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Category Archives: Epidemiology and outcomes research

Frailty : Not just a problem for older people

By Peter Hanlon and Frances Mair
It is often said that many of the challenges faced in healthcare are due to ‘ageing populations’. It is clear, however, that health (and the need for health services) is not simply related to how old a person is. There are many other factors more closely linked to an individual’s need for care, many of which are related to age. These include multimorbidity – having two or more long-term health conditions – and frailty. Frailty is closely linked to multimorbidity, but the terms are not interchangeable.
Frailty describes a reduction in the body’s in-built reserves which is generally due to the cumulative effect of a range of individual deficits. People with frailty are therefore more at risk of developing significant illness, sometimes in response to relatively minor events or ‘stressors’. To provide high quality healthcare to people with frailty involves a holistic approach, considering the whole person and their wider context, rather than purely focusing on individual diseases in isolation. Managing frailty also takes considerable resource, as people may require additional support or services, and are more likely to require hospital admission.
Both frailty and multimorbidity are more common with increasing age, and therefore most research and interventions to improve care has focused on elderly people. It is also true, however, that the majority of people with multimorbidity are aged under 65 years. This is particularly true in areas of high socioeconomic deprivation. Despite this, the prevalence and effects of frailty at younger ages and in multimorbidity has not been investigated. Most studies, as well as most health services, that seek to target frailty have tended to exclude people aged less than 65 years, even though many people in this age group are affected by multimorbidity and may benefit from an approach to healthcare that reflects this.
Our recent study [1], published in The Lancet Public Health, seeks to address this research gap. It suggests that frailty affects ‘middle-aged’ as well as older people. We found that frailty, while strongly associated with multimorbidity, identifies middle aged people at increased risk of death, over-and-above known risk factors and number of long-term health conditions.
This study analyses frailty in a younger population than most previous research. We used data from the UK Biobank cohort – a large study of around 500,000 volunteers aged between 37 and 73 years. Participants in the study were considered ‘frail’ if they met three or more of the following criteria: weight loss, slow walking pace, low hand grip strength, low physical activity, and exhaustion. People with one or two of these features were considered ‘pre-frail’.
While frailty does get more common with increasing age, we found that people of all ages had the potential to be ‘frail’ using this definition. While only a small proportion of ‘middle-aged’ people were identified as frail by this definition – 3% overall – frailty was much more common in people with multimorbidity.  Of people with 2 or more long-term conditions, 7% were frail. This increased to 18% among people with 4 or more long-term conditions. Frailty was also closely linked with socioeconomic deprivation and obesity.
Frailty was associated with more than double the risk of death in men of all ages included (37 to 73 years) and in females above the age of 45 years. This was after accounting for deprivation, lifestyle factors such as smoking, obesity and alcohol, and the number of long-term conditions. Frailty, therefore, appears to carry additional risk of premature death in younger people, over-and-above the recognised risk factors such as smoking and multimorbidity. People with ‘pre-frailty’ also had an increased risk of death in all of these age groups.
These findings highlight the challenges faced by primary care teams caring for patients with complex problems and multimorbidity, many of whom may be too young to be eligible for existing services focusing on frailty in the elderly. This is particularly true in areas of high socioeconomic deprivation, where both multimorbidity and frailty among younger people is much more common.
This study shows that frailty may be identifiable at an earlier stage than is traditionally understood. This may, therefore, represent an opportunity to explore ways of intervening earlier. If this is to happen, researchers and healthcare professions will need to broaden their focus on frailty to include a wider age range. Importantly, it also highlights the need for a move away from disease focused to more person centred care that provides a more holistic approach to patient care that is tailored to meet an individual’s specific requirements.
Identifying frailty in those with multimorbidity may have positive implications for care, planning interventions and a patient’s prognosis.  We suggest integration of an assessment of frailty into the routine assessment of people with multimorbidity might help identification of those at greater risk and ensure more accurate targeting of the multidimensional, patient-centred reorganisation of care required to address complex multimorbidity.
There is a pressing need to understand frailty in younger people much more fully. When trying to provide services and care for people with frailty and multimorbidity it will be crucial to consider the needs of younger people (particularly those in areas of high socioeconomic deprivation). Our work demonstrates that frailty, like multimorbidity, is not just a problem that affects older people.
[1] Peter Hanlon, Barbara I Nicholl, Bhautesh Dinesh Jani, Duncan Lee, Ross McQueenie, Frances S Mair. Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants. Lancet Public Health 2018. Published Online June 13, 2018. http://dx.doi.org/10.1016/S2468-2667(18)30091-4.

Multimorbidity in an Australian street health service

By Tom Brett
The Freo Street Doctor service is a free, primary care–based, mobile health clinic that has been operating in Fremantle, Western Australia since 2005. It operates from various locations in and around Fremantle, offering homeless and disadvantaged patients access to an accredited general practice service. It is serviced by a number of general practitioners, nurses, social workers and Aboriginal health workers as well as collaborating with numerous ancillary services to improve the health and circumstances of marginalised patients in this population group.
We report on a total of 4285 patients who attended the service over a 10 year period [1]. We found multimorbidity to be associated with increasing age, male sex and Aboriginality. An important finding from our study is the high Aboriginal attendance, comprising 31.5% of the total cohort (with 50.8% female). This attendance ratio is in sharp contrast with the <2% Aboriginal patients attending mainstream GP clinics Australia-wide.
Our research shows that multimorbidity is increasing over the past decade and presents as chronic physical and mental health problems in these marginalised, street health patients. These patients are at increased risk of ongoing neglect unless provided with a no-cost, multidisciplinary approach capable of delivering health and social services in a non-judgemental, comfortable and secure environment.
The progressive increase in attendance by young, especially Aboriginal, patients over the past decade, and the positive feedback from patients and allied services attending the Freo Street Doctor, make compelling arguments that this accredited, general practice–based service is addressing important health and social needs in an environment where they are clearly needed.
1. Arnold-Reed D, Troeung L,  Brett T, Chan She Ping-Delfos W, Strange C, Geelhoed E, Fischer C,  Preen D. Increasing multimorbidity in an Australian street health service – a 10 year retrospective cohort study. AJGP. 2018; 47 (4): 181-189.

The EpiChron Cohort Study of Chronic Diseases and Multimorbidity

By Alexandra Prados Torres
I would like to share with you the profile of the EpiChron Cohort recently published in the International Journal of Epidemiology, a large-scale population-based study aimed at understanding how multimorbidity and the main chronic conditions appears and evolve in the population, and impact on health services and health outcomes. Created in 2010, it will gather information of the 1.3 M inhabitants of the Spanish region of Aragon until 2020. It has been developed by the EpiChron Research Group on Chronic Diseases from Aragon Health Sciences Institute (IACS) and IIS Aragón. This Cohort aims to study the problems associated to multimorbidity and chronicity (e.g., polypharmacy, low adherence to medical plan, increased risk of mortality, frailty, inappropriate health services use) and to identify risk factors (e.g., clinical, social, demographical) of negative health related outcomes. We also aim to study the evolution of trajectories of multimorbidity patterns over time and their impact on health outcomes with the final goal of developing predictive modeling tools. One key point of the project is to scaling up the knowledge in the area of chronicity and multimorbidity and to foster collaborations with other European and international research groups working in this area to conduct cross-national studies.
Besides the main characteristics of the EpiChron Cohort, this paper describes the data quality control process followed to ensure an adequate level of accuracy, reliability and appropriateness of data for research in multimorbidity.  Moreover, the main findings obtained to date are detailed in the paper.
The publication can be found in the following link: Prados-Torres et al 2018

Paper – Multimorbidity in Brazil

By Bruno P Nunes and Sandro R Rodrigues Batista
In this paper, we evaluate the magnitude of multimorbidity in 60202 Brazilian adults, including the assessment of individual and contextual (state level) variables. The Brazilian national-based study was carried out in 2013. Multimorbidity was evaluated by a list of 22 physical and mental morbidities. Factor analysis and multilevel models were used to analyze the data. Multimorbidity frequency was 22.2% for ≥2 morbidities and 10.2% for ≥3 morbidities. For the whole Brazilian population, at least 41 and 19 million adults had multimorbidity, according ≥2 and ≥3 morbidities, respectively. The occurrence was different among states, being higher in southern Brazil (see below the Supplementary_figure_1). Contextual and individual social inequalities were observed.
To access the manuscript, please click in the following link:
Reference: Nunes BP, Chiavegatto Filho ADP, Pati S, Cruz Teixeira DS, Flores TR, Camargo-Figuera FA, Munhoz TN, Thumé E, Facchini LA, Rodrigues Batista SR. Contextual and individual inequalities of multimorbidity in Brazilian adults: a cross-sectional national-based study BMJ Open 2017;7:e015885. doi: 10.1136/bmjopen-2017-015885

Perceived stress and multimorbidity

By Anders Prior
Multimorbidity and especially mental-physical multimorbidity is an increasing concern worldwide. It is well-known that psychiatric illness impairs the prognosis in persons with chronic physical disease. However, little is known on the impact of non-syndromic mental stress; mental stress is common in the general population, and psychological problems are an increasingly frequent reason for primary care contacts. In two studies, we aimed to determine whether perceived mental stress is associated with potentially preventable hospitalizations and all-cause mortality in persons with various degrees of multimorbidity.
The Danish Civil Registration System allowed us to individually link health survey data with prospectively collected data from Danish health registers creating a unique population-based cohort.  The Danish National Health Survey 2010 provided data on e.g. perceived stress and lifestyle factors on a representative sample of 118,000 Danish citizens aged 25 or older. Danish health registers provided data on hospitalizations, demographic and socioeconomic factors. We developed a new Danish multimorbidity index based on recorded diagnoses and redeemed medicine prescriptions on all Danish citizens identifying 39 mental and physical long-term conditions. We adjusted for and analyzed the modifying effect of multimorbidity on the study outcomes.
In general, we found that high stress perception was associated with multimorbidity, an increased number of potentially preventable hospitalizations and increased all-cause mortality after adjusting for mental-physical multimorbidity, socioeconomic factors and lifestyle where appropriate, and there often seemed to be dose-response relations. In absolute numbers, persons with multimorbidity had a poorer prognosis and psychiatric conditions aggravated this.
This may be the first step to understand the impact of mental stress on physical health, to discuss mental stress in a general practice setting, and to create the foundation for developing potential interventions and practice guidelines for patients with stress in general practice. Hopefully, this may lead to better care and improved life expectancy of people with stress and chronic disease.
Prior A, Fenger-Grøn M, Larsen KK, et al. The association between perceived stress and mortality among people with multimorbidity: A prospective population-based cohort study. Am J Epidemiol. 2016;184(3):199-210.
Prior A, Vestergaard M, Davydow DS, et al. Perceived stress, multimorbidity, and risk for hospitalizations for ambulatory care-sensitive conditions: A population-based cohort study. Med Care. 2017;55(2):131-139.

Different multimorbidity measures affect estimated levels of physical quality of life

By Aline Ramond-Roquin
Health-related quality of life is adversely affected by the presence of multimorbidity in a way that an increasing number of concurrent chronic conditions is associated with lower scores of health-related quality of life. Studies aiming to quantify the impact of multimorbidity on the quality of life show wide heterogeneity in terms of the intensity of this association but these studies also present other important methodological differences such as population studied, measure of quality of life, measure of multimorbidity, etc.
Most operational definitions of multimorbidity have been based on a simple count of conditions which are screened as present or not in a given individual from a predetermined list of conditions. Many different lists of potential conditions have been proposed, with some being as short as six conditions and others as long as 40.
We investigated the influence of the list of conditions on the estimated level of the physical component of health-related quality of life in individuals with multimorbidity and found that the length of the list of candidate conditions considered has a great impact on the estimations of physical health-related quality of life.
This argues for careful methodological consideration when measuring multimorbidity and its association with different outcomes. We conclude that standardization of the measure of multimorbidity is needed to allow the comparison of the results across different studies on multimorbidity.
The article describing this study was published on line (1) and is freely accessible to those interested in this subject.
1) Ramond-Roquin A, Haggerty J, Lambert M, Almirall J, Fortin M: Different Multimorbidity Measures Result in Varying Estimated Levels of Physical Quality of Life in Individuals with Multimorbidity: A Cross-Sectional Study in the General Population. Biomed Res Int. 2016;2016:7845438.

Prevalence of multimorbidity in the general population and in primary care practices

By Martin Fortin
It is known that settings affect estimation of the prevalence of multimorbidity. In a recently published paper  [1], we have compared estimates of the prevalence of multimorbidity in the general population and in primary care clinical practices.
The new aspect of this recent study was that prevalence in both settings was measured simultaneously, in the same region, and with the same methods. This way, we eliminated methodological limitations found in previous studies that prevented to conclude definitively the extent to which prevalence estimates differ in these two study populations [2].
Also, we explored the effect of using different operational definitions of multimorbidity on the differences of prevalence observed between the two sampled populations.
We concluded that there is a difference of about 10% in prevalence estimates of multimorbidity between samples from the general population and primary care clinical practices, with a higher prevalence in the latter setting. The difference of the prevalence between the two settings was not affected by the use of different operational definitions of multimorbidity.
1.- Mokraoui NM, Haggerty J, Almirall J, Fortin M. Prevalence of self-reported multimorbidity in the general population and in primary care practices: a cross-sectional study. BMC Res Notes. 2016;9:314.
2.- Fortin M, Hudon C, Haggerty J, van den Akker M, Almirall J. Prevalence estimates of multimorbidity: a comparative study of two sources. BMC Health Services Research. 2010;10:111.

Multimorbidity in adults from a southern Brazilian city

By Bruno P. Nunes
We are very satisfied to disseminate another recent paper about multimorbidity from Brazil in International Research Community on Multimorbidity (IRCMo) site. In this paper, we explore the occurrence and patterns (through Factorial Analysis) in Brazilian adults [1]. The manuscript used data from a population-based study carried out in 2012 in the individuals (20 or more years) households living in Pelotas, southern Brazil. Multimorbidity was evaluated by a list of 11 morbidities (based on medical diagnosis; Patient Health Questionnaire 9 for depression; and Anatomical Therapeutic Chemical index). The sample was made up of 2927 adults. Multimorbidity reached 29.1 % (95 % CI: 27.1; 31.1) for ≥2, and 14.3 % (95 % CI: 12.8; 15.8) for ≥3 morbidities. Two patterns of morbidities (cardio-metabolic and joint problems; and respiratory diseases) were observed. The high frequency and the observed patterns increase the need to address multimorbidity in Brazilian health policies and diseases guidelines.
To access the manuscript, please click in the following link:
Furthermore, we reinforce our invite to researchers interested in cross-country comparisons about a wide range of issues related to multimorbidity (prevalence, patterns, inequalities, use of health services and others). Contact e-mail for further information: nunesbp@gmail.com.
1) Nunes BP, Camargo-Figuera FA, Guttier M, de Oliveira PD, Munhoz TN, Matijasevich A, Bertoldi AD, Wehrmeister FC, Silveira MP, Thumé E, Facchini LA. Multimorbidity in adults from a southern Brazilian city: occurrence and patterns. Int J Public Health. 2016 Apr 22. [Epub ahead of print]

Multimorbidity in Brazil

By Bruno P. Nunes, Elaine Thumé, and Luiz A. Facchini
We are very satisfied to disseminate our recent paper in International Research Community on Multimorbidity (IRCMo) site. This community was and continues to be very important for our studies related to this topic in Brazil.
Despite worldwide importance of multimorbidity and the specific Brazilian context (more than 200 million inhabitants, rapid epidemiologic and demographic transitions, and relatively new universal health system), populational information about occurrence of multiple health problems is scarce in the country. Thus, data from a population-based survey that we conducted in 2008 were used to provide information and start works about multimorbidity in Brazilian context. The sample was comprised by 1593 elderly (≥60 years old) who lived in Bagé, a medium-sized city in Southern Brazil. The individuals were interviewed in their households through face-to-face interviews. In total, 17 morbidities were used and we measured multimorbidity according to two cutoff points: ≥2 and ≥3 morbidities. Descriptive analysis, and dyads and triads of diseases were calculated. We found that 94% of the sample presented, at least, one morbidity. High blood pressure – HBP – (55.3%) and spinal column disease (37.4%) were the diseases most frequent. Multimorbidity reached 81.3% (95 % CI: 79.3; 83.3) and 64.0 % (95% CI: 61.5; 66.4) of the individuals for ≥2 and ≥3 morbidities, respectively. As found in others studies, most vulnerable elderly presented higher occurrence of multiple diseases. For example, 87.1% of the elderly without schooling presented 2 or more diseases (22.3 percentage points higher than elderly which studied 8 years or more).  Another challenge to public health system was demonstrated by higher frequency of multimorbidity between individuals without health private plan and those who are living in Family Health Strategy (organizational axis of primary health care) catchment areas.
These results about multimorbidity in older adults from Brazil may provide initial information to address multiple diseases in clinical protocols and contribute to subsidize actions in health services to management of multimorbidity.
To access the full manuscript, please click in the following link: http://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2505-8
Furthermore, we are drafting others papers about multimorbidity in Brazil, including evaluation of national-based studies. Therefore, we would like to invite researchers interested in cross-country comparisons about a wide range of issues related to multimorbidity (prevalence, patterns, inequalities, use of health services and others) to contact us. Contact e-mail for further information: nunesbp@gmail.com.
  • Reference: Nunes BP, Thumé E, Facchini LA: Multimorbidity in older adults: magnitude and challenges for the Brazilian health system. BMC Public Health 2015, 15(1):1172

Multimorbidity and functional decline: a systematic review

By Áine Ryan, Emma Wallace, Paul O’Hara, Susan M. Smith

Multimorbidity is recognised internationally as having a negative impact on patient outcomes. Functional decline is defined as developing difficulties with activities of daily living and is also independently associated with poorer health outcomes. We recently published a systematic review examining the association between multimorbidity and functional decline. We also examined the extent to which multimorbidity predicts future functional decline [1].
The review retrieved 37 relevant studies (nine cohort and 28 cross-sectional).The majority of studies (n= 31) demonstrated a consistent association between multimorbidity and poorer functional status. Future functional decline was more likely with increasing numbers of conditions and was also linked to condition severity.
We can be reasonably confident of the findings of this systematic review; as overall, there was minimal risk of bias in the included studies. However, variation in study participants, multimorbidity definitions, follow-up duration and outcome measures resulted in meta-analysis not being possible.
The findings of this systematic review are consistent with existing evidence linking multimorbidity and poorer health related quality of life. It also highlights a potential cumulative effect, in that both multimorbidity and functional decline independently predict poorer patient outcomes. This review examines one direction of effect, i.e. that baseline multimorbidity predicts future functional decline. Conversely, it is also possible that poor physical functioning will lead to worsening of multimorbidity, a relationship that our study group plans to examine in an ongoing prospective cohort study in Ireland [2].
This review suggests that functional decline needs to be carefully considered in patients with multimorbidity. Future research should focus on the development and testing of interventions which prioritise physical function in this patient group, particularly for patients with higher numbers of conditions and greater disease severity.

The complete article can be accessed at:

[1] Ryan A, Wallace E, O’Hara P, Smith SM. Multimorbidity and functional decline in community-dwelling adults: a systematic review. Health and Quality of Life Outcomes. DOI: 10.1186/s12955-015-0355-9.
[2] The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Ireland. www.tilda.ie