Graziano Onder

Assessing and Measuring Chronic Multimorbidity in the Older Population: A Proposal for Its Operationalization

Abstract Background Although the definition of multimorbidity as “the simultaneous presence of two or more chronic diseases” is well established, its operationalization is not yet agreed. This study aims to provide a clinically driven comprehensive list of chronic conditions to be included when measuring multimorbidity. Methods Based on a consensus definition of chronic disease, all four-digit level codes from the International Classification of Diseases, 10th revision (ICD-10) were classified as chronic or not by an international and multidisciplinary team. Chronic ICD-10 codes were subsequently grouped into broader categories according to clinical criteria. Last, we showed proof of concept by applying the classification to older adults from the Swedish National study of Aging and Care in Kungsholmen (SNAC-K) using also inpatient data from the Swedish National Patient Register. Results A disease or condition was considered to be chronic if it had a prolonged duration and either (a) left residual disability or worsening quality of life or (b) required a long period of care, treatment, or rehabilitation. After applying this definition in relation to populations of older adults, 918 chronic ICD-10 codes were identified and grouped into 60 chronic disease categories. In SNAC-K, 88.6% had ≥2 of these 60 disease categories, 73.2% had ≥3, and 55.8% had ≥4. Conclusions This operational measure of multimorbidity, which can be implemented using either or both clinical and administrative data, may facilitate its monitoring and international comparison. Once validated, it may enable the advancement and evolution of conceptual and theoretical aspects of multimorbidity that will eventually lead to better care.

Anticholinergic Medication Burden and 5-Year Risk of Hospitalization and Death in Nursing Home Elderly Residents With Coronary Artery Disease

OBJECTIVESnTo assess the association of the anticholinergic medication burden with hospitalization and mortality in nursing home elderly patients and to investigate the role of coronary artery disease (CAD).nnnDESIGNnLongitudinal (5-year) retrospective observational study.nnnSETTINGnNursing homes in Italy.nnnPARTICIPANTSnA total of 3761 nursing home older residents.nnnMEASUREMENTSnA comprehensive clinical and functional assessment was carried out through the interRAIxa0long-term care facility instrument. The anticholinergic burden was assessed through the anticholinergic cognitive burden (ACB) scale. Occurrence of hospitalization/all-cause mortality was the primary composite outcome. First hospitalization and all-cause mortality were the secondary outcomes of the study. Hazard ratios (HRs) and subdistribution HRs were obtained through Cox and competing risk (death as competing event for hospitalization) models.nnnRESULTSnWithin the sample (mean age 83 ± 7xa0years; 72% females) the incidence rate of the primary outcome was 10/100 person-year. After adjusting for potential confounders and compared with participants with an ACB of 0, those with an ACB of 1 [HR 1.46; 95% confidence interval (CI) 1.12-1.90] and ABC of 2+ (HR 1.41; 95% CI 1.11-1.79) presented an increased risk of developing the primary outcome. After stratification, the risk for the primary outcome increased along with the anticholinergic burden, only for participants affected by CAD (HR 1.53; 95% CI 0.94-2.50 and HR 1.71; 95% CI 1.09-2.68 for the ACB of 1 and ACB of 2+xa0groups). An ACB score of 2+xa0was marginally associated with first hospitalization, considering death as a competing risk, only for those with CAD (subdistribution HR 3.47; 95% CI 0.99-12.3).nnnCONCLUSIONSnAnticholinergic medication burden is associated to hospitalization and all-cause mortality in institutionalized older adults. CAD increases such risk. The effectiveness and safety profile of complex drug regimens should be reconsidered in this population.

An international perspective on chronic multimorbidity: approaching the elephant in the room

Abstract Multimorbidity is a common and burdensome condition that may affect quality of life, increase medical needs, and make people live more years of life with disability. Negative outcomes related to multimorbidity occur beyond what we would expect from the summed effect of single conditions, as chronic diseases interact with each other, mutually enhancing their negative effects, and eventually leading to new clinical phenotypes. Moreover, multimorbidity mirrors an accelerated global susceptibility and a loss of resilience, which are both hallmarks of aging. Due to the complexity of its assessment and definition, and the lack of clear evidence steering its management, multimorbidity represents one of the main current challenges for clinicians, researchers, and policymakers. The authors of this article recently reflected on these issues during two twin international symposia at the 2016 European Union Geriatric Medicine Society (EUGMS) meeting in Lisbon, Portugal, and the 2016 Gerontological Society of America (GSA) meeting in New Orleans, USA. The present work summarizes the most relevant aspects related to multimorbidity, with the ultimate goal to identify knowledge gaps and suggest future directions to approach this condition.

Inappropriate Use of Proton Pump Inhibitors in Elderly Patients Discharged from Acute Care Hospitals.

BackgroundProton-pump inhibitors (PPI) are extensively prescribed in older patients. However, little information is available on factors associated to PPI prescribing patterns among older patients discharged from hospital.ObjectiveTo evaluate the appropriateness and clinical correlates of PPI prescription at discharge in a population of 1081 older patients discharged from acute care Italian hospitals.DesignWe used data from the CRiteria to Assess Appropriate Medication Use among Elderly Complex Patients (CRIME) study, a multicenter observational study. The appropriateness of PPI prescriptions was defined according to the Italian Medicines Agency (AIFA) rules. Correlates of overprescribing (i.e prescribing without recognized AIFA indications) and underprescribing (i.e. not prescribing despite the presence of recognized AIFA indications) were investigated by logistic regression analysis.ResultsOverprescribing was observed in 30% of patients receiving PPIs at discharge. Underprescribing was observed in 11% of patients not receiving PPIs at discharge. Overprescribing of PPIs at discharge was negatively associated with age (OR=0.88, 95%CI=0.85-0.91), depression (OR=0.58, 95%CI=0.35-0.96), use of aspirin (OR=0.03, 95%CI=0.02-0.06) and systemic corticosteroids (OR=0.02, 95%CI=0.01-0.04). The negative association with number of medications (OR=0.95, 95%CI=0.88-1.03) and overall comorbidities (OR=0.92, 95%CI=0.83-1.02) was nearly significant. Conversely, older age (OR=1.09, 95%CI=1.04-1.14), use of aspirin (OR=24.0, 95%CI=11.5-49.8) and systemic corticosteroids (OR=19.3, 95%CI=11.5-49.8) and overall comorbidities (OR=1.22, 95%CI=1.04-1.42) were independent correlates of underprescribing.ConclusionOverprescribing of PPIs is more frequent in younger patients with lower burden of depression, whilst underprescribing is characterized by older age and greater burden of comorbidity and polypharmacy. Hospitalization should be considered as a clue to identify inappropriate use of PPIs and improve appropriateness of prescribing.

Health determinants and survival in nursing home residents in Europe: Results from the SHELTER study

OBJECTIVEnThe care processes directed towards institutionalized older people needs to be tailored on goals and priorities that are relevant for this specific population. The aim of the present study was (a) to describe the distribution of selected health determinants in a sample of institutionalized older adults, and (b) to investigate the impact on survival of such measures.nnnDESIGNnMulticentre longitudinal cohort-study.nnnSETTINGn57 nursing homes (NH) in 7EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non-EU country (Israel).nnnPARTICIPANTSn3036 NH residents participating in the Services and Health for Elderly in Long TERm care (SHELTER) study.nnnMEASUREMENTSnWe described the distribution of 8 health determinants (smoking habit, alcohol use, body mass index [BMI], physical activity, social participation, family visits, vaccination, and preventive visits) and their impact on 1-year mortality.nnnRESULTSnDuring the one-year follow up, 611 (20%) participants died. Overweight (HR 0.79; 95% C.I. 0.64-0.97) and obesity (HR 0.64; 95% C.I. 0.48-0.87) resulted associated with lower mortality then normal weight. Similarly, physical activity (HR 0.67; 95% C.I. 0.54-0.83), social activities (HR 0.63; 95% C.I. 0.51-0.78), influenza vaccination (HR 0.66; 95% C.I. 0.55-0.80) and pneumococcal vaccination (HR 0.76 95% C.I. 0.63-0.93) were associated with lower mortality. Conversely, underweight (HR 1.28; 95% C.I. 1.03-1.60) and frequent family visits (HR 1.75; 95% C.I. 1.27-2.42) were associated with higher mortality.nnnCONCLUSIONSnHealth determinants in older NH residents depart from those usually accounted for in younger and fitter populations. Ad hoc studies are warranted in order to describe other relevant aspects of health in frail older adults, with special attention on those institutionalized, with the ultimate goal of improving the quality of care and life.

Sarcopenia in Parkinson Disease: Comparison of Different Criteria and Association With Disease Severity

OBJECTIVESnIn Parkinson disease (PD), sarcopenia may represent the common downstream pathway that from motor and nonmotor symptoms leads to the progressive loss of resilience, frailty, and disability. Here we (1) assessed the prevalence of sarcopenia in older adults with PD using 3 different criteria, testing their agreement, and (2) evaluated the association between PD severity and sarcopenia.nnnDESIGNnCross-sectional, observation study.nnnSETTINGnGeriatric day hospital.nnnPARTICIPANTSnOlder adults with idiopathic PD.nnnMEASUREMENTSnBody composition was evaluated through dual energy x-ray absorptiometry. Handgrip strength and walking speed were measured. Sarcopenia was operationalized according to the Foundation for the National Institutes of Health, the European Working Group on Sarcopenia in Older Persons, and the International Working Group. Cohen k statistics was used to test the agreement among criteria.nnnRESULTSnAmong the 210 participants (mean age 73xa0years; 38% women), the prevalence of sarcopenia was 28.5%-40.7% in men and 17.5%-32.5% in women. The prevalence of severe sarcopenia was 16.8%-20.0% in men and 11.3%-18.8% in women. The agreement among criteria was poor. The highest agreement was obtained between the European Working Group on Sarcopenia in Older Persons (severe sarcopenia) and International Working Group criteria (kxa0=xa00.52 in men; kxa0=xa00.65 in women; Pxa0<xa0.01 for both). Finally, severe sarcopenia was associated with PD severity (odds ratio 2.30; 95% confidence interval 1.15-4.58).nnnCONCLUSIONSnSarcopenia is common in PD, with severe sarcopenia being diagnosed in 1 in every 5 patients with PD. We found a significant disagreement among the 3 criteria evaluated, in detecting sarcopenia more than in ruling it out. Finally, sarcopenia is associated with PD severity. Considering its massive prevalence, further studies should address the prognosis of sarcopenia in PD.

Anticholinergic burden and health outcomes among older adults discharged from hospital: results from the CRIME study

PurposeThe purpose of this study is to investigate whether there is an association between anticholinergic burden and mortality or rehospitalization in older adults discharged from hospital.MethodsProspective multicenter cohort study carried out with patients aged 65 and older discharged from seven acute care hospitals. The primary outcomes of the study were rehospitalization and mortality within 1xa0year after discharge. The study population was classified in three groups according to the anticholinergic exposure measured by the Anticholinergic Risk Scale (ARS) and Durán’s list at the time of hospital discharge: without risk (ARS/Duránxa0=xa00), low risk (ARS/Duránxa0=xa01), and high risk (ARS/Durán ≥xa02). Predictors of hospitalizations and mortality were examined using regression models adjusting for important covariates.ResultsThe mean age of the 921 participants was 81.2xa0years (SDxa0=xa07.4xa0years). Prevalence of exposure to medications with anticholinergic activity ranged from 19.6% with ARS to 32.1% with Durán’s list. During the follow-up period, 30.4% of participants were hospitalized and 19.4% died. Multivariate regression analysis showed that low anticholinergic burden quantified according to Durán’s list was significantly associated with all-cause mortality (OR 1.69, 95% CI 1.02–2.82). This association was not present after adjustment when using ARS. No statistically significant association was found between anticholinergic burden and hospitalizations.ConclusionsTaking medications with anticholinergic activity is associated with greater risk of mortality in older adults discharged from acute care hospitals. Strategies to reduce anticholinergic burden in vulnerable elders could be useful to improve health outcomes. Further research is required to assess the association between anticholinergic burden and hospitalizations in older patients.

Trajectories of functional decline in older adults with neuropsychiatric and cardiovascular multimorbidity: A Swedish cohort study

Background Functional decline is a strong health determinant in older adults, and chronic diseases play a major role in this age-related phenomenon. In this study, we explored possible clinical pathways underlying functional heterogeneity in older adults by quantifying the impact of cardiovascular (CV) and neuropsychiatric (NP) chronic diseases and their co-occurrence on trajectories of functional decline. Methods and findings We studied 2,385 people ≥60 years (range 60–101 years) participating in the Swedish National study of Aging and Care in Kungsholmen (SNAC-K). Participants underwent clinical examination at baseline (2001–2004) and every 3 or 6 years for up to 9 years. We grouped participants on the basis of 7 mutually exclusive clinical patterns of 0, 1, or more CV and NP diseases and their co-occurrence, from a group without any CV and NP disease to a group characterised by the presence of CV or NP multimorbidity, accompanied by at least 1 other CV or NP disorder. The group with no CV and/or NP diseases served as the reference group. Functional decline was estimated over 9 years of follow-up by measuring mobility (walking speed, m/s) and independence (ability to carry out six activities of daily living [ADL]). Mixed-effect linear regression models were used (1) to explore the individual-level prognostic predictivity of the different CV and NP clinical patterns at baseline and (2) to quantify the association between the clinical patterns and functional decline at the group level by entering the clinical patterns as time-varying measures. During the 9-year follow-up, participants with multiple CV and NP diseases had the steepest decline in walking speed (up to 0.7 m/s; p < 0.001) and ADL independence (up to three impairments in ADL, p < 0.001) (reference group: participants without any CV and NP disease). When the clinical patterns were analyzed as time varying, isolated CV multimorbidity impacted only walking speed (β −0.1; p < 0.001). Conversely, all the clinical patterns that included at least 1 NP disease were significantly associated with decline in both walking speed (β −0.21–−0.08; p < 0.001) and ADL independence (β −0.27–−0.06; p < 0.05). Groups with the most complex clinical patterns had 5%–20% lower functioning at follow-up than the reference group. Key limitations of the study include that we did not take into account the specific weight of single diseases and their severity and that the exclusion of participants with less than 2 assessments may have led to an underestimation of the tested associations. Conclusions In older adults, different patterns of CV and NP morbidity lead to different trajectories of functional decline over time, a finding that explains part of the heterogeneity observed in older adults’ functionality. NP diseases, alone or in association, are prevalent and major determinants of functional decline, whereas isolated CV multimorbidity is associated only with declines in mobility.

Frailty and multimorbidity: a systematic review and meta-analysis

BackgroundnMultimorbidity and frailty are complex syndromes characteristics of ageing. We reviewed the literature, and provided pooled estimations of any evidence regarding a) the coexistence of frailty and multimorbidity, and b) their association.nnnMethodsnWe searched PubMed and Web of Science for relevant articles up to September 2017. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting. Homogeneity (I2), risk of bias and publication bias were assessed. PROSPERO registration: 57890.nnnResultsnA total of 48 studies involving 78122 participants were selected, and 25 were included in one or more meta-analyses. Forty-five studies were cross-sectional and 3 longitudinal, with the majority of them including community-dwelling participants (n=35). Forty-three studies presented a moderate risk of bias, and 5 a low risk. Most of the articles defined multimorbidity as having two or more diseases and frailty according to the Cardiovascular Health Study criteria. In meta-analyses, the prevalence of multimorbidity in frail individual was 72% (95% Confidence Interval [95% CI] 63% to 81%; I2=91.3%) and the prevalence of frailty among multimorbid individuals was 16% (95% CI 12% to 21%; I2=96.5%). Multimorbidity was associated with frailty in pooled analyses (OR 2.27; 95% CI 1.97 to 2.62; I2 47.7%). The three longitudinal studies suggest a bidirectional association between multimorbidity and frailty.nnnConclusionsnFrailty and multimorbidity are two related conditions in older adults. Most frail individuals are also multimorbid but fewer multimorbid ones present also frailty. Our findings are not conclusive regarding the causal association between the two conditions. Further longitudinal and well-designed studies may help to untangle the relationship between frailty and multimorbidity.

The Complexity of the Geriatric Patient

Complexity is the result of medical, social, and psychological factors that challenge the effectiveness of the care process, making it not standard and more demanding to health professionals. Several conditions extremely common in older patients are responsible for complexity. Multimorbidity, complex medication regimens, geriatric syndromes, cognitive impairment, and low socioeconomic status are among them and limit the effectiveness of treatments and indications. What stated by guidelines might not work in complex older adults and often raises, among physicians, more doubts on potential harm than certainties. Goal-oriented care and participation of the patient in the decision-making process are warranted in the presence of complexity, in order to improve the efficacy of the treatment and preserve the quality of life. The Comprehensive Geriatric Assessment (CGA) can help in prioritizing specific intervention areas.