ReviewMultimorbidity and mortality in older adults: A systematic review and meta-analysis
Introduction
Multimorbidity is a frequent problem, mainly in the elderly population, among whom prevalence was found to be greater than 60% (Fortin, Stewart, Poitras, Almirall, & Maddocks, 2012). Although studies of this problem are recent, available data have shown negative consequences related to multimorbidity including an increased risk of disability, frailty and decrease in quality of life, as well as associations with mortality (Fortin et al., 2004, Gijsen et al., 2001, Marengoni et al., 2011; Mello, Engstrom, & Alves, 2014).
The biological plausibility of association between multimorbidity and mortality is analogous to physiologic mechanisms which increase the risk of death in individuals with a specific disease. Moreover, multimorbidity increases the risk of complications and consequences on the physiological system due to interactions between morbidities and disease treatment (American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity, 2012; Guthrie, Payne, Alderson, McMurdo, & Mercer, 2012; Mallet, Spinewine, & Huang, 2007; Marengoni et al., 2011, Salisbury, 2012, van Weel and Schellevis, 2006). Some studies have found higher risk of death among elderly people with multimorbidity compared to those without diseases (Landi et al., 2010; Marengoni, von Strauss, Rizzuto, Winblad, & Fratiglioni, 2009; Menotti et al., 2001, Wang et al., 2009), while other studies did not find differences (St. John, Tyas, Menec, & Tate, 2014; Woo & Leung, 2014). Furthermore, mortality in the elderly is multifactorial and includes environmental (Beelen et al., 2014; Meijer, Rohl, Bloomfield, & Grittner, 2012; Silva, Cesse, & Albuquerque, 2014), demographic (Luy & Gast, 2014) and socioeconomic characteristics (Silva et al., 2014), as well as being influenced by social relationships (Holt-Lunstad, Smith, & Layton, 2010), geriatric conditions (Landi et al., 2010, Landi et al., 2012; Shamliyan, Talley, Ramakrishnan, & Kane, 2013; Theou et al., 2012, Woo and Leung, 2014) and healthcare actions (Veras et al., 2014).
Despite this context, to the best of our knowledge, a pooled effect on the association between multimorbidity and mortality does not exist. The description of characteristics which modify association might be useful to inform future interventions to measure actions and programs related to elderly (Moraes, 2012, Salisbury, 2012, Salive, 2013). Thus, the objective of this study was, by means of a systematic review and meta-analysis, to evaluate and quantify the association between multimorbidity and mortality in older adults.
Section snippets
Search strategy and selection criteria
A systematic review of literature held on the PUBMED database published up until January 22nd 2015 was conducted. Manuscripts in English, Portuguese and Spanish were searched. The following terms were used: (“comorbidity” OR “co-morbidity” OR “multimorbidity” OR “multi-morbidity” OR “multiple diseases” OR “multiple morbidities” OR “multimorbid” OR “multiple pathology” OR “disease clustering” OR “Risk Adjustment” OR “Severity of Illness Index”) AND (“Mortality” OR “survival rate” OR “cause of
Results
The search identified 5806 studies. After title and abstract reading, 200 manuscripts were selected for full-text reading. The majority of these were excluded because they did not have effect measurement for association between multimorbidity and mortality or included comorbidity evaluation (disease index) (Fig. 1). Eight additional records were identified through references list of selected papers, reaching 32 papers in qualitative synthesis. Then, 26 articles were included in the
Discussion
Multimorbidity increases the risk of death regardless of its operationalization. High heterogeneity between studies was observed. A positive gradient between number of diseases and mortality was found, and ≥3 diseases as the cut-off point showed the strongest association with risk of death. Small samples, population-based studies, more comprehensive adjustment, multimorbidity without disease severity measurement and multimorbidity comparison groups were characteristics that appear to reduce the
Conflict of interest statement
The authors declare that they have no competing interests.
Funding
BPN, TRF and GIM are supported by Coordination for the Improvement of Higher Level- or Education- Personnel (CAPES). LAF is supported by Brazilian National Research Council (CNPq). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
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