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
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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
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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:christian.rausch@ki.se(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.
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Q 7
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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?
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