Gender Differences between Multimorbidity and All-Cause Mortality among Older Adults

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Comorbidity patterns in cardiovascular diseases: the role of life-stage and socioeconomic status

Cardiovascular diseases stand as a prominent global cause of mortality, their intricate origins often entwined with comorbidities and multimorbid conditions. Acknowledging the pivotal roles of age, sex, and social determinants of health in shaping the onset and progression of these diseases, our study delves into the nuanced interplay between life-stage, socioeconomic status, and comorbidity patterns within cardiovascular diseases. Leveraging data from a cross-sectional survey encompassing Mexican adults, we unearth a robust association between these variables and the prevalence of comorbidities linked to cardiovascular conditions. To foster a comprehensive understanding of multimorbidity patterns across diverse life-stages, we scrutinize an extensive dataset comprising 47,377 cases diagnosed with cardiovascular ailments at Mexico's national reference hospital. Extracting sociodemographic details, primary diagnoses prompting hospitalization, and additional conditions identified through ICD-10 codes, we unveil subtle yet significant associations and discuss pertinent specific cases. Our results underscore a noteworthy trend: younger patients of lower socioeconomic status exhibit a heightened likelihood of cardiovascular comorbidities compared to their older counterparts with a higher socioeconomic status. By empowering clinicians to discern non-evident comorbidities, our study aims to refine therapeutic designs. These findings offer profound insights into the intricate interplay among life-stage, socioeconomic status, and comorbidity patterns within cardiovascular diseases. Armed with data-supported approaches that account for these factors, clinical practices stand to be enhanced, and public health policies informed, ultimately advancing the prevention and management of cardiovascular disease in Mexico.

Sex differences in the reciprocal relationship between glycemic control and depressive symptoms among older adults with diabetes: Using a nationwide population-based sample

AIM

As life expectancy increases worldwide, the prevalence and the disease burden of diabetes in older adults are also increasing. This study aimed to examine sex differences in the reciprocal relationship between glycemic control and depressive symptoms among older adults with diabetes by using longitudinal data at two timepoints.

METHODS

Wave 1 (W1, 2016-2017) and wave 2 (W2, 2018-2019) data from the Korean Frailty and Aging Cohort Study were used. Finally, 416 older adults with diabetes who satisfied the inclusion criteria were analyzed (215 males, 201 females). The reciprocal relationship between depressive symptoms and glycosylated hemoglobin A1c (HbA1c) levels was examined using a cross-lagged panel model.

RESULTS

HbA1c levels and depressive symptoms at earlier time points were the most significant factors contributing to HbA1c levels and depressive symptoms at later timepoints. The relationship between HbA1c level and depressive symptoms differed according to sex. The cross-path from depressive symptoms (W1) to HbA1c levels (W2) was positively statistically significant in males (β = 0.18, SD = 0.05, P = 0.001). The path from HbA1c levels (W1) to depressive symptoms (W2) was positively statistically significant in females (β = 0.12, SD = 0.06, P = 0.032).

CONCLUSIONS

Early management of blood glucose levels and depressive symptoms is important in older adults with diabetes. Moreover, glycemic control through social activities in the community could be effective in relieving depressive symptoms in older females with diabetes, and managing depressive symptoms and glucose levels together could be effective in glycemic control in older males with diabetes. Geriatr Gerontol Int 2024; 24: 32-39.

Multimorbidity and 11-year mortality in adults: a prospective analysis using the Chilean National Health Survey

Research on morbidity and mortality often emphasizes individual diseases over the cumulative effects of multimorbidity, especially in low- and middle-income countries. This study aimed to analyze the association between multimorbidity and all-cause mortality in a representative sample of the Chilean population. This longitudinal study used data from 3701 subjects aged ≥15 years who participated in the Chilean National Health Survey conducted between 2009 and 2010. We included 16 self-reported highly prevalent morbidities. All-cause mortality data from an 11-year follow-up were collected from the Chilean Civil Registry. The Cox proportional hazard model, adjusted for confounders, determined the association between multimorbidity categories and all-cause mortality. Of the total sample, 24.3% reported no morbidity, while 50.4% two or more. After adjustment, participants with four or more morbidities had a 1.66 times higher mortality risk [95% confidence interval (CI): 1.03-2.67] than those without morbidities. The mortality risk increased by 10% for each additional morbidity [HR: 1.09 (CI: 1.04-1.16)]. Multimorbidity was common in the Chilean population and increased the mortality risk, which greatly challenges the health system to provide an integral and coordinated approach to healthcare.

Clustering by multiple long-term conditions and social care needs: a cross-sectional study among 10 026 older adults in England

BACKGROUND   : People with multiple long-term conditions (MLTC) face health and social care challenges. This study aimed to classify people by MLTC and social care needs (SCN) into distinct clusters and quantify the association between derived clusters and care outcomes. METHODS : A cross-sectional study was conducted using the English Longitudinal Study of Ageing, including people with up to 10 MLTC. Self-reported SCN was assessed through 13 measures of difficulty with activities of daily living, 10 measures of mobility difficulties and whether health status was limiting earning capability. Latent class analysis was performed to identify clusters. Multivariable logistic regression quantified associations between derived MLTC/SCN clusters, all-cause mortality and nursing home admission. RESULTS: Our study included 9171 people at baseline with a mean age of 66.3 years; 44.5% were men. Nearly 70.8% had two or more MLTC, the most frequent being hypertension, arthritis and cardiovascular disease. We identified five distinct clusters classified as high SCN/MLTC through to low SCN/MLTC clusters. The high SCN/MLTC included mainly women aged 70-79 years who were white and educated to the upper secondary level. This cluster was significantly associated with higher nursing home admission (OR=8.71; 95% CI: 4.22 to 18). We found no association between clusters and all-cause mortality. CONCLUSIONS: We have highlighted those at risk of worse care outcomes, including nursing home admission. Distinct clusters of individuals with shared sociodemographic characteristics can help identify at-risk individuals with MLTC and SCN at primary care level.

Multimorbidity patterns and mortality in older adults: Results from the KORA-Age study

The coexistence of several chronic diseases is very common in older adults, making it crucial to understand multimorbidity (MM) patterns and associated mortality. We aimed to determine the prevalence of MM and common chronic disease combinations, as well as their impact on mortality in men and women aged 65 years and older using the population-based KORA-Age study, based in South of Germany. The chronic disease status of the participants was determined in 2008/9, and mortality status was followed up until 2016. MM was defined as having at least two chronic diseases. We used Cox proportional hazard models to calculate the hazard ratios (HRs) and the 95% confidence intervals (CIs) for associations between MM and all-cause mortality. During the study period 495 men (24.6%) and 368 women (17.4%) died. Although the MM prevalence was almost the same in men (57.7%) and women (60.0%), the overall effect of MM on mortality was higher in men (HR: 1.81, 95% CI: 1.47–2.24) than in women (HR: 1.28, 95% CI: 1.01–1.64; p-value for interaction &lt;0.001). The type of disease included in the MM patterns had a significant impact on mortality risk. For example, when both heart disease and diabetes were included in the combinations of two and three diseases, the mortality risk was highest. The risk of premature death does not only depend on the number of diseases but also on the specific disease combinations. In this study, life expectancy depended strongly on a few diseases, such as diabetes, hypertension, and heart disease.

Sex differences in non-communicable disease multimorbidity among adults aged 45 years or older in India

OBJECTIVE

Older male and female adults differ in key characteristics such as disease-specific life expectancy, health behaviours and clinical presentations and non-communicable disease multimorbidity (NCD-MM). Therefore, examining the sex differences in NCD-MM among older adults is vital, as this issue is understudied in low-income and middle-income country (LMIC) contexts such as India, and has been growing in the past few decades.

DESIGN

Large scale nationally representative cross-sectional study.

SETTINGS AND PARTICIPANTS

Longitudinal Ageing Study in India (LASI 2017-2018) had data on 27 343 men and 31 730 women aged 45+, drawn from a sample of 59 073 individuals across India.

PRIMARY AND SECONDARY OUTCOMES MEASURES

We operationalised NCD-MM based on prevalence of the presence of two or more long-term chronic NCD morbidities. Descriptive statistics and bivariate analysis along with multivariate statistics were used.

RESULTS

Women aged 75+ had a higher prevalence of multimorbidity as compared with men (52.1% vs 45.17%). NCD-MM was more common among widows (48.5%) than widowers (44.8%). The female-to-male ratios of ORs (RORs) for NCD-MM associated with overweight/obesity and prior history of chewing tobacco were 1.10 (95% CI: 1.01 to 1.20) and 1.42 (95% CI: 1.12 to 1.80), respectively. The female-to-male RORs show that the odds of NCD-MM were greater in formerly working women (1.24 (95% CI: 1.06 to 1.44)) relative to formerly working men. The effect of increasing NCD-MM on limitations in activities of daily living and instrumental ADL was greater in men than women but reversed for the hospitalisation.

CONCLUSIONS

We found significant sex differences in NCD-MM prevalence among older Indian adults, with various associated risk factors. The patterns underlying these differences warrant greater study, given existing evidence on differential longevity, health burdens and health-seeking patterns all of which operate in a larger structural context of patriarchy. Health systems in turn must respond to NCD-MM mindful of these patterns and aim to redress some of the larger inequities they reflect.

Spatiotemporal distribution and determinants of overweight or obesity among urban women in Ethiopia: a multivariate decomposition analysis

BACKGROUND

Overweight /obesity is a global public health concern. It is higher among women than men in most continents of the world. This study aimed to determine the spatiotemporal distribution and determinants of changes in overweight/obesity over time among urban women in Ethiopia.

METHODS

We used data from three consecutive Demographic and Health Surveys in Ethiopia (2005, 2011, and 2016). The total weighted sample of 1112 in 2005, 3569 in 2011, and 3071 in 2016 urban women were included in the analysis. The primary outcome measure of this study was the spatiotemporal distribution and trends over time in overweight/obesity. Factors contributing to change in overweight/obesity were examined using a logit-based multivariate decomposition analysis.

RESULTS

Overweight/obesity increased from 14.2% in 2005 to 21% in 2016. Approximately 61.3% of the overall increase in overweight/obesity among urban women was due to the difference in coefficient (difference in the effect of characteristics) across the surveys. Changes in the composition of women aged 25-49 years (β = 0.012, 95% CI 0.008, 0.015), married women (β = 0.010, 95% CI 0.006, 0.014), women with formal education (primary: β = 0.007, 95% CI 0.003, 0.011, higher education: β = 0.014, 95% CI 0.006, 0.022), women with formal employment (β = 0.006, 95% CI 0.001, 0.011), and women with informal employment (β = - 0.002, 95% CI - 0.003, - 0.0004) were factors contributing to the change in overweight/obesity from 2005 to 2016. The risk difference (RD) in women's overweight/obesity significantly varied across regions in urban Ethiopia. Furthermore, a high proportion of overweight/obesity was found mainly in Tigray, Oromia, Amhara, and Addis Ababa.

CONCLUSIONS

The rate of overweight/obesity among women in urban Ethiopia has shown a significant increase over the last 11 years. This rate change was due to changes in the composition of women's age, educational status, marital status, and employment status. Therefore, program interventions should be targeted at older (> 25 years), educated, married, Addis Ababa residents, and formally employed women.

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

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

Functional mobility and 10-year all-cause and cause-specific mortality in older people from São Paulo, Brazil

BACKGROUND

A better understanding of performance in functional mobility tasks related to the mortality patterns for the different causes of death for the Brazilian older population is still a challenge.

OBJECTIVE

To analyze if gait speed and chair stand test performance are associated with mortality in older adults, and if the overall mobility status changes the effect of other mortality risk factors.

METHODS

The data were from SABE (Health, Well-being and Aging Study), a multiple-cohort study conducted in São Paulo, Brazil, with a representative sample of people aged 60 and more. Cox regression models were used to analyze 10-year all-cause and cause-specific mortality with consideration for gait speed and the chair stand test.

RESULTS

Of the 1411 participants, 26% died during the follow-up. The performance in the chair stand test had a more consistent association with mortality (hazard ratio (HR)=1.03, 95%CI: 1.00, 1.05) than gait speed. Being unable to perform the test also increased the risk to die by all-cause (HR=1.71, 95%CI: 1.21, 2.42) and by diseases of the circulatory system (HR=2.14, 95%CI: 1.25, 3.65). The stratified analysis of mobility performance changed the effects of some of the mortality risk factors, such as cognitive impairment and multimorbidity.

CONCLUSIONS

The chair stand test could be a better choice than 3-meters walking test as a mortality predictor. In addition, the impact of cognitive decline and multimorbidity were greater among those with reduced mobility, supporting the development of preventive interventions and public policies targeted at more vulnerable groups of older adults.

Effects of Health-Related Behaviors and Changes on Successful Aging among Indonesian Older People

Whether changes in health behaviors can improve successful aging has not been well explored. The purpose of this study was to assess the effects of health-related behaviors and changes on successful aging in Indonesian older adults. Data were from the fourth and fifth waves of the Indonesia Family Life Survey (IFLS), the participants were aged 60 years and older and who completed both waves (n = 1289). Successful aging indicators were defined as no chronic diseases, no physical function difficulties, no depressive symptoms, intact cognitive function, with social support, and with social participation. Health-related behaviors focused on smoking, physical activities, and protein intake. A logistic regression analysis was conducted. The overall successful aging rate in 2007 was 23.6%, and it had decreased to 5.6% by 2014. There were gender differences in smoking, physical activities, and behavioral changes, including promoting increased physical activity, no smoking/smoking cessation, and adequate protein intake by older adults. Quitting smoking, performing medium physical activity, and increasing protein intake were protective factors for successful aging, but the effects of behavioral changes differed by gender. Health-related behaviors and changes may impact successful aging among older adults. A healthy lifestyle is suggested to be adopted as early as possible in one's life course.

The effect of disease onset chronology on mortality among patients with multimorbidity: A Danish nationwide register study

Background

Multimorbidity is associated with increased mortality. Certain combinations of diseases are known to be more lethal than others, but the limited knowledge of how the chronology in which diseases develop impacts mortality may impair the development of effective clinical interventions for patients with multimorbidity.

Objective

To explore if in multimorbidity the chronology of disease onset is associated with mortality. Design: A prospective nationwide cohort study, including 3,986,209 people aged ≥18 years on 1 January 2000, was performed. We included ten diagnosis groups: lung, musculoskeletal, endocrine, mental, cancer, neurological, gastrointestinal, cardiovascular, kidney, and sensory organs. We defined multimorbidity as the presence of at least two diagnoses from two diagnosis groups (out of ten). To determine mortality, logistic regression models were used to calculate odds ratios (OR) and ratio of ORs (RORs).

Results

For most combinations of multimorbidity, the chronology of disease onset does not change mortality. However, when multimorbidity included mental health diagnoses, mortality was in general higher if the mental health diagnosis appeared first. If multimorbidity included heart and sensory diagnoses, mortality was higher if these developed second. For the majority of multimorbidity combinations, there was excess mortality if multimorbidity was diagnosed simultaneously, rather than consecutively, for example, heart and kidney (3.58 ROR; CI 2.39–5.36), or mental health and musculoskeletal diagnoses (2.38 ROR; CI 1.70–3.32).

Conclusions

Overall, in multimorbidity, the chronology in which diseases develop is not associated with mortality, with few exceptions. For almost all combinations of multimorbidity, diagnoses act synergistically in relation to mortality if diagnosed simultaneously.

Fatores associados à limitação da mobilidade funcional em idosos do Município de São Paulo, Brasil: análise comparativa ao longo de 15 anos

Este estudo teve como objetivo analisar a prevalência de limitação na mobilidade funcional autorreferida e os fatores associados no período entre os anos 2000 e 2015, em idosos residentes no Município de São Paulo, Brasil. Para as presentes análises foram utilizados os dados das quatro ondas (2000, 2006, 2010 e 2015) do Estudo Saúde, Bem Estar e Envelhecimento (SABE). Foram conduzidos modelos de regressão para analisar as características demográficas, socioeconômicas, comportamentais e relativas à saúde dos indivíduos associadas à limitação da mobilidade em cada onda do estudo, e análise multinível para a comparação entre as quatro ondas. Os resultados indicaram aumento nas prevalências de limitações na mobilidade autorreferida, mais evidente no ano de 2006. Foi observado, ainda, associação com condições crônicas de saúde, como a história de AVC (RP = 1,43; IC95%: 1,29; 1,58, em 2000), a presença de doenças osteoarticulares (RP = 1,35; IC95%: 1,23; 1,49, em 2015), e a queixa de “dor nas costas” (RP = 1,33; IC95%: 1,22; 1,45, em 2006), bem como com aspectos socioeconômicos, como a renda insuficiente (RP = 1,17; IC95%: 1,07; 1,28, em 2010). Em um contexto de envelhecimento populacional acelerado, esses resultados trazem informações relevantes para a promoção de políticas públicas voltadas à prevenção de declínio da mobilidade em pessoas idosas.

Multimorbidity and mortality in an older, rural black South African population cohort with high prevalence of HIV findings from the HAALSI Study

OBJECTIVES

Multimorbidity is associated with mortality in high-income countries. Our objective was to investigate the relationship between multimorbidity (≥2 of the following chronic medical conditions: hypertension, diabetes, dyslipidaemia, anaemia, HIV, angina, depression, post-traumatic stress disorder, alcohol dependence) and all-cause mortality in an older, rural black South African population. We further investigated the relationship between HIV multimorbidity (HIV as part of the multimorbidity cluster) and mortality, while testing for the effect of frailty in all models.

DESIGN

Population cohort study.

SETTING

Agincourt subdistrict of Mpumalanga province, South Africa.

PARTICIPANTS

4455 individuals (54.7% female), aged ≥40 years (median age 61 years, IQR 52-71) and resident in the study area.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was time to death and the secondary outcome measure was likelihood of death within 2 years of the initial study visit. Mortality was determined during annual population surveillance updates.

RESULTS

3157 individuals (70.9%) had multimorbidity; 29% of these had HIV. In models adjusted for age and sociodemographic factors, multimorbidity was associated with greater risk of death (women: HR 1.72; 95% CI: 1.18 to 2.50; men: HR 1.46; 95% CI: 1.09 to 1.95) and greater odds of dying within 2 years (women: OR 2.34; 95% CI: 1.32 to 4.16; men: OR 1.51; 95% CI: 1.02 to 2.24). HIV multimorbidity was associated with increased risk of death compared with non-HIV multimorbidity in men (HR 1.93; 95% CI: 1.05 to 3.54), but was not statistically significant in women (HR 1.85; 95% CI: 0.85 to 4.04); when detectable, HIV viral loads were higher in men (p=0.021). Further adjustment for frailty slightly attenuated the associations between multimorbidity and mortality risk (women: HR 1.55; 95% CI: 1.06 to 2.26; men: HR 1.36; 95% CI: 1.01 to 1.82), but slightly increased associations between HIV multimorbidity and mortality risk.

CONCLUSIONS

Multimorbidity is associated with mortality in this older black South African population. Health systems which currently focus on HIV should be reorganised to optimise identification and management of other prevalent chronic diseases.

Potential Benefits and Harms of Novel Antidiabetic Drugs During COVID-19 Crisis

Patients with diabetes have been reported to have enhanced susceptibility to severe or fatal COVID-19 infections, including a high risk of being admitted to intensive care units with respiratory failure and septic complications. Given the global prevalence of diabetes, affecting over 450 million people worldwide and still on the rise, the emerging COVID-19 crisis poses a serious threat to an extremely large vulnerable population. However, the broad heterogeneity and complexity of this dysmetabolic condition, with reference to etiologic mechanisms, degree of glycemic derangement and comorbid associations, along with the extensive sexual dimorphism in immune responses, can hamper any patient generalization. Even more relevant, and irrespective of glucose-lowering activities, DPP4 inhibitors and GLP1 receptor agonists may have a favorable impact on the modulation of viral entry and overproduction of inflammatory cytokines during COVID-19 infection, although current evidence is limited and not univocal. Conversely, SGLT2 inhibitors may increase the likelihood of COVID-19-related ketoacidosis decompensation among patients with severe insulin deficiency. Mindful of their widespread popularity in the management of diabetes, addressing potential benefits and harms of novel antidiabetic drugs to clinical prognosis at the time of a COVID-19 pandemic deserves careful consideration.