Enrique Alcalde-Cabero

ICF disability measured by WHO-DAS II in three community diagnostic groups in Madrid, Spain

OBJECTIVE The planning, provision and monitoring of medical and support services for patient groups with chronic ailments may require disability assessment and registration. The purpose of this study was to assess disability in three groups of patients with chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF) or stroke. METHODS Convenience samples of consecutive patients diagnosed with COPD (102), CHF (99), and stroke (99) were taken from 1,053 primary care users in the southern area of the autonomous region of Madrid. The patients were informed of the study and were assessed in their homes by trained field workers using the World Health Organization Disability Assessment Schedule II (WHO-DAS II). RESULTS None of the groups had patients with extreme disability on their global WHO-DAS II scores. The prevalence of severe disability differed among the groups and was highest for stroke and CHF (33.33% and 29.29%, respectively) and lowest for COPD (14.71%). The three groups shared two similar traits, namely, a higher prevalence of disability among women than men, and a specific pattern by domain, with the highest prevalence of severe/extreme limitations being found in household life activities and mobility. Severe restrictions in Social Participation were more frequent in patients with stroke and CHF. The group with moderate disability according to the global WHODAS II score (n=94) showed a high prevalence of severe limitations in mobility, life activities and self-care. CONCLUSIONS Disability among non-institutionalized persons with COPD, CHF and stroke is frequent and shows gender- and domain-related patterns similar to those described in a population-based study performed using the WHO-DAS II in elderly persons in Spain. ICF-validated disability categories could be useful in epidemiological surveys, individual assessments and primary care data monitoring systems.

Incidence of multiple sclerosis among European Economic Area populations, 1985-2009: the framework for monitoring

BackgroundA debate surrounding multiple sclerosis epidemiology has centred on time-related incidence increases and the need of monitoring. The purpose of this study is to reassess multiple sclerosis incidence in the European Economic Area.MethodsWe conducted a systematic review of literature from 1965 onwards and integrated elements of original research, including requested or completed data by surveys authors and specific analyses.ResultsThe review of 5323 documents yielded ten studies for age- and sex-specific analyses, and 21 studies for time-trend analysis of single data sets. After 1985, the incidence of multiple sclerosis ranged from 1.12 to 6.96 per 100,000 population, was higher in females, tripled with latitude, and doubled with study midpoint year. The north registered increasing trends from the 1960s and 1970s, with a historic drop in the Faroe Islands, and fairly stable data in the period 1980-2000; incidence rose in Italian and French populations in the period 1970-2000, in Evros (Greece) in the 1980s, and in the French West Indies in around 2000.ConclusionsWe conclude that the increase in multiple sclerosis incidence is only apparent, and that it is not specific to women. Monitoring of multiple sclerosis incidence might be appropriate for the European Economic Area.

Analysis of disability using WHODAS 2.0 among the middle-aged and elderly in Cinco Villas, Spain

BACKGROUND The prevalence of disability, as defined by the International Classification of Functioning, Disability and Health (ICF), among the middle-aged and elderly population is poorly known. OBJECTIVE To determine disability prevalence in a resident population sample aged ≥50 years, in the Cinco Villas district, Spain, from June 2008 through June 2009. METHODS We used the WHODAS 2.0 36-item questionnaire to quantify the prevalence of disability, globally and by domain, together with a 13-item combined measure of three domains, Getting around, Self-care and Life activities, claimed to reflect the need of integrated services. In addition, we performed exploratory analyses of the relationship between disability and different variables using ordinal logistic regression. RESULTS Disability was detected by global WHODAS score in 604 of a total of 1214 persons, i.e., a prevalence of 49.8% 95% CI (46.9-52.5), with the corresponding figures for mild, moderate, severe, and extreme disability being 26.8%, 16.0%, 7.6% and 0.1%, respectively. Disability increased with age, was higher among women, and for specific domains. Prevalence of severe/extreme disability among women vs. men was as follows: Getting around, 26.8% vs. 12.1%; Life activities, 25.2% vs. 6.8%; and Self-care, 9.5% vs. 6.0%. Disability was more frequent among subjects diagnosed with dementia, chronic liver disease, severe mental disease, and stroke. The abovementioned 13-item measure yielded prevalence figures for disability levels quite similar to those obtained using 36-item scores. CONCLUSIONS For the first time, this study furnishes detailed disability prevalence figures and data on associated variables in a middle-aged and elderly Western population.

Comparative Incidence of Conformational, Neurodegenerative Disorders.

Background The purpose of this study was to identify incidence and survival patterns in conformational neurodegenerative disorders (CNDDs). Methods We identified 2563 reports on the incidence of eight conditions representing sporadic, acquired and genetic, protein-associated, i.e., conformational, NDD groups and age-related macular degeneration (AMD). We selected 245 papers for full-text examination and application of quality criteria. Additionally, data-collection was completed with detailed information from British, Swedish, and Spanish registries on Creutzfeldt-Jakob disease (CJD) forms, amyotrophic lateral sclerosis (ALS), and sporadic rapidly progressing neurodegenerative dementia (sRPNDd). For each condition, age-specific incidence curves, age-adjusted figures, and reported or calculated median survival were plotted and examined. Findings Based on 51 valid reported and seven new incidence data sets, nine out of eleven conditions shared specific features. Age-adjusted incidence per million person-years increased from ≤1.5 for sRPNDd, different CJD forms and Huntingtons disease (HD), to 1589 and 2589 for AMD and Alzheimers disease (AD) respectively. Age-specific profiles varied from (a) symmetrical, inverted V-shaped curves for low incidences to (b) those increasing with age for late-life sporadic CNDDs and for sRPNDd, with (c) a suggested, intermediate, non-symmetrical inverted V-shape for fronto-temporal dementia and Parkinsons disease. Frequently, peak age-specific incidences from 20–24 to ≥90 years increased with age at onset and survival. Distinct patterns were seen: for HD, with a low incidence, levelling off at middle age, and long median survival, 20 years; and for sRPNDd which displayed the lowest incidence, increasing with age, and a short median disease duration. Interpretation These results call for a unified population view of NDDs, with an age-at-onset-related pattern for acquired and sporadic CNDDs. The pattern linking age at onset to incidence magnitude and survival might be explained by differential pathophysiological mechanisms associated with specific misfolded protein deposits.

Disability transitions after 30 months in three community-dwelling diagnostic groups in Spain

Background Little is known about changes in disability over time among community-dwelling patients. Accordingly, this study sought to assess medium-term disability transitions. Patients and Methods 300 chronic obstructive pulmonary disease (COPD), chronic heart failure and stroke patients living at home in Madrid were selected from general practitioner lists. In 2009, disability was assessed after a mean of 30 months using the World Health Organisation (WHO) Disability Assessment Schedule 2.0 (WHODAS 2.0). Follow-up was completed using death registries. Losses to follow-up were due to: death, 56; institutionalisation, 9; non-location, 18; and non-participation, 17. Changes in WHODAS 2.0 scores and life status were described and analysed using Cox and multinomial regression. Disability at end of follow-up was imputed for 56 deceased and 44 surviving patients. Results Mean disability scores for 200 surviving patients at end of follow-up were similar to baseline scores for the whole group, higher than their own baseline scores, and rose by 16.3% when imputed values were added. The strongest Cox predictors of death were: age over 84 years, adjusted hazard ratios with 95%CI 8.18 (3.06-21.85); severe/complete vs. no/mild disability, 5.18 (0.68-39.48); and stroke compared to COPD, 1.40 (0.67-2.91). Non-participants and institutionalised patients had higher proportions with severe/complete baseline disability. A one-point change in baseline WHODAS 2.0 score predicted independent increases in risk of 12% (8%-15%) for severe/complete disability or death. Conclusions A considerably high proportion of community-dwelling patients diagnosed with COPD, CHF and stroke undergo medium-term changes in disability or vital status. The main features of the emerging pattern for this group appear to be as follows: approximately two-thirds of patients continue living at home with moderately reduced functional status; 1/3 die or worsen to severe/complete disability; and 1/10 improve. Baseline disability scores, age and diagnosis are associated with disability and death in the medium term.

Drivers: A Biologically Contextualized, Cross-Inferential View of the Epidemiology of Neurodegenerative Disorders

Background: Sutherland et al. (2011) suggested that, instead of risk factors for single neurodegenerative disorders (NDDs), there was a need to identify specific “drivers”, i.e., risk factors with impact on specific deposits, such as amyloid-β, tau, or α-synuclein, acting across entities. Objectives and Methods: Redefining drivers as “neither protein/gene- nor entity-specific features identifiable in the clinical and general epidemiology of conformational NDDs (CNDDs) as potential footprints of templating/spread/transfer mechanisms”, we conducted an analysis of the epidemiology of ten CNDDs, searching for patterns. Results: We identified seven potential drivers, each of which was shared by at least two CNDDs: 1) an age-at-exposure-related susceptibility to Creutzfeldt-Jakob disease (CJD) and several late-life CNDDs; 2) a relationship between age at onset, survival, and incidence; 3) shared genetic risk factors for CJD and late-life CNNDs; 4) partly shared personal (diagnostic, educational, behavioral, and social risk factors) predating clinical onset of late-life CNDDs; 5) two environmental risk factors, namely, surgery for sporadic CJD and amyotrophic lateral sclerosis, and Bordetella pertussis infection for Parkinson’s disease; 6) reticulo-endothelial system stressors or general drivers (andropause or premenopausal estrogen deficiency, APOEɛ4, and vascular risk factors) for late-life CNDDs such as dementia/Alzheimer’s disease, type-2 diabetes mellitus, and some sporadic cardiac and vascular degenerative diseases; and 7) a high, invariant incidence ratio of sporadic to genetic forms of mid- and late-life CNDDs, and type-2 diabetes mellitus. Conclusion: There might be a systematic epidemiologic pattern induced by specific proteins (PrP, TDP-43, SOD1, α-synuclein, amyloid-β, tau, Langerhans islet peptide, and transthyretin) or established combinations of these.

Effect of cardiovascular prevention strategies on incident coronary disease hospitalisation rates in Spain; an ecological time series analysis.

Objective To assess the overall population impact of primary prevention strategies (promotion of healthy lifestyles, prevention of smoking and use of vascular risk drug therapy) of coronary disease in Spain. Design Ecological time series analysis, 1982–2009. Setting All public and private hospitals in Spain. Participants General population. Outcome Incident coronary disease hospitalisation as derived from official hospital discharge data. Methods Annual hospitalisation rates were modelled according to nationwide use of statins, antihypertensive, antidiabetic and antiplatelet drugs, and prevalences of smoking, obesity and overweight. Additive generalised models and mixed Poisson regression models were used for the purpose, taking year as the random-effect variable and adjusting for age, sex, prevalence of vascular risk factors and the number of hospital beds in intensive and coronary care units. Results Across 28 years and 671.5 million person-years of observation, there were 2 986 834 hospitalisations due to coronary disease; of these, 1 441 980 (48.28%) were classified as incident. Hospitalisation rates increased from 1982 to 1996, with an inflection point in 1997 and a subsequent 52% decrease until 2009. Prevalences of smoking, obesity, overweight and use of vascular risk drug therapy were significantly associated with hospitalisation rates (p<0.001): incidence rates ratios (95% CI) for the fourth versus the first quartile were 1.46 (1.42 to 1.50), 1.80 (1.78 to 1.83), 1.58 (1.55 to 1.60) and 0.57 (0.51 to 0.63), respectively. These variables accounted for 92% of interannual variability. Conclusions After decades of continuous rises, hospitalisation due to incident ischaemic heart disease has been cut by half, an achievement associated with the decline in smoking and the increase in vascular risk drug therapy. These results indicate that these two primary prevention strategies have been effective at a population level, thanks to an appropriate balance between financial and health goals, something that should be left intact despite the current economic crisis. Future strategies ought to lay special stress on excessive body weight prevention.

Etiologic Framework for the Study of Neurodegenerative Disorders as Well as Vascular and Metabolic Comorbidities on the Grounds of Shared Epidemiologic and Biologic Features

Background: During the last two decades, protein aggregation at all organismal levels, from viruses to humans, has emerged from a neglected area of protein science to become a central issue in biology and biomedicine. This article constitutes a risk-based review aimed at supporting an etiologic scenario of selected, sporadic, protein-associated, i.e., conformational, neurodegenerative disorders (NDDs), and their vascular- and metabolic-associated ailments. Methods: A rationale is adopted, to incorporate selected clinical data and results from animal-model research, complementing epidemiologic evidences reported in two prior articles. Findings: Theory is formulated assuming an underlying conformational transmission mechanism, mediated either by horizontal transfer of mammalian genes coding for specific aggregation-prone proteins, or by xeno-templating between bacterial and host proteins. We build a few population-based and experimentally-testable hypotheses focusing on: (1) non-disposable surgical instruments for sporadic Creutzfeldt-Jakob disease (sCJD) and other rapid progressive neurodegenerative dementia (sRPNDd), multiple system atrophy (MSA), and motor neuron disease (MND); and (2) specific bacterial infections such as B. pertussis and E. coli for all forms, but particularly for late-life sporadic conformational, NDDs, type 2 diabetes mellitus (T2DM), and atherosclerosis where natural protein fibrils present in such organisms as a result of adaptation to the human host induce prion-like mechanisms. Conclusion: Implications for cohort alignment and experimental animal research are discussed and research lines proposed.

Associations between chronic conditions, body functions, activity limitations and participation restrictions: a cross-sectional approach in Spanish non-clinical populations

Objectives To analyse the relationships between chronic conditions, body functions, activity limitations and participation restrictions in the International Classification of Functioning, Disability and Health (ICF) framework. Design A cross-sectional study. Setting 2 geographical areas in the Autonomous Region of Aragon, Spain, namely, a rural area, Cinco Villas, and an urban area in the city of Zaragoza. Participants 864 individuals selected by simple random sampling from the register of Social Security card holders, aged 50 years and over, positive to disability screening. Main outcome measures ICF Checklist—body function domains, WHO Disability Assessment Schedule 2.0 (WHODAS 2.0, 36-item (WHODAS-36)) global scores and medical diagnoses (chronic conditions) from primary care records. Results Mild disability (WHODAS-36 level 5–24%) was present in 51.5% of the sample. In the adjusted ordinal regression model with WHODAS-36 as the dependent variable, disability was substantially associated with moderate-to-complete impairment in the following functions: mental, OR 212.8 (95% CI 72 to 628.9); neuromusculoskeletal, OR 44.8 (24.2 to 82.8); and sensory and pain, OR 6.3 (3.5 to 11.2). In the relationship between health conditions and body function impairments, the strongest links were seen for: dementia with mental functions, OR 50.6 (25.1 to 102.1); cerebrovascular disease with neuromusculoskeletal function, OR 5.8 (3.5 to 9.7); and chronic renal failure with sensory function and pain, OR 3.0 (1.49 to 6.4). Dementia, OR 8.1 (4.4 to 14.7) and cerebrovascular disease, OR 4.1 (2.7 to 6.4) were associated with WHODAS-36 scores. Conclusions Body functions are heterogeneously linked to limitations in activities and restrictions on participation, with the highest impact being due to mental and musculoskeletal functions. This may be relevant for disability assessment and intervention design, particularly if defined on a body function basis. Control of specific health conditions, such as dementia and cerebrovascular disease, appears to be paramount in reducing disability among persons aged 50 years and over.

Inequalities in the risk of disability due to traffic injuries in the Spanish adult population, 2009–2010

BACKGROUND Although traffic injuries (TIs) are an important cause of disability the related factors are little known. We aimed to estimate the differences in risk of TI-related disability according to individual characteristics that might generate health inequalities. METHODS Cross-sectional study using a representative Spanish population sample drawn from the European Health Interview Survey 2009/2010. We calculated traffic crashes in the preceding year which resulted in injuries. Disability was measured using the Global Activity Limitation Indicator and four indicators of limitations (sensory, physical functional, self-care and domestic activities). Principal socio-demographic and behavioural/lifestyle variables were studied. We used multivariate logistic regression to estimate the risk (ORs) of TI-related disability in the sample as whole and disability-related factors in persons who had experienced TIs. RESULTS Persons with TIs had a higher risk of global disability (OR = 1.61; 95%CI:1.17-2.20), physical functional limitations (OR = 1.96; 95%CI:1.33-2.89) and self-care limitations (OR = 1.73; 95%CI:0.98-3.05). Among persons with TIs, GALI-related risk was higher in women (OR = 3.06, p = 0.002) and persons aged over 30 years (OR31-45years = 6.81, p < 0.001; OR46-64years = 5.96, p = 0.011; OR>64years = 4.54, p = 0.047). Lower risk was observed among persons with a higher educational level (OR = 0.22, p = 0.003). The risk of disability among persons with TIs who consumed illegal drugs was OR = 3.9 (p = 0.023). CONCLUSIONS Traffic injuries in the preceding year are associated with higher risk of disability, which is unevenly distributed. Individual (women and persons over 30 years), socio-economic (lower educational level) and behavioural (illegal drug use) factors are involved. Actions aimed at changing the unequal risk among vulnerable subgroups and providing health, social and protective services should be implemented.