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PREVALENCE AND FACTORS ASSOCIATED WITH MULTIMORBIDITIES IN BRAZILIAN OLDER ADULTS


ABSTRACT
This study aimed to identify the prevalence of multimorbidity in Brazilian older adults and factors associated with socioeconomic and lifestyle variables. This is a cross-sectional, population-based study carried out with data from the National Health Survey database. Seniors with multimorbidity where the ones with a diagnosis of two or more chronic diseases. The chi-square test was used in data analysis, and then prevalence ratios were estimated through Poisson multiple regression, both with 95% confidence level. In total, 11,697 older adults were evaluated and the multimorbidity prevalence was 53.1%. As a result of the multivariate analysis, female seniors (p<0.001), the oldest elderly (p=0.002), those who were not single, more strongly associated with widowers (p=0.001) and those with a health plan at the interview (p<0.001) were associated with multimorbidity. Also, in comparison with older adults with two chronic diseases, women are associated with three (p=0.003) and four or more chronic diseases (p<0.001). We can conclude that multimorbidity in Brazilian older adults is a widespread condition and that it has been influenced by socioeconomic factors and is poorly related to lifestyle.

Keywords: multimorbidity, older adults, associated factors

1. INTRODUCTION
The occurrence of multiple chronic diseases is a fairly common condition in health. Such a situation is probably due to the reduced diagnostic threshold for some chronic diseases, population aging or possibly the increased prevalence of these diseases1. Also, when it comes to the elderly population, the occurrence of different health problems in the same individual, also known as multimorbidity, appears as an even more frequent problem. This may be closely related to the increased life expectancy of the population2.
Concerning the concept of multimorbidity, although well-established in literature, the definition of the number of chronic conditions in the same individual varies considerably. Among these variations are studies that consider multimorbidity as the involvement of two or more chronic diseases and others as the presence of at least three3. Thus, multimorbidity prevalence estimates in older adults also vary. According to literature, the prevalence of multiple chronic diseases ranges from 30.7% to 57%4-10.
Given its prevalence, severity and impact on the quality of life, multimorbidity is currently considered a public health problem11. With a percentage that can exceed 50%, the prevalence of this condition in the elderly is high, and trend studies predict that this figure will increase further12-15. The presence of multimorbidity in the elderly can lead to severe losses, including more significant risks of death and functional decline, as well as reducing the life expectancy of this population segment16,17. While it can be controlled through treatments and lifestyle changes, the proper management of a patient with multimorbidity is a challenge for health services at different levels of complexity. Also, identifying the factors associated with the prevalence of this condition can help this management adequately12,18.
Thus, the identification of these associated factors facilitates the formulation of public policies aimed at the prevention of these diseases and the elaboration of strategies in the areas of promotion, surveillance and health care19. Besides this relevance, it is necessary to carry out studies of greater population coverage that evaluate the factors associated with multimorbidity in older adults, since the authors who proposed to study this subject did so with small populations5,6,8-10. In this context, this study aimed to identify the prevalence of multimorbidity in Brazilian older adults and its associated factors. Also, the search for associated factors was also performed comparing the presence of three and four or more chronic diseases with seniors who had two chronic diseases.
2. METHODS
This is a cross-sectional, population-based study. It was conducted from the National Health Survey (PNS) database, with data collected in 2013 and 2014. The PNS is representative for residents aged 18 and over, living in the country’s private households in urban areas covering the five geographic macro-regions. However, this study’s unit of analysis was only seniors (11,697 individuals), with age equal to or greater than 60 years. The PNS research project was approved by the National Research Ethics Commission, under Protocol Nº 328.159, of June 26, 2013.
The older adults with a multimorbidity condition should have had a diagnosis of two or more chronic diseases to estimate the prevalence of multimorbidity. The chronic diseases considered were those studied in the PNS, such as hypertension, diabetes, high cholesterol, heart disease, stroke, asthma, arthritis or rheumatism, spinal problems, depression, mental diseases (schizophrenia, bipolar disorder or obsessive-compulsive disorder), lung diseases (chronic bronchitis, emphysema or chronic obstructive pulmonary disease), cancer and kidney failure. For all the above mentioned chronic diseases, their identifications were provided from the question “has any doctor ever given you the diagnosis for this disease?”
Two blocks of variables were analyzed regarding the factors associated with the occurrence of multimorbidity in seniors. The first was represented by socioeconomic variables (gender, age, skin color or ethnicity, marital status, schooling and health plan) and the second by lifestyle variables (alcohol and tobacco use and physical activity). Besides verifying the association of these variables with the presence of two or more chronic diseases, the association of these variables was also made by comparing the presence of two and three chronic diseases and two and four chronic diseases.
Statistical Package for Social Science (SPSS) 20.0 was used to analyze the data. Initially, the frequency distribution of all variables of the study was performed to prepare the tables. Finally, the chi-square test was employed with a confidence level of 95% to verify the association between sociodemographic and lifestyle variables with the presence of multimorbidity in older adults. Multicollinearity was tested through chi-square tests for the independent variables with p<0.200, and because of the sample size, such associations were considered significant for a p-value=0.000001. Next, the adjusted prevalence ratios were estimated using Poisson multiple regression. It should also be noted that the data were weighted considering the sampling plan effect, non-response rates and post-stratification weights.
3. RESULTS
A total of 11,697 Brazilian elderly were evaluated, with a mean age of 70.1 years ( 0.1), ranging from 60 to 107 years. This study evidenced a predominance of female (60%), white older adults (54.7%), younger elderly (55 to 69 years, 55.2%), married (44.5%), incomplete primary school (38.4%), physically inactive (77.4%), without a health plan (68.3%), non-drinkers (73.6%) and non-smokers (84.7%). The prevalence of multimorbidity in the Brazilian seniors was 53.1%.
Table 1 shows the frequency of the independent variables and the association with the multimorbidity variable in the older adults in the univariate analysis. Based on the data presented, the prevalence of multimorbidity in seniors is associated with the females, older seniors, non-single (more strongly associated with widowers), low schooling, with a health plan and alcohol and tobacco non-user at the time the research. Again, in Table 1, the factors associated with the prevalence of multimorbidity in older adults were being females, older seniors, more strongly with the widowed marital status and with a health plan.
When comparing the older adults with two chronic diseases with those with three diseases (Table 2), the univariate analysis showed that the prevalence of three chronic diseases was associated with females, seniors with incomplete primary school, non-smokers and those not engaged in physical activities. In the multivariate analysis (Table 2), only the fact that seniors were female remained significant.
Finally, in Table 3, we compared the elderly who had two chronic diseases with those who had four or more. The univariate analysis showed a higher number of chronic diseases associated with female non-users of alcohol at the time of the interview. In this case, being a female remained significant after adjustment in the multivariate analysis.


4. DISCUSSION
This study aimed to identify the prevalence of multimorbidity in older adults, seeking association with socioeconomic conditions and lifestyle. The results found are representative of the Brazilian senior population. Given its seriousness in public health and the impact on the quality of life of these older adults, identifying such prevalence and associated factors is of great value for the establishment of measures aimed at the prevention of these diseases19.
The prevalence of multimorbidity in older adults found in this study was 53.1%, similar to those found in other studies4-10. Considering the frequency of this condition in more than half of the Brazilian senior population, one can see how common it is. This number becomes even more alarming when it is verified that multimorbidity is associated with disability, greater needs for health care and spending5. Therefore, preventive measures that seek active and healthy aging become increasingly necessary. This high prevalence can be explained by the increased life expectancy of these older adults, which allows a higher probability of accumulations of chronic diseases in these individuals2.
Being female was associated with a higher prevalence of multimorbidity in the elderly in the univariate and multivariate analyses. Also, women had more significant numbers of chronic diseases than men when multimorbidity was stratified into two, three or four or more chronic diseases. When comparing genders, these associations may be related to the fact that women have a longer life expectancy and worse health status compared to men. In turn, this implies a greater need for care to women’s health in all life cycles, in order to have healthy aging present in this population segment4-10.
Besides the female gender, the fact that they were older, had a health plan and were not single – more strongly associated with widowers – was associated with multimorbidity in older adults, even after adjustment for other variables. Concerning age, this study corroborates the literature4,6,7,9. Therefore, it is suggested that older seniors tend to have more multimorbidities6 because they suffer more acutely physiological aging. On the other hand, those with private health plans may have more access to medical visits, and consequently, it is easier for them to receive a diagnosis of the presence of chronic diseases. Another reason that may explain this association is the possibility that older adults have acquired private health plans after the diagnosis of chronic diseases in a health service. Because this is a cross-sectional study, there is no way of identifying what came first, multimorbidity or the acquisition of private health plans.
Concerning the association with those non-single seniors, it is understood that married, separated and specifically widowed older adults who had a more significant association may suffer more frequent abuse. When separating from the spouse or being widowed, seniors tend to return to their relatives’ homes and may suffer abandonment, emotional abuse, financial or material exploitation, neglect, and physical abuse. Such abuse, coupled with the physiological aging, may lead to a higher probability of accumulating chronic diseases20. The same is true for married older adults, who are housed in a home with spouses and a community, with the possibility of being abused.
Other factors were shown to be associated with multimorbidity in older adults within only univariate analysis, namely: lower levels of schooling and the fact that they did not use alcohol and tobacco at the time of the interview. Regarding the educational level, the literature on the subject corroborates the results of this study5,9. Worse off educational levels undermine the individual search for knowledge and consequently access to more information on health promotion towards adopting healthy lifestyles, not preventing the accumulation of chronic diseases5.
Regarding lifestyle, the results of this study differ from those published in the literature4,6. However, the results found here in the univariate analysis follow a logic, since older adults with more multimorbidities in Brazil are more associated with those with private health plans, and consequently tend to have more access to medical guidance. Given these guidelines, possibly the recommendations of not smoking and not using alcohol should be present since alcohol and tobacco are among the five most relevant risk factors for the onset and deterioration of chronic diseases21. Following the same rationale, this possible justification extends to the fact that seniors with a more significant number of chronic diseases are associated in the univariate analysis to the habit of not smoking and not consuming alcoholic beverages at the time of the research.
A differential mark of this study the evaluation of the association between physical activity and multimorbidity in older adults. Studies published in the literature that sought lifestyles associated with multimorbidity in the elderly did not evaluate the variable physical activity4,6. The results of this study revealed a low influence of this variable for both the prevalence of multimorbidity and a more considerable amount of chronic diseases found. This result should probably be related to the characteristic of the seniors evaluated, in which more than 70% do not perform physical activities. When comparing the presence of two and three diseases, only the univariate analysis evidenced that a more significant number of diseases became more present in older adults who did not perform physical activities. It is already agreed in the literature that physical inactivity is associated with a higher prevalence of falls, physical weakness, mood swings and obesity22. Thus, the increased number of chronic diseases accumulated in the Brazilian seniors may be correlated with the consequences of the lack of these daily physical exercises, since they increase the incidence of diabetes and osteoporosis, for example.
It is worth mentioning that longitudinal studies on the subject are required given some contradictory results with previous studies in the literature, especially with those related to the variables “alcohol and tobacco use”. Because this is a cross-sectional study, it hinders the possibility of identifying a well-established causal relationship, and therefore only hypotheses can be inferred. This study is characterized by a large population range and inference to the profile of the Brazilian older adults with multimorbidity. Thus, greater attention to preventive measures and incentive for healthy aging should be provided to the elderly female, older seniors, the widowed, separated or married, with low schooling level and physically inactive.
5. CONCLUSION
In conclusion, the results show that multimorbidity in Brazilian older adults is a widespread condition. It has been influenced by socioeconomic factors and is poorly related to lifestyle. Being female, older, having a low educational level and being widowed, separated or married were associated with the prevalence of multimorbidity in Brazilian seniors. Also, women are more associated with having a more significant number of chronic diseases.



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