (MAI 0-5 points: n=350 patients). Randomisation revealed balanced groups (IG: 36 practices/252 patients; CG: 36/253). Intervention had no significant effect on primary outcome: mean MAI sum scores decreased by 0.3 points in IG and 0.8 points in CG, resulting in a non-significant adjusted mean difference of 0.7 (95% CI -0.2 to 1.6) points in favour of CG. Secondary outcomes showed non-significant changes (quality of life slightly improved in IG but continued to decline in CG) or remained stable (functioning, medication adherence).

CONCLUSIONS

The intervention had no significant effects. Many patients already received appropriate prescriptions and enjoyed good quality of life and functional status. We can therefore conclude that in our study, there was not enough scope for improvement.

TRIAL REGISTRATION NUMBER

ISRCTN99526053. NCT01171339; Results.

Interprofessional Medication Management in Patients With Multiple Morbidities

BACKGROUND

Medication reviews and medication management are being used more and more around the world to improve medication safety. Both of these tools were originally conceived as pharmaceutical care activities and have recently been developed into interdisciplinary approaches. We studied the efficacy of interprofessional medication management for multimorbid patients that takes their medical conditions, but also their general living situation into account.

METHODS

A comprehensive medication management was performed, which involved the collection of information on the drugs each patient took, the way they were stored, the patient's drug intake and handling, and any problems that arose with pharmacotherapy. The interventional approach was evaluated over a period of 15 months in a cluster-randomized controlled trial with a stepped wedge design. The primary endpoint was the quality of pharmacotherapy, as assessed with the Medication Appropriateness Index (MAI). A mixed model was used to analyze efficacy.

RESULTS

162 patients were enrolled in the study; 142 were included in the intention-to-treat analysis (53.3% women, mean age 76.8 ± 6.3 years). The mean total MAI score decreased significantly (p ≤ 0.001) from the control phase (29.21, 95% CI [26.09; 32.33]) to the intervention phase (22.27 [19.00; 25.54]), with an effect strength (Cohen's d) of -0.24 [-0.36; -0.13]. The number of drug-related problems declined as well.

CONCLUSION

In this study, interprofessional collaboration increased medication safety. Working across disciplinary boundaries allowed for a decrease in drugrelated problems and brought up aspects outside the purview of the primary care physician.

Effects of resistance training on body composition and functional capacity among sarcopenic obese residents in long-term care facilities: a preliminary study

Background

Aging-related loss of muscle and strength with increased adiposity is prevalent among older people in long-term care (LTC) facilities. Studies have shown that people with sarcopenic obesity (SO) are at high risk of declining physical performance. At present, no interventional studies on residents with SO in nursing homes have been conducted in the literature. The objectives of this study include appraising the changes in body composition and physical performance following resistance training among residents with SO in LTC facilities.

Methods

This study used a quasiexperimental research design. Residents who are 60 years of age or above and have been living a sedentary lifestyle in LTC facilities for the past 3 months will be eligible for inclusion. The intervention group engaged in chair muscle strength training twice a week for 12 weeks, whereas the control group underwent the usual care. The main variables were physical parameters of being lean and fat, the strength of grip and pinch, and a functional independence measure using descriptive analysis, chi-squared test, t-test, and generalized estimating equation for statistical analysis through SPSS.

Results

A total of 64 respondents with SO completed the study. After training, total grip strength (p = 0.001) and total pinch strength (p = 0.014) of the intervention group differed significantly from those of the control group. The right grip strength of the intervention group increased by 1.71 kg (p = 0.003) and the left grip strength improved by 1.35 kg (p = 0.028) compared with baseline values. The self-care scores of the intervention group increased by 2.76 points over baseline scores, particularly for the action of dressing oneself. Although grip strength and self-care scores improved more among those in the intervention group, body fat and skeletal muscle percentages did not differ significantly between the groups after training (p > 0.05).

Conclusions

Resistance exercises for elderly residents in LTC facilities may play an important role in helping them maintain physical well-being and improve muscle strength.

Trial registration

Clinicaltrials.gov, number NCT02912338. Retrospectively registered on 09/21/2016.

The association between submarine service and multimorbidity: a cross-sectional study of Korean naval personnel

OBJECTIVE

We aimed to estimate the prevalence of multimorbidity (≥2 chronic health problems) among Korean submariners and to evaluate the association between submarine service and multimorbidity and disease burden.

STUDY DESIGN AND SETTING

This cross-sectional study included 590 naval personnel who visited a Korean primary care clinic during 2014-2015. Data regarding general characteristics and morbidities were collected from medical records, and disease burden was assessed using the Cumulative Illness Rating Scale (CIRS). Multiple logistic regression analysis was used to evaluate the association between submarine service and multimorbidity and disease burden.

RESULTS

The prevalence of multimorbidity was 11.7% among 180 non-submariners and 32.2% among 410 submariners. The prevalence of multimorbidity and the CIRS scores gradually increased with age. Submarine service was associated with higher risk of multimorbidity and disease burden compared with non-submarine service even after adjusting for age, alcohol consumption, smoking status and naval rank. However, a dose-response relationship was not evident between the duration of submarine service and the risk of multimorbidity as well as high disease burden.

CONCLUSIONS

Submarine service was significantly associated with a higher risk of multimorbidity and greater disease burden than non-submarine service. This finding suggests that multidimensional and holistic healthcare approaches are needed for submariners.

Causes of referral to the first endocrine visit of patients with thyroid carcinoma in a mildly iodine-deficient area

To evaluate the causes of the first referral to an endocrine visit of patients with thyroid cancer in a mildly iodine-deficient area and to correlate them with prognostic features. We studied 298 consecutive patients (64 M and 234 F) with thyroid cancer. Of these, 281 had differentiated thyroid cancer. The causes of referral were categorized as follows: (Group A) clinical evidence of a neck lump; (Group B) incidental imaging in subjects without known thyroid diseases; (Group C) incidental imaging during a workup of thyroid disorders. Also, in differentiated thyroid cancer cases, clinical, histomorphologic, and prognostic parameters were compared among the three different groups of referral causes. In both total thyroid cancer and differentiated thyroid cancer cohorts, Group A, B, and C accounted for about 25, 35, and 40 % of causes, respectively. Considering the differentiated thyroid cancer, in Group B, ultrasound accounted for 94 % of cases, with 73 % resulting from screening or serendipitous study. Within a median follow-up of 5.6 [IQR: 2.7-9.5] years, disease-free survival was significantly lower in patients of Group A (Log-Rank test p = 0.030 vs. the other groups of causes). However, at the Cox multivariate analysis only male sex (p = 0.002) and stage (p = 0.005), but not referral cause, resulted independent predictors of events. In patients without known thyroid disease, unjustified thyroid ultrasound represents the main cause of referral of thyroid cancer patients to the first endocrine visit. The fact that this is not related to the disease-free survival strengthens the concept of the uselessness of thyroid cancer screening.

Patient-provider relationship as mediator between adult attachment and self-management in primary care patients with multiple chronic conditions

OBJECTIVE

The conceptual model of attachment theory has been applied to understand the predispositions of patients in medical care and the patient-provider relationship. In patients with chronic conditions insecure attachment was connected to poorer self-management. The patient-provider relationship is associated with a range of health related outcomes and self-management skills. We determined whether the quality of the patient-provider relationship mediates the link between adult attachment and self-management among primary care patients with multiple chronic diseases.

METHOD

209 patients with a minimum of three chronic diseases (including type II diabetes, hypertension and at least one other chronic condition) between the ages of 50 and 85 from eight general practices were included in the APRICARE cohort study. Adult attachment was measured via self-report (ECR-RD), self-management skills by the FERUS and the patient-provider relationship by the PRA-D. The health status and chronicity were assessed by the GP. Multiple mediation analyses were used to examine whether aspects of the patient-provider relationship (communication, information, affectivity) are a mediators of associations between adult attachment and self-management.

RESULTS

The analysis revealed that the quality of the patient-provider relationship mediated the effect of attachment on self-management in patients with multiple chronic conditions. Particularly the quality of communication and information over the course of treatment has a significant mediating influence.

CONCLUSION

A personalized, attachment-related approach that promotes active patient-provider communication and gives information about the treatment to the patient may improve self-management skills in patients.

Anticholinergic Exposure in a Cohort of Adults Aged 80 years and Over: Associations of the MARANTE Scale with Mortality and Hospitalization

Anticholinergics are frequently prescribed for older adults and can lead to adverse drug events. The novel MARANTE (Muscarinic Acetylcholinergic Receptor ANTagonist Exposure) scale measures the anticholinergic exposure by incorporating potency and dosages of each medication into its calculations. The aims were to assess prevalence and intensity of the anticholinergic exposure in a longitudinal cohort study of community-dwelling patients aged 80 years and over (n = 503) and to study the impact on mortality and hospitalization. Chronic medication use at baseline (November 2008-September 2009) was entered and codified with the Anatomical Therapeutic Chemical classification. Time-to-event analysis until first hospitalization or death was performed at 18 months after inclusion, using Kaplan-Meier curves. Cox regression was performed to control for covariates. Mean age was 84 years (range 80-102), and mean number of medications was 5 (range 0-16). Prevalence of anticholinergic use was 31.8%, with 9% taking ≥2 anticholinergics (range 0-4). Main indications for anticholinergics were depression, pain and gastric dysfunction. Female gender, the level of multi-morbidity and the number of medications were associated with anticholinergic use. Mortality and hospitalization rate were 8.9% and 31.0%, respectively. After adjustment for the level of multi-morbidity and medication intake, multi-variable analysis showed increased risks of mortality (HR 2.3, 95% CI: 1.07-4.78) and hospitalization (HR 1.7; 95% CI: 1.13-2.59) in those with high anticholinergic exposure. The longitudinal study among Belgian community-dwelling oldest old demonstrated great anticholinergic exposure, which was associated with increased risk of mortality and hospitalization after 18 months.

Pilot study to test the feasibility of a trial design and complex intervention on PRIoritising MUltimedication in Multimorbidity in general practices (PRIMUMpilot)

OBJECTIVE

To improve medication appropriateness and adherence in elderly patients with multimorbidity, we developed a complex intervention involving general practitioners (GPs) and their healthcare assistants (HCA). In accordance with the Medical Research Council guidance on developing and evaluating complex interventions, we prepared for the main study by testing the feasibility of the intervention and study design in a cluster randomised pilot study.

SETTING

20 general practices in Hesse, Germany.

PARTICIPANTS

100 cognitively intact patients ≥65 years with ≥3 chronic conditions, ≥5 chronic prescriptions and capable of participating in telephone interviews; 94 patients completed the study.

INTERVENTION

The HCA conducted a checklist-based interview with patients on medication-related problems and reconciled their medications. Assisted by a computerised decision-support system (CDSS), the GPs discussed medication intake with patients and adjusted their medication regimens. The control group continued with usual care.

OUTCOME MEASURES

Feasibility of the intervention and required time were assessed for GPs, HCAs and patients using mixed methods (questionnaires, interviews and case vignettes after completion of the study). The feasibility of the study was assessed concerning success of achieving recruitment targets, balancing cluster sizes and minimising drop-out rates. Exploratory outcomes included the medication appropriateness index (MAI), quality of life, functional status and adherence-related measures. MAI was evaluated blinded to group assignment, and intra-rater/inter-rater reliability was assessed for a subsample of prescriptions.

RESULTS

10 practices were randomised and analysed per group. GPs/HCAs were satisfied with the interventions despite the time required (35/45 min/patient). In case vignettes, GPs/HCAs needed help using the CDSS. The study made no patients feel uneasy. Intra-rater/inter-rater reliability for MAI was excellent. Inclusion criteria were challenging and potentially inadequate, and should therefore be adjusted. Outcome measures on pain, functionality and self-reported adherence were unfeasible due to frequent missing values, an incorrect manual or potentially invalid results.

CONCLUSIONS

Intervention and trial design were feasible. The pilot study revealed important limitations that influenced the design and conduct of the main study, thus highlighting the value of piloting complex interventions.

TRIAL REGISTRATION NUMBER

ISRCTN99691973; Results.

Timed Up and Go (TUG) Test: Normative Reference Values for Ages 20 to 59 Years and Relationships With Physical and Mental Health Risk Factors

PURPOSE

The Timed Up and Go (TUG) test is a reliable, cost-effective, safe, and time-efficient way to evaluate overall functional mobility. However, the TUG does not have normative reference values (NRV) for individuals younger than 60 years. The purpose of this study was to establish NRV for the TUG for individuals aged between 20 and 59 years and to examine the relationship between the TUG and demographic, physical, and mental health risk factors.

METHODS

Two hundred participants, 50 per decade (ages 20-29, 30-39, 40-49, 50-59 years) were selected at their primary care visit, and timed as they performed the TUG by standing up out of a chair, walking 3 m, turning around, walking back to the chair, and sitting down. Information regarding the risk factors socioeconomic status, body mass index, an index of multimorbidities, perceptions of overall physical and mental health was obtained and used as predictors of TUG time independent of age.

RESULTS

TUG times were significantly different among the decades ( F = 6.579, P = .001) with slower times occurring with the 50-year-old decade compared with the 20s ( P = .001), 30s ( P = .001), and 40s ( P = .020). Slower TUG times were associated with lower SES, higher body mass index, more medical comorbidities, and worse perceived physical and mental health. Regression results indicated that perceived physical and mental health accounted for unique variance in the prediction of TUG time beyond age, gender, and socioeconomic status.

CONCLUSIONS

This study provided TUG NRV for adults in their 20s, 30s, 40s, and 50s. The TUG may have utility for primary care providers as they assess and monitor physical activity in younger adults, especially those with physical and mental health risk factors.

A High Sense of Coherence as Protection Against Adverse Health Outcomes in Patients Aged 80 Years and Older

PURPOSE

We set out to assess whether a high sense of coherence (SOC) protects from adverse health outcomes in patients aged 80 years and older who have multiple chronic diseases.

METHODS

A population-based prospective cohort study in 29 primary care practices throughout Belgium included 567 individuals aged 80 years and older. We plotted the highest tertile of SOC scores in Kaplan-Meier curves representing 3-year mortality and time to first hospitalization. Using Cox proportional hazard regression analyses and multiple logistic regression analyses adjusted for sociodemographic characteristics, depression, cognition, disability, and multimorbidity we examined the relationship between SOC and mortality, hospitalization, and decline in performance of activities of daily living (ADL).

RESULTS

Subjects with high SOC scores showed a higher cumulative survival than others (Log rank = 0.004) independent of other prognostic characteristics (adjusted hazard ratio 0.62 (95% CI, 0.38-1.00), P = .049). For ADL decline, a high SOC was shown to be protective, and this effect tended to be independent from the covariates under study (adjusted odds ratio 0.56 (95% CI, 0.31-1.0), P = .05).

CONCLUSION

Even very elderly persons with high SOC scores were shown to have lower mortality rates and less functional decline. These effects were independent of multimorbidity, depression, cognition, disability, and sociodemographic characteristics.

Co-morbidity burden in Parkinson's disease: Comparison with controls and its influence on prognosis

Background

Many aspects of co-morbidity burden in Parkinson’s disease (PD) are unclear, but it may be an important predictor of prognosis or confounder of associations in epidemiological studies.

Objectives

To determine how best to assess co-morbidity burden in PD, to compare with matched controls, and investigate its association with prognostic outcomes.

Methods

Data from an incident, community-based cohort with prospective follow-up (the PINE study) were used (198 patients with PD and 151 controls). The reliability of three co-morbidity scales (the Charlson co-morbidity index (CCI), the Cumulative Illness Rating scale and a simple disease count) were evaluated. The association with mortality and development of dependency was assessed with Cox regression. The co-morbidity burden in PD and controls was compared at baseline and over 5 years of follow-up using linear mixed modelling.

Results

The CCI was more reliable and was an independent predictor of mortality with a time-dependent effect (hazard ratio = 1.27 [1.08–1.49] in first four years of follow-up; no significant association after four years). Associations between the other scales and mortality and between each scale and development of dependency were non-significant once adjusted for confounders. Co-morbidity burden was similar between cases and controls at baseline and there was no evidence of differential accrual of co-morbidity between patients and controls (p = 0.94).

Conclusions

The CCI is probably the better scale for measuring co-morbidity burden in PD. There were no differences between PD and controls. Co-morbidity burden at diagnosis was associated with mortality in the early part of the disease course, but not later.

•

The Charlson Index was a reliable and valid way to measure co-morbidity burden in PD.

•

There was no difference in co-morbidity burden between PD and matched controls.

•

Higher co-morbidity at diagnosis was associated with higher early mortality.

Seasonal and Weather Effects on Older Drivers' Trip Distances

The purpose of this study was to determine if season or weather affected the objectively measured trip distances of older drivers (≥ 70 years; n = 279) at seven Canadian sites. During winter, for all trips taken, trip distance was 7 per cent shorter when controlling for site and whether the trip occurred during the day. In addition, for trips taken within city limits, trip distance was 1 per cent shorter during winter and 5 per cent longer during rain when compared to no precipitation when controlling for weather (or season respectively), time of day, and site. At night, trip distance was about 30 per cent longer when controlling for season and site (and weather), contrary to expectations. Together, these results suggest that older Canadian drivers alter their trip distances based on season, weather conditions, and time of day, although not always in the expected direction.

The prevalence of complex multimorbidity in Australia

OBJECTIVE

To measure prevalence of multimorbidity and complex multimorbidity in the Australian population from a nationally representative prospective study and to identify the most prevalent patterns of chronic conditions and body systems affected.

METHODS

A sub-study of the nationally representative BEACH program, using a random sample of 8,707 patients at encounters with 290 general practitioners. All diagnosed chronic conditions were recorded for each patient. Multimorbidity was defined as co-occurrence of 2+ chronic conditions, while complex multimorbidity was defined as 3+ body systems each affected by at least one chronic condition.

RESULTS

We estimated: 47.4% of patients at GP encounters and one-third (32.6%) of the population had multimorbidity; and 27.4% of patients at GP encounters and 17.0% of the Australian population had complex multimorbidity. The most prevalent combination pattern of three conditions was hypertension+hyperlipidaemia+ osteoarthritis (5.5% of patient at encounters and 3.3% of the population). Most prevalent combination of three body systems affected was circulatory+musculoskeletal+endocrine / nutritional/metabolic systems (11.1% of patients at encounters and 7.0% of the population).

CONCLUSIONS AND IMPLICATIONS

A significant proportion of Australians have not only multimorbidity, but complex multimorbidity. To meet the challenge posed by complex multimorbidity, the single disease focus of our healthcare system needs to be re-evaluated.

Mortality, hospitalisation, institutionalisation in community-dwelling oldest old: The impact of medication

BACKGROUND

High drug use and associated adverse outcomes are common in older adults. This study investigates association of medication use with mortality, hospitalisation, and institutionalisation in a cohort of community-dwelling oldest old (aged 80 and over).

METHODS

Baseline data included socio-demographic, clinical, and functional characteristics, and prescribed medications. Medications were coded by the Anatomic Therapeutic Chemical classification. Survival analysis was performed at 18 months after inclusion using Kaplan-Meier, and multivariate analysis with Cox regression to control for covariates.

RESULTS

Patients' (n=503) mean age was 84.4 years (range 80-102), and 61.2% was female. The median medication use was 5 (0-16). The mortality, hospitalisation, and institutionalisation rate were 8.9%, 31.0%, and 6.4% respectively. The mortality and hospitalisation group had a higher level of multimorbidity and weaker functional profile. Adjusted multivariate models showed an 11% increased hospitalisation rate for every additional medication taken. No association was found between high medication use and mortality, nor with institutionalisation. A higher association for mortality was observed among verapamil/diltiazem users, hospitalisation was higher among users of verapamil/diltiazem, loop diuretics and respiratory agents. Institutionalisation was higher among benzodiazepines users.

CONCLUSION

In the community-dwelling oldest old (aged 80 and over), high medication was clearly associated with hospitalisation, independent of multimorbidity. The association with mortality was clear in univariate, but not in multivariate analysis. No association with institutionalisation was found. The appropriateness of the high medication use should be further studied in relation to mortality, hospitalisation, and institutionalisation for this specific age group.

The clinical impact of valvular heart disease in a population-based cohort of subjects aged 80 and older

BACKGROUND

In our ageing society, valvular heart diseases (VHD) have become an increasing public health problem. However, the lack of studies describing the impact of these diseases on the outcome of very old subjects makes it difficult to appreciate their real clinical burden.

METHODS

Prospective, observational, population-based cohort study in Belgium. Five hundred fifty six subjects aged 80 years and older were followed up for 5.1 ± 0.25 years for mortality and 3.0 ± 0.25 years for hospitalization. Echocardiograms were performed at baseline. The Cumulative Illness Rating Scale (CIRS) was calculated for each subject.

RESULTS

The prevalence of moderate-to-severe VHD was 17% (n = 97). Mitral stenosis was more prevalent in women and an age-dependent increase of the prevalence of severe aortic stenosis was seen. The overall disease burden was higher in participants with VHD (median CIRS 3 [IQR 3-5] vs 4 [IQR 3-6] (P = 0.008)). Moderate-to-severe VHD, and more specifically mitral stenosis and aortic stenosis, was found to be an independent predictor of both all-cause (HR 1.42 (95% CI 1.04-1.95)) and cardiovascular mortality (HR 2.13 (95% CI 1.38-3.29)). Moderate-to-severe VHD was also found to be an independent predictor of the need for a first unplanned hospitalization (HR 1.43 (95% CI 1.06-1.94)).

CONCLUSIONS

A high prevalence of moderate-to-severe VHD was found in the very old. Moderate-to-severe VHD was identified as an independent risk factor for all-cause and cardiovascular mortality and as well for unplanned hospitalizations, independent of other structural cardiac abnormalities, ventricular function and major co-morbidities.

Detection of potentially inappropriate prescribing in the very old: cross-sectional analysis of the data from the BELFRAIL observational cohort study

BACKGROUND

Little is known about the prevalence and clinical importance of potentially inappropriate prescribing instances (PIPs) in the very old (>80 years). The main objective was to describe the prevalence of PIPs according to START (Screening Tool to Alert doctors to Right Treatment; omissions) and,STOPP (Screening Tool of Older Person's Prescriptions; over/misuse) and the Beers list (over/misuse). Secondary objectives were to identify determinants if PIPs and to assess the clinical importance to modify the treatment in case of PIPs.

METHODS

Cross-sectional analysis of baseline data of the BELFRAIL cohort, which included 567 Belgian patients aged 80 and older in primary care. Two independent researchers applied the screening tools to the study population to detect PIPs. Next, a multidisciplinary panel of experts rated the clinical importance of the PIPs on a subsample of 50 patients.

RESULTS

In this very old population (median age 84 years, 63 % female), the screening detected START-PIPs in 59 % of patients, STOPP-PIPs in 41 % and Beers-PIPs in 32 %. Assessment of the clinical importance revealed that the most frequent PIPs were of moderate or major importance. In 28 % of the subsample, the relevance of the PIP was challenged by the global medical, functional and social background of the patient hence the validity of some criteria was questioned.

CONCLUSION

Potentially inappropriate prescribing is highly prevalent in the very old. A good understanding of the patients' medical, functional and social context is crucial to assess the actual appropriateness of drug treatment.

The Influence of Adult Attachment on Patient Self-Management in Primary Care--The Need for a Personalized Approach and Patient-Centred Care

Objective

Self-management strategies are essential elements of evidence-based treatment in patients with chronic conditions in primary care. Our objective was to analyse different self-management skills and behaviours and their association to adult attachment in primary care patients with multiple chronic conditions.

Methods

In the apricare study (Adult Attachment in Primary Care) we used a prospective longitudinal design to examine the association between adult attachment and self-management in primary care patients with multimorbidity. The attachment dimensions avoidance and anxiety were measured using the ECR-RD. Self-management skills were measured by the FERUS (motivation to change, coping, self-efficacy, hope, social support) and self-management-behaviour by the DSMQ (glucose management, dietary control, physical activity, health-care use). Clinical diagnosis and severity of disease were assessed by the patients’ GPs. Multivariate analyses (GLM) were used to assess the relationship between the dimensions of adult attachment and patient self-management.

Results

219 patients in primary care with multiple chronic conditions (type II diabetes, hypertension and at least one other chronic condition) between the ages of 50 and 85 were included in the study. The attachment dimension anxiety was positively associated with motivation to change and negatively associated with coping, self-efficacy and hope, dietary control and physical activity. Avoidance was negatively associated with coping, self-efficacy, social support and health care use.

Conclusion

The two attachment dimensions anxiety and avoidance are associated with different components of self-management. A personalized, attachment-based view on patients with chronic diseases could be the key to effective, individual self-management approaches in primary care.

Effect evaluation of an interprofessional medication therapy management approach for multimorbid patients in primary care: a cluster-randomized controlled trial in community care (WestGem study protocol)

Background

Pharmaceutical practice worldwide is developing towards patient care. Medication Review (MR) and Medication Therapy Management (MTM) are evolving as the most prominent services in pharmaceutical care and have a strong potential to provide a large benefit for patients and society. MTMs can only be performed in an interprofessional, collaborative setting. Several international studies have explored the effects of a MTM on the quality of therapy and costs. For Germany the data is still deficient. This study aims to provide data on the effects of an interprofessional MTM regarding quality of therapy, quality of life, costs and cost-effectiveness.

Method/Design

The study is designed as a cluster-randomized controlled trial in primary care, involving 12 outpatient clinics (clusters) and 165 patients. Primary care units are allocated to interventions using a Stepped Wedge Design. All units are initially assigned to the control group. After a 6 month observation period, general practitioners (GP) are randomly allocated to one of three groups and the interprofessional medication therapy management approach is implemented sequentially per each group with a lag of 3 months between. The primary outcome is the change in the quality of therapy measured by the MAI (Medication Appropriateness Index). Secondary outcomes include changes in the number of drug related problems, medication complexity, changes in drug-adherence, changes in health-status and function, quality of life, direct costs and the incremental cost-effectiveness ratio. The acceptance of the interprofessional Medication Therapy Management approach is assessed by qualitative methods.

Discussion

The patient interview and brown bag review are activities, typically provided by the pharmacist. In this trial the patient is blinded to the pharmacist. The strength of having the patient blinded to the pharmacists is to exclude skepticism of the patient toward unknown pharmacies, which might be a major confounder in a regional and community setting. A weakness is that some patient related data might reach the pharmacists in a way, which might differ from self-acquired data.

Trial registration

Current controlled trials ISRCTN41595373.

[A way of helping "Mr. Minotaur" and "Ms. Ariadne" to exit from the multiple morbidity labyrinth: the "master problems"]

Multiple morbidity seems to be "infinite" and so is not easy to make useful decisions. A new concept is introduced: the "master problems", as a qualitative method to facilitate the exit from this maze of multiple morbidity. Metaphors from the art world have been used to teach this concept. These "master problems" generally remain hidden and can only "unravel" between the interstices of multiple morbidity, when the details of the system that defines the problem are explained. A problem with "energy" or a "master problem" is complex, multiple and dramatic or theatrical--everything in the clinical history history make us look into that particular question. It is what gives us a blow to the stomach, which causes our hearts to beat faster, that moves us on many levels, which has a high "density of emotions", human elements, social symbols, and opens solutions in a patient.

Multimorbidity among people with HIV in regional New South Wales, Australia

Background Multimorbidity is the co-occurrence of more than one chronic health condition in addition to HIV. Higher multimorbidity increases mortality, complexity of care and healthcare costs while decreasing quality of life. The prevalence of and factors associated with multimorbidity among HIV positive patients attending a regional sexual health service are described.

METHODS

A record review of all HIV positive patients attending the service between 1 July 2011 and 30 June 2012 was conducted. Two medical officers reviewed records for chronic health conditions and to rate multimorbidity using the Cumulative Illness Rating Scale (CIRS). Univariate and multivariate linear regression analyses were used to determine factors associated with a higher CIRS score.

RESULTS

One hundred and eighty-nine individuals were included in the study; the mean age was 51.8 years and 92.6% were men. One-quarter (25.4%) had ever been diagnosed with AIDS. Multimorbidity was extremely common, with 54.5% of individuals having two or more chronic health conditions in addition to HIV; the most common being a mental health diagnosis, followed by vascular disease. In multivariate analysis, older age, having ever been diagnosed with AIDS and being on an antiretroviral regimen other than two nucleosides and a non-nucleoside reverse transcriptase inhibitor or protease inhibitor were associated with a higher CIRS score.

CONCLUSION

To the best of our knowledge, this is the first study looking at associations with multimorbidity in the Australian setting. Care models for HIV positive patients should include assessing and managing multimorbidity, particularly in older people and those that have ever been diagnosed with AIDS.

Multimorbidity in patients enrolled in a community-based methadone maintenance treatment programme delivered through primary care

Background

Multimorbidity, the co-existence of two or more (2+) long-term conditions in an individual, is common among problem drug abusers.

Objective

To delineate the patterns, multimorbidity prevalence, and disease severity in patients enrolled in a community-based primary care methadone maintenance treatment (MMT) programme.

Design

This was a retrospective cohort study (n=274). The comparator group consisted of mainstream primary care patients. Electronic medical record assessment was performed using the Cumulative Illness Rating Scale.

Results

Prevalence of multimorbidity across 2+ domains was significantly higher within the MMT sample at 88.7% (243/274) than the comparator sample at 51.8% (142/274), p<0.001. MMT patients were seven times more likely to have multimorbidity across 2+ domains compared with mainstream patients (OR 7.29, 95% confidence interval 4.68–11.34; p<0.001). Prevalence of multimorbidity was consistently high across all age groups in the MMT cohort (range 87.8–100%), while there was a positive correlation with age in the comparator cohort (r=0.29, p<0.001). Respiratory, psychiatric, and hepatic–pancreatic domains were the three most common domains with multimorbidity. Overall, MMT patients (mean±SD, 1.97±0.43) demonstrated significantly higher disease severity than mainstream patients (mean±SD, 1.18±0.78), p<0.001. Prevalence of moderate disease severity observed in the <45-year MMT age group was 50% higher than the ≥45-year comparator age group.

Conclusions

Prevalence of multimorbidity and disease severity in MMT patients was greater than in the age- and sex-matched comparators. Patients with a history of drug abuse require co-ordinated care for treatment of their addiction, and to manage and prevent chronic illnesses. Community-based programmes delivered through primary care help fulfil this need.

A practice-based analysis of combinations of diseases in patients aged 65 or older in primary care

Background

Most evidence on chronic diseases has been collected for single diseases whereas in reality, patients often suffer from more than one condition. There is a growing need for evidence-based answers to multimorbidity, especially in primary care settings where family doctors (FD’s) provide comprehensive care for a high variety of chronic conditions. This study aimed to define which disease and problem combinations would be most relevant and useful for the development of guidelines to manage multimorbidity in primary care.

Methods

A practice-based cross sectional analysis of clinicians’ chart reviews in 543 patients aged over 65 registered within two family practices in Ghent, Belgium. Main outcome measures were prevalence of disease and problem combinations and association strengths.

Results

The prevalence of multimorbidity (Cumulative Illness Rating Scale >1) in the study sample is 82.6%. The most prevalent combination is hypertension-osteoarthritis (132/543). Moderate to strong associations (Yules Q > 0.50) are reported for 14 combinations but the corresponding prevalences are mostly below 5%. More than half of these associations show a contribution of a psychiatric problem or a social problem.

Conclusions

This study confirms the high prevalence of multimorbidity in patients aged over 65 in primary care. Hypertension-osteoarthritis is defined as a frequent combination however 94% of these patients have more than two disorders. The low prevalence of specific combinations, the high prevalence of psychiatric and social problems and the general complexity of multimorbidity will hamper the usefulness of randomized trials or guidelines at practice level. There is a need to explore new paradigms for addressing multimorbidity.