This study uses data from the Multidimensional Evaluation Form in Geriatrics project, a prospective observational study aimed at collecting data about the patterns and quality of prescriptions among older patients admitted to acute care wards of geriatric medicine located in Central Italy. Multimorbidity is defined as the simultaneous presence of two or more chronic physical health conditions. For this analysis, some chronic health conditions were included, namely tumors, cardiovascular diseases, chronic pulmonary diseases, diabetes mellitus, hypertension, stroke. All these conditions, were assessed by diagnosis of the disease carried out by the doctors. Additionally, the use of treatment/medication received in the 12 months prior to interview was indicative of a diagnosis and was included in prevalence estimates for each disease.
Participants
Two hundred fifty tree patients affected by different diseases were consecutively recruited and asked to participate. during follow-up medical visits at the Departments of INRCA, National Institute of Science and Health for Aging. Only two hundreds fourteen patients joined the study. Fifty two did not meet the inclusion criteria or did not answer all the questionnaires: it was therefore decided not to consider them in the study. So the sample included n. 162 Patients. The demographic variables are described in Table 1. They compiled the expected tests administered by specifically trained psychologists. The diagnosed diseases by the physicians were the following: tumors, cardiovascular diseases, diabetes, hypertension, ictus, pulmonary diseases. The presence of two or more pathologies in a single patient has been documented by the physicians (Table 2). Moreover the patients showed a medium (7%) to good (93%) self- functional sufficiency and intact cognitive abilities evaluated respectively by the following tests: ADL (Activities of Daily Living) and MMSE.
After completing the initial medical examination they were referred to the investigator. Inclusion criteria included age (over 65), with diagnosis of different diseases (from 1 to 4 years); presence of social relations. Patients were excluded if: they refused to participate; were unable to provide informed consent; had other forms of disease (dementia, terminal illness); MMSE > 24; were not self-sufficient; were using any type of psychotropic drugs (including antidepressants); they have no social relations.
Age and demographic data including marital status and educational levels were collected (Tab.1). No one of the examined subjects had financial difficulties.
Measures
All the patients filled in the following tests:
a) ADL -Physical functioning: activities of daily living. Limitation in ADL was used to assess physical functioning (44 , 45).
The questions were based on self- reported difficulty in engaging in activities during the last 30 days, using a five-point response scale ranging from none to extreme difficulty. The ADL measure included in SAGE was based on WHODAS 2.0 and has been validated in LMICs by WHO and collaborating agencies. WHODAS 2.0 is validated cross-culturally through a systematic research study. The cross-cultural applicability research study used various qualitative methods to explore the nature and practice of health status assessment in different cultures.
The study included linguistic analysis of health-related terminology, key informant interviews, focus groups, and quasi-quantitative methods such as pile sorting and concept mapping (carried out in tandem). Information was gathered on the conceptualization of disability and on important areas of day-to-day functioning. In this study, severe and extreme difficulties were combined to represent limitation in a particular activity. We have used an extended set of ADL that included sitting for long periods, walking 100 m, standing up, standing for long periods, climbing one flight of stairs, stooping/kneeling/crouching, picking up things with fingers, extending arms above shoulders, concentrating for 10 min, walking a long distance (1 km), bathing, getting dressed, carrying things, moving around inside home, getting up from lying down, and getting to and using the toilet. For the analysis, a dichotomous variable was created, which took value 1 if the respondent noted a limitation in one or more of the above ADLs (1+ ADL) and 0 otherwise.
b. MMSE- Mini Mental State Examination (46, 47) measures cognitive functions. The Italian versions of the MMSE modified from the Los Angeles Epidemiologic Catchment Area study was used. MMSE scores were dichotomized to indicate presence or absence of cognitive impairment using the published cut point of ≥24 (cognitive impairment absent) and <24 (cognitive impairment present).
c. Social Schedule describing sex, age, marital status, educational levels, presence of different kinds of interpersonal relation, and a self-assessment of health by the patient. It consisted of a single question: “How would you classify your health: excellent, good, acceptable, bad or very bad?” The score for “very bad” was 1 and for “excellent” it was 5. The patient was invited to select the most appropriate score. A schedule of clinical diagnosis (with years from first diagnosis) was included by physicians.
d. Quality of Life -Functional-Assessment of Cancer-Therapy-General (FACT-G) (48) has all requirements including reliability and validity for use in oncology clinical trials (Italian version). The score sums up to a total ranging from zero to 108 points, where a higher score indicates better quality of life. It includes the following subscales: Physical-Well-Being (PWB), Social-Well-Being(SWB), Emotional-Well-Being(EWB), Functional-Well-Being(FWB), FACT-General-Summary-Score (FACT_G). The score sums up to a total ranging from zero to 108 points, where a higher score indicates better quality of life.
e. Loneliness Scale by Jenny de Jong Gierveld (49) consisting of 11 items; six are formulated negatively and five are formulated positively. Loneliness is seen as a subjective experience and is, as such, not directly related to situational factors. The scale describing the sense of loneliness, or subjective social isolation, is defined as a situation experienced by the participant as one where there is an unpleasant or inadmissible lack of (quality of) certain relationships. Loneliness includes situations where the number of existing relationships is smaller than desirable or acceptable, as well as situations where the intimacy wished for has not been realized. The11-items multidimensional scale describes the following dimensions : (1) severe feelings of loneliness as well as less intense loneliness feelings; (2) negative as well as positive items; and (3) a latent continuum of deprivation. In addition, the scale met the criteria of the dichotomous logistic Rasch model.
f. The questionnaire WHOQOL-BRIEF of social support (50. De Girolamo et al., 2000) was used. The validated Italian version was administered. It comprises 13 questions. This tool, consistent with its original concept, is self-administered. In case of an inability to comprehend any question, assistance was available as follows: the researcher read such part of the research slowly, using the same words in order to maintain exactly the same meaning.
Clinical evaluation
The different diagnosis were made by the physicians for each diseases following the guide lines for each pathologies and in the occasion of follow-up visits at the time of tests administration expected for this research.
Statistical analysis
Data were expressed as means ± standard deviation (continuous variables) or as percentage (categorical variables) (Table1). The reliability of the FACT –G subscales was assessed by Cronbach’s coefficient alpha. The pathologies number was dichotomized by less than three and three or more pathologies. Statistical comparison between the these two categories of pathologies (multi-morbidity) and the dimensions of quality of life was performed by t-Student test. Moreover the sense of loneliness was categorize in four groups (not loneliness, moderate loneliness, severe loneliness, very severe loneliness). Moreover the WHOQOL was dichotomize by no or few social relations and presence of good social relations. Pearson’s coefficient was used to assess correlations between studied variables. The multiple linear regression models was assessed to evaluate the associations between the dimensions of quality of life FACT_G and multimorbidity considering the effect of age, sex, sense of loneliness and WHOQOL .The significance was accepted for p<0.05. All analyses were performed using SPSS V19.0 Statistical Software Package for Windows.