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Functional limitations in people with multimorbidity and the association with mental health conditions: Baseline data from the Canadian Longitudinal Study on Aging (CLSA)
Increasing multimorbidity is often associated with declining physical functioning, with some studies showing a disproportionate impact on functioning when mental health conditions are present. More research is needed because most multimorbidity studies exclude mental health conditions.
This study aims to improve our understanding of the association between functional limitation and multimorbidity, including a comparison of those with multimorbidity that includes versus excludes mental health conditions.
This is a population-based, cross-sectional analysis of data from The Canadian Longitudinal Study on Aging. Functional limitation was defined as the presence of any of 14 activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Multimorbidity, measured by the number of chronic conditions, included mood and anxiety disorders. Logistic regression explored the association between multimorbidity (with and without mental health conditions) and functional limitation. Factor analysis identified common condition clusters to help understand clinical complexity in those with mood/anxiety disorders and the potential influences on functional limitation.
There were 51,338 participants, with a similar proportion of men and women (49% versus 51%) and 42% age 65 years or older. Fifteen percent (15%) had no chronic conditions and 17% had 5+. Ten percent (10%) reported at least one ADL or IADL limitation. Odds ratios (ORs) for functional limitation increased with multimorbidity and were generally higher for those with versus without mental health conditions (e.g., ORs from 1 to 5+ chronic conditions increased 1.9 to 15.8 for those with mood/anxiety disorders versus 1.8 to 10.2 for those without). Factor analysis showed that mood/anxiety conditions clustered with somatic conditions (e.g., migraines, bowel/gastrointestinal disorders).
This study found higher odds of functional limitation for those with multimorbidity that included versus excluded mental health conditions, at all levels of multimorbidity. It highlights the need for concurrent management of mental and physical comorbidities to prevent functional limitations and future decline. This approach is aligned with the NICE clinical assessment and management guidelines for people with multimorbidity.
Journal Article
Social engagement and allostatic load mediate between adverse childhood experiences and multimorbidity in mid to late adulthood: the Canadian Longitudinal Study on Aging
Adverse childhood experiences (ACEs) are associated with multimorbidity in adulthood. This link may be mediated by psychosocial and biological factors, but evidence is lacking. The current study evaluates this mediation model.
We analyzed data from the Canadian Longitudinal Study of Aging (
= 27 170 community participants). Participants were 45-85 years at recruitment, when allostatic load and social engagement data were collected, and 3 years older at follow-up, when ACEs and multimorbidity data were collected. Structural equation modeling was used to test for mediation in the overall sample, and in sex- and age-stratified subsamples, all analyses adjusted for concurrent lifestyle confounds.
In the overall sample, ACEs were associated with multimorbidity, directly,
= 0.12 (95% confidence interval 0.11-0.13) and indirectly. Regarding indirect associations, ACEs were related to social engagement,
= -0.14 (-0.16 to -0.12) and social engagement was related to multimorbidity,
= -0.10 (-0.12 to -0.08). ACEs were related to allostatic load,
= 0.04 (0.03-0.05) and allostatic load was related to multimorbidity,
= 0.16 (0.15-0.17). The model was significant for males and females and across age cohorts, with qualifications in the oldest stratum (age 75-85).
ACEs are related to multimorbidity, directly and via social engagement and allostatic load. This is the first study to show mediated pathways between early adversity and multimorbidity in adulthood. It provides a platform for understanding multimorbidity as a lifespan dynamic informing the co-occurrence of the varied disease processes represented in multimorbidity.
Journal Article
Patients report high information coordination between rostered primary care physicians and specialists: A cross-sectional study
Our study aimed to describe patient experience of information coordination between their primary care physician and specialists and to examine the associations between their experience and their personal and primary care characteristics. We conducted a cross-sectional study of Ontario residents rostered to a primary care physician and visited a specialist physician in the previous 12 months by linking population-based health administrative data to the Health Care Experience Survey collected between 2013 and 2020. We described respondents’ sociodemographic and health care utilization characteristics and their experience of information coordination between their primary care physician and specialists. We measured the adjusted association between patient-reported measures of information coordination before and after respondents received care from a specialist physician and their type of primary care model. 1,460 out 20,422 (weighted 7.5%) of the respondents reported that their specialist physician did not have basic medical information about their visit from their primary care physician in the previous 12 months. 2,298 out of 16,442 (weighted 14.9%) of the respondents reported that their primary care physician seemed uninformed about the care they received from the specialist. Females, younger individuals, those with a college or undergraduate level of education, and users of walk-in clinics had a higher likelihood of reporting a lack of information coordination between the primary care and specialist physicians. Only respondents rostered to an enhanced fee-for-service model had a higher odds of reporting that the specialist physician did not have basic medical information about their visit compared to those rostered to a Family Health Team (OR 1.22, 95% Cl 1.12–1.40). We found no significant association between respondent’s type of primary care model and that their primary care physician was uninformed about the care received from the specialist physician. In this population-based health study, respondents reported high information coordination between their primary care physician and specialists. Except for respondents rostered to an enhanced fee-for-service model of care, we did not find any difference in information coordination across other primary care models.
Journal Article
Individual and population level impact of chronic conditions on functional disability in older adults
It is unknown if the relationship between multimorbidity and disability differs by combinations of chronic conditions. The objective of our study was to elucidate how joint effect of different combinations of chronic conditions impact the five year risk of functional disability at the population level.
Participants ≥65 years from the Canadian Study of Health and Aging were assessed for functional disability measured using activities of daily living (ADL) and instrumental ADL (IADL), and the presence of conditions in five disease domains; cardiometabolic, neurological, sensory, musculoskeletal, and respiratory. Logistic regression was used to assess the relationship between each disease domain and incident ADL and IADL measured at five years of follow up and population attributable risk (PAR) was modeled for diseases domains that were significantly associated with disability. Results were stratified by sex and age (65-74 years, ≥75 years).
There were 6272 participants free of ADL disability and 4571 participants free from IADL disability at baseline. For incident ADL, the greatest PAR values were 21.3 (9.8-32.8) for the cardiometabolic domain in males 65-74 years, 22.7 (4.7-40.8) for the musculoskeletal domain for females aged 65-74 years, and 11.2 (2.8-19.7) for the musculoskeletal domain in males ≥75 years. The PAR for the musculoskeletal, sensory, and neurological domains were similar in females ≥75 years(9.3-9.9). PAR values were lower but followed similar patterns for IADL disability.
The chronic disease domains which most strongly predicted incident ADLs and IADLs did not account for the greatest amount of disability at the population level.
Journal Article
Single-item versus scale: Comparing respondent demographic, social, and health characteristics by measure of loneliness using the Canadian Longitudinal Study on Aging (CLSA) data
Growing research and clinical attention to loneliness has led to a wide range of available measures; however, few studies directly compare different loneliness measures within the same population. Measures include single-item, direct questions and indirect, multi-item scales. This study compared responses and respondent characteristics between a direct single-item loneliness question and an indirect multi-item scale.
We conducted a cross-sectional analysis of population-based survey data from the Canadian Longitudinal Study on Aging (CLSA). The sample included baseline (2010-2015) and follow-up 1 respondents (2015-2018) from both the Tracking (computer-assisted telephone interviews) and Comprehensive (in-home assessment) cohorts (n = 43,235). Loneliness was assessed using a direct single-item question from the Center for Epidemiological Studies Depression Scale (CES-D-10) and the 3-item Loneliness Scale. We categorized loneliness using ordinal (not lonely, moderately lonely, severely lonely) and dichotomous (lonely/not lonely) classifications. Unweighted descriptive statistics were used to examine demographic, social, and health characteristics across measures and response categories.
Among the 43,235 CLSA respondents, 14% (n = 5,848) were identified by both the single-item question and the scale as lonely, 67% (n = 28,998) were identified as not lonely by both, leaving 19% classified differently based on measure. Individuals identified as lonely respondents by both measures were more often older, women, less educated, and had lower income. Those classified as severely lonely on the single item but not lonely on the scale were older than other groups. In contrast, respondents who were moderately lonely on the single-item question tended to be married, report higher income, and have greater social contact.
The direct single-item question and the indirect multi-item scale provided comparable overall classifications of loneliness in our CLSA sample. However, respondent characteristics varied across the more granular response categories, highlighting the importance of measure selection depending on study aims.
Journal Article
Correction: Single-item versus scale: Comparing respondent demographic, social, and health characteristics by measure of loneliness using the Canadian Longitudinal Study on Aging (CLSA) data
[This corrects the article DOI: 10.1371/journal.pone.0341572.].
Journal Article
Association between primary care physicians’ practice models and referral rates to specialists: A sex-based cross-sectional study
Referrals from primary care physicians (PCPs) to specialists are a key function of the primary care system, enabling access to secondary and tertiary health care services. Since the early 2000s, Ontario has implemented substantial primary care practice reforms, however, PCP referral patterns have not been examined since reforms were implemented. We conducted a cross-sectional study in Ontario analyzing PCPs’ referral patterns to specialists from January 1 to December 31, 2019. Data from physician administrative and Ontario Health Insurance Plan (OHIP) billing databases were linked for 9,301 PCPs practicing comprehensive primary care with 11.8 million patients. We calculated referral rates per physician and built a multivariable Poisson regression model stratified by physician sex, recognizing that female and male PCPs practice primary care differently, to examine the association between PCP’s referral rates and their practice model. Subgroup analyses were conducted for medical, surgical, diagnostics and General Practitioner (GP) focused practice specialties. Overall, PCPs in fee-for-service practice models (females: 0.72, 95% CI 0.71–0.72, males 0.71 95% CI 0.71–0.72) and Family Health Groups (females: 0.90, 95% CI 0.90–0.91, males 0.85 95% CI 0.84–0.85) had lower adjusted relative referral rates compared to those in Family Health Teams (FHTs); a finding that was consistent across medical and surgical specialties. Younger, part-time PCPs, those practicing in urban areas, those with larger roster sizes and those affiliated with a large practice group showed higher adjusted referral rates. Female PCPs tended to be younger (average age 47.2 years vs. 54.1 years for males; SMD=0.56), work part-time (32.1% vs. 17.9% for males; SMD=0.33), had a smaller patient roster (average 1,097.8 rostered patients vs. 1,442.1 for males; SMD=0.44), and had higher unadjusted referral rates to specialists compared to male PCPs (32.9 vs. 29.9 per 100 rostered patients). PCPs’ referral patterns in Ontario vary by practice model and PCP’s sex. Future changes to primary care practices should account for their effects on referral volumes to specialists.
Journal Article
Peaceful dying among Canada’s elderly: An analysis of the Canadian Longitudinal Study on Aging
Death is universal, yet relatively little is known about how Canadians experience their death. Using novel decedent interview data from the Canadian Longitudinal Study on Aging we describe the prevalence and characteristics of peace with dying among older Canadians.
We conducted a secondary analysis of decedent interview data from the Canadian Longitudinal Study on Aging. Proxies of deceased Canadian Longitudinal Study on Aging participants reported on participants' end-of-life experiences between January 2012 to March 2022. We examined end-of-life characteristics and their association with proxy reports of experiencing peace with dying. We conducted regression analysis to explore the association between demographic and end-of-life characteristics and experiencing peace with dying.
Of 3,672 deceased participants, 1,287 (35.0%) had a completed decedent questionnaire and were included in the analysis. Respondents reported that two-thirds (66.0%) of the deceased experienced peace with dying and 17% did not experience peace with dying. The unadjusted odds of experiencing peace with dying were higher for those with an appointed power of attorney (OR 1.80; CI 1.39-2.33), those who died of cancer (OR 1.71; CI 1.27-2.30), those in hospice/receiving palliative care (OR 1.67; CI 1.19-2.37), individuals older than 75 years (OR 1.55; CI 1.04-2.30), or widowed (OR 1.53; CI 1.12-2.10). Widowhood (OR 1.51; CI 1.01-2.29), having an end-of-life SDM (OR 1.58; CI 1.14-2.17), and dying of cancer (OR 1.67; CI 1.19-2.23) increased the adjusted odds of dying with peace.
Close to 1 in 5 older Canadians may not experience peace with dying, which supports greater focus on improving the end-of-life care. Our findings suggest that advanced planning may enhance the experience of a peaceful death in Canada.
Journal Article