In North America, the last two decades saw continued increases in population multimorbidity across all age groups. This trend, which is expected to endure in the coming years, has been attributed in large part to population aging and unhealthy lifestyle choices. While the societal consequences of multimorbidity have focused primarily on the burden it imposes on the sustainability of health systems and the need to implement innovative ways to deliver care, latent costs, such as possible increases in motor-vehicle accidents (MVAs) have received relatively little attention. The principal objective of this thesis was to investigate the relationship between multimorbidity and MVAs. To complement current knowledge on the topic, we conducted observational studies based on information recorded in electronic health records (EHR). The hypothesis that increasing levels of multimorbidity would translate into increasing risk of MVA was tested in both a general population of health care recipients and in persons with epilepsy, a subgroup of individuals predisposed to comorbidities and MVAs. To gain a better understanding of morbidity ascertainment in EHR data, preliminary validation studies were performed to evaluate the performance of Elixhauser comorbidity measures for predicting hospital mortality in our data source. A systematic review of risk factors contributing to the onset and progression of epilepsy was also performed in hopes of identifying elements that would help improve the methodological design of the principal thesis study limited to persons with epilepsy. Study results confirmed the excellent performance of the Elixhauser comorbidity measures for predicting hospital mortality in the Cerner Health Facts data repository. In the general health care recipient population, a positive exposure-outcome relationship was observed between multimorbidity and MVA risk. This relationship was consistent in adults across the lifespan and more pronounced in women than in men. In persons with epilepsy, the observed exposure-outcome relationship between multimorbidity and MVAs did not reach statistical significance. However, comorbid depression was identified as a risk factor for MVAs. Given increasing rates of multimorbidity in the general population, the findings of this thesis strongly support the need for replication and better characterization of the disease combinations that drive increases in MVA risk. Future work on this topic should also include estimates of MVA risk attributable to multimorbidity; this would inform and gauge the relevance of novel driving policies targeting individuals diagnosed with specific health conditions.

En utilisant un processus de recherche minutieux étape par étape, cette thèse a créé une équipe de recherche européenne pour concevoir son protocole de recherche. L'examen systématique de la littérature a montré une énorme quantité de définitions différentes (132 définitions différentes) et une grande diversité dans ces définitions (avec 1631 critères uniques distincts). La définition globale du concept de multimorbidité découlant de la revue systématique de la littérature est une étape pertinente.Les traductions du concept ont été finalisées pour le bulgare, le castellan, le catalan, le croate, le français, le galicien, l'allemand, le grec, l'italien et le polonais. Les études qualitatives ont confirmé le concept en MG et ont ajouté deux modificateurs de la Multimorbidité aux compétences fondamentales de la Wonca et la dynamique des relations médecin-patient comme aide à la détection et à la gestion de la multimorbidité. Le programme de recherche a porté sur les besoins futurs de recherche sur la mesure de la multimorbidité et son impact sur le patient. Elle a également renforcé la nécessité de simplifier ce concept en utilisant une approche pragmatique pour déterminer les variables utiles du concept sur ses résultats et son lien avec la complexité. / Using a step-by-step careful research process this thesis created a European research team to design its research protocol. The systematic review of literature showed a huge amount of different definitions (132 different definitions) and a great diversity in those definitions (with 1631 distinct single criteria). The comprehensive definition of the concept of multimorbidity issued from the systematic literature review was a relevant step.The translations of the concept were finalized for Bulgarian, Castellan, Catalan, Croatian, French, Galician, German, Greek, Italian and Polish. The qualitative studies confirmed the concept for FPs and added two modificators of Multimorbidity with the Wonca’s core competencies of FM and the doctor-patient relationship dynamics as a help to detect and manage multimorbidity.The research agenda focused future research needs on the measurement of multimorbidity and its impact on patient. It also enhanced the need for the simplification of this concept using a pragmatic approach to determine the useful variables of the concept on its outcomes and its link to complexity.

Family caregivers of older persons with dementia (PWD) and multiple chronic conditions (MCC) provide high levels of in-home care. Caregiving is complicated by transitions such as changes to one's environment, roles, relationships, and overall health. Although PWD often have MCC, few studies have focused on the influence of MCC on dementia caregiving and transitions. The purpose of this study was to explore the transition experiences of caregivers of PWD and MCC. This study is a sub-study of a larger pragmatic mixed methods randomized controlled trial called MyTools4Care (MT4C). Using interpretive description methodology, semi-structured interviews were conducted across Ontario with a subset of caregivers (n=19) and clinicians working with dementia caregivers (n=7). Purposive theoretical sampling and concurrent data collection and analysis were used. Participants described their transition experiences, factors that influenced these experiences, potential outcomes of transitions, and the influence of MCC on dementia caregiving. Participants identified five key transitions which included: (a) There's no turning off (progressive increase in responsibilities); (b) I'm filling in many roles (changes in roles and relationships); (c) I'm sick, too (changes in overall health and well-being); (d) Dementia defines my social life (changes in social boundaries), and; (e) I know that day will come (changes in preparing for the future). Study findings emphasized how the co-existence of dementia and MCC resulted in added complexity and burden to care management and decision-making for caregivers. Findings suggest that health care professionals (HCP) are an important extension of caregivers' support networks. Thus, HCP need to be comfortable, trained, and knowledgeable in diagnosing and managing dementia and MCCs in order to support caregivers in their transitions. Future research should explore the experience of dementia within the broad context of MCC in order to understand the impact on the dementia caregiving experience. / Thesis / Master of Science (MSc)

Increasing access to and improving knowledge of rehabilitation strategies is essential to address the adverse health outcomes related to the increased prevalence of multimorbidity with our aging population. Physical literacy is emerging as a strategy to increase lifelong participation in physical activity, however, there is limited research exploring how physical literacy can support optimal aging for adults with functional decline associated with chronic conditions. This thesis investigated how to frame physical literacy for adults through a rehabilitation lens and explored outcomes related to function, mobility, and health awareness as a result of a novel physical literacy intervention. The first study was an integrative review examining what is known about physical literacy for adults. Thirteen new physical literacy constructs emerged, that differed from the current physical literacy definition and addressed the needs of aging adults. Purposeful activities, knowledge of age-related changes, and social interaction were identified as the top three. The objective of the second expert consensus study was to understand what components are required when acquiring physical literacy as an adult from the perspectives of healthcare professionals and researchers in optimal aging. The third qualitative study explored how adults with multimorbidity describe physical literacy for adults while considering barriers and facilitators associated with fluctuating health status. The findings from the preceding qualitative studies helped inform the program development of the fourth physical literacy intervention study and fostered a new rehabilitation-focused Physical Literacy framework for Adults and adults with Chronic Conditions (PLACC). A pre-post study involving 20 adults with 2 or more conditions (95% female, 59 + 6 years) participated in a 5-week multi-component, virtually delivered physical literacy group intervention. Post-intervention significant improvements were found for physical function (p=<0.001; cohen’s D=0.90), as measured by the patient specific functional scale, mobility with the 4-meter walk test at self-selected speed (p=0.03, cohen’s D=0.53) and all 3 physical literacy awareness questions (p=0.001, p=<0.001, p=0.001). The results of this program of research can inform future public health interventions, involving rehabilitation-focused physical literacy programs, designed by physiotherapists, and aimed at improving function and mobility for adults with chronic conditions. / Thesis / Doctor of Philosophy (PhD) / In Ontario, almost 80% of adults over the age of 45 are living with at least one chronic condition, such as diabetes, high blood pressure or arthritis. These conditions require on-going management and can cause challenges with one’s function and mobility. Physical literacy is a term that is used commonly in schools and sports to describe the basic movement skills that children need to be active for life. It is unknown how physical literacy can help support adults with chronic conditions to improve their overall health. This thesis explored how physical literacy could improve function and mobility for adults and older adults with chronic conditions. The first study examined all the existing literature on adults and physical literacy. The second and third studies asked physiotherapy researchers and adults with chronic conditions what physical literacy means to them. The results of these studies found that there are different skills needed to become physically literate as an adult than what is needed to become a physically literate child. A new physical literacy model for adults was developed that guided an intervention study for adults with chronic conditions. Results of this intervention study found that a 5-week education program delivered virtually by a registered physiotherapist could improve adults’ awareness of what physical literacy is, improve function and mobility outcomes and positively impact behaviours. The results of this thesis have provided a new way of thinking about physical literacy for adults and older adults. Physical literacy for adults involves self-monitoring movement, having knowledge of age-related changes, participating in meaningful, safe, and social movement activities, and understanding the benefits of physical activity for the management of chronic conditions.

No description available.

Background: Health systems internationally face a common set of challenges: ageing populations, increasing numbers of patients suffering from multiple long-term conditions (multimorbidity) and severe pressure on health and care budgets. ‘Integrated care’ is pitched as the solution to current health system challenges. But, in the literature, what integrated care actually involves is complex and contested. Aims: 1. What does ‘integrated care’ currently look like in practice in the NHS? 2. What is the effectiveness of current models of ‘integrated care’? 3. To what extent are there differential effects of ‘integrated care’ for different types of multimorbidity? Methods: The thesis utilises routinely collected data, systematic review and meta-analysis, combined with quasi-experimental methods (difference-in-differences, and subgroup analysis, difference-in-difference-in-differences). Results: The current implementation of the concept of integrated care is predominantly carried out through multidisciplinary team (MDT) case management of ‘at risk’ (usually of secondary-care admissions) patients in primary care. This approach, however, has not proven capable of meeting health outcome and utilisation/cost aims. Patient satisfaction, though, is consistently improved by the approach. There might also be positive spill-over effects of increased team-working through MDTs for the wider practice population. There does not appear to be a multimorbidity subgroup which benefits significantly more than others in terms of secondary-care utilisation or cost. However, patients at the end of life and/or those with only primary-care sensitive conditions might benefit slightly more than others. Conclusions: Integrated care, in its current manifestation, is not a silver bullet that will enable health systems to simultaneously accomplish better health outcomes for those with long-term conditions and multimorbidity while increasing their satisfaction with services and reducing costs. The current financial climate might mean that other means of achieving prioritised aims are required in the short-term, with comprehensive primary care and population health strategies employed to better prevent/compress the negative effects of lifestyle-associated conditions in the longer-term.

This thesis explores the provision of services for people with multimorbidity in general practice. It considers 3 broad research questions: how services are organised; why they are configured in this way; and the impact this organisation has on service delivery. At present, there is no formalised system for managing multimorbidity in general practice. Current arrangements reflect the wider organisation of care for chronic conditions which typically involves managing individual chronic conditions. The needs of people with multimorbidity are often complex and require a number of services from several providers. Coordinating these services is challenging, not least because of the fragmented system within which professionals and providers are situated. Different clinical, managerial and funding arrangements complicate this situation, creating as it does a number of parallel work streams. Effective healthcare for people with multimorbidity requires different providers to work collaboratively to promote linkage across professional and service boundaries. Information flows and administration play an important role in promoting continuity and coordination within and across work streams that span primary, secondary and tertiary care. In some instances, inefficiencies in services can be linked to the lack of integrative working between the clinical and administrative aspects of care. At present, fragmented systems are perpetuated by the lack of a whole systems approach that would align clinical, managerial and financial aspects of service provision across organisations. This thesis demonstrates that, services in general practice are increasingly determined by factors external to it. Most notably the division of care across multiple providers and the financial and contractual arrangements which require an organisation of services that promotes a division of labour and a routinsation, aimed at optimising the daily through put of patients. If the present and future needs of people with multimorbidity are to be effectively met, changes to the way services are provided in general practice must be considered as part of a whole system of healthcare, whereby collaborations between different professionals and services are intentionally organised and actively managed. Although the evidence base for managing multimorbidity is limited, there is a growing recognition that in terms of improving outcomes for people with multimorbidity, improving clinical care alone is not as effective as simultaneously improving the organisation or design of services across the whole system of provision.

No description available.

No description available.

INTRODUÇÃO: Fatores genéticos estão associados a fenótipos do envelhecimento como a longevidade e algumas doenças relacionadas à idade, mas a identificação dos genes envolvidos no fenótipo complexo do envelhecimento permanece um desafio. Estudos de associação genômica ampla (GWAS), têm apontado o gene da Apolipoproteína E (APOE) como o único associado de maneira consistente à longevidade e alguns fenótipos do envelhecimento. Até o momento, entretanto, a associação do gene APOE com fenótipos alternativos como o envelhecimento saudável (ES), não tem sido demonstrada de maneira consistente. OBJETIVOS: determinar a influência do polimorfismo do APOE na variação de índices prognósticos do envelhecimento (multimorbidade, funcionalidade e acúmulo de déficits) em dez anos. MÉTODOS: estudo longitudinal de coorte retrospectiva de 125 idosos independentes inicialmente para atividades de vida diária (ABVD e AIVD), de um ambulatório assistencial em um hospital escola, em São Paulo. Na avaliação inicial, foram identificados o polimorfismo do gene APOE (alelos E2, E3 e E4), variável preditora primária, e algumas variáveis epigenéticas (clínicas, sociodemográficas e hábitos de vida). No seguimento, avaliações anuais de prontuários foram realizadas para identificar associações com perdas de envelhecimento fisiológico (índice de acúmulo de déficits, DI), ganho de multimorbidade (Cumulative Illness Rating Scale for Geriatrics, CIRS-G e Charlson comorbidity index, CCI) e dependência em ABVD/AIVD, e morte, em dez anos. Curvas de Kaplan-Meier e modelos de regressão de Cox foram utilizados para associações dos fatores genéticos e epigenéticos com piora funcional e morte, e de regressão linear múltipla para associações com os índices CIRS-G, CCI e DI. RESULTADOS: 125 participantes da avaliação inicial, idade média de 74,9 anos, 76,8% mulheres, e 81,6% brancos. A média do CIRS-G foi de 10,24. A distribuição dos alelos: E2 10%, E3 50,8%, e E4 39,2%. A presença de E2 e E4 em relação ao grupo controle E3/E3 não foram preditoras de piora nos índices prognósticos do envelhecimento. Alguns fatores epigenéticos apresentaram associações com desfechos em dez anos. Maior acúmulo de déficits: idade mais elevada p < 0,001; sedentarismo p=0,02; tabagismo p=0,02. Maior dependência em ABVD: idade mais elevada p=0,002; sexo masculino p=0,01; pontuação maior no CIRS-G p=0,02; sedentarismo p=0,02. Maior dependência para AIVD: idade mais elevada p < 0,001; sexo masculinop=0,01; sedentarismo p=0,02. Mortalidade: idade mais elevada p=0,002, pontuações maiores CCI p=0,001. Atividades metabólicas (beta=-4,37; p=0.003) e morar sozinho (beta=-2,28; p=0.005) foram associados com níveis mais baixos de CIRS-G em 10 anos, e etilismo (beta=1,78; p=0.04) com níveis mais altos de CIRS-G. CONCLUSÕES: O polimorfismo do gene APOE não influenciou o prognóstico do envelhecimento. O ganho inesperado de acúmulo de déficits apresentou associação com alguns preditores epigenéticos em idosos ambulatoriais (idade >= 80 anos, sedentarismo e tabagismo). A idade >=80 anos, sexo masculino e sedentarismo, foram associados a perda em dez anos de funcionalidade para ABVD e AIVD. Atividades metabólicas e morar sozinho foram associados a menor multimorbidade em dez anos. Mortalidade em dez anos foi associada a idade >= 80 anos e alta multimorbidade através do CCI / BACKGROUND: While genetic factors are linked to longevity and agerelated diseases, the identification of genes responsible for different aging phenotypes remains unclear. Previous studies, including the genome-wide association studies (GWAS), have indicated that Apolipoprotein E (APOE) gene is associated with longevity and other aging phenotypes. However, little is still known on the association of the APOE gene with healthy aging. OBJECTIVES: To determine the influence of the APOE gene polymorphism on the variation of aging prognostic indices (functionality, multimorbidity, and accumulation of deficits) over 10 years. METHODS: A retrospective cohort study comprising 125 older adults who were independent in activities of daily living (ADL and IADL) at baseline. Participants were evaluated at an ambulatory setting from an academical medical center at the University of Sao Paulo Medical School. Baseline assessment included the identification of the APOE gene polymorphism (alleles E2, E3, and E4), which was the primary predictor, and other epigenetic variables such as sociodemographic factors, multimorbidity, and behavior measures. Annual follow-up evaluations over 10 years were conducted to identify dependencies in ADL and IADL, multimorbidity, and death using the hospital medical charts. A cumulative deficit index was computed using the patients\" multimorbidity and functionality every year. Kaplan-Meier curves and Cox proportional hazard models were used to associate the genetic and epigenetic factors with time to dependence in ADL and IADL and death. Multiple linear regression models examined the association of risk factors with the scores of the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), Charlson comorbidity index, and deficit index at 10 years. RESULTS: Participants had a mean age of 74.9 years; 76.8% were female, and 81.6% white. The mean score in CIRS-G was 10.2 points. The distribution of the alleles of APOE was 10% for E2, 50.8% E3, and 39.2% E4. Compared to the allele E3/E3 (control group), the presence of allele E2 did not predict dependence in ADL and IADL. The presence of allele E4 did not predict any outcome. Some epigenetic risk factors were associated with the outcomes over 10 years. For significant increase in deficit index: older age, p < 0,001; sedentarism, p=0,02; tobacco consumption p=0,02 .For dependence in ADL: older age, p=0.002; men p=0,01 ; higher scores in the CIRS-G, p=0.02; sedentarism, p=0.02. For dependence in IADL: older age, p < 0.001; men p=0,01 ; sedentarism, p=0.02 For mortality: older age, p=0,002; higher score in the Charlson comorbidity index, p=0.001. While metabolic activities (beta=-4,37; p=0.003) and living alone (beta=-2,28; p=0.005) were associated with a lower score in the CIRS-G at 10 years of follow-up, alcohol consumption (beta=1,78; p=0.04) was associated with higher scores in this index. CONCLUSIONS: The APOE gene polymorphism did not influence the prognosis of aging. Older age, sedentarism and tobacco consumption were associated with a significant increase in deficit index. Older age, men and sedentarism were predictors of functional loss. Metabolic activities and living alone were associated with a lower score in the CIRS-G at 10 years of follow-up. Older age and multimorbidity at baseline were predictors of mortality