What Is the Impact of Physical Activity and Physical Function on the Development of Multimorbidity in Older Adults Over Time? A Population-Based Cohort Study

Racial inequalities in the development of multimorbidity of chronic conditions: results from a Brazilian prospective cohort

BACKGROUND

The occurrence of multimorbidity and its impacts have differentially affected population subgroups. Evidence on its incidence has mainly come from high-income regions, with limited exploration of racial disparities. This study investigated the association between racial groups and the development of multimorbidity and chronic conditions in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

METHODS

Data from self-reported white, brown (pardos or mixed-race), and black participants at baseline of ELSA-Brasil (2008-2010) who were at risk for multimorbidity were analysed. The development of chronic conditions was assessed through in-person visits and self-reported diagnosis via telephone until the third follow-up visit (2017-2019). Multimorbidity was defined when, at the follow-up visit, the participant had two or more morbidities. Cumulative incidences, incidence rates, and adjusted incidence rate ratios (IRRs) were estimated using Poisson models.

RESULTS

Over an 8.3-year follow-up, compared to white participants: browns had a 27% greater incidence of hypertension and obesity; and blacks had a 62% and 45% greater incidence, respectively. Blacks also had 58% more diabetes. The cancer incidence was greater among whites. Multimorbidity affected 41% of the participants, with a crude incidence rate of 57.5 cases per 1000 person-years (ranging from 56.3 for whites to 63.9 for blacks). Adjusted estimates showed a 20% higher incidence of multimorbidity in black participants compared to white participants (IRR: 1.20; 95% CI: 1.05-1.38).

CONCLUSIONS

Significant racial disparities in the risk of chronic conditions and multimorbidity were observed. Many associations revealed a gradient increase in illness risk according to darker skin tones. Addressing fundamental causes such as racism and racial discrimination, alongside considering social determinants of health, is vital for comprehensive multimorbidity care. Intersectoral, equitable policies are essential for ensuring health rights for historically marginalized groups.

The association between intensity-specific physical activity and the number of multiple chronic diseases among Chinese elderly: A study based on the China Health and Retirement Longitudinal study (CHARLS)

Background

With ageing, the elderly are facing a complex situation where multiple chronic diseases coexist. This paper aims to investigate the effect of intensity-specific physical activity on the number of multiple chronic diseases in the elderly.

Methods

Our data came from wave 4 of the China Health and Retirement Longitudinal Survey (CHARLS), which involved 10,341 residents aged ≥ 60 years. The intensity-specific physical activity was divided into two categories: moderate-intensity physical activity (MPA) lasting ≥ 150 min/week and vigorous-intensity physical activity (VPA) lasting ≥ 75 min/week. Data on 14 types of chronic diseases were collected. Propensity score matching (PSM) with controlling nine confounding factors were used to analyse the effects of intensity-specific physical activity.

Results

Among 10,341 samples, 40.12% of the elderly often participated in MPA and 25.72% participated in VPA. The PSM results showed that performing 150 min/week of MPA leads to 0.0675(P<0.05) fewer multiple chronic diseases than not achieving this standard, and VPA up to 75 min/week leads to 0.0785(P<0.05) fewer multiple chronic disease than that does not meet this criterion. Additionally, VPA is more effective than MPA.

Conclusion

Both MPA of at least 150 min/week and VPA of at least 75 min/week can significantly reduce the number of multiple chronic diseases in elderly. Elderly people should increase their exercise intensity as much as possible while ensuring safety.

Association between sarcopenia and multimorbidity among middle-aged and older adults in China: Findings from the China Health and Retirement Longitudinal Study

BACKGROUND

Little is known about the association between sarcopenia and multimorbidity among middle-aged and older adults. This study investigated whether sarcopenia is associated with multimorbidity in middle-aged and older Chinese individuals.

MATERIALS AND METHODS

A total of 12,760 participants from China Health and Retirement Longitudinal Study (CHARLS) 2015, with data on 14 specified chronic diseases and sarcopenia status were included in the cross-sectional analysis. A total of 7345 participants without multimorbidity from the CHARLS 2015 were included and followed up in 2018 in the longitudinal analysis. Logistic regression models were used in a cross-sectional investigation to assess the association between sarcopenia status and multimorbidity. In a longitudinal analysis, the relationships between sarcopenia status and multimorbidity were investigated using Cox proportional hazards models.

RESULTS

Multimorbidity was prevalent in the no sarcopenia, possible sarcopenia, and sarcopenia groups at 38.8 % (3765/9713), 56.6 % (1199/2118), and 48.5 % (451/929), respectively. Multivariable regression revealed that both possible sarcopenia (β = 0.088, P<0.001) and sarcopenia (β = 0.028, P = 0.009), contributed to the number of chronic diseases. Logistic regression revealed that possible sarcopenia (OR: 1.56, 95 % CI: 1.39-1.76) was associated with multimorbidity. In the longitudinal analysis, participants in the possible sarcopenia group (HR: 1.19, 95 % CI:1.03-1.38) were more prone to experience new onset multimorbidity than did participants in the no sarcopenia group.

CONCLUSIONS

Possible sarcopenia is associated with the development of multimorbidity in middle-aged and older Chinese populations. Health screening of populations with possible sarcopenia can facilitate early detection of multimorbidity.

Risk factors for multimorbidity in adulthood: A systematic review

BACKGROUND

Multimorbidity, the coexistence of multiple chronic diseases in an individual, is highly prevalent and challenging for healthcare systems. However, its risk factors remain poorly understood.

OBJECTIVE

To systematically review studies reporting multimorbidity risk factors.

METHODS

A PRISMA-compliant systematic review was conducted, searching electronic databases (MEDLINE, EMBASE, Web of Science, Scopus). Inclusion criteria were studies addressing multimorbidity transitions, trajectories, continuous disease counts, and specific patterns. Non-human studies and participants under 18 were excluded. Associations between risk factors and multimorbidity onset were reported.

RESULTS

Of 20,806 identified studies, 68 were included, with participants aged 18-105 from 23 countries. Nine risk factor categories were identified, including demographic, socioeconomic, and behavioral factors. Older age, low education, obesity, hypertension, depression, low pysical function were generally positively associated with multimorbidity. Results for factors like smoking, alcohol consumption, and dietary patterns were inconsistent. Study quality was moderate, with 16.2% having low risk of bias.

CONCLUSIONS

Several risk factors seem to be consistently associated with an increased risk of accumulating chronic diseases over time. However, heterogeneity in settings, exposure and outcome, and baseline health of participants hampers robust conclusions.

Life's Essential 8: Optimizing Health in Older Adults

The population worldwide is getting older as a result of advances in public health, medicine, and technology. Older individuals are living longer with a higher prevalence of subclinical and clinical cardiovascular disease (CVD). In 2010, the American Heart Association introduced a list of key prevention targets, known as "Life's Simple 7" to increase CVD-free survival, longevity, and quality of life. In 2022, sleep health was added to expand the recommendations to "Life's Essential 8" (eat better, be more active, stop smoking, get adequate sleep, manage weight, manage cholesterol, manage blood pressure, and manage diabetes). These prevention targets are intended to apply regardless of chronologic age. During this same time, the understanding of aging biology and goals of care for older adults further enhanced the relevance of prevention across the range of functions. From a biological perspective, aging is a complex cellular process characterized by genomic instability, telomere attrition, loss of proteostasis, inflammation, deregulated nutrient-sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion, and altered intercellular communication. These aging hallmarks are triggered by and enhanced by traditional CVD risk factors leading to geriatric syndromes (eg, frailty, sarcopenia, functional limitation, and cognitive impairment) which complicate efforts toward prevention. Therefore, we review Life's Essential 8 through the lens of aging biology, geroscience, and geriatric precepts to guide clinicians taking care of older adults.

Overweight, obesity and risk of multimorbidity: A systematic review and meta-analysis of longitudinal studies

This study aimed to review and quantify the association between overweight and obesity in the risk of multimorbidity among the general population. We conducted a systematic review and meta-analysis in the databases of Pubmed, Lilacs, Web of Science, Scopus, and Embase. We included cohort studies that assessed the association between overweight and/or obesity with the risk of multimorbidity. The Newcastle-Ottawa assessed the studies' individual quality. A random-effect model meta-analysis was performed to evaluate the association between overweight and obesity with the relative risk (RR) of multimorbidity; the I² test evaluated heterogeneity. After excluding duplicates, we found 1.655 manuscripts, of which eight met the inclusion criteria. Of these, seven (87.5%) evidenced an increased risk of multimorbidity among subjects with overweight and/or obesity. Overall, we observed an increased risk of multimorbidity among subjects with overweight (RR: 1.26; CI95%: 1.12; 1.40, I²  = 98%) and obesity (RR: 1.99; CI95%: 1.45;2.72, I²  = 99%) compared to normal weight. According to the I² test, the heterogeneities of the meta-analyses were high. The Newcastle-Ottawa scale showed that all studies were classified as high quality. Further longitudinal studies are needed, including different populations and stratifications by sex, age, and other variables.

Patterns and Predictors of Multimorbidity in the Azar Cohort

BACKGROUND

The co-existence of chronic diseases (CDs), a condition defined as multimorbidity (MM), is becoming a major public health issue. Therefore, we aimed to determine the patterns and predictors of MM in the Azar Cohort.

METHODS

We evaluated the prevalence of MM in 15,006 (35-70-year old) subjects of the Azar Cohort Study. MM was defined as the co-existence of two or more CDs. Data on the subjects' socioeconomic status, demographics, sleeping habits, and physical activity were collected using questionnaires.

RESULTS

The overall prevalence of MM was 28.1%. The most prevalent CDs, in decreasing order, were obesity, hypertension, depression, and diabetes. Obesity, depression, and diabetes were the most co-occurring CDs. The MM risk increased significantly with age, illiteracy, and in females. Also, the subjects within the lowest tertile of physical activity level (OR=1.89; 95% CI: 1.75-2.05) showed higher MM risk than those with the highest level of physical activity. Findings regarding current smoking status indicated that being an ex-smoker or smoker of other types of tobacco significantly increased the risk of MM.

CONCLUSION

The reduction of MM is possible by promoting public health from an early age among people of various socioeconomic conditions. It is vital to offer the necessary health support to the aging population of Iran.

Development and feasibility of an inter-agency physical activity and education programme for adults with multimorbidity in primary care: Activ8

Background

While physical activity is widely recommended for many long-term conditions, it may be difficult to achieve for patients managing multiple conditions. We aimed to determine the feasibility of an inter-agency exercise and education programme for patients with multimorbidity in primary care.

Methods

We conducted an uncontrolled pilot study with adults with multimorbidity, recruited in two community healthcare organisations in an urban area in Ireland. The six-week pilot intervention combined an individually tailored gym-based exercise programme and education to support self-management. Feasibility of the Activ8 programme was assessed using a mixed methods process evaluation. Outcome measures at baseline and at 6 weeks included recruitment and retention, gait speed, grip strength, quality of life and self-efficacy. Focus groups and interviews explored participants and facilitators’ perceptions of the programme.

Results

19 participants with ≥2 chronic conditions were recruited over three-weeks with similar attrition at both sites (≤40%). Overall, the results indicate that Activ8 was feasible and acceptable to patients and practitioners. Quantitative outcome measures suggested improvements in most outcomes. Qualitative data analysis indicated that Activ8 addressed an overarching concept of patient-centeredness among participants. Three key themes included perceived personal programme impact, the personalised composition of the programme and the evolving nature of primary care practice.

Conclusion

While further definitive evidence is needed and attrition from the programme needs to be considered, the Activ8 Programme was acceptable to both patients and professionals in two different primary care areas with the potential for positive impacts for adults living with multimorbidity.

Physical Activity and Multimorbidity Among Community-Dwelling Older Adults: A Systematic Review With Meta-Analysis

OBJECTIVE

This study evaluated the relationship between physical activity (PA) and multimorbidity in community-dwelling older adults.

DATA SOURCE

A systematic review and meta-analysis in the following databases: Pubmed, Lilacs, Scielo, Web of Science, Scopus, and AgeLine.

STUDY INCLUSION AND EXCLUSION CRITERIA

It included observational studies investigating the association between physical activity and multimorbidity, with older adults, published until May 2021. Studies with institutionalized individuals or that assessed specific diseases were excluded.

DATA EXTRACTION

Two reviewers independently extracted the studies based on previous inclusion and exclusion criteria, started by selecting titles, followed by abstracts and full-text reading.

DATA SYNTHESIS

Meta-analysis results were reported as Odds Ratio (OR) with a 95% confidence interval using R language. The Newcastle Ottawa scale was used to assess the quality of the studies.

RESULTS

Fifteen studies were included in the systematic review, from which 12 reported an inverse association between physical activity and multimorbidity. In the meta-analysis, from over 77 000 older adults, there was an inverse association between physical activity and multimorbidity [OR: .81; 95% CI: .73-.89]. We found significant results only for men in the analysis by sex.

CONCLUSIONS

Low levels of physical activity were associated with a higher risk of multimorbidity in older adults. It is expected that public policies will be conducted aimed at the practice of physical activity among older adults.

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

Aims

The aim of this study is to investigate the prevalence, impact of health determinants on non-communicable diseases (NCDs), and multimorbidity among urban elderly in India.

Methods

This is a cross-sectional study involving a total of 1,671 (870 male and 801 female) respondents aged 60-80 years. Multistage sampling was used for the recruitment of the participants. A total of 12 sample areas from 12 cities of six southern states of south India were selected. Through survey form, information regarding demographic characteristics, health-influencing lifestyle factors, and history of nine NCDs was collected.

Results

The mean age of participants was 68.5 ± 6.01 years.. The prevalence of hypertension was 40.4%, followed by diabetes (31.2%), arthritis (22.1%), sensory impairment (10.1%), heart diseases (7.8%), and dyslipidemia (7.0%). 74.1% of participants had at least one morbidity, and 40.0% of people had multimorbidity. Being overweight is the highest risk health determinant for hypertension, diabetes, heart disease, high cholesterol, stroke, and joint pain. Obese people have 64% more risk of hypertension than people with normal BMI. People with disturbed sleep have increased risk of hypertension, high cholesterol, and joint pain by more than 80% compared to people with proper sleep. Among the modifiable health determinants of obesity, disturbed sleep, constipation, and physical activity up to 30 minutes were positively associated with multimorbidity. Those in the age group of 70 to 80 years have a high risk for NCDs and multimorbidity compared to those in the age group of 60 to 70 years.

Conclusions

A healthy lifestyle is necessary to reduce the burden of NCDs among the elderly. Developing holistic health policies seems an urgent need.

Investigation of the role of sleep and physical activity for chronic disease prevalence and incidence in older Irish adults

Background

Chronic diseases are the leading cause of death worldwide. Many of these diseases have modifiable risk factors, including physical activity and sleep, and may be preventable. This study investigated independent associations of physical activity and sleep with eight common chronic illnesses.

Methods

Data were from waves 1, 3 and 5 of The Irish Longitudinal Study on Ageing (n = 5,680). Inverse probability weighted general estimating equations were used to examine longitudinal lifetime prevalence and cumulative incidence of self-reported conditions.

Results

Sleep problems were significantly associated with increased odds of incident and prevalent arthritis and angina. Additionally sleep problems were associated with higher odds of lifetime prevalence of hypertension and diabetes. Physical activity was negatively associated incident osteoporosis and respiratory diseases and negatively associated with lifetime prevalence of hypertension, high cholesterol and diabetes.

Conclusions

Worse sleep quality and lower physical activity were associated with higher odds of chronic diseases. Interventions to improve sleep and physical activity may improve health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14108-6.

What is the impact of multimorbidity on out-of-pocket healthcare expenditure among community-dwelling older adults in Ireland? A cross-sectional study

OBJECTIVES

Individuals with multimorbidity use more health services and take more medicines. This can lead to high out-of-pocket (OOP) healthcare expenditure. This study, therefore, aimed to assess the association between multimorbidity (two or more chronic conditions) and OOP healthcare expenditure in a nationally representative sample of adults aged 50 years or over.

DESIGN

Cross-sectional analysis of data collected in 2016 from wave 4 of The Irish Longitudinal Study on Ageing.SettingIreland.ParticipantsCommunity-dwelling adults aged 50 years and over.MethodA generalised linear model with log-link and gamma distributed errors was fitted to assess the association between multimorbidity and OOP healthcare expenditure (including general practitioner, emergency department, outpatients, specialist consultations, hospital admissions, home care and prescription drugs).

RESULTS

Overall, 3453 (58.5%) participants had multimorbidity. Among those with any OOP healthcare expenditure, individuals with multimorbidity spent more on average per annum (€806.8 for two conditions, €885.8 for three or more conditions), than individuals with no conditions (€580.3). Pharmacy-dispensed medicine expenditure was the largest component of expenditure. People with multimorbidity on average spent more of their equivalised household income on healthcare (7.1% for two conditions, 9.7% for three or more conditions), than people with no conditions (5.0%). A strong positive association was found between number of conditions and OOP healthcare expenditure (p<0.001) and between having private health insurance and OOP healthcare expenditure (p<0.001). A strong negative association was found between eligibility for free primary/hospital care and heavily subsidised medicines and OOP healthcare expenditure (p<0.001).

CONCLUSIONS

This study suggests that having multimorbidity in Ireland increases OOP healthcare expenditure, which is problematic for those with more conditions who have lower incomes. This highlights the need for this financial burden to be considered when designing healthcare/funding systems to address multimorbidity, so that access to essential healthcare can be maximised for those with greatest need.

Clinically Recognized Varicose Veins and Physical Function in Older Individuals: The ARIC Study

BACKGROUND

Although a few studies reported an association between varicose veins and physical function, this potentially bidirectional association has not been systematically evaluated in the general population.

METHOD

In 5 580 participants (aged 71-90 years) from the Atherosclerosis Risk in Communities study, varicose veins were identified in outpatient and inpatient administrative data prior to (prevalent cases) and after (incident cases) visit 5 (2011-2013). Physical function was evaluated by the Short Physical Performance Battery (SPPB, score ranging from 0 to 12). We evaluated (i) cross-sectional association between prevalent varicose veins and physical function, (ii) association of prevalent varicose veins with subsequent changes in physical function from visit 5 to visits 6 (2016-2017) and 7 (2018-2019), and (iii) association of physical function at visit 5 with incident varicose veins during a median follow-up of 3.6 years (105 incident varicose veins among 5 350 participants without prevalent cases at baseline).

RESULTS

At baseline, varicose veins were recognized in 230 (4.1%) participants and cross-sectionally associated with reduced physical function. Longitudinally, prevalent varicose veins were not significantly associated with a decline in SPPB over time. In contrast, a low SPPB ≤6 was associated with a greater incidence of varicose veins compared to SPPB ≥10 (adjusted hazard ratio 2.13 [95% confidence interval = 1.19, 3.81]).

CONCLUSION

In community-dwelling older adults, varicose veins and low physical function were associated cross-sectionally. Longitudinally, low physical function was a risk factor for incident varicose veins, but not vice versa. Our findings suggest an etiological contribution of low physical function to incident varicose veins.

Multimorbidity patterns and function among adults in low- and middle-income countries: a scoping review protocol

BACKGROUND

A fifth of adults in low- and middle-income countries (LMICs) have multimorbid conditions, which are linked to socio-economic deprivation and aging. Multimorbidity is associated with high rates of functional problems and disability, increased healthcare utilization, and lower quality of life. Literature on multimorbidity and associations with function is mostly from high-income countries (HICs) and focused among older adults. Moreover, data regarding disease patterns and their impact on person-centered outcomes are limited. There is a need for research into understanding common patterns of multimorbidity, and their association with functional impairments, particularly in LMICs. Such information may contribute towards evidence-based and context-relevant strategic policy, planning, and delivery models for health and rehabilitation services, which is imperative in attaining Universal Health Coverage (UHC). The planned scoping review aims to provide an overview of the scope and nature of existing literature on multimorbidity patterns and function among adults in LMICs.

METHODS

A scoping review will be conducted using a five-step framework and reported according to the PRISMA-ScR guidelines. A comprehensive electronic search of PubMed/MEDLINE, Scopus, EBSCOhost, Scielo, Cochrane and Google Scholar will be conducted and updated from the last pilot search ran in September 2020. Studies of any design will be included if they are reported in English, published (between January 1976 and the last search date) in a peer-reviewed journal, and describe multimorbidity patterns and associations with physical functional impairments, activity limitations or participation restrictions among adults in LMICs. Search results will be independently screened by two reviewers and data extraction will cover study characteristics, participants' characteristics, multimorbidity measures, patterns analysis, and functional measures. Descriptive statistics and narrative synthesis will be used to synthesize and summarize findings.

DISCUSSION

Patients with multimorbidity have unique and cross-cutting needs, hence the need for integrated and person-centered approaches to policy, planning, and delivery of medical and rehabilitation services. Considering the shift towards UHC and primary healthcare-led management of chronic diseases, the proposed scoping review is timely. Findings will provide insights into the current extent and scope of multimorbidity research, and guide future inquiry in the field.

TRIAL REGISTRATION

Open Science Framework (OSF), https://osf.io/gcy7z/.

Association of multimorbidity and physical activity among older adults in India: an analysis from the Longitudinal Ageing Survey of India (2017-2018)

OBJECTIVE

To examine the association of multimorbidity and physical activity among older adults in India.

DESIGN

A cross-sectional study was conducted using large representative survey data.

SETTING AND PARTICIPANTS

The study used data from the nationally representative 'Longitudinal Ageing Study in India (LASI),' conducted during 2017-2018. The study included a total sample of 65 336 older adults aged 45 years and above in India.

METHODS

Moderate and vigorous physical activities were measured separately by self-reported questionnaires. Physical activity was calculated as minutes of metabolic equivalent tasks per week. The outcome variable was a categorical variable where 2=the prevalence of more than one morbidity, 1=presence of one morbidity and 0=none. Bivariate analysis and multinomial logistic regression were applied to fulfil the objectives.

RESULTS

27.39% of older adults in India had multimorbidity. 31.02% of older adults did not engage in any moderate physical activities. Also, 59.39% of older adults did not engage in any vigorous physical activities. Older adults reporting low (adjusted relative risk ratio (A RRR): 1.10, 95% CI 1.03 to 1.18) and moderate (A RRR): 1.05, 95% CI 0.98 to 1.13) level of moderate physical activity were significantly more likely to suffer from multimorbidity compared with no involvement in moderate physical activity. However, older adults who reported high (A RRR: 0.79, 95% CI 0.75 to 0.84), moderate (A RRR: 0.88, 95% CI 0.80 to 0.98) and low level of vigorous physical activity (A RRR: 0.94, 95% CI 0.86 to 1.02) had significantly less multimorbidity in comparison to those who never engaged in vigorous physical activity.

CONCLUSION

Lack of physical activity is associated with multimorbidity among older adults. Physical activity promotion should be adopted as a primary strategy in reducing the burden of morbidity and multimorbidity.

Incidence of multimorbidity and associated factors during the COVID-19 pandemic in Brazil: a cohort study

BACKGROUND

Due to the coronavirus disease 2019 (COVID-19) pandemic, access to healthcare services may have become difficult, which may have led to an increase in chronic diseases and multimorbidity.

OBJECTIVES

To assess the incidence of multimorbidity and its associated factors among adults living in the state of Rio Grande do Sul, Brazil.

DESIGN AND SETTING

Cohort study conducted in Rio Grande do Sul, Brazil.

METHODS

We included data from the two waves of the Prospective Study About Mental and Physical Health (PAMPA). Data were collected via online questionnaires between June and July 2020 (wave 1) and between December 2020 and January 2021 (wave 2). Multimorbidity was defined as the presence of two or more diagnosed medical conditions.

RESULTS

In total, 516 individuals were included, among whom 27.1% (95% confidence interval, CI: 23.5-31.1) developed multimorbidity from wave 1 to 2. In adjusted regression models, female sex (hazard ratio, HR: 1.97; 95% CI: 1.19-3.24), middle-aged adults (31-59 years) (HR: 1.78; 95% CI: 1.18-2.70) and older adults (60 or over) (HR: 2.41; 95% CI: 1.25-4.61) showed higher risk of multimorbidity. Back pain (19.4%), high cholesterol (13.3%) and depression (12.2%) were the medical conditions with the highest proportions reported by the participants during wave 2.

CONCLUSION

The incidence of multimorbidity during a six-month period during the COVID-19 pandemic was 27.1% in the state of Rio Grande do Sul, Brazil.

Inequalities in developing multimorbidity over time: A population-based cohort study from an urban, multi-ethnic borough in the United Kingdom

Background

Social and material deprivation accelerate the development of multimorbidity, yet the mechanisms which drive multimorbidity pathways and trajectories remain unclear. We aimed to examine the association between health inequality, risk factors and accumulation or resolution of LTCs, taking disease sequences into consideration.

Methods

We conducted a retrospective cohort of adults aged 18 years and over, registered between April 2005 and May 2020 in general practices in one inner London borough (n = 826,936). Thirty-two long term conditions (LTCs) were selected using a consensus process, based on a definition adapted to the demographic characteristics of the local population. sThe development and resolution of these LTCs were examined according to sociodemographic and clinical risk factors (hypertension; moderate obesity (BMI 30·0-39·9 kg/m2), high cholesterol (total cholesterol > 5 mmol/L), smoking, high alcohol consumption (>14 units per week), and psychoactive substance use), through the application of multistate Markov chain models.

Findings

Participants were followed up for a median of 4.2 years (IQR = 1·8 - 8·4); 631,760 (76%) entered the study with no LTCs, 121,424 (15%) with 1 LTC, 41,720 (5%) with 2 LTCs, and 31,966 (4%) with three or more LTCs. At the end of follow-up, 194,777 (24%) gained one or more LTCs, while 45,017 (5%) had resolved LTCs and 27,021 (3%) died. In multistate models, deprivation (hazard ratio [HR] between 1·30 to 1·64), female sex (HR 1·13 to 1·20), and Black ethnicity (HR 1·20 to 1·30; vs White) were independently associated with increased risk of transition from one to two LTCs, and shorter time spent in a healthy state. Substance use was the strongest risk factor for multimorbidity with an 85% probability of gaining LTCs over the next year. First order Markov chains identified consistent disease sequences including: chronic pain or osteoarthritis followed by anxiety and depression; alcohol and substance dependency followed by HIV, viral hepatitis, and liver disease; and morbid obesity followed by diabetes, hypertension, and chronic pain.

Interpretation

We examined the relations among 32 LTCs, taking the order of disease occurrence into consideration. Distinctive patterns for the development and accumulation of multimorbidity have emerged, with increased risk of transitioning from no conditions to multimorbidity and mortality related to ethnicity, deprivation and gender. Musculoskeletal disorders, morbid obesity and substance abuse represent common entry points to multimorbidity trajectories.

Change in Physical Activity and Function in Patients with Baseline Advanced Nondialysis CKD

BACKGROUND AND OBJECTIVES

Although progressive decline in physical activity and function are common in individuals with worsening CKD, little is known about the effect of dialysis initiation on physical activity. We assessed for any association of progression to dialysis in people with advanced CKD with temporal rates of change in physical activity and function.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Canadian Frailty Observation and Interventions Trial (CanFIT) participants with an eGFR of <30 ml/min per 1.73 m² were included. Outcomes included change in physical activity level, measured using the Physical Activity Scale for the Elderly, and physical function, measured using the chair stand, 4-m gait speed, and grip strength tests. Generalized linear regression models were conducted to determine whether dialysis initiation was associated with greater decline in physical activity or function.

RESULTS

Of 386 individuals, 162 progressed to dialysis. Both assessments were completed by 98% of individuals for the Physical Activity Scale for the Elderly, 86% for the chair stand test, 84% for the gait speed test, and 91% for the grip strength test. Median (interquartile range) interassessment follow-up was 427 (357-578) days for the "stable advanced CKD" group and 606 (428-1000) days for the "progressed to dialysis" group. Self-reported physical activity and gait speed significantly declined in both groups. Mean (SD) chair stand time increased from 20.8 (17.1) to 24.0 (21.0) seconds among patients with stable advanced CKD, and from 18.5 (15.4) to 27.4 (22.2) seconds among those who progressed to dialysis (adjusted difference in change, 5.2 seconds; 95% confidence interval, 0.8 to 9.7 seconds; P=0.02).

CONCLUSIONS

Patients with advanced CKD experience progressive declines in physical activity and function. Transition to dialysis is associated with accelerated decline in physical function, as measured by the chair stand test.

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

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Estimating changes in physical behaviour during lockdowns using accelerometry-based simulations in a large UK cohort

To contain the recent COVID-19 outbreak restrictions have been imposed, which has limited outdoor activity. These physical behaviour changes can have serious health implications, but there is little objective information quantifying these changes. This study aimed to estimate the change in physical behaviour levels during full lockdown conditions using objective data collected from a thigh-worn activity monitor. Data used was from 6,492 individuals in the 1970 British Cohort Study, collected between 2016 and 2018. Using walking bout characteristics, days were classified as either "indoor only" (n=861), "indoor and exercise" (n=167) and "outdoor active" (n=31,934). When compared to "outdoor active" days, "indoor only" days had 6,590 fewer steps per day (2,320 vs 8,876, p < 0.001), a longer sedentary time (1.5 hours, p < 0.001), longer lying time (1.4 hours, p < 0.001) and shorter standing (1.9 hours, p < 0.001) and stepping (1.3 hours, p < 0.001) times. The "indoor and exercise" days had a smaller number of steps compared to "outdoor active" (7,932 vs 8,876, p < 0.05). There is a strong relationship between reduced daily stepping, and increased sedentary time, with a range of poor health outcomes. This has important implications for public health policy and messaging during pandemics.

Sex Differences in the Associations of Handgrip Strength and Asymmetry With Multimorbidity: Evidence From the English Longitudinal Study of Ageing

OBJECTIVES

To determine the sex-specific associations of handgrip strength (HGS) and asymmetry with incident multimorbidity and examine whether these relationships differ by sex.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

Secondary analyses of data from the English Longitudinal Study of Ageing (ELSA, waves 2-8). The analytic sample included 3977 participants (51.4% female) aged ≥50 years who had data for HGS on both hands and were living without multimorbidity at baseline.

MEASURES

HGS was assessed with a handheld dynamometer. Individuals in the lowest tertile of sex-specific age-adjusted HGS were defined as having low HGS. The largest HGS readings from the nondominant and dominant hand were used to calculate HGS ratio [nondominant HGS (kg)/dominant HGS (kg)]. Those with HGS ratio <0.90 or >1.10 had any HGS asymmetry. Further, those with HGS ratio <0.90 had dominant HGS asymmetry, whereas those with HGS ratio >1.10 had nondominant HGS asymmetry. Multimorbidity was defined as the coexistence of ≥2 chronic diseases. Cox proportional hazards regression models were conducted for analyses.

RESULTS

Low HGS was associated with multimorbidity among older men [hazard ratio (HR) 1.20, 95% confidence interval (CI) 1.03-1.40] and women (HR 1.19, 95% CI 1.03-1.38). No significant effect modification by sex was observed (P-interaction = .71). HGS asymmetry increased the risk of multimorbidity in women only (HR 1.23, 95% CI 1.07-1.41). The relationship between HGS asymmetry and multimorbidity risk differed by sex (P-interaction = .01). Similarly, both dominant HGS asymmetry (HR 1.21, 95% CI 1.05-1.40) and nondominant HGS asymmetry (HR 1.32, 95% CI 1.03-1.68) were related to incident multimorbidity in women only. There was a significant interaction between dominant HGS asymmetry and sex (P-interaction = .02).

CONCLUSIONS AND IMPLICATIONS

Examining HGS asymmetry in HGS test protocols can provide novel insights for the predictive power of HGS in the accumulation of diseases, particularly in women.

Prognostic Interplay of Functional Status and Multimorbidity Among Older Patients Discharged From Hospital

OBJECTIVES

The purpose of this study was to investigate the prognostic weight of multimorbidity and functional impairment over long-term mortality among older patients discharged from acute care hospitals.

DESIGN

A prospective multicenter observational study.

SETTING AND PARTICIPANTS

Our series consisted of 1967 adults aged ≥65 years consecutively admitted to acute care wards in Italy, in the context of the Report-AGE project.

METHODS

After signing a written informed consent, all patients underwent comprehensive geriatric assessment by Inter-RAI Minimum Data Set acute care. The primary endpoint of the present study was long-term mortality. Patients were grouped into 3 functional clusters and 3 disease clusters using the K-medians cluster analysis. The association of functional clusters, disease clusters, and Charlson score categories with long-term mortality was investigated through Cox regression analysis and the intercluster classification agreement was further estimated. Finally, the additive effect of either disease clusters or Charlson score on predictive ability of functional clusters was assessed by using changes in Harrell's C-index and categorical Net Reclassification Index (NRI).

RESULTS

Functional clusters, disease clusters, and Charlson score were significant predictors of long-term mortality, but the interclassification agreement was poor. Functional clusters predicted mortality with greater accuracy [C-index 0.66, 95% confidence interval (CI) 0.65-0.68] compared with disease clusters (C-index 0.54, 95% CI 0.53-0.56), and Charlson score (C-index 0.58, 95% CI 0.56-0.59). Adding multimorbidity (NRI 0.23, 95% CI 0.14-0.31) or Charlson score (NRI 0.13, 95% CI 0.03-0.20) to functional cluster model slightly improved the accuracy of prediction.

CONCLUSIONS AND IMPLICATIONS

Functional impairment may better predict prognosis compared with multimorbidity, which may be relevant to optimally address individuals' needs and to design tailored preventive interventions.

Longitudinal Follow-Up Studies on the Bidirectional Association between ADL/IADL Disability and Multimorbidity: Results from Two National Sample Cohorts of Middle-Aged and Elderly Adults

BACKGROUND AND OBJECTIVES

Few studies have investigated the bidirectional relationship between disability and multimorbidity, which are common conditions among the older population. Based on the data from the China Health and Retirement Longitudinal Study (CHARLS) and the Survey of Health, Ageing and Retirement in Europe (SHARE), we aimed to investigate the bidirectional relationship between disability and multimorbidity.

METHODS

The activities of daily living (ADLs) and the instrumental activities of daily living (IADLs) scales were used to measure disability. In stage I, we used multinomial logistic regression to assess the longitudinal association between ADL/IADL disability and follow-up multimorbidity. In stage II, binary logistic regression was used to evaluate the multimorbidity effect on future disability.

RESULTS

Compared with those free of disability, people with disability possessed ascending risks for developing an increasing number of diseases. For ADL disability, the odds ratio (OR) (95% confidence interval [CI]) values of developing ≥4 diseases were 4.10 (2.58, 6.51) and 6.59 (4.54, 9.56) in CHARLS and SHARE; for IADL disability, the OR (95% CI) values were 2.55 (1.69, 3.84) and 4.85 (3.51, 6.70) in CHARLS and SHARE. Meanwhile, the number of diseases at baseline was associated, in a dose-response manner, with future disability. Compared with those without chronic diseases, participants carrying ≥4 diseases had OR (95% CI) values of 4.82 (3.73, 6.21)/4.66 (3.65, 5.95) in CHARLS and 3.19 (2.59, 3.94)/3.28 (2.71, 3.98) in SHARE for developing ADL/IADL disability.

CONCLUSION

The consistent findings across 2 national longitudinal studies supported a strong bidirectional association between disability and multimorbidity among middle-aged and elderly adults. Thus, tailored interventions should be taken to prevent the mutual development of disability and multimorbidity.

The functional burden of diabetic retinopathy in the United States

OBJECTIVE

To study the association between diabetic retinopathy (DR) and physical functional difficulty using contemporary psychometric validation techniques, and to explore the predictors of physical difficulty among those with diabetes, non-proliferative DR (NPDR), or proliferative DR (PDR).

METHODS

Cross-sectional study using the National Health and Nutrition Examination Survey (NHANES) database from 2005-2008. Participants were classified as either (i) no diabetes no DR, (ii) diabetes without DR, (iii) mild/moderate NPDR, or (iv) severe NPDR/PDR. The presence of DR was detected by retinal imaging and severity was graded using the Early Treatment Diabetic Retinopathy Study Protocol. The physical difficulty was assessed using a 13-question self-reported questionnaire, validated using factor analysis and item response theory (graded response model) psychometric techniques. Secondary analyses of diabetes and DR populations most at risk of reporting greater physical functional difficulty were undertaken.

RESULTS

A total of 5321 participants over the age of 40 were included in our study. Of the 13 original physical difficulty questions, one latent trait was identified and 9 questions demonstrated good discrimination and were subsequently retained. In univariable analyses, participants with diabetes and any form of DR all reported significantly higher physical functional difficulty vs those with neither diabetes nor DR (p < 0.01 for all). In multivariable analyses, while those with diabetes or any form of DR remained more likely to report higher physical difficulty vs those with neither diabetes nor DR, only those with severe NPDR/PDR reported substantially higher scores (2.1 sum points higher, p = 0.002). Among participants with diabetes or any form of DR, those with 3 or more medical comorbidities and those with depression reported substantially higher sum physical difficulty scores (p < 0.05 for all).

CONCLUSIONS

Those with diabetes or DR experience greater functional physical difficulty than those without, particularly profound among those with severe forms of DR. For those with DR, the presence of concurrent depression or medical comorbidities conferred a significantly higher risk of physical difficulty. Providers and healthcare systems should be aware of particularly vulnerable DR populations at increased risk of experiencing daily functioning deficits.

Risk recognition and identification of sports activities in colleges and universities

Recently, Intense training in specialized sport among colleges and universities has steadily improved. Although most sportspeople accept that some degree of expertise in sport is required to achieve the elite stage, there is controversy over risk recognition and identification of sports activities in colleges and universities to optimize future performance. There is concern that a young athlete can suffer from sports specialization before adolescence due to various risk factors such as injuries, social tension, and hypertension etc..,. Furthermore, PubMed and OVID are looking to discuss sports specialization and athlete experience-based consensus opinions and position statements based on Universities and Colleges. Risk recognition and identification tools are developed to identify the locations of athletes within the specialization spectrum using Linear Structural Modeling (LSM). Here, a degree of sports expertise is needed to create elite skill levels to overcome risk factors that have been suggested in the linear model. In most sports, though, such accelerated preparation should be deferred until late adolescence to reduce risk factors. The psychological burden has been analyzed for recognition, and classification based on the case study has been firmly researched in this paper.

Physical Activity, Mental Health and Consumption of Medications in Pre-Elderly People: The National Health Survey 2017

Background: The promotion of Physical Activity (PA) is an important public health goal to reduce comorbidity and diseases associated with aging such as anxiety and depression. Aim: To investigate the association between level of PA, mental health and the consumption of medications among a representative cohort of Spanish pre-elderly people. Methods: Cross-sectional study with 5977 participants aged 50 to 64 years who participated in the National Health Survey in Spain 2017. The levels of PA were evaluated using the International Physical Activity Questionnaire and the mental conditions were measured by the Goldberg Health Questionnaire-12 (GHQ-12). The chi-square test was used for qualitative variables; Pearson’s correlation was conducted between GHQ-12 score with different quantitative variables; and a logistic regression was used to determine the association between PA and mental health with the sociodemographic characteristics. Results: The participants were 51.9% women and 48.1% men with a mean age of 56.79 years, and 35.5% of participants had a low level of PA. A low level of PA was associated with cases of mental health vulnerability, anxiety and depression (in women), the consumption of more medications and greater multimorbidity. Conclusion: It is important that people reach old age with an optimal health status in order to reduce age-related disability and morbidity. More than a third of the Spanish pre-elderly do not reach the levels of PA recommended by the WHO. People who had low level of PA consumed more medications and had higher mental health vulnerability and greater multimorbidity.

Age-Related Macular Degeneration and Visual and Physical Disability in a Nationally Representative Sample from the United States

Purpose

Outline the association between age-related macular degeneration (AMD) and functional difficulty using novel item response theory (IRT) psychometric techniques, and highlight populations particularly at risk of functional impairment.

Methods

This cross-sectional study included 5604 US adults. Primary outcomes were item response theory–adjusted visual and physical difficulty scores. Secondary analyses of AMD populations at highest risk of reporting greater functional difficulty were undertaken.

Results

In total, there were 386 participants with early AMD (mean presenting visual acuity [pVA], 0.12) and 55 with late AMD (mean pVA, 0.35). Those with late AMD reported substantially higher item visual difficulty, whereas those with both early/late AMD reported significantly higher item physical difficulty versus those with no AMD (P < .05). In univariate regression, only those with late AMD reported significantly higher visual difficulty versus those with no AMD (10.1 points [95% confidence interval (CI), 8.2–12.1 points] vs 7.1 points [95% CI, 7.0–7.2 points]; P = .003). Both early/late AMD reported higher physical difficulty versus those with no AMD (11.6 points [95% CI, 11.1–12.1 points; P = .005]; 13.4 points [95% CI, 11.8–15.0 points; P = .03], respectively, versus 11.0 points [95% CI, 10.9–11.1 points]. After adjustment for sociodemographic and medical variables (excluding pVA), only those with late AMD reported significantly greater visual and physical difficulty versus those with no AMD (10.0 points [95% CI, 8.2–11.9 points] vs 7.1 [95% CI, 7.0–7.2 points; P = .002]; and 12.7 points [95% CI, 11.3–14.0 points] vs 11.0 [95% CI, 10.9–11.1 points; P = .02], respectively); greater visual difficulty in those with late AMD persisted after additionally adjusting for pVA versus those with no AMD (9.1 points [95% CI, 7.6–10.6 points] vs 7.1 points [95% CI, 7.0–7.2 points; P = .01]). Among individuals with AMD, lower income, higher medical comorbidities, depression, and pVA predicted greater visual and physical difficulties.

Conclusions

AMD confers significant functional difficulty among US adults with sociodemographic characteristics influencing dysfunction; highlighting the value of alternatives to Snellen visual acuity in assessing visual characteristics. With aging populations and the increasing prevalence of AMD, health care professionals should be aware of the functional burden of AMD and recognize those at higher risk of functional difficulty.

Translational Relevance

Contemporary psychometric validation techniques can be effective in accurately describing the level of functional impairment for those with visual impairment.

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

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

Chronic kidney disease in the context of multimorbidity patterns: the role of physical performance : The screening for CKD among older people across Europe (SCOPE) study

Background

Chronic kidney disease (CKD) is known to be associated with several co-occurring conditions. We aimed at exploring multimorbidity patterns associated with CKD, as well as the impact of physical performance and CKD severity on them in a population of older outpatients.

Methods

Our series consisted of 2252 patients enrolled in the Screening of CKD among Older People across Europe multicenter observational study. Hypertension, stroke, transient ischemic attack, cancer, hip fracture, osteoporosis, Parkinson’s disease, asthma, chronic obstructive pulmonary disease, congestive heart failure, angina, myocardial infarction, atrial fibrillation, anemia, CKD (defined as GFR < 60, < 45 or < 30 ml/min/1.73 m²), cognitive impairment, depression, hearing impairment and vision impairment were included in the analyses. Physical performance was assessed by the Short Physical Performance Battery (SPPB) and used as stratification variable. Pairs of co-occurring diseases were analyzed by logistic regression. Patterns of multimorbidity were investigated by hierarchical cluster analysis.

Results

CKD was among the most frequently observed conditions and it was rarely observed without any other co-occurring disease. CKD was significantly associated with hypertension, anemia, heart failure, atrial fibrillation, myocardial infarction and hip fracture. When stratifying by SPPB, CKD was also significantly associated with vision impairment in SPPB = 5–8 group, and hearing impairment in SPPB = 0–4 group. Cluster analysis individuated two main clusters, one including CKD, hypertension and sensory impairments, and the second including all other conditions. Stratifying by SPPB, CKD contribute to a cluster including diabetes, anemia, osteoporosis, hypertension and sensory impairments in the SPPB = 0–4 group. When defining CKD as eGFR< 45 or 30 ml/min/1.73 m², the strength of the association of CKD with hypertension, sensory impairments, osteoporosis, anemia and CHF increased together with CKD severity in pairs analysis. Severe CKD (eGFR< 30 ml/min/1.73 m²) contributed to a wide cluster including cardiovascular, respiratory and neurologic diseases, as well as osteoporosis, hip fracture and cancer.

Conclusions

CKD and its severity may contribute significantly to specific multimorbidity patterns, at least based on the cluster analysis. Physical performance as assessed by SPPB may be associated with not negligible changes in both co-occurring pairs and multimorbidity clusters.

Trial registration

The SCOPE study is registered at clinicaltrials.gov (NCT02691546).

Pathogenesis of multimorbidity-what is known?

Background

Multimorbidity is gaining increasing attention due to its substantial medical, healthcare political and social challenges. So far, however, there have been only few studies attempting to characterize the underlying pathogenesis.

Method

A selective literature search was carried out in PubMed.

Results

There is no generally accepted definition of multimorbidity. In the studies published so far, attempts have mostly been made to identify frequent clusters of diseases. In order to prevent multimorbidity, however, it is necessary to characterize the underlying mechanisms of development in more detail. For this purpose, a concept is presented based on the previously published data, in particular from longitudinal studies showing the importance of known risk factors. Possible pathogenetic processes involving multimorbidity are briefly discussed.

Conclusion

For most pathogenetic processes leading to multimorbidity there is no suitable pharmacological treatment available; however, behavior such as lack of exercise, dietary habits, smoking and high alcohol consumption are of considerable importance for the development of multimorbidity and can in principle be influenced by treatment.

Associations between Multimorbidity and Physical Performance in Older Chinese Adults

Background: Evidence on the association between physical performance and multimorbidity is scarce in Asia. This study aimed to identify multimorbidity patterns and their association with physical performance among older Chinese adults. Methods: Individuals aged ≥60 years from the China Health and Retirement Longitudinal Study 2011-2015 (N = 10,112) were included. Physical performance was measured by maximum grip strength (kg) and average gait speed (m/s) categorized as fast (>0.8 m/s), median (>0.6-0.8 m/s), and slow (≤0.6 m/s). Multimorbidity patterns were explored using exploratory factor analysis. Generalized estimating equation was conducted. Results: Four multimorbidity patterns were identified: cardio-metabolic, respiratory, mental-sensory, and visceral-arthritic. An increased number of chronic conditions was associated with decreased normalized grip strength (NGS). Additionally, the highest quartile of factor scores for cardio-metabolic (β = -0.06; 95% Confidence interval (CI) = -0.07, -0.05), respiratory (β = -0.03; 95% CI = -0.05, -0.02), mental-sensory (β = -0.04; 95% CI = -0.05, -0.03), and visceral-arthritic (β = -0.04; 95% CI = -0.05, -0.02) patterns were associated with lower NGS compared with the lowest quartile. Participants with ≥4 chronic conditions were 2.06 times more likely to have a slow gait speed. Furthermore, the odds ratios for the highest quartile of factor scores of four patterns with slow gait speed compared with the lowest quartile ranged from 1.26-2.01. Conclusion: Multimorbidity was related to worse physical performance, and multimorbidity patterns were differentially associated with physical performance. A shift of focus from single conditions to the requirements of a complex multimorbid population was needed for research, clinical guidelines, and health-care services. Grip strength and gait speed could be targeted to routinely measure clinical performance among older adults with multimorbidity, especially mental-sensory disorders, in clinical settings.

Physical Activity, Ability to Walk, Weight Status, and Multimorbidity Levels in Older Spanish People: The National Health Survey (2009-2017)

Background. Many studies have shown a relationship between physical functioning and health status in older people. Aim. The purpose of this study was to analyze the temporal trends of physical activity (PA), ability to walk, weight status, self-perceived health, and disease or chronic health problems in people over 65 years from 2009 to 2017, using the European Health Survey in Spain and the National Health Survey in Spain. Methods. This study included 13,049 older people: 6026 (2330 men and 3696 women; age (mean, SD (Standard Deviation)) = 75.61 ± 7.11 years old) in 2009 and 7023 (2850 men and 4173 women; age (mean, SD) = 76.01 ± 7.57 years old) in 2017. Results. In 2017, older people exhibited lower values of moderate PA (p < 0.001), a lower number of hours of walking per week (p < 0.001), and worse self-perceived health status (p < 0.001) compared to 2009. These differences are maintained when comparing the sexes. Compliance with PA recommendations was 27.9% and 6.1% (chi-squared = 352.991, p < 0.001) in 2009 and 2017, respectively. There were no significant differences in weight status between older people in 2009 and 2017. In 2017, older people had significantly high percentages of disease or chronic health problems (p < 0.05), number of diseases (p < 0.001), severe difficulty walking 500 m without assistance (p < 0.05), and severe difficulty going up or down 12 stairs. Conclusions. From 2009 to 2017, Spanish older people worsened their PA levels and perception of their health status, and they increased their disease levels, which could be associated with the worsening of ability to walk in 2017.

Age-Friendly Environments, Active Lives? Associations Between the Local Physical and Social Environment and Physical Activity Among Adults Aged 55 and Older in Ireland

Despite the benefits, one in three older adults in Ireland has low activity levels. This study examined associations between the local social and built environment and physical activity of older adults to identify age-friendly factors that support physical activity among the aging population. Data were from the population-representative Healthy and Positive Ageing Initiative Age-Friendly City and Counties Survey (N = 10,540). Physical activity was measured using a short-form of the International Physical Activity Questionnaire. Mixed-effects negative binomial regression models were adjusted for known health and sociodemographic correlates of physical activity. Results are reported as unstandardized beta coefficients (β) with standard errors. Loneliness, community participation, and difficulty in accessing green spaces partially explained the differences in the number of minutes that respondents were physically active. Combined with individual-level behavior change interventions, improvements to the local environment and promoting social connectedness may also be useful in promoting physical activity among older adults.

Patterns of physical activity and health-related quality of life amongst patients with multimorbidity in a multi-ethnic Asian population

Background

The co-occurrence of two or more chronic medical conditions in an individual is defined as multimorbidity. Lifestyle factors, including poor dietary patterns, physical inactivity, tobacco use, and excessive alcohol consumption are key modifiable risk factors that play a role in the development of chronic medical conditions and potentially multimorbidity. The current study aimed to examine the level of physical activity among those with multimorbidity and its association with socio-demographic factors, clinical parameters, and health-related quality of life (HRQoL) among community-dwelling adults attending a primary care clinic in Singapore.

Methods

This cross-sectional study was conducted among patients with multimorbidity between August 2014 and June 2016. Physical activity was measured using the International Physical Activity Questionnaire (IPAQ) Short Form. HRQoL was measured using the EuroQol-5 Dimension (EQ-5D-3 L). Data on clinical parameters including hemoglobin A1c (HbA1C), low-density lipoprotein cholesterol (LDL-C), and blood pressure were collected from patient records. Multivariable logistic regression analysis and linear regression were performed to determine the association between IPAQ and clinical health outcomes, as well as HRQoL measures, respectively.

Results

In all, 932 respondents with multimorbidity were recruited for the study. Of these, 500 (53.8%) had low physical activity, 325 (35.0%) had moderate physical activity, while 104 (11.2%) had high physical activity. Respondents who were insufficiently active had significantly higher odds of being overweight/ obese (OR: 1.5, 95% confidence interval [CI]: 1.1–1.9, p = 0.01) as compared to those who were sufficiently physically active. The multiple linear regression model revealed that insufficient activity level was negatively associated with EQ-5D index score (β = − 0.05, p <  0.001) and the visual analogue scale (β = − 4.4, p <  0.001) measuring HRQoL as compared to sufficient activity levels in respondents with multimorbidity.

Conclusions

The low levels of physical activity among patients with multimorbidity, and its association with overweight status and poorer HRQoL emphasizes the importance of increasing physical activity in this population. Family physicians treating patients with chronic diseases need to continue encouraging and helping individuals to initiate and maintain appropriate physical activity levels.

Strength and multimorbidity among community-dwelling elderly from southern Brazil

OBJECTIVE

The number of chronic diseases is associated with the reduction in muscle mass and strength in older people (≥60 y of age). The purpose of this study was to asses the association between multimorbidities and handgrip strength in older community-dwelling individuals from a city in southern Brazil, identifying potential differences according to sex and loss of muscle mass.

METHODS

This was a cross-sectional population-based study among older individuals living in the urban area of Pelotas, Rio Grande do Sul, Brazil. Grip strength was assessed with digital dynamometers according to the criteria of the European Working Group on Sarcopenia in Older People (EWGSOP) to define dynapenia. Multimorbidity was defined by self-report as the presence of at least 5 diseases diagnosed by a physician. Covariates of the study were age, sex, socioeconomic status, schooling, marital status, nutritional status, alcohol consumption, and smoking habits. Statistical analyses were stratified according to the presence of myopenia (low muscle mass).

RESULTS

We received completed information from 1336 individuals ≥60 y of age. Multimorbidity was 50% and 16% more prevalent, respectively, among men and women classified in the lower quartile of manual grip strength (prevalence ratio [PR], 1.50; 95% confidence interval [CI], 1.15-1.95 for men and PR, 1.16; 95% CI, 1.03-1.32 for women) compared with those from the upper quartile. Among men without myopenia, the presence of dynapenia increased the odds of having multimorbidity (PR, 1.42; 95% CI, 1.18-1.71). Among those with myopenia, there was a 10% increase in the prevalence of multimorbidity only for women with dynapenia (PR, 1.10; 95% CI, 1.00-1.21).

CONCLUSION

Results from the present study indicated an association between manual grip strength and multimorbidity among this population, and the effect measures were greater in men. Manual grip strength proved to be a good marker of health in this population, especially in those who did not present with myopenia.

Do Older Adults with Multimorbidity Meet the Recommended Levels of Physical Activity? An Analysis of Scottish Health Survey

There is a positive association between physical activity (PA) and improved health in older adults. The objective of this study was to assess the prevalence and determinants of meeting recommended levels of PA among older adults with multimorbidity. Data has been derived from the nationally representative Scottish Health Surveys (2014–2017). A sub-sample of 2230 older adults (aged 65+) with multimorbidity were the study participants. Physical activity was evaluated using current recommended guidelines. Overall, 32.3% of the participants met the recommended levels of PA. Independent predictors of meeting the recommended levels of PA include male gender [odds ratio (OR) 2.00 (95% confidence interval (CI) 1.58–2.54)], living in the least deprived areas [OR 1.79 (95% CI 1.20–2.69)]; being a non-smoker [OR 2.22 (95% CI 1.48–3. 34)]. Also, meeting recommended PA decreased with age [OR 0.92 (95% CI 0.90–0.94)] and body mass index [OR 0.93 (95% CI 0.91–0.95]; but increased per additional portion of fruit and vegetables taken [OR 1.19 (95% CI 1.12–1.25)] and with increase in well-being scale score [OR 1.05 (95% CI 1.03 to 1.06)]. Adherence to PA guidelines seems to be more related to age, BMI, gender (i.e. higher PA adherence in men vs. women), social support (i.e. social deprivation), dietary habits (i.e. fruit and vegetable intake) and social isolation among the elderly. In the one-third of older population, adherence to PA was associated to better mental health. Therefore, adaptation of PA guideline to suit theses determinants factors would reduce the gap difference among older adults with multimorbidity and enhance their mental well-being.

Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways

This review discusses the interplay between multimorbidity (i.e. co-occurrence of more than one chronic health condition in an individual) and functional impairment (i.e. limitations in mobility, strength or cognition that may eventually hamper a person's ability to perform everyday tasks). On the one hand, diseases belonging to common patterns of multimorbidity may interact, curtailing compensatory mechanisms and resulting in physical and cognitive decline. On the other hand, physical and cognitive impairment impact the severity and burden of multimorbidity, contributing to the establishment of a vicious circle. The circle may be further exacerbated by people's reduced ability to cope with treatment and care burden and physicians' fragmented view of health problems, which cause suboptimal use of health services and reduced quality of life and survival. Thus, the synergistic effects of medical diagnoses and functional status in adults, particularly older adults, emerge as central to assessing their health and care needs. Furthermore, common pathways seem to underlie multimorbidity, functional impairment and their interplay. For example, older age, obesity, involuntary weight loss and sedentarism can accelerate damage accumulation in organs and physiological systems by fostering inflammatory status. Inappropriate use or overuse of specific medications and drug-drug and drug-disease interactions also contribute to the bidirectional association between multimorbidity and functional impairment. Additionally, psychosocial factors such as low socioeconomic status and the direct or indirect effects of negative life events, weak social networks and an external locus of control may underlie the complex interactions between multimorbidity, functional decline and negative outcomes. Identifying modifiable risk factors and pathways common to multimorbidity and functional impairment could aid in the design of interventions to delay, prevent or alleviate age-related health deterioration; this review provides an overview of knowledge gaps and future directions.

Handgrip strength, chronic physical conditions and physical multimorbidity in middle-aged and older adults in six low- and middle income countries

PURPOSE

Handgrip strength provides a clinically validated marker of overall health and mortality risk. There are however, no multi-national population-based studies investigating the associations between handgrip strength, chronic physical conditions, and physical multimorbidity (i.e., ≥2 chronic conditions). We aimed to assess these associations among community-dwelling middle-aged and older adults using nationally representative data from six in low- and middle-income countries (LMICs).

METHODS

Cross-sectional, community-based data on individuals aged ≥50 years from the World Health Organization's Study on Global Ageing and Adult Health were analyzed. Eleven chronic physical conditions (angina, arthritis, asthma, chronic back pain, chronic lung disease, diabetes, edentulism, hearing problems, hypertension, stroke, visual impairment) were assessed. Weak handgrip strength was defined as <30 kg for men and <20 kg for women. Multivariable logistic regression analysis was conducted.

RESULTS

The final sample included 34,129 individuals (62.4 ± 16.0 years; 52.1% female). After adjustment for potential confounders, when compared to those with no chronic physical conditions, having 1, 2, 3, and ≥4 physical chronic conditions was associated with 1.22 (95%CI = 1.08-1.37), 1.29 (95%CI = 1.11-1.50), 1.41 (95%CI = 1.18-1.68), and 1.78 (95%CI = 1.46-2.18) times higher odds for weak handgrip strength. Similar associations were observed in the analyses stratified by age and sex. There was a moderate level of between-country heterogeneity in the association between weak handgrip strength and physical multimorbidity (Higgin's I² = 67.8%) with the pooled estimate being 1.26 (95%CI = 1.06-1.50).

CONCLUSION

Weaker handgrip strength is associated with a range of chronic physical conditions and multimorbidity. Future research should seek to establish the predictive value of this inexpensive measure for clinical use.

Performance-based clinical tests of balance and muscle strength used in young seniors: a systematic literature review

BACKGROUND

Many balance and strength tests exist that have been designed for older seniors, often aged ≥70 years. To guide strategies for preventing functional decline, valid and reliable tests are needed to detect early signs of functional decline in young seniors. Currently, little is known about which tests are being used in young seniors and their methodological quality. This two-step review aims to 1) identify commonly used tests of balance and strength, and 2) evaluate their measurement properties in young seniors.

METHODS

First, a systematic literature search was conducted in MEDLINE to identify primary studies that employed performance-based tests of balance and muscle strength, and which aspects of balance and strength these tests assess in young seniors aged 60-70. Subsequently, for tests used in ≥3 studies, a second search was performed to identify method studies evaluating their measurement properties. The quality of included method studies was evaluated using the Consensus-based Standards for selection of health Measurement Instruments (COSMIN) checklist.

RESULTS

Of 3454 articles identified, 295 met the inclusion criteria. For the first objective, 69 balance and 51 muscle strength tests were identified, with variations in administration mode and outcome reporting. Twenty-six balance tests and 15 muscle strength tests were used in ≥3 studies, with proactive balance tests and functional muscle power tests used most often. For the second objective, the search revealed 1880 method studies, of which nine studies (using 5 balance tests and 1 strength test) were included for quality assessment. The Timed Up and Go test was evaluated the most (4 studies), while the Community Balance and Mobility (CBM) scale was the second most assessed test (3 studies). For strength, one study assessed the reliability of the Five times sit-to-stand.

CONCLUSION

Commonly used balance and muscle strength tests in young seniors vary greatly with regards to administration mode and outcome reporting. Few studies have evaluated measurement properties of these tests when used in young seniors. There is a need for standardisation of existing tests to improve their informative value and comparability. For measuring balance, the CBM is a new and promising tool to detect even small balance deficits in balance in young seniors.

Prevalence of multimorbidity in community settings: A systematic review and meta-analysis of observational studies

BACKGROUND

With ageing world populations, multimorbidity (presence of two or more chronic diseases in the same individual) becomes a major concern in public health. Although multimorbidity is associated with age, its prevalence varies. This systematic review aimed to summarise and meta-analyse the prevalence of multimorbidity in high, low- and middle-income countries (HICs and LMICs).

METHODS

Studies were identified by searching electronic databases (Medline, Embase, PsycINFO, Global Health, Web of Science and Cochrane Library). The term 'multimorbidity' and its various spellings were used, alongside 'prevalence' or 'epidemiology'. Quality assessment employed the Newcastle-Ottawa scale. Overall and stratified analyses according to multimorbidity operational definitions, HICs/LMICs status, gender and age were performed. A random-effects model for meta-analysis was used.

RESULTS

Seventy community-based studies (conducted in 18 HICs and 31 LMICs) were included in the final sample. Sample sizes ranged from 264 to 162,464. The overall pooled prevalence of multimorbidity was 33.1% (95% confidence interval (CI): 30.0-36.3%). There was a considerable difference in the pooled estimates between HICs and LMICs, with prevalence being 37.9% (95% CI: 32.5-43.4%) and 29.7% (26.4-33.0%), respectively. Heterogeneity across studies was high for both overall and stratified analyses (I 2 > 99%). A sensitivity analysis showed that none of the reviewed studies skewed the overall pooled estimates.

CONCLUSION

A large proportion of the global population, especially those aged 65+, is affected by multimorbidity. To allow accurate estimations of disease burden, and effective disease management and resources distribution, a standardised operationalisation of multimorbidity is needed.