Marie-France Dubois

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.

Vascular Dementia Incidence and Risk Factors in the Canadian Study of Health and Aging

BACKGROUND AND PURPOSE Very few population-based studies have systematically examined incident vascular dementia (VaD). From the Canadian Study of Health and Aging cohort, incidence rates of VaD were determined and risk factors analyzed. METHODS This was a cohort incidence study that followed 8623 subjects presumed to be free of dementia over a 5-year period. The risk factors were examined with a nested prospective case-control study. Exposure was determined by means of a risk factor questionnaire administered to the subject or a proxy at the beginning of the study. RESULTS On the basis of 38 476 person-years at risk, the annual incidence rate was estimated to be 2.52 per thousand undemented Canadians (95% CI 2. 02 to 3.02). Including an estimation of the probability of VaD among the decedents, this figure rose to 3.79. For the risk factors study, 105 incident cases of VaD according to the NINCDS-AIREN criteria were compared with 802 control subjects. Significant risk factors were: age (OR=1.05), residing in a rural area (2.03), living in an institution (2.33), diabetes (2.15), depression (2.41), apolipoprotein E epsilon4 (2.34), hypertension for women (2.05), heart problems for men (2.52), taking aspirin (2.33), and occupational exposure to pesticides or fertilizers (2.05). Protective factors were eating shellfish (0.46) and regular exercise for women (0.46). There was no relation with sex, education, or alcohol. CONCLUSIONS The study confirmed some previously reported risk factors but also suggested new ones. It raised concerns about the prescription of aspirin and perhaps other factors related to rural life.

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.

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.

Comparative assessment of three different indices of multimorbidity for studies on health-related quality of life

BackgroundMeasures of multimorbidity are often applied to source data, populations or outcomes outside the scope of their original developmental work. As the development of a multimorbidity measure is influenced by the population and outcome used, these influences should be taken into account when selecting a multimorbidity index. The aim of this study was to compare the strength of the association of health-related quality of life (HRQOL) with three multimorbidity indices: the Cumulative Illness Rating Scale (CIRS), the Charlson index (Charlson) and the Functional Comorbidity Index (FCI). The first two indices were not developed in light of HRQOL.MethodsWe used data on chronic diseases and on the SF-36 questionnaire assessing HRQOL of 238 adult primary care patients who participated in a previous study. We extracted all the diagnoses for every patient from chart review to score the CIRS, the FCI and the Charlson. Data for potential confounders (age, sex, self-perceived economic status and self-perceived social support) were also collected. We calculated the Pearson correlation coefficients (r) of the SF-36 scores with the three measures of multimorbidity, as well as the coefficient of determination, R2, while controlling for confounders.ResultsThe r values for the CIRS (range: -0.55 to -0.18) were always higher than those for the FCI (-0.47 to -0.10) and Charlson (-0.31 to -0.04) indices. The CIRS explained the highest percent of variation in all scores of the SF-36, except for the Mental Component Summary Score where the variation was not significant. Variations explained by the FCI were significant in all scores of SF-36 measuring physical health and in two scales evaluating mental health. Variations explained by the Charlson were significant in only three scores measuring physical health.ConclusionThe CIRS is a better choice as a measure of multimorbidity than the FCI and the Charlson when HRQOL is the outcome of interest. However, the FCI may provide a good option to evaluate the physical aspect of HRQOL for the ease in its administration and scoring. The Charlson index may not be recommended as a measure of multimorbidity in studies related to either physical or mental aspects of HRQOL.

Effects of aerobic physical exercise in the elderly with type 2 diabetes mellitus

The objective of this study was to determine the impact of an aerobic physical exercise program in the treatment of a group of elderly patients with type 2 diabetes mellitus (DM) in relation to metabolic control, physical capacity, quality of life (QOL) and attitudes toward diabetes. Patients were randomly assigned to either an experimental (n=19) or a control (n=20) group. The following measurements were conducted at baseline and after week 16: glycosylated hemoglobin (hbA1c), fructosamine, 3 h oral glucose tolerance test, treadmill test (Balke-Naughton), and a questionnaire on QOL and attitudes toward DM. After the intervention, the experimental group showed a significant decrease of glucose excursion during the oral glucose tolerance test (OGTT) (area under the curve) (16.6+/-3.8 vs. 15.3+/-3.1, P<0.05) and an increase in total time on the treadmill (s) (423+/-207 vs. 471+/-230, P<0.05). An improvement in the attitudes toward DM was observed in the experimental group (P=0.01) but not in the control group. Female gender, higher body mass index and hbA1c were factors associated with a response to the intervention. This study suggests that physical exercise has significant effects on glucose excursion during an OGTT and exercise tolerance in elderly patients with type 2 DM.

Assessing the effectiveness of interventions to promote advance directives among older adults: A systematic review and multi-level analysis

Many studies have investigated the effectiveness of interventions in promoting advance directives (ADs) but there is uncertainty as to what works best, and in whom. We conducted a systematic review of the evidence in this regard, using both classical meta-analysis approaches and multi-level analyses. Eleven databases were searched for relevant reports published through March 2007. All prospective studies were eligible, whether involving a single group or several and, in the latter case, regardless of the allocation mechanism. Outcomes included formal and informal ADs assessed by chart review or self-report. Heterogeneous sets of outcomes were pooled under a random-effects model. The search yielded 55 studies, half of which targeted outpatients. Most groups of subjects were educated in a single session led by one healthcare professional. Outcomes were measured within six months of the intervention in 73% of cases. The largest set of single-arm studies yielded an overall AD completion rate of 45.6%. Across randomized trials, the largest pooled odds ratio was 4.0, decreasing to 2.6 when all comparative studies were included. Multi-variable analyses identified the provision of oral information over multiple sessions as the most successful intervention. This was true regardless of the target population. These findings support the effectiveness of educational interventions in increasing the formulation of ADs and provide practical advice on how best to achieve this goal.

A Prospective Evaluation of the Charlson Comorbidity Index for Use in Long-Term Care Patients

Longitudinal cohort study.

The Incidence of Vascular Dementia in Canada: A Comparison with Europe and East Asia

Vascular dementia (VaD) is the second commonest subtype of dementia after Alzheimer’s disease (AD). However, its incidence has been studied much less extensively than that of AD. This article reviews the incidence data for VaD reported in the international literature. Results from 10 incidence studies are compared to those of the Canadian Study of Health and Aging using age-standardized incidence ratios (SIR). SIRs vary from 0.42 to 2.68, indicating that geographical variation is still present after taking into account the countries’ differential age distributions. It is still unclear if these differences are due to genetic and/or environmental factors since a large part reflects methodological differences between studies.

Participation in daily activities and social roles of older adults with visual impairment

Purpose. (1) to document participation in daily activities and social roles of older adults seeking services for visual impairment (VI) and compare it with that of the older population without VI or other disabilities, and (2) to explore correlates of their participation. Methods. The 64 participants (46 women) had an average age of 79.3 years (SD = 5.9 years) and presented various types of VI. Participants were interviewed at home to collect information regarding their visual function (National Eye Institute Visual Function Questionnaire-25), sociodemographic and clinical characteristics, including depressive symptoms (Geriatric Depression Scale), and participation (Assessment of Life Habits/LIFE-H). Each participant was matched with another person without disabilities randomly recruited from the community. Results for the two populations on the Life-H participation domains were compared using t-tests. In the group with VI, general information (independent variables) was examined in relation to participation main scores (dependent variables), followed by multiple linear regression analyses. Results. Participation in daily activities and social roles of participants with VI (mean ± SD (/9) = 6.8 ± 1.0 and 5.6 ± 1.6, respectively) was significantly lower than that of participants without VI (8.1 ± 0.4 and 8.3 ± 0.4) (p < 0.0001). Depressive symptoms and perceived quality of distance vision were the strongest correlates and together explained more than 65% of the variance in the participation scores of the subjects with VI. Conclusions. This study demonstrates the participation restrictions associated with VI and underlines the importance of psychological aspects in participation.