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Cerebral palsy (CP) is no longer just a childhood disability. Children with CP grow up and become adolescents and eventually adults. However their risk of cardiovascular disease (CVD) and multimorbidity, defined as the presence of at least two chronic conditions, is poorly understood. This thesis sought to investigate CVD risk in individuals with CP and identify important health variables to understand and prevent multimorbidity development in this population. First, we discovered that adults with CP have an increased prevalence of CVD and an increased risk of death due to CVD compared to the general population, which raises concerns about CVD in people with CP and warrants further study. We investigated differences in cardiovascular health and moderate-to-vigorous physical activity (MVPA) in ambulatory adolescents and adults with CP between Gross Motor Function Classification System (GMFCS) levels I and II. Our findings suggest individuals who are GMFCS level II may be at increased risk for CVD in comparison to individuals who are GMFCS level I. We then evaluated longitudinal changes in risk factors of CVD in a cohort of individuals with CP. After a time interval of 4.0 ± 1.2 years, we found decreased absolute and relative brachial artery flow mediated dilation as measures of endothelial function, while carotid artery intima media thickness increased. We also discovered that 75% of participants with CP reported poor sleep quality, 80% engaged in less than the recommended 150 minutes of MVPA per week and 14% had poor eating behaviours. Taken together, this research suggests that individuals with CP experience accelerated aging for disease progression, specifically CVD, and that physical activity, sleep, and nutrition, together, could provide a framework for a lifestyle intervention to reduce and prevent multimorbidity risk in individuals with CP. / Thesis / Doctor of Philosophy (PhD) / Cerebral palsy is the most common child-onset physical disability. The disability can result in low levels of physical activity, obesity, and risk for morbid conditions that get worse over the lifecourse. The studies in this thesis furthered our understanding of cardiovascular disease and cardiovascular disease risk, investigated the relationship between physical activity and cardiovascular health, and evaluated changes in cardiovascular disease risk over time in individuals with cerebral palsy. We investigated three modifiable behaviours in individuals with cerebral palsy, which told us that they have poor sleep quality, do not engage in the recommended amount of physical activity, and could be at risk for poor nutrition. This work suggests that individuals with CP may be at an accelerated risk for cardiovascular disease, and that physical activity, sleep, and nutrition are important and modifiable factors that should be assessed and managed in this population.

This study explored longitudinal change in executive function (EF) and episodic memory (EM) related to multimorbidity, number of chronic conditions, change in chronic conditions overtime in a nationally representative sample of young, middle-aged,and older adults. Participants were from the second (2004-2006) and third (2013-2015) waves of the Survey of Midlife Development in the United States (MIDUS; N=2,532). Participants completed telephone interviews and questionnaires providing information on demographics and chronic conditions. The Brief Test of Adult Cognition by Telephone (BTACT) assessedcognitive function. The BTACT includes measures of EM (ex. word list recall) and EF (ex. digits backward, category fluency, etc.).Overall, only change in chronic conditions was associated with EF decline in the whole sample. In young adults multimorbidity and number of chronic conditions was significantly associated with both EF and EM decline, whereas only change in number of chronic conditions was significantly associated with EF decline in middle aged adults.Future research is needed to assess a broader range of chronic conditions to determine their overall burden on EF and EM over time.

INTRODUÇÃO: Os termos múltiplas comorbidades e multimorbidade são crescentes na literatura médica, trazendo e traduzindo uma nova forma de avaliar e cuidar de pacientes graves que acumulam doenças crônicas. Estudos apontam piores prognósticos para o transtorno bipolar (TB) quando associado à comorbidades específicas. Entretanto, fatores correlacionados ao número total de transtornos associados, e não a cada transtorno de forma específica, ainda não foram investigados no TB. OBJETIVOS: A finalidade deste estudo é avaliar diferentes aspectos relacionados à presença de múltiplas comorbidades psiquiátricas de Eixo I ao longo da vida em amostra de pacientes com TB. MÉTODO: Uma amostra de 294 pacientes bipolares foi investigada. Os diagnósticos de TB e das comorbidades psiquiátricas foram confirmados através entrevista clínica estruturada para transtornos de Eixo I (SCID-I) do DSM-IV. Um protocolo padrão do PROTAHBI foi aplicado para a obtenção de dados sócio-demográficos e variáveis clínicas. Os níveis de funcionamento, a qualidade de vida (QV), assim como, a presença de sintomas depressivos, ansiosos e maníacos foram avaliados através de instrumentos específicos validados na literatura. Múltiplas comorbidades foram consideradas presentes quando três ou mais diagnósticos psiquiátricos, adicionais ao TB, eram constatados. LIMITAÇÕES: Comorbidades com transtornos de Eixo II e III não foram investigadas neste estudo. RESULTADOS: A prevalência ao longo da vida para pelo menos uma comorbidade foi de 68.8% (n = 203), para duas ou três foi de 34.2% (n = 101) e para múltiplas comorbidades foi de 34.6% (n = 102). Na análise comparativa para as variáveis clínicas, diferenças correlacionadas ao número total de comorbidades foram detectadas. Um significativo impacto negativo foi verificado na avaliação do funcionamento e na QV dos pacientes com múltiplas comorbidades. CONCLUSÕES: A presença de múltiplas comorbidades psiquiátricas de Eixo I ocorre em cerca de um terço dos pacientes bipolares e revela uma maior gravidade e complexidade ao transtorno, independentemente de quais transtornos específicos co-ocorram. Questões acerca de sua adequada contemplação nos critérios de classificação diagnóstica e guidelines de tratamento também foram suscitadas. / BACKGROUND: The concepts multiple comorbidities and multimorbidity are growing in relevance in medical literature, enabling a new perspective to understand and treat patients with severe and cumulative chronic diseases. Studies report worse prognoses of bipolar disorder (BD) when associated with specific comorbidities. However, factors underlying co-occurring rather than single disorders have not been analyzed yet. OBJECTIVES: The present study aims at assessing the impact of psychiatric multiple comorbidities with Axis I disorder on bipolar patients. METHODS: A sample of 294 bipolar patients was examined. BD and comorbidities diagnoses were confirmed by means of Structured Clinical Interview for DSM-IV Axis I disorders. A PROTAHBI standard protocol provided the access for the social-demographic data and clinical variables. Levels of functioning and quality of live as well as the presence of depressive, anxiety and manic symptoms were evaluated by means of proper instruments validated in medical literature. Multiple comorbidities were considered when three or more comorbid psychiatric diagnoses were verified. LIMITATIONS: Axis II and III comorbidities were not considered in this investigation. RESULTS: Lifetime prevalence of any comorbidity was 68.8% (n = 203), of one or two comorbidities was 34.2% (n = 101), and of multiples comorbidities was 34.6% (n = 102). ). In the comparative analysis of clinical variables, some differences between the groups were detected. A significant negative impact was verified when assessing functioning and quality of life of patients with multiple comorbidities. CONCLUSIONS: The presence of Axis I psychiatric comorbidities was found in one third of the bipolar patients and revealed a more severe and complex disorder, regardless of which particular disorders may co-occur. Concerns were raised about whether current medical classification systems and practice guidelines are properly addressing this issue.

INTRODUÇÃO: Os termos múltiplas comorbidades e multimorbidade são crescentes na literatura médica, trazendo e traduzindo uma nova forma de avaliar e cuidar de pacientes graves que acumulam doenças crônicas. Estudos apontam piores prognósticos para o transtorno bipolar (TB) quando associado à comorbidades específicas. Entretanto, fatores correlacionados ao número total de transtornos associados, e não a cada transtorno de forma específica, ainda não foram investigados no TB. OBJETIVOS: A finalidade deste estudo é avaliar diferentes aspectos relacionados à presença de múltiplas comorbidades psiquiátricas de Eixo I ao longo da vida em amostra de pacientes com TB. MÉTODO: Uma amostra de 294 pacientes bipolares foi investigada. Os diagnósticos de TB e das comorbidades psiquiátricas foram confirmados através entrevista clínica estruturada para transtornos de Eixo I (SCID-I) do DSM-IV. Um protocolo padrão do PROTAHBI foi aplicado para a obtenção de dados sócio-demográficos e variáveis clínicas. Os níveis de funcionamento, a qualidade de vida (QV), assim como, a presença de sintomas depressivos, ansiosos e maníacos foram avaliados através de instrumentos específicos validados na literatura. Múltiplas comorbidades foram consideradas presentes quando três ou mais diagnósticos psiquiátricos, adicionais ao TB, eram constatados. LIMITAÇÕES: Comorbidades com transtornos de Eixo II e III não foram investigadas neste estudo. RESULTADOS: A prevalência ao longo da vida para pelo menos uma comorbidade foi de 68.8% (n = 203), para duas ou três foi de 34.2% (n = 101) e para múltiplas comorbidades foi de 34.6% (n = 102). Na análise comparativa para as variáveis clínicas, diferenças correlacionadas ao número total de comorbidades foram detectadas. Um significativo impacto negativo foi verificado na avaliação do funcionamento e na QV dos pacientes com múltiplas comorbidades. CONCLUSÕES: A presença de múltiplas comorbidades psiquiátricas de Eixo I ocorre em cerca de um terço dos pacientes bipolares e revela uma maior gravidade e complexidade ao transtorno, independentemente de quais transtornos específicos co-ocorram. Questões acerca de sua adequada contemplação nos critérios de classificação diagnóstica e guidelines de tratamento também foram suscitadas. / BACKGROUND: The concepts multiple comorbidities and multimorbidity are growing in relevance in medical literature, enabling a new perspective to understand and treat patients with severe and cumulative chronic diseases. Studies report worse prognoses of bipolar disorder (BD) when associated with specific comorbidities. However, factors underlying co-occurring rather than single disorders have not been analyzed yet. OBJECTIVES: The present study aims at assessing the impact of psychiatric multiple comorbidities with Axis I disorder on bipolar patients. METHODS: A sample of 294 bipolar patients was examined. BD and comorbidities diagnoses were confirmed by means of Structured Clinical Interview for DSM-IV Axis I disorders. A PROTAHBI standard protocol provided the access for the social-demographic data and clinical variables. Levels of functioning and quality of live as well as the presence of depressive, anxiety and manic symptoms were evaluated by means of proper instruments validated in medical literature. Multiple comorbidities were considered when three or more comorbid psychiatric diagnoses were verified. LIMITATIONS: Axis II and III comorbidities were not considered in this investigation. RESULTS: Lifetime prevalence of any comorbidity was 68.8% (n = 203), of one or two comorbidities was 34.2% (n = 101), and of multiples comorbidities was 34.6% (n = 102). ). In the comparative analysis of clinical variables, some differences between the groups were detected. A significant negative impact was verified when assessing functioning and quality of life of patients with multiple comorbidities. CONCLUSIONS: The presence of Axis I psychiatric comorbidities was found in one third of the bipolar patients and revealed a more severe and complex disorder, regardless of which particular disorders may co-occur. Concerns were raised about whether current medical classification systems and practice guidelines are properly addressing this issue.

INTRODUÇÃO: Os termos múltiplas comorbidades e multimorbidade são crescentes na literatura médica, trazendo e traduzindo uma nova forma de avaliar e cuidar de pacientes graves que acumulam doenças crônicas. Estudos apontam piores prognósticos para o transtorno bipolar (TB) quando associado à comorbidades específicas. Entretanto, fatores correlacionados ao número total de transtornos associados, e não a cada transtorno de forma específica, ainda não foram investigados no TB. OBJETIVOS: A finalidade deste estudo é avaliar diferentes aspectos relacionados à presença de múltiplas comorbidades psiquiátricas de Eixo I ao longo da vida em amostra de pacientes com TB. MÉTODO: Uma amostra de 294 pacientes bipolares foi investigada. Os diagnósticos de TB e das comorbidades psiquiátricas foram confirmados através entrevista clínica estruturada para transtornos de Eixo I (SCID-I) do DSM-IV. Um protocolo padrão do PROTAHBI foi aplicado para a obtenção de dados sócio-demográficos e variáveis clínicas. Os níveis de funcionamento, a qualidade de vida (QV), assim como, a presença de sintomas depressivos, ansiosos e maníacos foram avaliados através de instrumentos específicos validados na literatura. Múltiplas comorbidades foram consideradas presentes quando três ou mais diagnósticos psiquiátricos, adicionais ao TB, eram constatados. LIMITAÇÕES: Comorbidades com transtornos de Eixo II e III não foram investigadas neste estudo. RESULTADOS: A prevalência ao longo da vida para pelo menos uma comorbidade foi de 68.8% (n = 203), para duas ou três foi de 34.2% (n = 101) e para múltiplas comorbidades foi de 34.6% (n = 102). Na análise comparativa para as variáveis clínicas, diferenças correlacionadas ao número total de comorbidades foram detectadas. Um significativo impacto negativo foi verificado na avaliação do funcionamento e na QV dos pacientes com múltiplas comorbidades. CONCLUSÕES: A presença de múltiplas comorbidades psiquiátricas de Eixo I ocorre em cerca de um terço dos pacientes bipolares e revela uma maior gravidade e complexidade ao transtorno, independentemente de quais transtornos específicos co-ocorram. Questões acerca de sua adequada contemplação nos critérios de classificação diagnóstica e guidelines de tratamento também foram suscitadas. / BACKGROUND: The concepts multiple comorbidities and multimorbidity are growing in relevance in medical literature, enabling a new perspective to understand and treat patients with severe and cumulative chronic diseases. Studies report worse prognoses of bipolar disorder (BD) when associated with specific comorbidities. However, factors underlying co-occurring rather than single disorders have not been analyzed yet. OBJECTIVES: The present study aims at assessing the impact of psychiatric multiple comorbidities with Axis I disorder on bipolar patients. METHODS: A sample of 294 bipolar patients was examined. BD and comorbidities diagnoses were confirmed by means of Structured Clinical Interview for DSM-IV Axis I disorders. A PROTAHBI standard protocol provided the access for the social-demographic data and clinical variables. Levels of functioning and quality of live as well as the presence of depressive, anxiety and manic symptoms were evaluated by means of proper instruments validated in medical literature. Multiple comorbidities were considered when three or more comorbid psychiatric diagnoses were verified. LIMITATIONS: Axis II and III comorbidities were not considered in this investigation. RESULTS: Lifetime prevalence of any comorbidity was 68.8% (n = 203), of one or two comorbidities was 34.2% (n = 101), and of multiples comorbidities was 34.6% (n = 102). ). In the comparative analysis of clinical variables, some differences between the groups were detected. A significant negative impact was verified when assessing functioning and quality of life of patients with multiple comorbidities. CONCLUSIONS: The presence of Axis I psychiatric comorbidities was found in one third of the bipolar patients and revealed a more severe and complex disorder, regardless of which particular disorders may co-occur. Concerns were raised about whether current medical classification systems and practice guidelines are properly addressing this issue.

Bakgrund: År 2060 beräknas antalet personer över 65 år att ha ökat till 56 % av befolkningen i Sverige. Fastän äldre patienter nyttjar ambulansen i allt högre omfattning så har inte utbildningen för ambulanssjuksköterskor förändrats särskilt mycket för att möta de specifika behov som en äldre befolkning har. Den förväntade livslängden ökar bland jordens befolkning och under det senaste århundradet har kroniska hälsoproblem ersatt infektiösa sjukdomar som den dominerande belastningen på hälso- och sjukvården. Nästan alla kroniska tillstånd är starkt relaterade till åldrande. Syfte: Att belysa ambulanssjuksköterskors upplevelse av att vårda äldre patienter som är multisjuka. Metod: Ett ändamålsenligt urval av nio ambulanssjuksköterskor intervjuades om sina upplevelser av att vårda äldre patienter som är multisjuka. Intervjuerna analyserades med kvalitativ innehållsanalys. Resultat: Utifrån analysen presenterades fem huvudkategorier; Att utesluta livshot, Att det är komplext att ge vård till äldre, Att bygga upp en bank av kunskaper, Att kunna göra något för den äldre patienten och Att lyssna till den äldre patientens livshistoria. De flesta deltagare beskrev det på ett eller annat sätt som positivt att vårda äldre patienter. Alla beskrev hur det var viktigt att se till hela patienten och dennes omgivning och att anpassa kommunikationen för att kunna ge bästa vård. Mer utbildning efterfrågades för att kunna möta de behov som finns hos den äldre patientgruppen. Akutsjukvård ansågs inte alltid vara den bästa vården för denna patientgrupp. Slutsats: Ambulanssjuksköterskorna upplevde arbete med de äldre patienterna både roligt och utmanande. Även om deltagarna tyckte att grundutbildningen gav en bra grund att stå på i sitt yrke så ville många utöka sina kunskaper inom området äldre patienter och deras sjukdomar. Deltagarna beskrev tydligt vikten av att se till hela patienten vid vårdtillfället och hur den holistiska synen på människan och dess omgivning både kunde ge lindring men även mer information om patienten och dennes sjukdomshistoria. Synen på vad vård och omsorg innebär verkar vara genomgående lika hos alla deltagare i studien. Ett intresse för att göra gott för individen genomsyrar de svar som kommer fram i studien. / Background: In 2060, the number of people over 65 years old is estimated to have increased to 56% of the population in Sweden. Although older patients use the ambulance to an increasing extent, the training for ambulance nurses has not changed much to meet the specific needs of an elderly population. Life expectancy is increasing among the world's population and over the last century, chronic health problems have replaced infectious diseases as the dominant burden on health care. Almost all chronic conditions are strongly related to aging. Objective: To illustrate the paramedics experience of caring for elderly patient with multimorbidity. Method: An appropriate selection of nine paramedics were interviewed of their experiences in caring for elderly patients with multimorbidity. The interviews were analyzed with the help of a qualitative content analysis. Results: The analyze presented five categories; To exclude lifethreat, To care for the elderly is complex, To build up a bank of knowledge, To do something for the elderly patient and To listen to the elderly patients life story. Most participants described it to be positive in one way or another to care for older patients. All the participants describe how important is was to see the whole patient and their surrounding and to adapt the communication to give the best care. More education was requested to be able to meet the needs of the elderly patients. Emergency care was not always considered to be the best care for this group of patients. Conclusion: The paramedics experienced the work with elderly patient to be both fun and challenging. Even if the participants thought that the basic training of the nursing programme provided a good foundation for their profession a lot of them wanted to increase their knowledge in the area of older patients and their diseases. The participants clearly described the importance of seeing the whole patient when caring for them and how the holistic view of the human being and their surroundings could both palliate but also give more information about the patient and their anamnesis. The approach to what nursing and care really means seems to be consistent in all the participants in the study. An interest to do good for the individual pervades the answers in this study.

Background: The prevalence of psychiatric diagnoses is increasing in society and nurses in somatic care frequently encounter patients with psychiatric diagnoses in their work. Psychiatric- and somatic multimorbidity is common and the nurse is expected to care with aperson-centered and holistic approach for patients in accordance with established documents and laws. Previous research indicates a stigmatization of these patients in society and by the nurses themselves. Aim: The aim of this study was to illustrate nurses’ experiences of caring for patients with psychiatric diagnoses in somatic care. Method: A qualitative literature-based study with eight scientific articles were included and analyzed with Friberg´s description of the five-step model. Results: Three main themes were identified with seven additional subthemes. The nurse’s personal challenges: nurses felt fear and anxiety when caring for patients with psychiatric diagnoses with psychiatric and somatic multimorbidity in a somatic care setting because of the lack of knowledge and trust for the patients. Organizational Barriers: inadequate teamwork and collaboration on and between the units made it difficult. Perceptions of patients: stigmatization and preconceptions by the nurses influenced the care of the patients. Conclusion: It indicates that nurses experience uncertainty in caring for patients with psychiatric diagnoses in somatic care. There is a substantial knowledge gap in the field, and further research is needed for nurses to feel more confident working with patients with psychiatric diagnoses in somatic care. / Personer med psykiatriska sjukdomar är ett ökande folkhälsoproblem. I takt med utvecklingen blir det vanligare att patienter med psykiatriska diagnoser även blir somatiskt sjuka. Sjuksköterskor i den somatiska vården möter därmed ofta patienter med psykiatriska diagnoser i deras arbete. Sjuksköterskan ska bemöta, vårda och behandla patienter enligt de styrdokument och lagar som finns, vilket innebär bland annat att vårda patienten utifrån ett personcentrerat och holistiskt perspektiv. Tidigare forskning visar att sjuksköterskor brister i omvårdnaden av patienter med psykiatrisk och somatisk samsjuklighet, vilket kan bero på kunskapsbrist, rädsla och organisatoriska barriärer. Syftet med examensarbetet är att belysa sjuksköterskors erfarenheter av att vårda patienter med psykiatriska diagnoser inom somatisk vård. En litteraturbaserad studie med kvalitativ metod där åtta vetenskapliga artiklar inkluderades och analyserades utifrån Fribergs femstegsmodell för att undersöka sjuksköterskors subjektiva erfarenheter, känslor och tankar. Resultatet delas upp i tre teman: Sjuksköterskans personliga utmaningar, organisatoriska barriärer och stigmatisering. Samtliga teman går hand i hand och påverkar varandra. Sjuksköterskans personliga utmaningar innefattar rädsla, oro, kunskapsbrist och bristande förtroende för patienter med psykiatriska diagnoser. Rädslan visar sig främst då sjuksköterskan känner att de inte har kontroll över situationen. Detta går hand i hand med den kunskapsbrist som sjuksköterskorna vittnar om. Organisatoriska barriärer i form av otillräcklig teamsamverkan är också bidragande faktorer till svårigheter vid vårdande av somatisk och psykiatrisk samsjuklighet. Den stigmatiserande bild som finns i samhället av personer med psykiatriska diagnoser påverkar patientens möte med vården negativt då förutfattade meningar från sjuksköterskan existerar.  Slutsatsen indikerar på att sjuksköterskor upplever stor osäkerhet vid vårdande av patienter med psykiatriska diagnoser inom somatisk vård. Kunskapsluckan inom området är stor och ytterligare forskning behövs för att sjuksköterskor ska bli trygga i att arbeta utifrån problemområdet.

O envelhecimento da população implica em aumento da prevalência de doenças crônicas não transmissíveis (DCNT) e uso de polifarmácia (uso de 5 ou mais medicamentos concomitantemente). Porém, o uso de medicamentos pode ter um efeito negativo em pacientes com multimorbidade. Entende-se como competição terapêutica (CT) a interação medicamento-doença em que o tratamento recomendado para certa condição pode alterar negativamente (competir com) outra condição coexistente. Neste âmbito, o objetivo principal deste trabalho foi estimar a prevalência de CT e avaliar características associadas à CT em idosos da comunidade. O presente estudo usou como base o estudo populacional de idosos do município de São Paulo: Estudo Saúde, Bem-estar e Envelhecimento, onda 2015. As CTs foram definidas a partir de guias de prática clínica (GPCs) com alta qualidade, selecionados a partir de revisão sistemática e avaliação da qualidade. Somente cerca de um quarto dos GPC apresentaram alta qualidade e foram usados para extração das CTs. A média de idade dos 1.224 idosos do SABE foi 70,8, 56,2% eram mulheres, 84% viviam acompanhados, 27,5% estudaram 9 anos e mais, quase 50% declararam renda insuficiente para cobrir com as despesas diárias, metade autoavaliaram a saúde como regular ou ruim, cerca de 40% relataram polifarmácia. Estatinas, inibidores da enzima de recaptação de angiotensina e inibidores da bomba de próton foram as classes de medicamentos mais relatadas. Multimorbidade foi reportada por 61,7% dos idosos. A prevalência de CT foi de 13,2%. Entre idosos com multimorbidade, a prevalência de CT foi de 21,4%. No modelo final de regressão logística, CT foi associada com polifarmácia (OR: 4,70; IC 95% 3,00 7,36), hospitalização no último ano (OR: 1,75; IC 95% 1,07 2,87), queda no último ano (OR: 1,57; IC 95% 1,04 2,36) e pior autoavaliação de saúde (OR: 1,92; IC 95% 1,23 2,99). Profissionais de saúde devem ter cautela ao selecionar GPC e ao prescrever medicamentos a idosos com multimorbidade. / Aging implies in an increasing prevalence of noncommunicable diseases (NCDs) and polypharmacy use (use of 5 or more medications concomitantly). However, medications may have a negative effect on patients with multimorbidity. Therapeutic competition (TC) is known as a drug-disease interaction in which the treatment recommended for a certain condition can negatively alter (compete with) another coexisting condition. In this context, the main objective of this study was to estimate the prevalence of TC and evaluate characteristics associated with TC in community dwelling older adults. The present study used the population-based study of older adults living in the city of São Paulo (SABE study, 2015 survey). TCs were identified by using clinical practice guidelines (CPGs) with high quality. A systematic review and critical appraisal of CPGs were conducted to identify high-quality CPGs. Only about a quarter of CPGs were of high quality and were used for CT extraction. A total of 80 CTs were identified from the high-quality CPGs. The mean age of the 1,224 SABE participants was 70.8, 56.2% were women, 84% did not live alone, 27.5% studied 9 years and over, almost 50% declared insufficient income to cover daily expenses, half self-assessed health, such as regular or poor, about 40% reported polypharmacy. Statins, angiotensin-reuptake enzyme inhibitors and proton pump inhibitors were the most commonly reported drug classes. Multimorbidity was reported by 61.7% seniors. The prevalence of TC was 13.2%. Among seniors with multimorbidity, the prevalence of TC was 21.4%. In the final logistic regression model, TC was associated with polypharmacy (OR: 4.70, 95% CI 3.00 - 7.36), hospitalization in the last year (OR: 1.75, 95% CI 1.07-2 , 95% CI 1.04 - 2.36) and worse health self - assessment (OR: 1.92, 95% CI 1.23 - 2.99), a decrease in the last year (OR: 1.57; Health professionals should be careful when selecting CPGs and prescribing medications to older adults with multimorbidity.

The condition of multimorbidity — the presence of two or more medical conditions in an individual — is a growing phenomenon worldwide. In the United States, multimorbid patients represent more than a third of the population and the trend is steadily increasing in an already aging population. There is thus a pressing need to understand the patterns in which multimorbidity occurs, and to better understand the nature of the care that is required to be provided to such patients. In this thesis, we use data from the Medical Expenditure Panel Survey (MEPS) from the years 2011 to 2015 to identify combinations of multiple chronic conditions (MCCs). We first quantify the significant heterogeneity observed in these combinations and how often they are observed across the five years. Next, using two criteria associated with each combination -- (a) the annual prevalence and (b) the annual median expenditure -- along with the concept of non-dominated Pareto fronts, we determine the degree of impact each combination has on the healthcare system. Our analysis reveals that combinations of four or more conditions are often mixtures of diseases that belong to different clinically meaningful groupings such as the metabolic disorders (diabetes, hypertension, hyperlipidemia); musculoskeletal conditions (osteoarthritis, spondylosis, back problems etc.); respiratory disorders (asthma, COPD etc.); heart conditions (atherosclerosis, myocardial infarction); and mental health conditions (anxiety disorders, depression etc.). Next, we use unsupervised learning techniques such as association rule mining and hierarchical clustering to visually explore the strength of the relationships/associations between different conditions and condition groupings. This interactive framework allows epidemiologists and clinicians (in particular primary care physicians) to have a systematic approach to understand the relationships between conditions and build a strategy with regards to screening, diagnosis and treatment over a longer term, especially for individuals at risk for more complications. The findings from this study aim to create a foundation for future work where a more holistic view of multimorbidity is possible.