Comorbidity of somatic chronic diseases and decline in physical functioning:: the Longitudinal Aging Study Amsterdam

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Abstract

Objective

To assess the association of decline in physical functioning with number of chronic diseases and with specific comorbidity in different index diseases.

Methods

A longitudinal design was employed using data from 2,497 older adults participating in the Longitudinal Aging Study Amsterdam. Logistic regression analyses were used to determine influence of chronic diseases on change in physical functioning, operationalized using the Edwards-Nunnally index.

Results

Decline in physical functioning was associated with number of chronic diseases (adjusted ORs from 1.58 for 1, to 4.05 for ⩾3 diseases). Comorbidity of chronic nonspecific lung disease and malignancies had the strongest exacerbating influence on decline. An exacerbating effect was also found for arthritis in subjects with diabetes or malignancies and for stroke in subjects with chronic nonspecific lung disease or malignancies. A weaker effect than expected was observed for diabetes in subjects with stroke, malignancies, cardiac disease, or peripheral atherosclerosis.

Conclusion

Comorbidities involving chronic diseases that share etiologic factors or pathophysiologic mechanisms appear to have a weaker negative influence on decline in physical functioning than expected. Results indicate that combinations of diseases that both influence physical functioning, but through different mechanisms (locomotor symptoms vs. decreased endurance capacity) may be more detrimental than other combinations.

Introduction

The role of chronic diseases and comorbidity as determinants of mobility limitations is intuitively important, but not well understood. A higher number of chronic diseases is consistently associated with a higher prevalence of mobility limitations [1], [2], [3], and longitudinally with a higher incidence of mobility loss [4]. In elderly people, the specific chronic diseases that are most consistently associated with either a higher prevalence or higher incidence of mobility limitations include arthritis [2], [5], [6], [7], [8], [9], cardiac diseases [2], [4], [6], [7], [8], [9], cerebrovascular disorders [2], [4], [5], [6], [7], [9], chronic obstructive pulmonary disease [6], [7], [8], [9], diabetes mellitus [2], [4], [7], [8], [9], and, to a lesser extent, cancer [2], [7], [8], [9] and atherosclerosis [2], [9].

Generally, the presence of chronic diseases in population surveys is measured by self-reports pertaining to the presence or absence of a specific disease, and comorbidity is defined as the number of chronic diseases reported (see end of “Discussion” section). Using this definition, comorbidity consistently shows a strong association with all kinds of health outcomes, such as mobility limitations, perceived health, use of health care facilities, and mortality [10], [11]. Previous research, however, has shown that specific combinations of chronic diseases may have a different influence on physical functioning than would be expected on the basis of the addition of the influences of the individual diseases [2]. Moreover, the influence of comorbidity in specific chronic diseases deserves further study. Little is known about whether this influence differs across specific chronic diseases [2].

Although there has been an enormous increase in publications addressing the impact of comorbidity [11] and the evidence supporting comorbidity as a risk factor for functional decline is considered to be strong [10], [11], relatively few studies have employed a longitudinal design. In the recent review by Gijsen et al. [11], 18 cross-sectional and only six longitudinal studies addressing the influence of comorbidity on functional status or quality of life were identified. Most of these studies (50%) used a comorbidity index or count. Of the longitudinal studies, two studies were confined to cancer patients, two studies dealt with patients who experienced stroke, one focused on persons with knee osteoarthritis, and one with comorbidity of anxiety disorders. Thus, the differences in patient groups hamper comparison and generalization of the findings from these studies.

In the present study, we investigate the impact of comorbidity in the general population, that is, the number of chronic diseases, as well as that of comorbidity of specific chronic diseases on 3-year change in physical functioning. The additional influence of comorbidity on change in physical functioning in specific chronic diseases is investigated for chronic diseases that often afflict the elderly, and that have been repeatedly shown to influence physical functioning and thereby the ability of older people to live independently in the community. Seven specific chronic diseases with a high prevalence in the elderly population were selected: chronic nonspecific lung disease (CNSLD: asthma, chronic bronchitis or pulmonary emphysema), cardiac disease (including myocardial infarction), peripheral atherosclerosis, stroke, diabetes mellitus, arthritis (rheumatoid arthritis or osteoarthritis), and malignancies.

Section snippets

Design

The present study uses a longitudinal design. Data were collected in the context of the Longitudinal Aging Study Amsterdam (LASA) [12], a longitudinal study on predictors and consequences of changes in physical, cognitive, emotional, and social functioning among older persons. In this study, data from the first two measurement cycles, conducted in 1992/1993 (baseline: T1) and 1995/1996 (follow-up: T2), are used.

Subjects

A sample of people aged 55 to 85 years, stratified according to age, gender, and

Results

Characteristics of the total study sample (n = 2,497), as well as differences in characteristics between subjects with no change and decline in physical functioning, are presented in Table 1. The majority of subjects showed no change in physical functioning during the 3 years of follow-up (73.6% no change, 21.4% decline, 5.0% improvement). Because the number of subjects who improved was small (n = 126), their results are not presented separately and multivariate logistic regression analyses were

Discussion

It appears useful to first compare our results regarding the frequency of occurrence of specific combinations of chronic diseases with those from previous studies. Most of the disease combinations that occur in a higher frequency than expected involve so-called causal comorbidities [26] (coexistence based on a proven common pathophysiologic cause): cardiac disease, peripheral atherosclerosis, stroke, and diabetes mellitus. This is in line with reports from other studies [2], [27], [28]. In

Acknowledgements

This contribution is based on data from the Longitudinal Aging Study Amsterdam (LASA), which is funded mainly by a long-term grant from The Netherlands Ministry of Health, Welfare and Sports.

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