Aging with multimorbidity: a systematic review of the literature
TL;DR: Methodological issues in evaluating multimorbidity are discussed as well as future research needs, especially concerning etiological factors, combinations and clustering of chronic diseases, and care models for persons affected by multiple disorders.
About: This article is published in Ageing Research Reviews.The article was published on 2011-09-01. It has received 2107 citations till now. The article focuses on the topics: Health care.
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TL;DR: Numerical definitions of polypharmacy did not account for specific comorbidities present and make it difficult to assess safety and appropriateness of therapy in the clinical setting, according to a systematic review of existing literature.
Abstract: Multimorbidity and the associated use of multiple medicines (polypharmacy), is common in the older population. Despite this, there is no consensus definition for polypharmacy. A systematic review was conducted to identify and summarise polypharmacy definitions in existing literature. The reporting of this systematic review conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. MEDLINE (Ovid), EMBASE and Cochrane were systematically searched, as well as grey literature, to identify articles which defined the term polypharmacy (without any limits on the types of definitions) and were in English, published between 1st January 2000 and 30th May 2016. Definitions were categorised as i. numerical only (using the number of medications to define polypharmacy), ii. numerical with an associated duration of therapy or healthcare setting (such as during hospital stay) or iii. Descriptive (using a brief description to define polypharmacy). A total of 1156 articles were identified and 110 articles met the inclusion criteria. Articles not only defined polypharmacy but associated terms such as minor and major polypharmacy. As a result, a total of 138 definitions of polypharmacy and associated terms were obtained. There were 111 numerical only definitions (80.4% of all definitions), 15 numerical definitions which incorporated a duration of therapy or healthcare setting (10.9%) and 12 descriptive definitions (8.7%). The most commonly reported definition of polypharmacy was the numerical definition of five or more medications daily (n = 51, 46.4% of articles), with definitions ranging from two or more to 11 or more medicines. Only 6.4% of articles classified the distinction between appropriate and inappropriate polypharmacy, using descriptive definitions to make this distinction. Polypharmacy definitions were variable. Numerical definitions of polypharmacy did not account for specific comorbidities present and make it difficult to assess safety and appropriateness of therapy in the clinical setting.
1,533 citations
TL;DR: The first World report on ageing and health is released, reviewing current knowledge and gaps and providing a public health framework for action, built around a redefinition of healthy ageing that centres on the notion of functional ability.
1,341 citations
Karolinska University Hospital1, Karolinska Institutet2, Pasteur Institute3, University of Toulouse4, Wolfson Centre for Age-Related Diseases5, University of Cambridge6, University of New South Wales7, Pierre-and-Marie-Curie University8, Umeå University9, La Trobe University10, University of British Columbia11, University of Geneva12, Douglas Mental Health University Institute13, Alzheimer Europe14, German Center for Neurodegenerative Diseases15, University of Cologne16, London School of Economics and Political Science17, Radboud University Nijmegen18, Rockefeller University19, VU University Medical Center20, University of Southern California21, Brigham and Women's Hospital22, University of Copenhagen23, UCL Institute of Neurology24, University of Gothenburg25
TL;DR: This poster aims to demonstrate the efforts towards in-situ applicability of EMMARM, which aims to provide real-time information about the physical and cognitive properties of Alzheimer's disease and other dementias.
Abstract: Defeating Alzheimer's disease and other dementias : a priority for European science and society
1,215 citations
TL;DR: An overview of the global impact and burden of frailty, the usefulness of the frailty concept in clinical practice, potential targets for frailty prevention, and directions that need to be explored in the future are provided.
1,075 citations
TL;DR: The limitations of the current evidence base means that further and better designed studies are needed to inform policy, research and clinical practice, with the goal of improving health-related quality of life for patients with multimorbidity.
Abstract: Introduction
Multimorbidity is a major concern in primary care. Nevertheless, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. The aim of this study is to systematically review studies of the prevalence, patterns and determinants of multimorbidity in primary care.
Methods
Systematic review of literature published between 1961 and 2013 and indexed in Ovid (CINAHL, PsychINFO, Medline and Embase) and Web of Knowledge. Studies were selected according to eligibility criteria of addressing prevalence, determinants, and patterns of multimorbidity and using a pretested proforma in primary care. The quality and risk of bias were assessed using STROBE criteria. Two researchers assessed the eligibility of studies for inclusion (Kappa = 0.86).
Results
We identified 39 eligible publications describing studies that included a total of 70,057,611 patients in 12 countries. The number of health conditions analysed per study ranged from 5 to 335, with multimorbidity prevalence ranging from 12.9% to 95.1%. All studies observed a significant positive association between multimorbidity and age (odds ratio [OR], 1.26 to 227.46), and lower socioeconomic status (OR, 1.20 to 1.91). Positive associations with female gender and mental disorders were also observed. The most frequent patterns of multimorbidity included osteoarthritis together with cardiovascular and/or metabolic conditions.
Conclusions
Well-established determinants of multimorbidity include age, lower socioeconomic status and gender. The most prevalent conditions shape the patterns of multimorbidity. However, the limitations of the current evidence base means that further and better designed studies are needed to inform policy, research and clinical practice, with the goal of improving health-related quality of life for patients with multimorbidity. Standardization of the definition and assessment of multimorbidity is essential in order to better understand this phenomenon, and is a necessary immediate step.
771 citations
Cites background or result from "Aging with multimorbidity: a system..."
...The review by Marengoni et al was limited to the population aged 65 years and older, and included patients admitted to hospitals and nursing homes; for these reasons, our results cannot be compared [2]....
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...Multimorbidity 2 the presence of more than one health condition in an individual [1,2] 2 is increasingly being recognised as the norm rather than the exception in primary care patients [3]....
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References
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TL;DR: The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death fromComorbid disease for use in longitudinal studies and further work in larger populations is still required to refine the approach.
39,961 citations
"Aging with multimorbidity: a system..." refers methods in this paper
...Most used indices are: the Charlson Comorbidity Index (Charlson et al., 1987), the Index of Co-Existent Diseases (ICED) (Greenfield et al., 1993), and the Cumulative Illness Rating Scale (CIRS) (Linn et al., 1968)....
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TL;DR: A narrative review of current understanding of the definitions and distinguishing characteristics of each of these conditions, including their clinical relevance and distinct prevention and therapeutic issues, and how they are related is provided.
Abstract: Three terms are commonly used interchangeably to identify vulnerable older adults: comorbidity, or multiple chronicconditions,frailty, anddisability. However, in geriatricmedicine,there isagrowingconsensusthatthese are distinct clinical entities that are causally related. Each, individually, occurs frequently and has high import clinically. This article provides a narrative review of current understanding of the definitions and distinguishing characteristics of each of these conditions,including theirclinical relevance and distinct prevention and therapeutic issues, and how they are related. Review of the current state of published knowledge is supplemented by targeted analysesin selectedareas where no current publisheddataexists. Overall,the goalof this articleis to providea basis fordistinguishingbetweenthesethreeimportantclinicalconditionsinolderadultsandshowinghowuseofseparate, distinct definitions of each can improve our understanding of the problems affecting older patients and lead to development of improved strategies for diagnosis, care, research, and medical education in this area.
3,394 citations
"Aging with multimorbidity: a system..." refers background in this paper
...In the Cardiovascular Health Study, of the 2762 participants, 2131 were affected by 2+ chronic conditions, but did not have either disability or frailty (Fried et al., 2004)....
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...Multimorbidity and disability along with frailty identify the vulnerable subset of the old population (Fried et al., 2004)....
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TL;DR: The evidence presented in this paper suggests that the apparent leveling off of life expectancy in various countries is an artifact of laggards catching up and leaders falling behind, not a sign that life expectancy is approaching its limit.
Abstract: Is human life expectancy approaching its limit? Many--including individuals planning their retirement and officials responsible for health and social policy--believe it is, but the evidence presented in the
Policy Forum
suggests otherwise. For 160 years, best-performance life expectancy has steadily increased by a quarter of a year per year, an extraordinary constancy of human achievement. Mortality experts have repeatedly asserted that life expectancy is close to an ultimate ceiling; these experts have repeatedly been proven wrong. The apparent leveling off of life expectancy in various countries is an artifact of laggards catching up and leaders falling behind.
2,462 citations
TL;DR: It is suggested that adhering to current CPGs in caring for an older person with several comorbidities may have undesirable effects and could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care.
Abstract: ContextClinical practice guidelines (CPGs) have been developed to improve the
quality of health care for many chronic conditions. Pay-for-performance initiatives
assess physician adherence to interventions that may reflect CPG recommendations.ObjectiveTo evaluate the applicability of CPGs to the care of older individuals
with several comorbid diseases.Data SourcesThe National Health Interview Survey and a nationally representative
sample of Medicare beneficiaries (to identify the most prevalent chronic diseases
in this population); the National Guideline Clearinghouse (for locating evidence-based
CPGs for each chronic disease).Study SelectionOf the 15 most common chronic diseases, we selected hypertension, chronic
heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes
mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis,
which are usually managed in primary care, choosing CPGs promulgated by national
and international medical organizations for each.Data ExtractionTwo investigators independently assessed whether each CPG addressed
older patients with multiple comorbid diseases, goals of treatment, interactions
between recommendations, burden to patients and caregivers, patient preferences,
life expectancy, and quality of life. Differences were resolved by consensus.
For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease,
type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated
the recommendations from the relevant CPGs.Data SynthesisMost CPGs did not modify or discuss the applicability of their recommendations
for older patients with multiple comorbidities. Most also did not comment
on burden, short- and long-term goals, and the quality of the underlying scientific
evidence, nor give guidance for incorporating patient preferences into treatment
plans. If the relevant CPGs were followed, the hypothetical patient would
be prescribed 12 medications (costing her $406 per month) and a complicated
nonpharmacological regimen. Adverse interactions between drugs and diseases
could result.ConclusionsThis review suggests that adhering to current CPGs in caring for an
older person with several comorbidities may have undesirable effects. Basing
standards for quality of care and pay for performance on existing CPGs could
lead to inappropriate judgment of the care provided to older individuals with
complex comorbidities and could create perverse incentives that emphasize
the wrong aspects of care for this population and diminish the quality of
their care. Developing measures of the quality of the care needed by older
patients with complex comorbidities is critical to improving their care.
2,247 citations
"Aging with multimorbidity: a system..." refers background or methods in this paper
...…patients with ultimorbidity by using different outcomes (Table 4): applicability nd experience of clinical guidelines in elderly with multimorbidty (Boyd et al., 2005), applicability of a new primary care practice odel for caring for patients with multimorbidity (Soubhi et al., 010), evaluation of…...
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...Boyd et al. (2005) To evaluate the applicability of disease-specific clinical guidelines in elderly with multimorbidity Different aspects of clinical guidelines for the most common chronic diseases were evaluated Adhering to disease-specific clinical guidelines in caring elderly with multimorbidity may have undesirable effects such as adverse interactions between drugs and diseases...
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TL;DR: Better primary care, especially coordination of care, could reduce avoidable hospitalization rates, especially for individuals with multiple chronic conditions.
Abstract: Methods: A cross-sectional analysis was conducted on a nationally random sample of 1217103 Medicare feefor-service beneficiaries aged 65 and older living in the United States and enrolled in both Medicare Part A and Medicare Part B during 1999. Multiple logistic regression was used to analyze the influence of age, sex, and number of types of chronic conditions on the risk of incurring inpatient hospitalizations for ambulatory care sensitive conditions and hospitalizations with preventable complications among aged Medicare beneficiaries. Results: In 1999, 82% of aged Medicare beneficiaries had 1 or more chronic conditions, and 65% had multiple chronic conditions. Inpatient admissions for ambulatory care sensitive conditions and hospitalizations with preventable complications increased with the number of chronic conditions. For example, Medicare beneficiaries with 4 or more chronic conditions were 99 times more likely than a beneficiary without any chronic conditions to have an admission for an ambulatory care sensitive condition (95% confidence interval, 86-113). Per capita Medicare expenditures increased with the number of types of chronic conditions from $211 among beneficiaries without a chronic condition to $13973 among beneficiaries with 4 or more types of chronic conditions. Conclusions: The risk of an avoidable inpatient admission or a preventable complication in an inpatient setting increases dramatically with the number of chronic conditions. Better primary care, especially coordination of care, could reduce avoidable hospitalization rates, especially for individuals with multiple chronic conditions.
2,063 citations
"Aging with multimorbidity: a system..." refers background or methods in this paper
...…et al., 2006a,b; Walker, 2007; Min et al., 007; Wong et al., 2008; Loza et al., 2009; Table 3c); and eight xamined health care utilization and costs (Wolff et al., 2002; oël et al., 2005, 2007; Byles et al., 2005; Friedman et al., 2006; aux et al., 2008; Condelius et al., 2008; Schneider et al.,…...
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...Author, year of publication Setting Participants Study design/ascertainment of diseases Outcome Results Wolff et al. (2002) US Medicare fee-for-service N = 1,217,103 (65+ years) Cross-sectional Administrative database Hospitalizations, complications, and expenditures Increasing no. of diseases increases hospitalizations, preventable complications, and expenditures Noël et al. (2005) Ambulatory primary care in US N = 60 (30–80 years) Cross-sectional Medical records Care needs Identified problems included: poor functioning, negative psychological reactions, inference with work and leisure, polypharmacy....
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..., 2007), ospital admission and related costs (Wolff et al., 2002; Byles et al., 005; Friedman et al., 2006; Condelius et al., 2008), number of precription and satisfaction in primary care (Laux et al....
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...…Akker et al., 1998; Schram et al., 2008; Uijen and van de Lisdonk, 2008), Sweden (Marengoni et al., 2008), Australia (Walker, 2007; Britt et al., 2008), Canada (Fortin et al., 2005), Spain (Loza et al., 2009), and US (Wolff et al., 2002; John et al., 2003; Sharkey, 2003; Schneider et al., 2009)....
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...Author, year of publication Setting Participants Study design/ascertainment of diseases Outcome Results Wolff et al. (2002) US Medicare fee-for-service N = 1,217,103 (65+ years) Cross-sectional Administrative database Hospitalizations, complications, and expenditures Increasing no. of diseases…...
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