Dementia and co-occurring chronic conditions: a systematic literature review to identify what is known and where are the gaps in the evidence?

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Abstract

<div class="section"> <a class="named-anchor" id="S1">  </a> <h5 class="section-title" id="d14166452e254">Objective</h5> <p id="P1">The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality. </p> </div><div class="section"> <a class="named-anchor" id="S2">  </a> <h5 class="section-title" id="d14166452e259">Methods</h5> <p id="P2">This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study. </p> </div><div class="section"> <a class="named-anchor" id="S3">  </a> <h5 class="section-title" id="d14166452e264">Results</h5> <p id="P3">Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions. </p> </div><div class="section"> <a class="named-anchor" id="S4">  </a> <h5 class="section-title" id="d14166452e269">Conclusions</h5> <p id="P4">This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. </p> </div>

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Contribution of chronic diseases to disability in elderly people in countries with low and middle incomes: a 10/66 Dementia Research Group population-based survey

Renata M Sousa, Cleusa Ferri, Daisy Acosta … (2009)

Summary Background Disability in elderly people in countries with low and middle incomes is little studied; according to Global Burden of Disease estimates, visual impairment is the leading contributor to years lived with disability in this population. We aimed to assess the contribution of physical, mental, and cognitive chronic diseases to disability, and the extent to which sociodemographic and health characteristics account for geographical variation in disability. Methods We undertook cross-sectional surveys of residents aged older than 65 years (n=15 022) in 11 sites in seven countries with low and middle incomes (China, India, Cuba, Dominican Republic, Venezuela, Mexico, and Peru). Disability was assessed with the 12-item WHO disability assessment schedule 2.0. Dementia, depression, hypertension, and chronic obstructive pulmonary disease were ascertained by clinical assessment; diabetes, stroke, and heart disease by self-reported diagnosis; and sensory, gastrointestinal, skin, limb, and arthritic disorders by self-reported impairment. Independent contributions to disability scores were assessed by zero-inflated negative binomial regression and Poisson regression to generate population-attributable prevalence fractions (PAPF). Findings In regions other than rural India and Venezuela, dementia made the largest contribution to disability (median PAPF 25·1% [IQR 19·2–43·6]). Other substantial contributors were stroke (11·4% [1·8–21·4]), limb impairment (10·5% [5·7–33·8]), arthritis (9·9% [3·2–34·8]), depression (8·3% [0·5–23·0]), eyesight problems (6·8% [1·7–17·6]), and gastrointestinal impairments (6·5% [0·3–23·1]). Associations with chronic diseases accounted for around two-thirds of prevalent disability. When zero inflation was taken into account, between-site differences in disability scores were largely attributable to compositional differences in health and sociodemographic characteristics. Interpretation On the basis of empirical research, dementia, not blindness, is overwhelmingly the most important independent contributor to disability for elderly people in countries with low and middle incomes. Chronic diseases of the brain and mind deserve increased prioritisation. Besides disability, they lead to dependency and present stressful, complex, long-term challenges to carers. Societal costs are enormous. Funding Wellcome Trust; WHO; US Alzheimer's Association; Fondo Nacional de Ciencia Y Tecnologia, Consejo de Desarrollo Cientifico Y Humanistico, Universidad Central de Venezuela.

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Incidence and Prediction of Falls in Dementia: A Prospective Study in Older People

Louise Allan, Clive Ballard, Elise N Rowan … (2009)

Background Falls are a major cause of morbidity and mortality in dementia, but there have been no prospective studies of risk factors for falling specific to this patient population, and no successful falls intervention/prevention trials. This prospective study aimed to identify modifiable risk factors for falling in older people with mild to moderate dementia. Methods and Findings 179 participants aged over 65 years were recruited from outpatient clinics in the UK (38 Alzheimer's disease (AD), 32 Vascular dementia (VAD), 30 Dementia with Lewy bodies (DLB), 40 Parkinson's disease with dementia (PDD), 39 healthy controls). A multifactorial assessment of baseline risk factors was performed and fall diaries were completed prospectively for 12 months. Dementia participants experienced nearly 8 times more incident falls (9118/1000 person-years) than controls (1023/1000 person-years; incidence density ratio: 7.58, 3.11–18.5). In dementia, significant univariate predictors of sustaining at least one fall included diagnosis of Lewy body disorder (proportional hazard ratio (HR) adjusted for age and sex: 3.33, 2.11–5.26), and history of falls in the preceding 12 months (HR: 2.52, 1.52–4.17). In multivariate analyses, significant potentially modifiable predictors were symptomatic orthostatic hypotension (HR: 2.13, 1.19–3.80), autonomic symptom score (HR per point 0–36: 1.055, 1.012–1.099), and Cornell depression score (HR per point 0–40: 1.053, 1.01–1.099). Higher levels of physical activity were protective (HR per point 0–9: 0.827, 0.716–0.956). Conclusions The management of symptomatic orthostatic hypotension, autonomic symptoms and depression, and the encouragement of physical activity may provide the core elements for the most fruitful strategy to reduce falls in people with dementia. Randomised controlled trials to assess such a strategy are a priority.

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Patterns of chronic multimorbidity in the elderly population.

Laura Fratiglioni, Debora Rizzuto, Xin-Chao Wang … (2009)

To describe patterns of comorbidity and multimorbidity in elderly people. A community-based survey. Data were gathered from the Kungsholmen Project, a urban, community-based prospective cohort in Sweden. Adults aged 77 and older living in the community and in institutions of the geographically defined Kungsholmen area of Stockholm (N=1,099). Diagnoses based on physicians' examinations and supported by hospital records, drug use, and blood samples. Patterns of comorbidity and multimorbidity were evaluated using four analytical approaches: prevalence figures, conditional count, logistic regression models, and cluster analysis. Visual impairments and heart failure were the diseases with the highest comorbidity (mean 2.9 and 2.6 co-occurring conditions, respectively), whereas dementia had the lowest (mean 1.4 comorbidities). Heart failure occurred rarely without any comorbidity (0.4%). The observed prevalence of comorbid pairs of conditions exceeded the expected prevalence for several circulatory diseases and for dementia and depression. Logistic regression analyses detected similar comorbid pairs. The cluster analysis revealed five clusters. Two clusters included vascular conditions (circulatory and cardiopulmonary clusters), and another included mental diseases along with musculoskeletal disorders. The last two clusters included only one major disease each (diabetes mellitus and malignancy) together with their most common consequences (visual impairment and anemia, respectively). In persons with multimorbidity, there exists co-occurrence of diseases beyond chance, which clinicians need to take into account in their daily practice. Some pathological mechanisms behind the identified clusters are well known; others need further clarification to identify possible preventative strategies.

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Author and article information

Journal

Title: International Journal of Geriatric Psychiatry

Abbreviated Title: Int J Geriatr Psychiatry

Publisher: Wiley

ISSN: 08856230

Publication date Created: April 2017

Publication date (Print): April 2017

Publication date (Electronic): February 01 2017

Volume: 32

Issue: 4

Pages: 357-371

Affiliations

[1 ]Department of Psychiatry and Behavioral Sciences; University of Washington School of Medicine; Seattle WA USA

[2 ]Health Promotion Research Center; University of Washington; Seattle WA USA

[3 ]Department of Community and Behavioral Health, Colorado School of Public Health; University of Colorado Anschutz Medical Campus; Aurora CO USA

[4 ]National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention; Atlanta GA USA

[5 ]College of Social Work, Hamilton College; University of South Carolina; Columbia SC USA

[6 ]Division of Health Care Policy and Research, School of Medicine; University of Colorado and the Denver Veterans Affairs Medical Center; Denver CO USA

[7 ]UW School of Nursing; Northwest Research Group on Aging; Seattle WA USA

[8 ]National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, and Rollins School of Public Health; Emory University; Atlanta GA USA

[9 ]Betty Irene Moore School of Nursing; University of California; Davis CA USA

[10 ]Departments of Family Medicine, Epidemiology, and Global Health, School of Medicine and School of Public Health; University of Washington; Seattle WA USA