University of Groningen
Geriatric Syndromes and Incident Chronic Health Conditions Among 9094 Older
Community-Dwellers
Rausch, Christian; van Zon, Sander; Liang, Yajun; Laflamme, Lucie; Möller, Jette; de Rooij,
Sophia; Bültmann, Ute
Published in:
Journal of the American Medical Directors Association
DOI:
10.1016/j.jamda.2021.02.030
IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from
it. Please check the document version below.
Document Version
Version created as part of publication process; publisher's layout; not normally made publicly available
Publication date:
2021
Link to publication in University of Groningen/UMCG research database
Citation for published version (APA):
Rausch, C., van Zon, S., Liang, Y., Laflamme, L., Möller, J., de Rooij, S., & Bültmann, U. (2021). Geriatric
Syndromes and Incident Chronic Health Conditions Among 9094 Older Community-Dwellers: Findings
From the Lifelines Cohort Study. Journal of the American Medical Directors Association.
https://doi.org/10.1016/j.jamda.2021.02.030
Copyright
Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).
Take-down policy
If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim.
Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum.
Original Study
Geriatric Syndromes and Incident Chronic Health Conditions Among
9094 Older Community-Dwellers: Findings From the Lifelines
Cohort Study
Q 1
Q 14
Christian Rausch MD, MSc
a,b,
*
, Sander van Zon
a, Yajun Liang
b, Lucie La
flamme
b,
Jette Möller
b, Sophia de Rooij
c,d, Ute Bültmann
aQ 2
aDepartment of Health Sciences, University of Groningen, University Medical Center Groningen, Community and Occupational Medicine, Groningen, The Netherlands
bDepartment of Global Public Health, Karolinska Institutet, Stockholm, Sweden cMedical School Twente, Medical Spectrum Twente, Enschede, The Netherlands
dDepartment of Internal Medicine, University of Groningen, University Medical Center Groningen, Center for Geriatric Medicine, Groningen, The Netherlands
Keywords: Geriatric syndromes elderly
chronic health conditions aging
a b s t r a c t
Objectives: To determine the association between geriatric syndromes and any specific incident chronic health conditions among older community-dwellers.
Design: Population-based cohort study over a median follow-up period of 43 months.
Setting and Participants: Participants from the Lifelines Cohort Study aged 60 years and older without presence of the studied chronic health conditions at baseline (n¼ 9094).
Methods: Baseline assessment took place between November 2006 and December 2013 and included information on socioeconomic (age, sex, level of education and income), social contact, and health-related factors (eg, self-rated health, body mass index, chronic health conditions, and health behavior [alcohol consumption and smoking]). Participants also reported the presence of geriatric syndromes (ie, included falls, incontinence, vision impairment, hearing impairment, depressive symptoms, and frailty at baseline). Three follow-up questionnaires were used to examine the incidence of any and specific chronic health conditions (ie, pulmonary and cardiovascular diseases, diabetes, cancer, and neurological dis-eases). Cox regression was used to analyze the longitudinal associations between geriatric syndromes and incident chronic health conditions.
Results: Older community-dwelling individuals with at least one geriatric syndrome (44.7%, n¼ 4038) had an increased risk of developing any new chronic health condition (hazard ratio [HR] 1.35; 95% confidence interval [CI] 1.21e1.51). The association was attenuated but remained significant after adjustment for socioeconomic factors, social contact, health status, and health behavior (HR 1.27; 95% CI 1.12e1.43). Analyses for specific chronic health conditions showed that compared with older community-dwellers without geriatric syndromes, those with geriatric syndromes had an increased risk to develop a cardiovascular health condition (HR 1.42; 95% CI 1.13e1.79) or diabetes (HR 1.53; 95% CI 1.11 e2.11). They had no increased risk to develop pulmonary conditions, cancer, or neurological conditions. Conclusion and Implications: The presence of geriatric syndromes is associated with incident chronic health conditions, specifically cardiovascular conditions and diabetes. Increased awareness is needed among older people with geriatric syndromes and their physicians. Comprehensive assessments of geriatric syndromes may help to prevent or at least delay the development of chronic health conditions. Ó 2021 AMDA e The Society for Post-Acute and Long-Term Care Medicine. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
The number of people aged 60 years and older is increasing
globally.1 This demographic change challenges health care systems
and providers as older people present with complex multicausal health conditions ranging from physical problems like gait instability
and falls to mental health problems like depressive symptoms.2,3
The authors declare no conflicts of interest.
* Address correspondence to Christian Rausch, MD, MSc, University of Groningen, University Medical Center Groningen, Department of Health Sciences, Community and Occupational Medicine, Groningen, The Netherlands.
E-mail address:[email protected](C. Rausch).
https://doi.org/10.1016/j.jamda.2021.02.030
1525-8610/Ó 2021 AMDA e The Society for Post-Acute and Long-Term Care Medicine. This is an open access article under the CC BY license (http://creativecommons.org/ licenses/by/4.0/). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110
JAMDA
j o u r n a l h o m e p a g e : w w w . j a m d a . c o mComplex health conditions among older people are often defined as geriatric syndromes, referred to as conditions linked to accumulated
aging-related impairments in multiple organ systems.4
Geriatric syndromes are defined as phonotypical presentations of
accumulated and underlying aging-related dysfunctions spanning
over different organ systems.4Geriatric syndromes include among
others urinary incontinence, falls, depressive symptoms, and vision
and hearing impairment.4e6The presence of geriatric syndromes
in-dicates a decline in health and is associated with subsequent
disability, institutionalization, hospitalization, and mortality.7e12
Furthermore, cross-sectional studies have shown geriatric syn-dromes to co-occur with other chronic health conditions like
cardio-vascular diseases and diabetes.13e15
Processes related to pathological aging (eg, increased in
flamma-tion or cellular senescence) contribute to dysfuncflamma-tions leading to geriatric syndromes, but also contributing to chronic health
conditions.3,7,13,16,17A better understanding of the association between
geriatric syndromes and subsequent chronic health conditions may help physicians and health care professionals to identify older people at increased risk for the development of chronic health conditions and further health decline. Although geriatric syndromes have been shown to occur with chronic health conditions, little is known on their timely association, that is, whether older community-dwelling people with geriatric syndromes are at increased risk to develop new chronic
health conditions.13,16
Thus, this study aims to determine the associations between
geriatric syndromes and any specific incident chronic health
condi-tions among older community-dwelling people over 43 months. Methods
Design and Sample
The study was conducted within the sampling frame of the
Life-lines Cohort Study.18 Lifelines is a multidisciplinary prospective
population-based cohort study examining in a unique 3-generation design the health and health-related behaviors of 167,729 persons living in the north of the Netherlands. It uses a broad range of investigative procedures in assessing the biomedical, sociodemo-graphic, behavioral, physical, and psychological factors that contribute to the health and disease of the general population, with a special focus on multimorbidity and complex genetics. The population is considered to be broadly representative for the northern provinces of
the Netherlands.19More details on the design and the recruitment of
the participants has been described elsewhere.18Briefly, individuals
were consecutively recruited via their general practitioner, via family members, or self-registration on the Lifelines website. Participants were then invited for an initial comprehensive baseline assessment at a Lifelines research location between November 2006 and December 2013. The initial baseline assessment involved questionnaires and physical examinations. The Lifelines Cohort Study followed partici-pants up to 5 years after the baseline assessment. At a second and third measurement, participants received follow-up questionnaires digitally and via post. At a second comprehensive assessment (fourth measurement), participants were again invited for an assessment to a Lifelines research location that involved questionnaires and physical examinations.
The current study used data from participants aged 60 years and
older at baseline (n ¼ 22,541). Participants who self-reported
car-diovascular diseases, cancer, diabetes, or pulmonary or neurological
conditions at baseline (n¼ 10,432) were excluded (seeSupplementary
File 1). Recorded medication uses (ie, recorded by trained research staff, related to cardiovascular diseases, diabetes, pulmonary, and
neurological conditions) were included in the classification of chronic
health conditions at baseline (seeSupplementary File 1).20
Partici-pants with missing information on chronic health conditions
(n¼ 1614) and geriatric syndromes (n ¼ 1401) at baseline were also
excluded from the analysis. Thefinal study population consisted of
9094 older community-dwelling individuals. Participants were asked in the follow-up questionnaires whether they have had any of the chronic health conditions, that is, cardiovascular diseases, cancer, diabetes, pulmonary or neurological conditions, since the last
ques-tionnaire (seeSupplementary File 1). This allowed us to study only
those participants who developed chronic health conditions after the baseline assessment.
The median follow-up time from baseline assessment was 13 months (interquartile range [IQR] 12 to 15 months) to the second measurement, 24 months (IQR, 23 to 27 months) to the third mea-surement, and 43 months (IQR 35 to 51 months) to fourth measure-ment (and examination).
Lifelines was conducted according to the guidelines in the Decla-ration of Helsinki, and all procedures involving human subjects were approved by the xxxxxxxxxxxxxxxxxxxxxxx (for BLIND REVIEW
PROCESS) (ethics number: 2007/152). Written informed consent wasQ 3
obtained from all participants during the visit at the research center.18,21
Measures
Geriatric syndromes
Self-reported geriatric syndromes were measured at baseline and included falls, incontinence, vision impairment, hearing impairment,
depressive symptoms, and frailty (see Supplementary File 2). Falls
were assessed with saying yes to 1 of the following 2 questions, including a question on hip fracture as a proxy for falls (dizziness with falling in the past 12 months or hip fracture in the past 12 months, yes/no). Incontinence was assessed with marking incontinence as a current physical problem in the Lifelines questionnaire (have or had incontinence, yes). Vision impairment was assessed with 2 questions (need glasses and limited by eyesight, yes/no). Hearing impairment was assessed with 2 questions (need a hearing aid and being limited by hearing problems, yes/no). Depressive symptoms were assessed with the 9-item mini-international neuropsychiatric interview (M.I.N.I.) on depression, with 2 items indicative for depressive symptoms (presence of at least 1 primary depression item and 1 other
item, yes/no).22Frailty was assessed with a modified version of the
Frailty index (Fried et al.23) and included weight loss, decreased
endurance, slowness, weakness, and physical activity. Participants were considered frail when indicating at least 3 of 5 frailty measures: weight loss (unexpected weight loss of 3 or 6 kg within the past 3 or 6 months, respectively, yes/no), decreased endurance (have or had
difficulty performing work or other activities, eg, it took extra physical
effort, yes/no), slowness (limited in walking 100 m or limited in
climbing a flight of stairs, yes/no), weakness (limited in lifting or
carrying groceries, yes/no), and physical activity (number of days physically active; ie, gardening, cycling, or other activities, fewer than 2 days within a week). Geriatric syndromes were categorized into none or at least 1 geriatric syndrome.
Incident chronic health conditions
The incidence of a chronic health condition was based on self-reports on the most common and burdensome chronic health
con-ditions among older people.24 Chronic health conditions were
assessed on an aggregate level (presence of any chronic health
con-dition) and specific level, that is, organ system or disease level
(questions seeSupplementary File 1).24The assessed chronic health
conditions included cardiovascular conditions (stroke, heart attack, or heart failure), cancer, neurological conditions (dementia or Parkinson
C. Rausch et al. / JAMDA xxx (2021) 1e6 2 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240
disease), pulmonary conditions (asthma, chronic obstructive pulmo-nary disease [COPD], chronic bronchitis, or emphysema) or diabetes. Information from 3 follow-up measurements was used. The incidence of chronic health conditions was not mutually exclusive, as partici-pants could have had more than 1 incident chronic health condition over the follow-up period.
Covariates
Age, sex, level of education, individual equalized income, social contact, self-rated health (SRH), body mass index (BMI), alcohol
intake and smoking at baseline were included as covariates.6,25Age
was measured as calendar age. Level of education was categorized into the highest level of education achieved (tertiary education,
sec-ondary education, and primary education).26 Individual equalized
income was categorized based on previous Lifelines studies (do not
want to say, do not know, <1000, 1000e1299, 1300e1599,
1600e1899, >1899 V/month).27,28Information on social contact was
dichotomized based on having social contacts with fewer than 5
people over 2 weeks (yes, no).29SRH was assessed using 1 item of the
RAND-36 relating to self-rated health and dichotomized into
excel-lent/very good/good health and fair/poor health.30BMI was calculated
as BMI ¼ weight (kg)/length (m)2 based on measured height and
length and categorized into 4 groups (underweight: BMI<18.5 kg/
m2; normal weight: BMI18.5 kg/m2to24.9 kg/m2; overweight:
BMI 25.0 kg/m2 to 29.9 kg/m2; or obese: BMI 30.0 kg/m2).31
Alcohol intake was categorized into 4 groups based on the average number of alcoholic drinks consumed on a day (nondrinker, light
drinker with<1 drink a day, moderate drinker with 1e2 drinks a day,
and heavy drinker with more than 2 drinks a day).32Smoking status
was categorized into current, past, or nonsmoker.32Some covariates
had partially missing information ranging from n ¼ 4 on weight
status (n¼ 4, 0.0%) to n ¼ 255 on limited social contact (n ¼ 255,
2.5%). Missing information was categorized as a dummy variable and included in the analysis.
Statistical Analysis
Compared with the study population, the excluded participants, that is, those with missing information on geriatric syndromes and
chronic health conditions (n ¼ 3015) were on average older
(67.1 years), more likely to be women (61.7%), with a primary educa-tion (59.1%), and obese (15.4%).
Baseline characteristics of the total study population and stratified
by presence of geriatric syndromes were presented as means and SDs for continuous variables and as frequencies and percentages for
cat-egorical variables. We used t-tests and
c
2 tests for comparison ofbaseline characteristics of those with and without a geriatric syn-drome at baseline. The incidence of self-reported chronic health
conditions, aggregated and specific, over 3 measurements was
pre-sented in percentages with 95% confidence intervals for participants
with and without geriatric syndromes at baseline. The association of geriatric syndromes at baseline and incident chronic health conditions over time was estimated using Cox regression. The follow-up time for any chronic health condition was calculated as the time interval be-tween baseline assessment and the time of self-report of any of the
preceding conditions. The follow-up time for specific chronic health
conditions was calculated as the time interval between baseline assessment and the time of self-report of the conditions. The analyses
were adjusted for confounders in 3 steps. In the first model, we
adjusted for baseline age and sex. In the second model, we addition-ally adjusted for socioeconomic and social factors. In the third model we adjusted for age, sex, and health-related factors (ie, SRH, BMI, alcohol, and smoking behavior). In the fourth model, we further adjusted for age, sex, health status, health behavior, socioeconomic, and social factors.
Results
Sample Characteristics
A total of 9094 older community-dwelling individuals were
included in the analysis; the average age was 65.2 years (Table 1).
More than half of the older community-dwelling people were women (55.3%). Of the older community-dwelling people, 4038 (44.7%) re-ported at least 1 geriatric syndrome at baseline. Older community-dwelling individuals with geriatric syndromes tended to be older than older community-dwelling individuals without geriatric syn-dromes (mean age 65.6 years vs 64.8 years), were more likely to have an individual equalized income of less than 1000 euro (10.4% vs 8.5%), reported more often poor to fair health (9.4% vs 2.8%), were obese
Table 1
Baseline Characteristics by Geriatric Syndromes (n¼ 9094) Characteristics Total (9094) Geriatric Syndromes at
Baseline P Value* None (n¼ 5056) At Least 1 (n¼ 4038) Mean age, y (SD) 65.2 (4.5) 64.8 (4.2) 65.6 (4.9) <.001 Sex, n (%) Male 4062 (44.7) 2144 (42.4) 1918 (47.5) Female 5032 (55.3) 2912 (57.6) 2120 (52.5) <.001 Education, n (%) Tertiary education 2217 (24.4) 1275 (25.2) 942 (23.3) Secondary education 1923 (21.2) 1085 (21.5) 847 (21.0) Primary education 4509 (49.6) 2474 (48.9) 2035 (50.4) Other 352 (3.9) 178 (3.5) 174 (4.3) Missing 84 (0.9) 44 (0.9) 40 (1.0) .076
Individual equalized income (inV per mo), n (%)
>1899 3275 (36.0) 1893 (37.4) 1382 (34.2) 1600e1899 377 (4.1) 196 (3.9) 181 (4.5) 1300e1599 1274 (14.0) 704 (13.9) 570 (14.1) 1000e1299 1571 (17.3) 822 (16.3) 749 (18.5) <1000 848 (9.3) 430 (8.5) 418 (10.4) Not knowing 407 (4.5) 237 (4.7) 170 (4.2) Not wanting to say 1162 (12.8) 662 (13.1) 500 (12.4) Missing 180 (2.0) 112 (2.2) 68 (1.7) <.001 Social contact, n (%) <5 people 7914 (87.0) 4455 (88.1) 3459 (85.7) 5 people 952 (10.5) 515 (10.2) 437 (10.8) Missing 288 (2.5) 86 (1.7) 142 (3.5) <.001 Self-rated health, n (%) Excellent to good 8571 (94.3) 4918 (97.3) 3655 (90.5) Fair to poor 516 (5.7) 138 (2.7) 378 (9.4) Missing 5 (0.1) 0 (0.0) 5 (0.1) <.001 Weight status, n (%) Underweight 31 (0.3) 12 (0.2) 19 (0.5) Normal 3546 (39.0) 2030 (40.2) 1516 (37.5) Overweight 4402 (48.2) 2423 (47.9) 1979 (49.0) Obese 1111 (12.2) 591 (11.7) 520 (12.9) Missing 4 (0.0) 0 (0.0) 4 (0.1) <.01 Alcohol consumption, n (%) Nondrinker 1494 (16.4) 799 (15.8) 695 (17.2) Light 4428 (48.7) 2507 (49.6) 1921 (47.6) Moderate 2237 (24.6) 1263 (25.0) 974 (24.1) Heavy 746 (8.2) 407 (8.0) 339 (8.4) Missing 189 (2.1) 80 (1.6) 109 (2.7) <.01 Smoking, n (%) Never 3379 (37.2) 1940 (38.4) 1439 (35.6) Former smoker 4517 (49.7) 2477 (49.0) 2040 (50.5) Current smoker 979 (10.8) 545 (10.8) 434 (10.7) Missing 219 (2.4) 94 (1.9) 125 (3.1) <.001 Geriatric syndromes, n (%)y Fall 49 (0.5) 0 (0.0) 49 (1.2) Incontinence 264 (2.9) 0 (0.0) 264 (6.5) Vision impairment 1749 (19.2) 0 (0.0) 1749 (43.3) Hearing impairment 2429 (26.7) 0 (0.0) 2429 (60.2) Depressive symptoms 232 (2.5) 0 (0.0) 232 (5.7) Frailty 435 (4.7) 0 (0.0) 435 (10.7)
*t-test andc2test for association.
yNot mutually exclusive. Q 6
241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370
(12.9% vs 11.7%), and were less likely to have never smoked (35.6% vs 38.4%).
Incidence of Chronic Health Conditions
Figure 1shows the incidence of chronic health conditions among older community-dwelling individuals with none or at least 1 geriatric syndrome at baseline (see suppl. Table 1
Q 4 ). Of all older
community-dwelling individuals included in the analysis, n ¼ 1223 (13.4%)
developed a chronic health condition during follow-up. Compared with older community-dwelling individuals without geriatric syn-dromes, those with geriatric syndromes were more likely to develop a
chronic health condition (15.9% vs 11.5%), more specifically pulmonary
(6.3% vs 4.9%) and cardiovascular health conditions (4.5 % vs 2.7%). Older community-dwelling individuals with at least 1 geriatric syndrome had an increased risk for any incident chronic health
con-dition (hazard ratio [HR] 1.35, 95% confidence interval [CI] 1.21e1.51),
particularly for pulmonary (HR 1.30, 95% CI 1.09e1.55) and
cardio-vascular health conditions (HR 1.51, 95% CI 1.21e1.89) and diabetes
(HR 1.66, 95% CI 1.21e2.28) (model 1) (Table 2). After adjusting for
socioeconomic factors, social factors, health status, and health behavior (model 4), the associations between geriatric syndromes and
any incident chronic health condition (HR 1.27, 95% CI 1.12e1.43),
cardiovascular health conditions (HR 1.42, 95% CI 1.13e1.79), and
diabetes (HR 1.53, 95% CI 1.11e2.11) attenuated but remained
signifi-cant (model 4). The association with pulmonary diseases was no
longer significant.
Discussion
This population-based study examined the association between geriatric syndromes and incident chronic health conditions among older community-dwelling people. Older community-dwelling people with at least 1 geriatric syndrome at baseline were more likely to develop a chronic health condition, especially cardiovascular
conditions and diabetes, compared with those without any geriatric
syndrome. These associations remained significant even after
adjusting for socioeconomic factors, social contact, health behavior, and health-related factors.
Previous studies have examined the association between geriatric syndromes and severe health outcomes, like institutionalization,
hospitalization, and mortality,7e9,33or determined the cross-sectional
association with chronic health conditions.13,14,34Earlier, Huang et al.,9
showed that the presence of only 1 geriatric syndrome increased the risk of mortality, and that this association was independent of the presence or occurrence of chronic health conditions. In addition, other studies demonstrated cross-sectional associations between geriatric syndromes and a variety of chronic health conditions, including
car-diovascular conditions and diabetes.13,14 Our study adds to these
findings and provides suggestive evidence that the presence of geri-atric syndromes is also associated with the development of any new
chronic health conditions. One explanation for thisfinding may be
that geriatric syndromes contribute directly to an increased suscep-tibility for other health conditions, as they may cause stress to
phys-iological reserves.3,11,35 A more specific explanation may be that
existing geriatric syndromes reveal underlying pathophysiological processes related to ongoing pathological aging and other health
conditions.4,34 Studies have shown aging-related mechanisms, like
cellular senescence, or increased inflammation in specific organs to be
similar to pathogenetic mechanisms of specific diseases like
dia-betes.2,3,15Geriatric syndromes may be a sign of accumulating
aging-related impairments across different organs, which over time may contribute to the development of new chronic health conditions, for
example, in the cardiovascular system.3,15
Evidence on the longitudinal association between geriatric
syn-dromes and development of specific chronic health conditions is
limited. Earlier studies suggested geriatric syndromes to occur when older people are already burdened by chronic health conditions like
cancer.36Ourfindings complement cross-sectional studies on geriatric
syndromes and specific chronic health conditions.13,14 In our
11.5 % 4.9 % 2.7 % 3,0 % 1,4 % 0.3 % 15.9 % 6.3 % 4.5 % 3.7 % 2,3 % 0.6 % 0 2 4 6 8 10 12 14 16 18 Any subsequent chronic health condi on (n=1,223) Pulmonary (n=504) Cardiovascular (n=319)
Cancer (n=303) Diabetes (n=160) Neurological (n=36) No geriatric syndrome at baseline (n=5,056)
At least one geriatric syndrome at baseline (n=4,038)
)I C % 5 9( % ni ec ne di c ni es a C
Any and specific incident chronic health condi ons1
1not mutually exclusive
Fig. 1. Case incidence of any and specific chronic health conditions by presence of geriatric syndromes at baseline (n ¼ 9094) in percentages and 95% CIs. C. Rausch et al. / JAMDA xxx (2021) 1e6
4 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500
longitudinal study, geriatric syndromes were associated with incident cardiovascular conditions and diabetes. Aging-related mechanisms,
like increased inflammatory processes, have been linked to the
pre-sentation of geriatric syndromes, but also cardiovascular conditions
and diabetes.15,37 Such overlap between aging and disease-related
pathophysiological mechanisms may not exist for all chronic health conditions. Studies on progressive aging and the development of cancer have shown that aging can increase the risk for cancer, but also interferes with its progression, potentially causing stagnation of
can-cer growth.38Furthermore, the association between aging and cancer
may also depend on the organ or tissue affected, which would explain
that we did notfind an association between geriatric syndromes and
any cancer.38In addition, it may be that older people with a severe
illness like cancer no longer participate in Lifelines. Inflammatory
processes have also been suggested as shared mechanisms between geriatric syndromes and neurological or neurodegenerative
condi-tions like Parkinson disease and dementia.3However, we did notfind
an association between geriatric syndromes and the development of these neurological conditions. It is possible that a lack of power and the relatively short follow-up period may not have allowed us to adequately capture this association.
Strengths and Limitations
The Lifelines Cohort Study provided a large population sample size in which the association between geriatric syndromes and incident chronic health conditions was assessed. In addition, Lifelines provided comprehensive information on sociodemographic, social contact, health, and health-behavioral factors enabling adjustments for known confounders. Furthermore, Lifelines is considered broadly
represen-tative of the Northern Netherlands.18,19We also must acknowledge
some limitations. Consensus on a set list of predefined geriatric
syn-dromes is still lacking and we may not have included all geriatric syndromes. Yet, we have included the most prevalent geriatric
syn-dromes derived from literature.4,5,39
In addition, the self-reports of geriatric syndromes and chronic health conditions may be subject to information bias. Geriatric syn-dromes may be underestimated due to social desirability (ie, stigma on geriatric syndromes like urinary incontinence or recall bias). This also may be the case for chronic health conditions. Both may have contributed to an underestimation of the association between geri-atric syndromes and incident chronic health conditions. For example, older people with incident chronic health conditions did not report geriatric syndromes at baseline due to fear of stigma. To assess the
association between geriatric syndromes and the incident of any and
specific chronic health conditions independently, we excluded those
with a previous history of the analyzed chronic health conditions. This may have led to the selection of a healthy study population and may underestimate the magnitude of the problem with geriatric syn-dromes. For this study we did not have access to bio samples and laboratory data. The Lifelines Cohort and Biobank does collect bio samples and laboratory data. However, this information is limited to the baseline assessment and would not have improved our study, as data are not available at follow-up when incident chronic health conditions are assessed. Future studies using bio samples and labo-ratory data are needed to further elucidate the association between geriatric syndromes and incidence of chronic health conditions. Implications
Geriatric syndromes may indicate an increased risk for future chronic health conditions. Physicians and health care professionals should be aware of this association with chronic health conditions when diagnosing older people with geriatric syndromes. The pre-sentation of geriatric syndromes therefore requires a comprehensive assessment and monitoring to prevent or delay chronic health con-ditions. More research is needed to understand the underlying mechanisms between geriatric syndromes and the subsequent
development of specific chronic health conditions.
Conclusion and Implications
Geriatric syndromes are associated with incident chronic health
conditions, specifically cardiovascular conditions and diabetes, when
adjusted for sociodemographic, social contact, health-related, and health-behavioral factors. Increased awareness is needed among older people with geriatric syndromes and their physicians. Comprehensive assessments of geriatric syndromes may help to prevent or at least delay the development of chronic health conditions.
Acknowledgments
Q 5
The Lifelines Biobank initiative has been made possible by subsidy from the Dutch Ministry of Health, Welfare and Sport, the Dutch Ministry of Economic Affairs, the University Medical Center Groningen (UMCG the Netherlands), University Groningen, and the Northern Provinces of the Netherlands.
Table 2
Association Between Geriatric Syndromes and Any Specific Incident Chronic Health Conditions Over Follow-up Period, Adjusted HR and 95% CI (n ¼ 9094) Geriatric Syndromes
at Baseline
Incident Chronic Health Condition (n¼ 1223)
Specific Incident Chronic Health Conditions
Pulmonary (n¼ 504) Cardiovascular (n¼ 319) Cancer (n¼ 303) Diabetes (n¼ 160) Neurological (n¼ 36) Model 1
None 1.00 1.00 1.00 1.00 1.00 1.00
At least 1 1.35 (1.21e1.51) 1.30 (1.09e1.55) 1.51 (1.21e1.89) 1.13 (0.90e1.42) 1.66 (1.21e2.28) 1.91 (0.96e3.79) Model 2
None 1.00 1.00 1.00 1.00 1.00 1.00
At least 1 1.36 (1.21e1.52) 1.27 (1.07e1.52) 1.49 (1.19e1.87) 1.19 (0.94e1.49) 1.65 (1.20e2.26) 1.96 (0.99e3.90) Model 3
None 1.00 1.00 1.00 1.00 1.00 1.00
At least 1 1.27 (1.13e1.43) 1.17 (0.97e1.40) 1.42 (1.13e1.79) 1.15 (0.91e1.44) 1.54 (1.11e2.12) 1.87 (0.93e3.73) Model 4
None 1.00 1.00 1.00 1.00 1.00 1.00
At least 1 1.27 (1.12e1.43) 1.15 (0.96e1.38) 1.42 (1.13e1.79) 1.13 (0.90e1.42) 1.53 (1.11e2.11) 1.93 (0.96e3.87) Model 1 adjusted for age and sex.
Model 2 as model 1 and in addition adjusted for socioeconomic and social factors. Model 3 as model 1 and in addition adjusted for health status and health behavior.
Model 4 as model 1 and in addition adjusted for health status, health behavior, socioeconomic, and social factors.
501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630
The authors acknowledge the services of the Lifelines Cohort Study, the contributing research centers delivering data to Lifelines, and all the study participants.
References
Q 7
1. WHO. Aging and Lifecourse. 2015. Available at: www.who.int/aging/age_ friendly_cities/index.html. Accessed May 4, 2016.
2. Fabbri E, Zoli M, Gonzalez-Freire M, et al. Aging and multimorbidity: New tasks, priorities, and frontiers for integrated gerontological and clinical research. J Am Med Dir Assoc 2015;16:640e647.
3. Franceschi C, Garagnani P, Morsiani C, et al. The continuum of aging and age-related diseases: Common mechanisms but different rates. Front Med 2018; 5:61.
4. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc 2007;55:780e791.
5. Tabue-Teguo M, Grasset L, Avila-Funes JA, et al. Prevalence and co-occurrence of geriatric syndromes in people aged 75 years and older in France: Results from the bordeaux three-city study. J Gerontol A Biol Sci Med Sci 2018;73: 109e116.
6. Liang Y, Rausch C, Laflamme L, Möller J. Prevalence, trend and contributing factors of geriatric syndromes among older Swedes: Results from the Stock-holm County Council Public Health Surveys. BMC Geriatr 2018;18:322. 7. Wang S-Y, Shamliyan TA, Talley KMC, et al. Not just specific diseases:
Sys-tematic review of the association of geriatric syndromes with hospitalization or nursing home admission. Arch Gerontol Geriatr 2013;57:16e26.
Q 8
8. Chiu CJ, Cheng YY. Utility of geriatric syndrome indicators for predicting sub-sequent health care utilization in older adults in Taiwan. Int J Environ Res Public Health 2019;16:456.
9. Huang CC, Lee JD, Yang DC, et al. Associations between geriatric syndromes and mortality in community-dwelling elderly: Results of a national longitudinal study in Taiwan. J Am Med Dir Assoc 2017;18:246e251.
10. Rikkert M, Rigaud A, van Hoeyweghen R. Geriatric syndromes: Medical misnomer or progress in geriatrics? Neth J Med 2003;61:83e87.
11. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet 2013;381: 752e762.
12. Wierenga PC, Buurman BM, Parlevliet JL, et al. Association between acute geriatric syndromes and medication-related hospital admissions. Drugs Aging 2012;29:691e699.
13. Vetrano DL, Foebel AD, Marengoni A, et al. Chronic diseases and geriatric syndromes: The different weight of comorbidity. Eur J Intern Med 2016;27: 62e67.
Q 9
14. Lee PG, Cigolle C, Blaum C. The co-occurrence of chronic diseases and geriatric syndromes: The health and retirement study. J Am Geriatr Soc 2009;57: 511e516.
15. Stewart R. Cardiovascular disease and frailty: What are the mechanistic links? Clin Chem 2019;65:80e86.
16. Koroukian SM, Warner DF, Owusu C, Given CW. Multimorbidity redefined: Prospective health outcomes and the cumulative effect of co-occurring con-ditions. Prev Chronic Dis 2015;12:E55.
17. Koroukian SM, Schiltz N, Warner DF, et al. Combinations of chronic conditions, functional limitations, and geriatric syndromes that predict health outcomes. J Gen Intern Med 2016;31:630e637.
18. Scholtens S, Smidt N, Swertz MA, et al. Cohort profile: LifeLines, a three-generation cohort study and biobank. Int J Epidemiol 2015;44:1172e1180. 19. Klijs B, Scholtens S, Mandemakers JJ, et al. Representativeness of the LifeLines
Cohort Study. PLoS One 2015;10:e0137203.
20. Meems LMG, De Borst MH, Postma DS, et al. Low levels of Vitamin D are associated with multimorbidity: Results from the LifeLines Cohort Study. Ann Med 2015;47:474e481.
21. Stolk RP, Rosmalen JGM, Postma DS, et al. Universal risk factors for multifac-torial diseases. Eur J Epidemiol 2008;23:67e74.
22. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuro-psychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59(Suppl 20):22e33: quiz 34e57.
23. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146eM157.
24. Prince MJ, Wu F, Guo Y, et al. The burden of disease in older people and im-plications for health policy and practice. Lancet 2015;385:549e562. 25. Lounassalo I, Salin K, Kankaanpää A, et al. Distinct trajectories of physical
ac-tivity and related factors during the life course in the general population: A systematic review. BMC Public Health 2019;19:271.
26. OECD, European Union. UNESCO institute for statistics. ISCED 2011 operational manual: Guidelines for classifying national education programmes and related
qualifications. OECD publishing; 2015. Q 10
27. Klijs B, Kibele EUB, Ellwardt L, et al. Neighborhood income and major depressive disorder in a large Dutch population: Results from the LifeLines Cohort study. BMC Public Health 2016;16:773.
28. OECD. Divided We Stand: Why Inequality Keep Risisng. OECD; 2011.https:// doi.org/10.1787/9789264119536-en. Q 11 29. Klijs B, Mendes de Leon CF, Kibele EUB, Smidt N. Do social relations buffer the
effect of neighborhood deprivation on health-related quality of life? Results from the LifeLines Cohort Study. Health Place 2017;44:43e51.
30. Hays RD, Morales LS. The RAND-36 measure of health-related quality of life. Ann Med 2001;33:350e357.
31. World Health Organization. Waist circumference and waist-hip ratio: Report of a WHO expert consultation, Geneva, 8e11 December 2008. 2011. Available at:
https://apps.who.int/iris/handle/10665/44583. Accessed July 8, 2019. 32. Slagter SN, van Vliet-Ostaptchouk JV, Vonk JM, et al. Combined effects of
smoking and alcohol on metabolic syndrome: The LifeLines Cohort Study. PLoS One 2014;9:e96406.
33. Kane RL, Shamliyan T, Talley K, Pacala J. The association between geriatric syndromes and survival. J Am Geriatr Soc 2012;60:896e904.
34. Clerencia-Sierra M, Calderón-Larrañaga A, Martínez-Velilla N, et al. Multi-morbidity patterns in hospitalized older patients: Associations among chronic diseases and geriatric syndromes. PLoS One 2015;10:e0132909.
35. Ferrucci L, Cavazzini C, Corsi A, et al. Biomarkers of frailty in older persons. J Endocrinol Invest 2002;25(10 Suppl):10e15.
36. Mohile SG, Fan L, Reeve E, et al. Association of cancer with geriatric syndromes in older Medicare beneficiaries. J Clin Oncol 2011;29:1458e1464.
37. Musi N, Bartke A. Diabetes and aging. In: Advances in Geroscience. Springer International Publishing; 2015. p. 355e376. Q 12 38. Chatsirisupachai K, Palmer D, Ferreira S, Magalhães JP. A human tissue-specific
transcriptomic analysis reveals a complex relationship between aging, cancer, and cellular senescence. Aging Cell 2019;18:e13041.
39. Rosso AL, Eaton CB, Wallace R, et al. Geriatric syndromes and incident disability in older women: Results from the women’s health initiative observational study. J Am Geriatr Soc 2013;61:371e379.
C. Rausch et al. / JAMDA xxx (2021) 1e6 6 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760
Supplementary File 1. Questions on chronic health conditions at baseline and follow-up, and medications considered at baseline for validation.
Pulmonary disease - Baseline:
Self-reported pulmonary disease (chronic obstructive pul-monary disease [COPD], emphysema, or chronic bronchitis) and asthma/COPD medication (Anatomical Therapeutic
Chemical Classification System [ATC]: R03AC, R03AK, R03BA,
R03BB, R03BC01, R03BC03, R03DA04, R03DC) - Follow-up:
Self-reported pulmonary disease
Which of the following diseases have you had or have since the last questionnaire, COPD, emphysema, or chronic bron-chitis? Which of the following diseases have you had or have since the last questionnaire, asthma?
Cardiovascular disease - Baseline:
Self-reported heart failure and any use of heart
failureerelated medications, for example, diuretics (ATC:
C03A, C03B, C03C, C03E, C03X), angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin receptor blocker (ATC: C09), aldosterone antagonist (ATC: C03D), and beta blocker (ATC: C07)
Use of antihypertensives (ATC: C02,C03,C04, C07 C08, C09) Self-reported vascular disease (myocardial infarction, stroke, percutaneous coronary intervention, coronary artery bypass grafting) and use of vitamin K antagonist (ATC: B01AA), or ascal (ATC: B01AC06), or acetylsalicylic acid (ATC: B01AC08), or clopidogrel (ATC: B01AC04)
- Follow-up:
Self-reported cardiovascular disease
Which of the following diseases have you had or have since the last questionnaire, heart infarct, attack?
Which of the following diseases have you had or have since the last questionnaire, heart failure?
Which of the following diseases have you had or have since the last questionnaire, stroke?
Cancer - Baseline:
Self-reported presence of cancer
Do you have or had cancer? Have you been cured? - Follow-up:
Self-reported presence of cancer
Which of the following diseases have you had or have since the last questionnaire, cancer?
Diabetes - Baseline:
- Self-reported presence of diabetes, Do you have diabetes? - Or use of oral anti-diabetics (ATC code: A10B), insulin (ATC:
A10A) - Follow-up:
Self-reported presence of diabetes
Which of the following diseases have you had or have since the last questionnaire, diabetes?
Neurological disease - Baseline:
Self-reported dementia
Self-reported Parkinson disease and anti-parkinson medi-cation (ATC: N04BC02, N04BB01, N04BC07, N04BX02,
N04BA02, N04BC05, N04BD02, N04BC04, N04BC09,
N04BD01, N04BX01) - Follow-up:
Self-reported presence of dementia or Parkinson disease Which of the following diseases have you had or have since the last questionnaire, dementia?
Which of the following diseases have you had or have since the last questionnaire, Parkinson disease?
Supplementary File 2. Questions on geriatric syndromes Falls
Could you indicate which of the following disorders you have (had)? (list of several disorders follows) Dizziness with falling (in the past 12 months).
or
Hip fracture (in the past 12 months). Incontinence
Could you indicate which of the following disorders you have (had)? (list of several disorders follows)
Incontinence. Vision impairment
Do you need glasses or contact lenses? No; Yes, for nearby; Yes, for seeing far away; Yes, both.
And
Do you experience problems in daily life because of poor vision? No; Yes, some problems; Yes, many problems.
Hearing impairment
Do you need a hearing aid? Yes; no.
And
Are you limited by problems with your hearing in daily life? No; Yes, some problems; Yes, many problems.
Depressive symptoms
Depressive symptoms were assessed with the 9-item mini-international neuropsychiatric interview (M.I.N.I.) on depression
[24], with 2 items indicative for depressive symptoms (presence of atQ 13
least 1 primary depression item and 1 other item, yes/no). Frailty
Weight loss. Have you lost a lot of weight recently without wanting to (6 kg in 6 months or 3 kg in 1 month)? Yes; no; I do not know. 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775 776 777 778 779 780 781 782 783 784 785 786 787 788 789 790 791 792 793 794 795 796 797 798 799 800 801 802 803 804 805 806 807 808 809 810 811 812 813 814 815 816 817 818 819 820 821 822 823 824 825 826 827 828 829 830 831 832 833 834 835 836 837 838 839 840 841 842 843 844 845 846 847 848 849 850 851 852 853 854 855 856 857 858 859 860 861 862 863 864 865 866 867 868 869 870 871 872 873 874 875 876 877 878 879 880 881 882 883 884 885 886 887 888 889 890
Decreased endurance. During the past 4 weeks, have you had any of the following problems with your work or other regular daily
ac-tivities as a result of your physical health? Had difficulty performing
the work or other activities (for example, it took extra effort). Yes; no. Slowness. Does your health now limit you in the following activ-ities? Walking 100 meters. No; Yes limited a little; Yes, limited a lot.
or
Climbing 1flight of stairs. No; Yes limited a little; Yes, limited a lot.
Weakness. Does your health now limit you in the following ac-tivities? Lifting or carrying groceries. No; Yes limited a little; Yes, limited a lot.
Physical activity. On average, how many days per week do you bicycle, do odd jobs, garden, or exercise for, all activities added together, at least half an hour?
C. Rausch et al. / JAMDA xxx (2021) 1e6 6.e2 891 892 893 894 895 896 897 898 899 900 901 902 903 904 905 906 907 908 909 910 911 912 913 914 915 916 917 918 919 920 921 922 923 924 925 926 927 928 929 930 931 932 933 934 935 936 937 938 939 940 941 942 943 944 945 946 947 948 949 950 951 952 953 954 955 956 957 958 959 960 961 962 963 964 965 966 967 968 969 970 971 972 973 974 975 976 977 978 979 980 981 982 983 984 985 986 987 988 989 990 991 992 993 994 995 996 997 998 999 1000 1001 1002 1003 1004 1005 1006 1007 1008 1009 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019 1020
