Impact of cardiovascular and neuropsychiatric multimorbidity on older adults' health

Multimorbidity, the presence of two or more chronic diseases in one person, is common in older people, and associates with a number of negative outcomes. In this thesis, we propose a methodology to assess and measure multimorbidity in older individuals. We use it to describe the longitudinal evolution and prognosis of multimorbidity clusters, and to investigate the extent to which clusters of cardiovascular and neuropsychiatric multimorbidity impact and interact with physical function. Data are from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K), a population-based study including 3,363 community-dwelling and institutionalized individuals aged ≥60 years. Study I. We provided a clinically driven list of 60 chronic diseases for the assessment of multimorbidity in older adults. After applying this methodology to the 3,363 SNAC-K participants, we found that 88.6% of them had two or more diseases, 73.2% had three or more diseases, and only 11.4% had zero or one single disease. Given the ceiling effect associated with the use of a cutoff, multimorbidity should be rather be considered as a continuous metric, which better reflects the progressive accumulation of diseases starting in early aging and continuing up to very late life. Study II. We identified and traced the evolution of multimorbidity clusters over 12 years of 2,931 SNAC-K participants with two or more diseases. At baseline, 51.3% of participants were included in one of five clusters; the rest were part of an unspecified group, given that no disease patterns could cluster them. Cardiometabolic risk factors, the evolution of several diseases, and death may have steered most of the longitudinal transitions among the multimorbidity clusters we described over a period of 12 years. Study III. We investigated the association of cardiovascular and neuropsychiatric multimorbidity with 9 years of change in walking speed and intact basic activities of daily living in 2,385 SNAC-K participants. Neuropsychiatric disease, alone or combined with cardiovascular disease, showed the strongest detrimental impact on functional decline. Cardiovascular multimorbidity showed an association solely with decline in walking speed. Study IV. We studied the interplay between cardiovascular multimorbidity and functional impairment, as well as between neuropsychiatric multimorbidity and functional impairment, on all-cause and causespecific mortality in 3,241 SNAC-K participants. Slow walking speed provided additional prognostic information in terms of all-cause and cause-specific mortality beyond the number of both cardiovascular and/or neuropsychiatric diseases. Conclusions. The use of a standardized methodology to assess chronic disease and multimorbidity may enhance comparability across studies, settings, and geographical regions. Studying the natural evolution of multimorbidity in older individuals may help to better hypothesize about underlying mechanisms and provide important prognostic information. In this regard, multimorbidity clusters including cardiovascular and neuropsychiatric disease emerge as major determinants of functional decline and higher mortality rate. Finally, the adoption of a simple and easy-to-use measure of functional impairment such as walking speed may help health-care professionals identify older people affected by specific groups of chronic disease with similar needs, health trajectories, and prognoses

Relationship between People's Interest in Medication Adherence, Health Literacy, and Self-Care: An Infodemiological Analysis in the Pre- and Post-COVID-19 Era

The prevalence of non-communicable diseases has risen sharply in recent years, particularly among older individuals who require complex drug regimens. Patients are increasingly required to manage their health through medication adherence and self-care, but about 50% of patients struggle to adhere to prescribed treatments. This study explored the relationship between interest in medication adherence, health literacy, and self-care and how it changed during the COVID-19 pandemic. We used Google Trends to measure relative search volumes (RSVs) for these three topics from 2012 to 2022. We found that interest in self-care increased the most over time, followed by health literacy and medication adherence. Direct correlations emerged between RSVs for medication adherence and health literacy (r = 0.674, p < 0.0001), medication adherence and self-care (r = 0.466, p < 0.0001), and health literacy and self-care (r = 0.545, p < 0.0001). After the COVID-19 pandemic outbreak, interest in self-care significantly increased, and Latin countries showed a greater interest in self-care than other geographical areas. This study suggests that people are increasingly interested in managing their health, especially in the context of the recent pandemic, and that infodemiology may provide interesting information about the attitudes of the population toward chronic disease management

Peak expiratory flow, walking speed and survival in older adults: An 18-year longitudinal population-based study

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Association Between Speed of Multimorbidity Accumulation in Old Age and Life Experiences: A Cohort Study

Abstract Rapidly accumulating multiple chronic conditions (multimorbidity) during aging are associated with many adverse outcomes. We explored the association between 4 experiences throughout life—childhood socioeconomic circumstances, early-adulthood education, midlife occupational stress, and late-life social network—and the speed of chronic disease accumulation. We followed 2,589 individuals aged ≥60 years from the Swedish National Study on Aging and Care in Kungsholmen for 9 years (2001–2013). Information on life experiences was collected from detailed life-history interviews. Speed of disease accumulation was operationalized as the change in the count of chronic conditions obtained from clinical examinations, medical histories, laboratory data, drug use, and register linkages over 9 years. Linear mixed models were used to analyze the data. Speed of disease accumulation was lower in individuals with more than elementary education (for secondary, β × time = −0.065, 95% CI: −0.126, −0.004; for university, β × time = −0.118, 95% CI: −0.185, −0.050); for active occupations compared with high-strain jobs (β × time = −0.078, 95% CI: −0.138, −0.017); and for richer social networks (for moderate tertile, β × time = −0.102, 95% CI: −0.149, −0.055; for highest tertile, β × time = −0.135, 95% CI: −0.182, −0.088). The association between childhood circumstances and speed of disease accumulation was attenuated by later-life experiences. Diverse experiences throughout life might decelerate chronic disease accumulation during aging

Methodological issues in the observational studies conducted in older population: a narrative review

Introduction Well-conducted observational studies may represent valuable tools for getting insight to disease etiology, detecting the effect of age-related changes, and providing an important perspective on health risk factors and disabilities in an aging population. Nevertheless, this kind of research poses several challenges for researchers. The main aim of this narrative review was to address the potential methodological issues in performing the observational studies in the elderly, the factors that influence their participation, and the possible solutions for overcoming the barriers to research in this population. Methods Comprehensive search for the papers published in the period from January 1st 1980 until 31st July 2016 in English or Italian was conducted through MEDLINE, Scopus and Web of Science electronic databases. Findings from the included papers were finally summarized. Results In cohort studies, the following barriers were addressed: sample size calculation, ascertainment of the target population, frequency of data collection, exposure determination, multifactorial loss to follow-up (drop-outs), cognitive impairment, definition of confounders, and ethical aspects. Case-control studies were reported to be prone to the issues like ascertainment of cases and controls, willingness to participate, data accuracy, recall bias, issues related to patients’ multimorbidity, and cognitive impairment. Conclusions Important factors to consider in research in elderly people include: precise definition of the study population, well conducted recruitment process, engagement with family and home care staff, cognitive impairment assessment and the consequent relevant ethical and legal issues, relief of participant burden in order to minimize withdrawal, and engagement with the media

Impact of COVID-19-Related Lockdown on Psychosocial, Cognitive, and Functional Well-Being in Adults With Down Syndrome

People with Down Syndrome (DS) have a high prevalence of physical and psychiatric comorbidities and experience early-onset dementia. With the outbreak of CoVID-19 pandemic, strict social isolation measures have been necessary to prevent the spreading of the disease. Effects of this lockdown period on behavior, mood and cognition in people with DS have not been assessed so far. In the present clinical study, we investigated the impact of CoVID-19-related lockdown on psychosocial, cognitive and functional well-being in a sample population of 46 adults with DS. The interRAI Intellectual Disability standardized assessment instrument, which includes measures of social withdrawal, functional impairment, aggressive behavior and depressive symptoms, was used to perform a three time-point evaluation (two pre-lockdown and one post-lockdown) in 37 subjects of the study sample, and a two time point evaluation (one pre- and one post-lockdown) in 9 subjects. Two mixed linear regression models - one before and one after the lockdown - have been fitted for each scale in order to investigate the change in the time-dependent variation of the scores. In the pre-lockdown period, significant worsening over time (i.e., per year) was found for the Depression Rating Scale score (beta = 0.55; 95% CI 0.34; 0.76). In the post-lockdown period, a significant worsening in social withdrawal (beta = 3.05, 95% CI 0.39; 5.70), instrumental activities of daily living (beta = 1.13, 95% CI 0.08; 2.18) and depression rating (beta = 1.65, 95% CI 0.33; 2.97) scales scores was observed, as was a significant improvement in aggressive behavior (beta = -1.40, 95% CI -2.69; -0.10). Despite the undoubtful importance of the lockdown in order to reduce the spreading of the CoVID-19 pandemic, the related social isolation measures suggest an exacerbation of depressive symptoms and a worsening in functional status in a sample of adults with DS. At the opposite, aggressive behavior was reduced after the lockdown period. This finding could be related to the increase of negative and depressive symptoms in the study population. Studies with longer follow-up period are needed to assess persistence of these effects

Prognosis and Interplay of Cognitive Impairment and Sarcopenia in Older Adults Discharged from Acute Care Hospitals

Sarcopenia and cognitive impairment are associated with an increased risk of negative outcomes, but their prognostic interplay has not been investigated so far. We aimed to investigate the prognostic interaction of sarcopenia and cognitive impairment concerning 12-month mortality among older patients discharged from acute care wards in Italy. Our series consisted of 624 patients (age = 80.1 ± 7.0 years, 56.1% women) enrolled in a prospective observational study. Sarcopenia was defined following the European Working Group on Sarcopenia in Older People (EWGSOP) criteria. Cognitive impairment was defined as age- and education-adjusted Mini-Mental State Examination (MMSE) score < 24 or recorded diagnosis of dementia. The study outcome was all-cause mortality during 12-month follow-up. The combination of sarcopenia and cognitive ability was tested against participants with intact cognitive ability and without sarcopenia. Overall, 159 patients (25.5%) were identified as having sarcopenia, and 323 (51.8%) were cognitively impaired. During the follow-up, 79 patients (12.7%) died. After adjusting for potential confounders, the combination of sarcopenia and cognitive impairment has been found associated with increased mortality (HR = 2.12, 95% CI = 1.05-4.13). Such association was also confirmed after excluding patients with dementia (HR = 2.13, 95% CI = 1.06-4.17), underweight (HR = 2.18, 95% CI = 1.03-3.91), high comorbidity burden (HR = 2.63, 95% CI = 1.09-6.32), and severe disability (HR = 2.88, 95% CI = 1.10-5.73). The co-occurrence of sarcopenia and cognitive impairment may predict 1-year mortality in older patients discharged from acute care hospitals

Serum total cholesterol and risk of cardiovascular and non-cardiovascular mortality in old age: a population-based study

Abstract Background Whether the suggested inverse association between total cholesterol and mortality in old age varies according to cause of death and use of cholesterol medications remains to be elucidated. The aim of this study was to assess the associations of total cholesterol with cardiovascular and non-cardiovascular mortality in old age, and to explore whether their associations vary by use of cholesterol-lowering medications. Methods The study participants included 3090 older adults (age ≥ 60 years, 63.7% women) from a population-based cohort study, i.e., the Swedish National study on Aging and Care in Kungsholmen, Stockholm. At baseline (2001–2004), data on demographic factors, lifestyles, cardiovascular risk factors, use of medications, global cognitive function, mobility limitation, and apolipoprotein E genotype were collected through interviews, clinical examinations, laboratory tests as well as from the Swedish national patient register. Vital statistics data (e.g., date and causes of death) till December 31, 2011 for all participants were derived from Swedish cause of death register. Data were analyzed using Cox proportional hazards model for all-cause mortality and Fine-Gray competing risks regression model for cause-specific mortality controlling for multiple potential confounders. Results During 23,196 person-years of follow-up (median per person, 7.5 years), 1059 (34.3%) participants died. Compared to normal total cholesterol (<5.18 mmol/l), borderline-high (5.18–6.21 mmol/l) and high (≥6.22 mmol/l) total cholesterol were associated with a decreased risk of all-cause mortality, with the multiple-adjusted hazard ratio (95% confidence interval, CI) of 0.71 (0.61–0.83) and 0.68 (0.57–0.80), respectively (P for trend <0.001). The competing risk regression models revealed that the reduced all-cause mortality associated with high total cholesterol (≥6.22 mmol/l)) was mainly due to the reduced risk of non-cardiovascular mortality (hazard ratio = 0.67, 95% CI = 0.51–0.88). These associations were statistically evident only among individuals without use of cholesterol-lowering medications. Conclusions The inverse association between high total cholesterol and reduced all-cause mortality in older adults is primarily due to non-cardiovascular mortality, especially among those who are not treated with cholesterol-lowering medications

Appropriateness of pharmacological treatment in older people with dementia

Dementia is associated with a number of comorbidities often observed in older people, including hypertension, cardiovascular disease, stroke and diabetes. Treating these comorbidities in older adults with dementia results challenging for many reasons. First, older adults with dementia are generally excluded from clinical trials, so application of clinical guidelines for treatment of chronic diseases in this population might lead to polypharmacy and adverse drugs effects. Second, memory, intellectual function, judgment and language are commonly impaired in patients with cognitive deficits, compromising the compliance to complex pharmacological regimens, increasing the risk of adverse drug reactions. Third, cognitive impairment is associated with limited life expectancy and therefore limits the efficacy of pharmacological treatments and questions the appropriateness of treatment. In the present study we examine most relevant concerns related to the treatment of comorbidities in demented patients, referring also to the existing criteria for inappropriate drugs in the elderly. The application of such instruments, along with the comprehensive geriatric assessment of the older adult with cognitive impairment, could result useful to reduce the burden of polypharmacy and inappropriate drug prescriptions

Hospital length of stay and 30-day readmissions in older people: their association in a 20-year cohort study in Italy

Background: There are conflicting data on whether hospital length of stay (LOS) reduction affects readmission rates in older adults. We explored 20-year trends of hospital LOS and 30-day rehospitalizations in a cohort of Italian older people, and investigated their association. Methods: Participants in the Pro.V.A. project (n = 3099) were followed-up from 1996 to 2018. LOS and 30-day rehospitalizations, i.e. new hospitalizations within 30 days from a previous discharge, were obtained from personal interviews and regional registers. Rehospitalizations in the 6 months before death were also assessed. Linear regressions evaluated the associations between LOS and the frequency of 30-day rehospitalizations, adjusting for the mean age of the cohort within each year. Results: Over 20 years, 2320 (74.9%) participants were hospitalized. Mean LOS gradually decreased from 17.3 days in 1996 to 11.3 days in 2018, while 30-day rehospitalization rates increased from 6.6% in 1996 to 13.6% in 2018. LOS was inversely associated with 30-day rehospitalizations frequency over time (β = -2.33, p = 0.01), similarly in men and women. A total of 1506 individuals was hospitalized within 6 months before death. The frequency of 30-day readmissions at the end of life increased from 1.4% in 1997 to 8.3% in 2017 and was associated with mean LOS (β = -1.17, p = 0.03). Conclusions: The gradual LOS reduction observed in the latter decades is associated with higher 30-day readmission rates in older patients in Italy. This suggests that a careful pre-discharge assessment is warranted in older people, and that community healthcare services should be improved to reduce the risk of readmission