Multimorbidity among Two Million Adults in China

Prevalence and pattern of multimorbidity in China: a cross-sectional study of 224,142 adults over 60 years old

Aim

To examine the prevalence and potential risk factors of multimorbidity among older adult in China. In addition, we investigated the pattern of multimorbidity.

Methods

This study is based on data from the fourth Sample Survey of the Aged Population in Urban and Rural China (SSAPUR) in 2015, a comprehensive survey of individuals aged 60 years or older in China. We calculated baseline data and prevalence rates for comorbidities, stratified by household registration, age, sex, education, exercise, and health insurance. Univariate and multivariate logistic regression analyses were conducted to identify potential risk factors for comorbidities. Furthermore, we determined the prevalence rates for the three most frequent disease combinations.

Results

A total of 215,040 participants were included in our analysis. The prevalence of multimorbidity was 50.5% among the older adult in China. The prevalence rate was slightly higher in rural areas than in urban areas, with rates of 51.5 and 49.6%, respectively (p < 0.001). Moreover, the prevalence rate was higher in females than in males, with rates of 55.2 and 45.3%, respectively (p < 0.001). Multivariate logistic regression analysis revealed that individuals aged 70-79 years (OR:1.40, 95% CI: 1.38-1.43, p < 0.001) and over 80 years (OR:1.41, 95% CI: 1.38-1.45, p < 0.001) had a higher prevalence of multimorbidity than those aged 60-69 years. The most prevalent pair of comorbidities was hypertension and osteoarthropathy, with 19.6% of the participants having these two conditions, accounting for 5.4% of the total participants.

Conclusion

Our findings indicate a high prevalence of multimorbidity among the older adult in China. Increased expenditure on preventive health care, popularization of general medicine and popular medical education may be adopted by the Government to cope with the high prevalence of multimorbidity.

The diabetes mellitus multimorbidity network in hospitalized patients over 50 years of age in China: data mining of medical records

OBJECTIVE

Many diabetes mellitus (DM) patients suffer from multimorbidity. Understanding the DM multimorbidity network should be given priority. The purpose of this study is characterize the DM multimorbidity network in people over 50 years.

METHODS

Data on 75 non-communicable diseases (NCDs) were extracted from electronic medical records of 309,843 hospitalized patients older than 50 years who had at least one NCD. The association rules analysis was used as a novel classification method and combined with the Chi-square tests to identify associations between NCDs and DM.

RESULT

A total of 12 NCDs were closely related to DM, {cholelithiasis, DM} was an unexpected combination. {dyslipidemia, DM} and {gout, DM} had the largest lift in the male and female groups, respectively. The negative related group included 7 NCDs. There were 9 NCDs included in the strong association rules. Most combinations were different by age and sex. In males, the strongest rule was {peripheral vascular disease (PVD), dyslipidemia, DM}, while {hypertension, dyslipidemia, chronic liver disease (CLD), DM} was the strongest in females. In patients younger than 70 years, hypertension, CLD, and dyslipidemia were the most dominant NCDs in the DM multimorbidity network. In patients 70 years or older, chronic kidney disease (CKD), CVD, CHD, and heart disease (HD) frequently co-occurred with DM.

CONCLUSION

Future primary healthcare policies for DM should be formulated based on age and sex. In patients younger than 70 years, more attention to hypertension, CLD, and dyslipidemia is required, while attention to CKD, CVD, CHD and HD is needed in patients older than 70 years.

Learning prevalent patterns of co-morbidities in multichronic patients using population-based healthcare data

The prevalence of longstanding chronic diseases has increased worldwide, along with the average age of the population. As a result, an increasing number of people is affected by two or more chronic conditions simultaneously, and healthcare systems are facing the challenge of treating multimorbid patients effectively. Current therapeutic strategies are suited to manage each chronic condition separately, without considering the whole clinical condition of the patient. This approach may lead to suboptimal clinical outcomes and system inefficiencies (e.g. redundant diagnostic tests and inadequate drug prescriptions). We develop a novel methodology based on the joint implementation of data reduction and clustering algorithms to identify patterns of chronic diseases that are likely to co-occur in multichronic patients. We analyse data from a large adult population of multichronic patients living in Tuscany (Italy) in 2019 which was stratified by sex and age classes. Results demonstrate that (i) cardio-metabolic, endocrine, and neuro-degenerative diseases represent a stable pattern of multimorbidity, and (ii) disease prevalence and clustering vary across ages and between women and men. Identifying the most common multichronic profiles can help tailor medical protocols to patients' needs and reduce costs. Furthermore, analysing temporal patterns of disease can refine risk predictions for evolutive chronic conditions.

Urban-rural differences in associations among perceived stress, resilience and self-care in Chinese older adults with multiple chronic conditions

BACKGROUND

Social determinants of health (SDH) are mainly comprised of structural and intermediary domains. Emerging evidence suggests that the burden of multiple chronic conditions (MCCs) in older adults is exacerbated by structural determinants (e.g. low income and low education). However, less attention was paid to the intermediary determinants (i.e. material circumstances, psychosocial factors and behavioural factors) of MCCs.

OBJECTIVES

To investigate the associations among perceived stress, resilience and self-care in Chinese older adults with MCCs by comparing urban and rural groups.

METHODS

A convenience sample (125 and 115 participants from urban and rural settings, respectively) of Chinese older adults with MCCs was enrolled between January and April 2022. Hierarchical multiple regression analyses and propensity score weights were used to determine the associations among perceived stress, resilience and self-care.

RESULTS

Hypothesis 1 regarding the negative associations between perceived stress and self-care was fully supported in the rural group. However, for the urban group, the negative association was only supported for the relationship between MCCs-related perceived stress and self-care maintenance. Hypothesis 2 was fully supported regarding the positive associations between resilience and the three components of self-care in both groups, although the relationship between resilience and self-care monitoring was marginally significant in the urban group. Hypothesis 3 regarding the moderating effect of resilience was only supported in the relationship between general perceived stress and self-care monitoring in the rural group. After adding the propensity score weights, the moderating effect was no longer statistically significant in the rural group.

CONCLUSIONS

The urban-rural disparities in the Chinese context might largely be attributed to the complex interactions of the structural determinants and intermediary determinants. Findings can inform the development of culturally tailored interventions to promote self-care and reduce urban-rural disparities for Chinese older adults with MCCs.

IMPLICATIONS FOR PRACTICE

With the increasing number of older adults in China who are living with multiple chronic conditions and the call for effective interventions to improve their health outcomes, current findings can inform the development and implementation of nurse-led culturally tailored interventions to promote self-care and reduce urban-rural disparities for Chinese older adults with MCCs.

Associated adverse health outcomes of polypharmacy and potentially inappropriate medications in community-dwelling older adults with diabetes

Aim: This study aimed to identify the association of chronic polypharmacy and potentially inappropriate medications (PIMs) with adverse health outcomes (AHOs) in community-dwelling older adults with diabetes in China. Methods: A 2-year retrospective cohort study was conducted using 11,829 community-followed older adults with diabetes and medical records from 83 hospitals and 702 primary care centers in Shenzhen, China. Chronic polypharmacy and PIMs were identified from prescription records using Beers' criteria, and their associated AHO was analyzed using multivariable logistic regression analysis. Results: The prevalence of chronic polypharmacy and at least one PIM exposure was 46.37% and 55.09%, respectively. The top five PIMs were diuretics, benzodiazepines, first-generation antihistamines, sulfonylureas, and insulin (sliding scale). Chronic polypharmacy was positively associated with all-cause hospital admission, admission for coronary heart disease, admission for stroke, admission for dementia, and emergency department visits. Exposure to PIMs was positively associated with all-cause hospital admission, admission for heart failure (PIMs ≥2), admission for stroke (PIMs ≥3), emergency department visits, bone fracture, constipation, and diarrhea. Conclusion: Chronic polypharmacy and PIMs were prevalent in older adults with diabetes in Chinese communities. Iatrogenic exposure to chronic polypharmacy and PIMs is associated with a higher incidence of different AHOs. This observational evidence highlights the necessity of patient-centered medication reviews for chronic polypharmacy and PIMs use in older patients with diabetes in primary care facilities in China and draws attention to the caution of polypharmacy, especially PIM use in older adults with diabetes in clinical practice.

Identification of status quo and association rules for chronic comorbidity among Chinese middle-aged and older adults rural residents

Background

Chronic comorbidity has become a major challenge in chronic disease prevention and control. This issue is particularly pronounced in rural areas of developing countries, where the prevalence of chronic disease comorbidity is high, especially among middle-aged and older adults populations. However, the health status of middle-aged and older adults individuals in rural areas of China has received inadequate attention. Therefore, it is crucial to investigate the correlation among chronic diseases to establish a reference basis for adjusting health policies aimed at promoting the prevention and management of chronic diseases among middle-aged and older adults individuals.

Methods

This study selected 2,262 middle-aged and older adults residents aged 50 years or older in Shangang Village, Jiangsu Province, China, as the study population. To analyze the chronic comorbidity of middle-aged and older adults residents with different characteristics, we used the χ² test with SPSS statistical software. Data analysis was conducted using the Apriori algorithm of Python software, set to mine the strong association rules of positive correlation between chronic disease comorbidities of middle-aged and older adults residents.

Results

The prevalence of chronic comorbidity was 56.6%. The chronic disease comorbidity group with the highest prevalence rate was the lumbar osteopenia + hypertension group. There were significant differences in the prevalence of chronic disease comorbidity among middle-aged and older adults residents in terms of gender, BMI, and chronic disease management. The Apriori algorithm was used to screen 15 association rules for the whole population, 11 for genders, and 15 for age groups. According to the order of support, the most common association rules of comorbidity of three chronic diseases were: {lumbar osteopenia} → {hypertension} (support: 29.22%, confidence: 58.44%), {dyslipidemia} → {hypertension} (support: 19.14%, confidence: 65.91%) and {fatty liver} → {hypertension} (support: 17.82%, confidence: 64.17%).

Conclusion

The prevalence of chronic comorbidity among middle-aged and older adults rural residents in China is relatively high. We identified many association rules among chronic diseases, dyslipidemia is mostly the antecedent, and hypertension is primarily the result. In particular, the majority of comorbidity aggregation patterns consisted of hypertension and dyslipidemia. By implementing scientifically-proven prevention and control strategies, the development of healthy aging can be promoted.

Association of comorbid depression and obesity with cardiometabolic multimorbidity among middle-aged and older Chinese adults: A cohort study

PURPOSE

To evaluate the association of comorbid depression and obesity with the risk of incident cardiometabolic multimorbidity among middle-aged and older Chinese adults.

METHODS

This cohort study extracted data from the 2011 and 2015 waves of the China Health and Retirement Longitudinal Study (CHARLS). Depression was confirmed by the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10) with a cut-off score ≥10. Obesity was defined as a body mass index ≥28 kg/m². Participants were categorized into four groups based on depression and obesity status at baseline, i.e., with neither condition, depression only, obesity only, and with both conditions. Cardiometabolic multimorbidity was defined as the coexistence of two or more of heart diseases, stroke, and diabetes mellitus. Logistic regression models were established to estimate the associations.

RESULTS

A total of 9,308 participants without cardiometabolic multimorbidity at baseline were included (mean [SD] age, 58.8 [9.0] years; 4,449 [47.8%] were males). During four-year of follow-up, 349 (3.8%) participants developed cardiometabolic multimorbidity. Compared to participants without depression or obesity, comorbid depression and obesity was associated with greater risk of cardiometabolic multimorbidity (adjusted OR: 4.79, 95% CI: 3.09-7.43) than that in participants with depression alone (adjusted OR: 1.84, 95% CI: 1.37-2.46) or obesity alone (adjusted OR: 2.26, 95% CI: 1.48-3.45). The findings were consistent in different gender and age groups.

CONCLUSIONS

Comorbid depression and obesity was associated with excessive risk of cardiometabolic multimorbidity. Intervention targeting at individuals with both depression and obesity might have substantial benefit in minimizing the risk of cardiometabolic multimorbidity.

Psychometric properties of the self-care of chronic illness inventory in Chinese older adults with multiple chronic conditions

BACKGROUND

Existing self-care measures for the Chinese population are specific to single chronic conditions. No generic self-care measures exist for the Chinese population with multiple chronic conditions.

OBJECTIVES

To test the structural validity, concurrent validity and reliability of the Self-care of Chronic Illness Inventory (SC-CII) in Chinese older adults with multiple chronic conditions.

METHODS

This cross-sectional study was reported following the Strengthening the Reporting of Observational Studies in Epidemiology guideline. A diverse sample of Chinese older adults with multiple chronic conditions (n = 240) was recruited. Structural validity was assessed with confirmatory factor analysis. Concurrent validity was investigated with hypotheses testing of the relationships between perceived stress, resilience and self-care. Reliability was assessed with Cronbach's alpha and McDonald's omega. Finally, a simultaneous confirmatory factor analysis was conducted to test the general model with all items and all three subscales.

RESULTS

Confirmatory factor analysis supported the two-factor structure of the self-care maintenance and self-care management subscales and the one-factor structure of the self-care monitoring subscale. Concurrent validity was supported by the significant negative correlation (r ranged from -0.18 to -0.38, p < .01) with perceived stress and the significant positive correlation (r ranged from 0.31 to 0.47, p < .01) with resilience. Reliability estimates ranged from 0.77 to 0.82 across the three subscales. The simultaneous confirmatory factor analysis did not support the more general model with the combined set of items.

CONCLUSION

The SC-CII is valid and reliable for Chinese older adults with multiple chronic conditions. Future cross-cultural assessment should be conducted to investigate the measurement equivalence of the SC-CII in individuals from Western and Eastern cultural groups.

IMPLICATIONS FOR PRACTICE

With the increasing number of older adults in China who are living with multiple chronic conditions and the call for culturally tailored self-care interventions, this self-care measure can be used in geriatric primary care settings, long-term facilities and homes to improve the understanding and practice of self-care in older Chinese adults.

Social determinants of multimorbidity patterns: A systematic review

Social determinants of multimorbidity are poorly understood in clinical practice. This review aims to characterize the different multimorbidity patterns described in the literature while identifying the social and behavioral determinants that may affect their emergence and subsequent evolution. We searched PubMed, Embase, Scopus, Web of Science, Ovid MEDLINE, CINAHL Complete, PsycINFO and Google Scholar. In total, 97 studies were chosen from the 48,044 identified. Cardiometabolic, musculoskeletal, mental, and respiratory patterns were the most prevalent. Cardiometabolic multimorbidity profiles were common among men with low socioeconomic status, while musculoskeletal, mental and complex patterns were found to be more prevalent among women. Alcohol consumption and smoking increased the risk of multimorbidity, especially in men. While the association of multimorbidity with lower socioeconomic status is evident, patterns of mild multimorbidity, mental and respiratory related to middle and high socioeconomic status are also observed. The findings of the present review point to the need for further studies addressing the impact of multimorbidity and its social determinants in population groups where this problem remains invisible (e.g., women, children, adolescents and young adults, ethnic groups, disabled population, older people living alone and/or with few social relations), as well as further work with more heterogeneous samples (i.e., not only focusing on older people) and using more robust methodologies for better classification and subsequent understanding of multimorbidity patterns. Besides, more studies focusing on the social determinants of multimorbidity and its inequalities are urgently needed in low- and middle-income countries, where this problem is currently understudied.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

None.

Heart Failure and Multimorbidity in Asia

PURPOSE OF THE REVIEW

Multimorbidity, the presence of two or more comorbidities, is common in patients with heart failure (HF) and worsens clinical outcomes. In Asia, multimorbidity has become the norm rather than the exception. Therefore, we evaluated the burden and unique patterns of comorbidities in Asian patients with HF.

RECENT FINDINGS

Asian patients with HF are almost a decade younger than Western Europe and North American patients. However, over two in three patients have multimorbidity. Comorbidities usually cluster due to the close and complex links between chronic medical conditions. Elucidating these links may guide public health policies to address risk factors. In Asia, barriers in treating comorbidities at the patient, healthcare system and national level hamper preventative efforts. Asian patients with HF are younger yet have a higher burden of comorbidities than Western patients. A better understanding of the unique co-occurrence of medical conditions in Asia can improve the prevention and treatment of HF.

Prevalence of common chronic disease and multimorbidity patterns in Guangdong province with three typical cultures: analysis of data from the Diverse Life-Course Cohort study

Background

Variations in the prevalence and pattern of multimorbidity might be attributable to lifestyle and environmental factors. This study was performed to determine the prevalence of common chronic diseases and to reveal multimorbidity patterns among adults in Guangdong province with Chaoshan, Hakka, and island cultures.

Methods

We used data collected at the baseline survey (April-May 2021) of the Diverse Life-Course Cohort study and included 5,655 participants aged ≥20 years. Multimorbidity was defined as the presence of two or more of the 14 chronic diseases collected by self-reports, physical examinations, and blood tests. Multimorbidity patterns were explored by association rule mining (ARM).

Results

Overall, 40.69% of participants had multimorbidity, and the prevalence among coastland (42.37%) and mountain residents (40.36%) was higher than that among island residents (37.97%). The prevalence of multimorbidity increased rapidly with higher age groups and showed an inflection point at 50 years, beyond which >50% of the middle-aged and older adults had multimorbidity. The proportion of people with two chronic diseases accounted for most cases of multimorbidity, and the strongest association was found between hyperuricemia and gout (lift of 3.26). The most prevalent multimorbidity pattern was dyslipidemia and hyperuricemia in the coastland areas and dyslipidemia combined with hypertension in the mountain and island areas. Furthermore, the most common triad combination consisted of cardiovascular diseases, gout, and hyperuricemia, which was verified in the mountain and coastal areas.

Conclusion

These observations of multimorbidity patterns, including the most frequent multimorbidity and associations, will help healthcare providers develop healthcare plans that improve the effectiveness of multimorbidity management.

Gender and Socioeconomic Differences in the Prevalence and Patterns of Multimorbidity among Middle-Aged and Older Adults in China

BACKGROUND

Multimorbidity has become a global public health concern. Knowledge about the prevalence and patterns of multimorbidity will provide essential information for public intervention and clinical management. This study aimed to examine gender and socioeconomic differences in the prevalence and patterns of multimorbidity among a nationally representative sample of middle-aged and older Chinese individuals.

METHODS

Data were obtained from the 2018 wave of the China Health and Retirement Longitudinal Study. Latent class analysis was conducted to discriminate among the multimorbidity patterns. Multinomial logit analysis was performed to explore gender and socioeconomic factors associated with various multimorbidity patterns.

RESULTS

A total of 19,559 respondents over 45 years old were included in the study. The findings showed that 56.73% of the respondents reported multimorbidity, with significantly higher proportions among women. Four patterns, namely "relatively healthy class", "respiratory class", "stomach-arthritis class" and "vascular class", were identified. The women were more likely to be in the stomach-arthritis class. Respondents with a higher SES, including higher education, urban residence, higher consumption, and medical insurance, had a higher probability of being in the vascular class. Conclusions: Significant gender and socioeconomic differences were observed in the prevalence and patterns of multimorbidity. The examination of gender and socioeconomic differences for multimorbidity patterns has great implications for clinical practice and health policy. The results may provide insights to aid in the management of multimorbidity patients and improve health resource allocation.

Associations Among Multimorbid Conditions in Hospitalized Middle-aged and Older Adults in China: Statistical Analysis of Medical Records

BACKGROUND

Multimorbidity has become a new challenge for medical systems and public health policy. Understanding the patterns of and associations among multimorbid conditions should be given priority. It may assist with the early detection of multimorbidity and thus improve quality of life in older adults.

OBJECTIVE

This study aims to comprehensively analyze and compare associations among multimorbid conditions by age and sex in a large number of middle-aged and older Chinese adults.

METHODS

Data from the home pages of inpatient medical records in the Shenzhen National Health Information Platform were evaluated. From January 1, 2017, to December 31, 2018, inpatients aged 50 years and older who had been diagnosed with at least one of 40 conditions were included in this study. Their demographic characteristics (age and sex) and inpatient diagnoses were extracted. Association rule mining, Chi-square tests, and decision tree analyses were combined to identify associations between multiple chronic conditions.

RESULTS

In total, 306,264 hospitalized cases with available information on related chronic conditions were included in this study. The prevalence of multimorbidity in the overall population was 76.46%. The combined results of the 3 analyses showed that, in patients aged 50 years to 64 years, lipoprotein metabolism disorder tended to be comorbid with multiple chronic conditions. Gout and lipoprotein metabolism disorder had the strongest association. Among patients aged 65 years or older, there were strong associations between cerebrovascular disease, heart disease, lipoprotein metabolism disorder, and peripheral vascular disease. The strongest associations were observed between senile cataract and glaucoma in men and women. In particular, the association between osteoporosis and malignant tumor was only observed in middle-aged and older men, while the association between anemia and chronic kidney disease was only observed in older women.

CONCLUSIONS

Multimorbidity was prevalent among middle-aged and older Chinese individuals. The results of this comprehensive analysis of 4 age-sex subgroups suggested that associations between particular conditions within the sex and age groups occurred more frequently than expected by random chance. This provides evidence for further research on disease clusters and for health care providers to develop different strategies based on age and sex to improve the early identification and treatment of multimorbidity.

Multimorbidity patterns and associated factors in older Chinese: results from the China health and retirement longitudinal study

Background

This study aimed to investigate multimorbidity patterns and their associated factors among elderly population in China.

Methods

A total of 10,479 participants aged at least 60 years were drawn from the 2018 wave of the China Health and Retirement Longitudinal Study (CHARLS). Latent class analysis (LCA) was performed to identify distinct multimorbidity classes based on 14 self-reported chronic conditions. The multinomial logit model was used to analyze the associated factors of multimorbidity patterns, focusing on individuals' demographic characteristics, socioeconomic status (SES), and health behaviors.

Results

Among the 10,479 participants (mean age [SD]: 69.1 [7.1]), 65.6% were identified with multimorbidity. Five multimorbidity clusters were identified by LCA: relatively healthy class (49.8%), vascular class (24.7%), respiratory class (5.6%), stomach-arthritis class (14.5%), and multisystem morbidity class (5.4%). Multinomial logit analysis with the relatively healthy class as the reference showed that participants of older age and female sex were more likely to be in the vascular class and multisystem morbidity class. The probability of being in the vascular class was significantly higher for those with high SES. Ever smoking was associated with a higher probability of being in the respiratory class and multisystem morbidity class. Physical activity was associated with lower odds of being assigned to the vascular class, respiratory class, and multisystem class.

Conclusion

The distinct multimorbidity patterns imply that the prevention and care strategy should target a group of diseases instead of a single condition. Prevention interventions should be paid attention to for individuals with risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03154-9.

Development and Validation of a Multimorbidity Index Predicting Mortality Among Older Chinese Adults

Objective

This study aimed to develop and validate a multimorbidity index using self-reported chronic conditions for predicting 5-year mortality risk.

Methods

We analyzed data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) and included 11,853 community-dwelling older adults aged 65–84 years. Restrictive association rule mining (ARM) was used to identify disease combinations associated with mortality based on 13 chronic conditions. Data were randomly split into the training (N = 8,298) and validation (N = 3,555) sets. Two multimorbidity indices with individual diseases only (MI) and disease combinations (MIDC) were developed using hazard ratios (HRs) for 5-year morality in the training set. We compared the predictive performance in the validation set between the models using condition count, MI, and MIDC by the concordance (C) statistic, the Integrated Discrimination Improvement (IDI), and the Net Reclassification Index (NRI).

Results

A total of 13 disease combinations were identified. Compared with condition count (C-statistic: 0.710), MIDC (C-statistic: 0.713) showed significantly better discriminative ability (C-statistic: p = 0.016; IDI: 0.005, p < 0.001; NRI: 0.038, p = 0.478). Compared with MI (C-statistic: 0.711), the C-statistic of the model using MIDC was significantly higher (p = 0.031), while the IDI was more than 0 but not statistically significant (IDI: 0.003, p = 0.090).

Conclusion

Although current multimorbidity status is commonly defined by individual chronic conditions, this study found that the multimorbidity index incorporating disease combinations showed supreme performance in predicting mortality among community-dwelling older adults. These findings suggest a need to consider significant disease combinations when measuring multimorbidity in medical research and clinical practice.

Age- and Sex-Specific Differences in Multimorbidity Patterns and Temporal Trends on Assessing Hospital Discharge Records in Southwest China: Network-Based Study

Background

Multimorbidity represents a global health challenge, which requires a more global understanding of multimorbidity patterns and trends. However, the majority of studies completed to date have often relied on self-reported conditions, and a simultaneous assessment of the entire spectrum of chronic disease co-occurrence, especially in developing regions, has not yet been performed.

Objective

We attempted to provide a multidimensional approach to understand the full spectrum of chronic disease co-occurrence among general inpatients in southwest China, in order to investigate multimorbidity patterns and temporal trends, and assess their age and sex differences.

Methods

We conducted a retrospective cohort analysis based on 8.8 million hospital discharge records of about 5.0 million individuals of all ages from 2015 to 2019 in a megacity in southwest China. We examined all chronic diagnoses using the ICD-10 (International Classification of Diseases, 10th revision) codes at 3 digits and focused on chronic diseases with ≥1% prevalence for each of the age and sex strata, which resulted in a total of 149 and 145 chronic diseases in males and females, respectively. We constructed multimorbidity networks in the general population based on sex and age, and used the cosine index to measure the co-occurrence of chronic diseases. Then, we divided the networks into communities and assessed their temporal trends.

Results

The results showed complex interactions among chronic diseases, with more intensive connections among males and inpatients ≥40 years old. A total of 9 chronic diseases were simultaneously classified as central diseases, hubs, and bursts in the multimorbidity networks. Among them, 5 diseases were common to both males and females, including hypertension, chronic ischemic heart disease, cerebral infarction, other cerebrovascular diseases, and atherosclerosis. The earliest leaps (degree leaps ≥6) appeared at a disorder of glycoprotein metabolism that happened at 25-29 years in males, about 15 years earlier than in females. The number of chronic diseases in the community increased over time, but the new entrants did not replace the root of the community.

Conclusions

Our multimorbidity network analysis identified specific differences in the co-occurrence of chronic diagnoses by sex and age, which could help in the design of clinical interventions for inpatient multimorbidity.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exploring the non-communicable disease (NCD) network of multi-morbid individuals in India: A network analysis

Nationally representative evidence discussing the interplay of non-communicable diseases (diseases) are scarce in India. Therefore, the present study aims to fill this research void by providing empirical evidence on disease networking using a large nationally representative cross-sectional sample segregated by gender among older adults in India. The analysis utilized data on 10,606 multimorbid women and 7,912 multimorbid men from the Longitudinal Ageing Study in India (LASI), 2017-18. Multimorbidity was defined as the co-occurrence of two or more diseases in an individual using a list of 16 self-reported diseases. Weighted networks were visualized to illustrates the complex relationships between the diseases using network analysis. The findings suggest that women possess a higher burden of multimorbidity than men. Hypertension, musculoskeletal disorder, gastrointestinal disorder, diabetes mellitus, and skin diseases were reported as the most recurrent diseases. 'Hypertension-musculoskeletal disorder', 'diabetes mellitus-hypertension', 'gastrointestinal disorders-hypertension' and 'gastrointestinal disorders- musculoskeletal disorder' were recurrent disease combinations among the multimorbid individuals. The study generated compelling evidence to establish that there are statistically significant differences between the prevalence of diseases and how they interact with each other between women and men. These findings further accentuate that disease networks are slightly more complex among women. In totality, the study visualizes disease association, identifies the most influential diseases to the network, and those which acts as a bridge between other diseases, causing multimorbidity among the older adult population in India.

Prevalence of potentially inappropriate medications and association with comorbidities in older adults with diabetes in an outpatient visitation setting

AIMS

Potentially inappropriate medications had been found associated with adverse drug events such as falls, emergency department admissions and hospital readmissions. There is lack of information about the prevalence of potentially inappropriate medications and associated chronic conditions in older patients with diabetes in China. This study aimed to assess the prevalence of potentially inappropriate medications in older adults with diabetes in an outpatient visitation setting and the association with polypharmacy due to comorbidities.

MATERIALS AND METHODS

This was a 3-year repeated cross-sectional study which conducted in outpatient setting of 52 hospitals in Shenzhen, China, using 2019 Beers criteria. The prevalence of potentially inappropriate medications, polypharmacy and comorbidities in older adults with diabetes in an outpatient setting was expressed as percentages. Logistic models were used to investigate the association between potentially inappropriate medication exposure and age, sex, polypharmacy and comorbidities.

RESULTS

Among the 28,484 older adults with diabetes in 2015, 31,757 in 2016 and 24,675 in 2017, the prevalence of potentially inappropriate medications was 43.2%, 44.88% and 42.40%, respectively. The top five potentially inappropriate medications were diuretics (20.56%), benzodiazepines (13.85%), androgens (13.18%), non-steroidal anti-inflammatory drugs (12.94%) and sulfonylureas (6.23%). After adjustment for age and polypharmacy, the probability of potentially inappropriate medication exposure was associated with chronic gastrointestinal diseases, followed by osteoarthritis and rheumatoid arthritis, chronic pulmonary disease, chronic kidney disease, tumor, dementia, chronic liver disease, hypertension, cardiovascular disease, cerebrovascular disease and hyperlipemia.

CONCLUSION

Potentially inappropriate medications were common in older patients with diabetes in an outpatient visitation setting. Higher probability of potentially inappropriate medication exposure was associated with the comorbidity chronic gastrointestinal diseases as well as osteoarthritis and rheumatoid arthritis. To ensure that iatrogenic risks remain minimal for older adults with diabetes, the clinical comorbidities should be considered.

The Moderating Role of Empathy Profiles in the Relationship Between Knowledge About Aging and Attitudes Toward Older Adults Among Nursing Students

Knowledge about aging (KA) and empathy affect nursing students' attitudes toward older adults. However, little is known about the mechanisms underlying this phenomenon from an integrated, person-centered perspective. The purposes of the present study were (1) to identify empathy profiles based on the Interpersonal Reactivity Index (IRI) among Chinese nursing students and (2) to explore whether these latent empathy profiles moderate the association between KA and attitudes toward older people. A cross-sectional survey design was used, and a battery of questionnaires - including those on demographic information, the Chinese version of Palmore's Facts on Aging Quiz (C-FAQ), the Chinese version of Kogan's Attitude Toward Older People Scale (C-KAOP), and the IRI - was filled in by 622 Chinese nursing students (M age 21.76; SD = 1.33). The mean total scores on KAOP and C-FAQ were 164.96 ± 18.32 and 10.436 ± 3.015, respectively, indicating relatively positive attitudes toward older people but low KA among Chinese nursing students. Latent profile analysis was used to identify a three-profile solution characterized by distinct levels of four dimensions of empathy, namely average empathy (AE, n = 399), high empathy (HE, n = 42), and low empathy (LE, n = 181). Subsequent linear regression analysis revealed that the LE rather than the HE profile predicted positive attitudes toward older adults. It is worth noting that the LE profile played a remarkable moderating role in associations between KA and negative attitudes toward older adults after controlling for covariant variables. Both the identification of distinct empathy profiles and the interplay between the LE profile and KA are of significance in reducing negative attitudes toward older adults among Chinese nursing students. Nursing educators should combine improving nursing students' levels of KA and fostering greater empathy to reduce negative attitudes toward older adults. Such training should give priority to nursing students with LE.

Multimorbidity in the elderly in China based on the China Health and Retirement Longitudinal Study

This study aimed to investigate the spatial distribution and patterns of multimorbidity among the elderly in China. Data on the occurrence of 14 chronic diseases were collected for 9710 elderly participants in the 2015 waves of the China Health and Retirement Longitudinal Study (CHARLS). Web graph, Apriori algorithm, age-adjusted Charlson comorbidity index (AAC), and Spatial autocorrelation were used to perform the multimorbidity analysis. The multimorbidity prevalence rate was estimated as 49.64% in the elderly in China. Three major multimorbidity patterns were identified: [Asthma/Chronic lungs diseases]: (Support (S) = 6.17%, Confidence (C) = 63.77%, Lift (L) = 5.15); [Asthma, Arthritis, or rheumatism/ Chronic lungs diseases]: (S = 3.12%, C = 64.03%, L = 5.17); [Dyslipidemia, Hypertension, Arthritis or rheumatism/Heart attack]: (S = 3.96%, C = 51.56, L = 2.69). Results of the AAC analysis showed that the more chronic diseases an elderly has, the lower is the 10-year survival rate (P < 0.001). Global spatial autocorrelation showed a positive spatial correlation distribution for the prevalence of the third multimorbidity pattern in China (P = 0.032). The status of chronic diseases and multimorbidity among the elderly with a spatial correlation is a significant health issue in China.

Prevalence and Patterns of Comorbidity Among Middle-Aged and Elderly People in China: A Cross-Sectional Study Based on CHARLS Data

INTRODUCTION

Under the background of the accelerated aging of the population, comorbidity in the elderly has gradually become a social problem. At present, the related studies on chronic diseases are mainly focused on a single disease. This study aimed to investigate the prevalence of common chronic diseases, the conditions and patterns of comorbidity in middle-aged and elderly people in China.

METHODS

We extracted the data from China Health and Retirement Longitudinal Study (CHARLS). A total of 14 diseases were included, and the prevalence was assessed by self-report. We calculate different disease combinations and perform descriptive statistics analysis of chronic disease and comorbidity status.

RESULTS

Among the 6754 subjects, 2833 (42.0%) people had at least one chronic disease, and 1138 (17.0%) people had two or more diseases at the same time. The top three diseases of prevalence were hypertension (15.4%), arthritis or rheumatism (11.0%), and stomach or digestive diseases (9.3%). Common dual disease combinations were hypertension and dyslipidemia, hypertension and arthritis or rheumatism, arthritis or rheumatism and stomach or digestive diseases.

CONCLUSION

Comorbidity is common in the population, and the pattern of chronic disease comorbidity is complex. Hypertension exists in a variety of comorbidity patterns, and its screening and prevention should be strengthened.

Estimation of losses of quality-adjusted life expectancy attributed to the combination of cognitive impairment and multimorbidity among Chinese adults aged 45 years and older

OBJECTIVES

This study aims to estimate the losses of quality-adjusted life expectancy (QALE) due to the joint effects of cognitive impairment and multimorbidity, and to further confirm additional losses attributable to this interaction among middle-aged and elderly Chinese people.

METHODS

The National Cause of Death Monitoring Data were linked with the China Health and Retirement Longitudinal Study (CHARLS). A mapping and assignment method was used to estimate health utility values, which were further used to calculate QALE. Losses of QALE were measured by comparing the differences between subgroups. All the losses of QALE were displayed at two levels: the individual and population levels.

RESULTS

At age 45, the individual-level and population-level losses of QALE attributed to the combination of cognitive impairment and multimorbidity were 7.61 (95% CI: 5.68, 9.57) years and 4.30 (95% CI: 3.43, 5.20) years, respectively. The losses for cognitive impairment alone were 3.10 (95% CI: 2.29, 3.95) years and 1.71 (95% CI: 1.32, 2.13) years at the two levels. Similarly, the losses for multimorbidity alone were 3.53 (95% CI: 2.53, 4.56) years and 1.91 (95% CI: 1.24, 2.63) years at the two levels. Additional losses due to the interaction of cognitive impairment and multimorbidity were indicated by the 0.98 years of the individual-level gap and 0.67 years of the population-level gap.

CONCLUSION

Among middle-aged and elderly Chinese people, cognitive impairment and multimorbidity resulted in substantial losses of QALE, and additional QALE losses were seen due to their interaction at both individual and population levels.

Diabetes multimorbidity combinations and disability in the Mexican Health and Aging Study, 2012-2015

PURPOSE

The aim of this study was to investigate the relationship between specific combinations of chronic conditions and disability in Mexican older adults with diabetes.

METHODS

This was a prospective cohort study of Mexican adults (n = 2558) with diabetes and aged 51 or older that used data from the 2012 and 2015 waves of the Mexican Health and Aging Study. The main outcome was an index that measured ability to perform activities of daily living and instrumental activities of daily living. The main independent variables were diabetes multimorbidity combinations, defined as diabetes and at least one other chronic condition. The authors calculated the prevalence of each multimorbidity combination present in the sample in 2012 and used negative binomial regression models to estimate the association of the most prevalent of these combinations with disability incidence in 2015.

RESULTS

The three most prevalent combinations were: 1) diabetes-hypertension (n = 637, 31.9%) 2) diabetes-hypertension-depression (n = 388, 19.4%) and 3) diabetes-depression (n = 211, 10.6%). In fully adjusted models comparing participants with specific multimorbidity combinations to participants with diabetes alone, the combinations that had an increased association with disability were diabetes-hypertension-depression, diabetes-depression and diabetes-hypertension-arthritis-depression. In nested models, the addition of arthritis to combinations including depression increased this association.

CONCLUSIONS

Consistent with prior studies, multimorbidity combinations including depression were associated with increased risk of disability. However, the effect size of this relationship was lower than what had been previously been reported internationally. This highlights the need for globally oriented multimorbidity research.