Gina Bravo

Prevalence of Multimorbidity Among Adults Seen in Family Practice

PURPOSE There are few valid data that describe the extent of multimorbidity in primary care patients. The purpose of this study was to estimate its prevalence in family practice patients by counting the number of chronic medical conditions and using a measure that considers the severity of these conditions, the Cumulative Illness Rating Scale (CIRS). METHODS The study was carried out in the Saguenay region (Québec, Canada) in 2003. The participation of adult patients from 21 family physicians was solicited during consecutive consultation periods. A research nurse reviewed medical records and extracted the data regarding chronic illnesses. For each chronic condition, a severity rating was determined in accordance with the CIRS scoring guidelines. RESULTS The sample consisted of 320 men and 660 women. Overall, 9 of 10 patients had more than 1 chronic condition. The prevalence of having 2 or more medical conditions in the 18- to 44-year, 45- to 64-year, and 65-year and older age-groups was, respectively, 68%, 95%, and 99% among women and 72%, 89%, and 97% among men. The mean number of conditions and mean CIRS score also increased significantly with age. CONCLUSIONS Whether measured by simply counting the number of conditions or using the CIRS, the prevalence of multimorbidity is quite high and increases significantly with age in both men and women. Patients with multimorbidity seen in family practice represent the rule rather than the exception.

Relationship Between Multimorbidity and Health-Related Quality of Life of Patients in Primary Care

Previous studies about the association of multimorbidity and the health-related quality of life (HRQOL) in primary-care patients are limited because of their reliance on simple counts of diseases from a limited list of diseases and their failure to assess the severity of disease. We evaluated the association while taking into account the severity of the medical conditions based on the Cumulative Illness Rating Scale (CIRS) score, and controlling for potential confounders (age, sex, household income, education, self-perception of economic status, number of people living in the same dwelling, and perceived social support). We randomly selected 238 patients to construct quintiles of increasing multimorbidity (CIRS). Patients completed the 36-item Medical Outcomes study questionnaire (SF-36) to evaluate their HRQOL. Applying bivariate and multivariate linear regression analyses, we used the CIRS as either a continuous or a categorical (quintiles) variable. Use of the CIRS revealed a stronger association of HRQOL with multimorbidity than using a simple count of chronic conditions. Physical more than mental health deteriorated with increasing multimorbidity. Perceived social support and self-perception of economic status were significantly related to all scales of the SF-36 (p < 0.05). Increased multimorbidity adversely affected HRQOL in primary-care adult patients, even when confounding variables were controlled for.

Reliability, Validity and Reference Values of the Zarit Burden Interview for Assessing Informal Caregivers of Community-Dwelling Older Persons with Dementia

Zarit Burden Interview (ZBI) is the most widely used instrument for assessing the burden experienced by the caregivers of persons with dementia. As part of the Canadian Study of Health and Aging, the 22-item ZBI was administered to a representative sample of 312 informal caregivers of community-dwelling subjects with dementia. The mean score was 22.4 out of 88 (sd: 16.2) and the median score was 18.5, which is far lower than those reported in previous studies using this instrument with convenience samples. There was no significant difference in the burden score according to the age, gender, living arrangement, marital status or employment status of the caregiver. The ZBI score was more strongly correlated to the depressive mood of the caregivers (r = 0.59) and the behaviour problems of the care recipients (r = 0.64) than their cognitive (r = 0.32) and functional (r = 0.31) status. Following a factor analysis, a 12-item short version of the instrument is proposed with two factors: personal strain (3 items) and role strain (9 items).

Estimating the reliability of continuous measures with cronbach's alpha or the intraclass correlation coefficient: Toward the integration of two traditions

The epidemiological literature has been ambiguous concerning reliability estimates for continuous variables. Reproducibility and internal consistency have been presented as different aspects of reliability, the former being estimated with some form of intraclass correlation coefficient, the latter with Cronbachs alpha. Based on demonstrations available in the literature this paper recalls that both estimates are based on the same measurement model and on the same definition of reliability. It also highlights the conditions under which they are equivalent and provides practical suggestions concerning the estimation of reliability, based on design considerations.

Age- and education-specific reference values for the mini-mental and modified mini-mental state examinations derived from a non-demented elderly population

Main objective. To report age‐ and education‐specific reference values for the Mini‐Mental State Examination (MMSE) and Modified Mini‐Mental State (3MS) Examination.

Meta-analysis of the Effectiveness of Physical Activity for the Prevention of Bone Loss in Postmenopausal Women

A meta-analysis was done to measure the effect of physical activity on the bone mass of healthy postmenopausal women. All studies published between 1966 and 1996, in French or English, were reviewed for inclusion from Medline search, bibliographies of relevant studies, review articles and books. Studies had to be prospective intervention trials, randomized or not, evaluating the effectiveness of an exercise program of any duration, frequency and intensity, with a control group. Studies had to measure bone parameters and involve healthy postmenopausal women over 50 years of age who were free of symptomatic osteoporosis at the time of study entry. Effect sizes (ES) were calculated for each bone parameter and site measured in every eligible study according to Hedges and Olkin. DerSimonian and Lairds model was used to estimate overall effect sizes when combining studies. All analyses were bone parameter and site specific. Of 217 papers extracted from the literature, 187 did not meet eligibility criteria and 12 others were rejected. The two main reasons for rejection were that both genders were combined in the analyses and no exercise group without drag interaction was present. Eighteen studies were included for meta-analysis. Taking into account the frequency, duration, compliance rate and average age of the subjects, the programs were judged of moderate intensity and focused on walking, running, physical conditioning and aerobics. A significant effect of physical activity was detected on the bone mineral density at the L2–4 level of the lumbar column in studies published after 1991 (ES=0.8745,p<0.05). No effect could be seen, however, on forearm and femoral bone mass. Although applied to a small number of studies, this meta-analysis suggests that exercise programs in a population of postmenopausal women over 50 years of age are effective for preventing spinal bone mineral density loss at the L2–4 level. However, such programs do not have any effect on the forearm or femoral bone mass.

The Purdue Pegboard Test: Normative data for people aged 60 and over

Manual dexterity is frequently evaluated in rehabilitation services to estimate hand function. Several tests have been developed for this purpose, including the Purdue Pegboard, which measures fine manual dexterity. The goals of the study were to verify the test-retest reliability with subjects aged 60 and over without upper limb impairment, and to develop normative data based on a random sample of healthy older community-living individuals. The results show that the test-retest reliability is good (intra-class correlation coefficients from 0.66 to 0.90, depending on the subtest). Norms are presented to help clinicians involved in rehabilitation services to better differentiate real dexterity deficits from those that may be attributed to normal ageing.

Impact of a 12‐Month Exercise Program on the Physical and Psychological Health of Osteopenic Women

OBJECTIVE: To describe the effect of a supervised physical activity program on the physical and psychological health of osteopenic women.

Performance of the ‘Unaffected’ Upper Extremity of Elderly Stroke Patients

BACKGROUND AND PURPOSE The main objective of this study was to compare the sensorimotor performance of the unaffected upper extremity (UE) of elderly stroke patients with that of healthy elderly people. METHODS The group of stroke patients was composed of 43 hemiplegic/paretic subjects who had had a cerebrovascular accident at least 6 months earlier. They were > or = 60 years old, were right-handed before the stroke, had visual perception within normal limits, and showed no major cognitive impairments. A group of 43 healthy subjects matched for dominance, age, and sex was used for comparison. The main parameters of the performance of the unaffected UE of the stroke subjects and of the same side of the healthy subjects were measured with valid, reliable instruments. Some variables potentially related to the unaffected UE were also measured: affected UE motor function, functional independence, length of time since the stroke, self-perceived health status, activity level, and hand anthropometry. RESULTS Statistical analyses showed significant deficits in the unaffected UE of hemiplegic/paretic subjects compared with normal subjects with regard to the following parameters: gross manual dexterity, fine manual dexterity, motor coordination, global performance, and kinesthesia (P < .01 to P < .0001). No significant clinical or statistical difference was found for grip strength (P < .81), static and moving two-point discrimination (P = .21 and P = .12), or touch/pressure threshold (P < .91). CONCLUSIONS Many factors (frequency of use of the unaffected hand, sensorimotor interaction tasks, severity of the deficits in corticifugal projections, and deficits in postural stabilization) could interact to provide the clinical picture obtained in the present study.

Psychological Distress and Multimorbidity in Primary Care

PURPOSE Psychological distress may decrease adherence to medical treatments and lead to poorer health outcomes of chronic diseases. The aim of this study was to evaluate the relationship between psychological distress and multimorbidity among patients seen in family practice after controlling for potential confounding variables and taking into account the severity of diseases. METHODS We evaluated 238 patients to construct quintiles of increasing multimorbidity based on the Cumulative Illness Rating Scale (CIRS), which is a comprehensive multimorbidity index that takes into account disease severity. Patients completed a psychiatric symptom questionnaire as a measurement of their psychological distress. In the first model of logistic regression analyses, we used the counted number of chronic diseases as the independent variable. In subsequent models, we used the quintiles of CIRS. RESULTS After adjusting for confounding factors, multimorbidity measured by a simple count of chronic diseases was not related to psychological distress (OR, 1.12; 95% CI, 0.97–1.29; P = .188), whereas multimorbidity measured by the CIRS remained significantly associated (OR, 1.67; 95% CI, 1.19–2.37; P = .002). The estimate risk of psychological distress by quintile of CIRS was as follows: Q1/2 = 1.0; Q3 = OR, 1.72; 95% CI, 0.53–5.86; Q4 = OR, 2.99; 95% CI, 1.01–9.74; Q5 = OR, 4.67; 95% CI, 1.61–15.16. CONCLUSIONS Psychological distress increased with multimorbidity when we accounted for disease severity. Clinicians should be aware of the possible presence of psychological distress, which can further complicate the comprehensive management of these complex patients.