Aging and Multimorbidity: New Tasks, Priorities, and Frontiers for Integrated Gerontological and Clinical Research

doi:10.1016/j.jamda.2015.03.013

Journal of the American Medical Directors Association

Volume 16, Issue 8, 1 August 2015, Pages 640-647

https://doi.org/10.1016/j.jamda.2015.03.013 Get rights and content

Abstract

Aging is characterized by rising susceptibility to development of multiple chronic diseases and, therefore, represents the major risk factor for multimorbidity. From a gerontological perspective, the progressive accumulation of multiple diseases, which significantly accelerates at older ages, is a milestone for progressive loss of resilience and age-related multisystem homeostatic dysregulation. Because it is most likely that the same mechanisms that drive aging also drive multiple age-related chronic diseases, addressing those mechanisms may reduce the development of multimorbidity. According to this vision, studying multimorbidity may help to understand the biology of aging and, at the same time, understanding the underpinnings of aging may help to develop strategies to prevent or delay the burden of multimorbidity. As a consequence, we believe that it is time to build connections and dialogue between the clinical experience of general practitioners and geriatricians and the scientists who study aging, so as to stimulate innovative research projects to improve the management and the treatment of older patients with multiple morbidities.

Section snippets

Multi-morbidity: Implications and Challenges for Medical Care and Research

The aging of the world's population and its increasing longevity during recent decades induced profound changes in the world's political and economic landscape and presented many challenges to health and social care systems. In response, medical science created new diagnostic and therapeutic tools that improved rates of long-term survival for patients affected by chronic morbidity and an increasing prevalence of multiple chronic conditions. Noteworthy for this discussion, multimorbidity, the

The Lack of a Standardized Operational Approach

“Comorbidity” and “multimorbidity” are often used as interchangeable terms. However, in recent years, comorbidity more often describes the combined effects of additional diseases in reference to an index disease (eg, comorbidity in cancer). Meanwhile, multimorbidity is more often meant to describe simultaneous occurrence of 2 or more diseases that may or may not share a causal link in an individual patient.15, 16, 17 Such distinctions certainly help; however, methodological problems affecting

The Growing Burden of Chronic Diseases

According to a recent report, nearly 80% of Medicare beneficiaries have at least 2 chronic conditions and more than 60% have at least 3 chronic conditions.²⁰ Experts estimate that 26% of the US population will be living with multiple chronic conditions by 2030.²¹ Although multimorbidity is not limited to older adults, its prevalence increases substantially with age. In a cross-sectional study that included 1.7 million patients in Scotland, Barnett and colleagues²² found that 30.4% of the

Biological Mechanisms Linking Aging to Chronic Diseases

Acknowledging that aging is the major risk factor for most chronic diseases also inspires the idea that slowing the process of aging represents a fruitful approach to delaying or preventing chronic conditions affecting the elderly. During recent decades, the integrative nature of human physiology has become much more clearly apparent. Pathologies once thought to be distinct from each other are now understood to be connected. Consequently, traditional research on aging that investigates

The Example of Dementia

Dementia is presented here as an example of an index disease that embodies all the complex challenges of multimorbidity. First, patients with dementia have a higher number of comorbidities than any other long-term disorder.⁷⁴ In particular, they present on average 4 additional chronic medical conditions, including the 2 most frequent: hypertension and diabetes.⁴ Second, dementia itself often may be considered an expression of multimorbidity (involving both vascular and degenerative components).

New Directions for the Future

Despite the exponential growth of literature on geriatric multimorbidity and its research tasks, a number of critical questions remain unsolved. Perhaps the essential first step is to create a consistent definition and standardized metric of multimorbidity, which can then be validated among different settings and populations. Such a tool would facilitate studies of biological mechanisms for the accumulation of multimorbidity in some individuals at levels greater than the occurrence of morbidity

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In this national birth cohort study, we studied people born at Helsinki University Central Hospital, Helsinki, Finland between Jan 1, 1934, and Dec 31, 1944, who attended child welfare clinics in the city, and were living in Finland in 1971. Individuals who had died or emigrated from Finland before 1987 were excluded, alongside participants without any registry data and who died before the end of the registry follow-up on Dec 31, 2017. Early anthropometry, growth, wartime parental separation, and socioeconomic factors were recorded from birth, child welfare clinic, or school health-care records, and Finnish National Archives. International Classification of Diseases codes of diagnoses for chronic diseases were obtained from the Care Register for Health Care starting from 1987 (when participants were aged 42–53 years) until 2017. Linear mixed models were used to study the association between early-life factors and the rate of change in the number of chronic diseases over 10-year periods.
From Jan 1, 1934, to Dec 31, 2017, 11 689 people (6064 [51·9%] men and 5625 [48·1%] women) were included in the study. Individuals born to mothers younger than 25 years (β 0·09; 95% CI 0·06–0·12), mothers with a BMI of 25–30 kg/m² (0·08; 0·05–0·10), and mothers with a BMI more than 30 kg/m² (0·26; 0·21–0·31) in late pregnancy accumulated chronic diseases faster than those born to older mothers (25–30 years) and those with a BMI of less than 25 kg/m². Individuals with a birthweight less than 2·5 kg (0·17; 0·10–0·25) and those with a rapid growth in height and weight from birth until age 11 years accumulated chronic diseases faster during their life course. Additionally, paternal occupational class (manual workers vs upper-middle class 0·27; 0·23–0·30) and wartime parental separation (0·24; 0·19–0·29 for boys; 0·31; 0·25–0·36 for girls) were associated with a faster rate of chronic disease accumulation.
Our findings suggest that the foundation for accumulating chronic diseases is established early in life. Early interventions might be needed for vulnerable populations, including war evacuee children and children with lower socioeconomic status.
Finska Läkaresällskapet, Liv och Hälsa rf, the Finnish Pediatric Research Foundation, and Folkhälsan Research Center.
For the Finnish and Swedish translations of the abstract see Supplementary Materials section.
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Prospectively collected data on 12,755 older persons aged 65+ years were derived from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS, www.topics-mds.eu). Latent class analyses were performed to identify unobserved relationship patterns between morbidities in older persons. Using linear mixed models, the average difference in health-related quality of life (EQ-5D) and general quality of life scores (Cantril's Self Anchoring Ladder) as well as limitations in Activities of Daily Living and Instrumental Activities of Daily Living (ADL/IADL) were examined over a 12-month period.
Five multimorbidity patterns were identified: sensory (n = 3882), cardio-metabolic (n = 2627), mental health (n = 920), osteo-articular (n = 4486), and system decline (n = 840). Relative to older persons in the sensory group, multimorbidity patterns did not have a strong effect on health-related quality of life, general quality of life or ADL/IADLs over a one-year period.
The observed multimorbidity patterns are similar to others based on different methodologies and study populations. When examining the effect of such patterns on quality of life, the EQ-5D and Cantril's Ladder may be insufficient outcome measures. Further investigations into the prognostic value of morbidity patterns would be of benefit.
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Global trends and developments in mindfulness interventions for diabetes: a bibliometric study
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: The authors declare no conflicts of interest.

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Review ArticleAging and Multimorbidity: New Tasks, Priorities, and Frontiers for Integrated Gerontological and Clinical Research

Abstract

Section snippets

Multi-morbidity: Implications and Challenges for Medical Care and Research

The Lack of a Standardized Operational Approach

The Growing Burden of Chronic Diseases

Biological Mechanisms Linking Aging to Chronic Diseases

The Example of Dementia

New Directions for the Future

Lancet

J Am Med Dir Assoc

Lancet

J Clin Epidemiol

J Clin Epidemiol

Mayo Clin Proc

Ageing Res Rev

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

Cell

Cell

Lancet Diabetes Endocrinol

J Clin Epidemiol

Eur J Intern Med

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Ann Fam Med

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Epidemiol Rev

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Med Care

Chronic Care: Making the Case for Ongoing Care

Aging and the burden of multimorbidity: Associations with inflammatory and anabolic hormonal biomarkers

J Gerontol A Biol Sci Med Sci

Prevalence, expenditures, and complications of multiple chronic conditions in the elderly

Arch Intern Med

Prevalence of multimorbidity among adults seen in family practice

Ann Fam Med

Multiple chronic diseases and quality of life: Patterns emerging from a large national sample, Australia

Chronic Illn

Prevalence of chronic diseases and multimorbidity among the elderly population in Sweden

Am J Public Health

Multimorbidity in primary care: Prevalence and trend over the last 20 years

Eur J Gen Pract

Prevalence and patterns of multimorbidity in Australia

Med J Aust

Prevalence of multiple chronic conditions in the United States' Medicare population

Health Qual Life Outcomes

Epidemiology and impact of multimorbidity in primary care: A retrospective cohort study

Br J Gen Pract

Review Article
Aging and Multimorbidity: New Tasks, Priorities, and Frontiers for Integrated Gerontological and Clinical Research