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Towards a Research Agenda on Living Well with Multiple Chronic Conditions: A Resilience Model and Multi-level Profile
AUTHORS KATHERINE COATTA & ANDREW WISTER
DEPARTMENT OF GERONTOLOGY, SIMON FRASER UNIVERSITY VANCOUVER CAMPUS, CANADA
Age Pyramids of the Canadian Population, 2009 & 2036
Purpose
Cross-cultural and generational comparative analysis of multiple chronic illness patterns
Demographic, health and social profile
“The Canadian Case”
Identify areas for multivariate analyses
Background
Attention devoted to multiple chronic illnesses (multiple morbidity), given potential synergistic effects, population aging & health care discourse
Research is still in infancy
Multiple chronic conditions have been correlated with longer hospital stays, increased use of health care resources, and decreased productivity
The ‘well-being paradox’ (Windle, Woods & Markland, 2010) - life satisfaction maintained in the face of poor health
Has led to ‘living well’ with multiple chronic illnesses
Defining Multiple Morbidity
1) Simple dichotomies: 0 vs. 1+ Illnesses; OR 0,1 vs. 2+
2) Additive Scales (counts of illnesses)
3) Weighted based on HRQL or diagnostic criteria (onset, severity)
4) Comorbidity (index disease)
5) Combinations of selected illnesses
90% of older adults have 1+ chronic illness; 70% have 2+ (2008/09 Canadian Community Health Survey CCHS)
[asthma, arthritis, osteoporosis, back problems, blood pressure, migraine headaches, bronchitis, emphysema, COPD, diabetes, heart disease, cancer, ulcers, stroke, urinary incontinence, bowel disorder, cataracts, glaucoma and thyroid problems]
Theoretical Frame for Living Well with Multiple Chronic Illnesses
Adaptation (Homeostasis; Person-environment)
Connections among individuals, community & health policies (Socio-ecological theory, e.g. Stokols, 1991)
Behavioural change and action (TOPB, Social learning, Transtheoretical model, etc.)
Interconnectedness of hardiness and resources at individual, community & policy spheres (Resilience Theory)
Population health and health care interface (Chronic Care Models)
Adapted from: Barr, V., Robsinson, S., Marin-Link, B., Underhill, L., Dotts, A., Ravensdale, D. & Salivaras, S. (2003) The expanded chronic care model: An integration of concepts and strategies from population health promotion and the chronic care model. Hospital Quarterly, 7(1), 73-82
Methods
Analyses of the CCHS 4.2 Healthy Aging 2008/09
45+ (N = 30, 639)
Weighted to Canadian population and rescaled to limit overpowering analyses
Chronic illness additive measure (selected 8 illnesses common across CCHS and Australian HILDA survey)
Age Groups: 45-64; 65-74; 75+
Gender
Prevalence of Chronic Illnesses
Male Female Male Female Male Female Male FemaleArthritis/ Osteoporosis High Blood Pressure Heart Disease Diabetes
0
10
20
30
40
50
60
70
Fig. 1A – Prevalence of Chronic Illnesses by Age Group & Gender
Perc
ent
(%)
Male 45-64 yrs 65-74 yrs 75+ yrs
Female
45-64 yrs 65-74 yrs 75+ yrs
Prevalence of Chronic Illnesses
Male 45-64 yrs 65-74 yrs 75+ yrs
Female
45-64 yrs 65-74 yrs 75+ yrs
Male Female Male Female Male Female Male FemaleAsthma Bronchitis/ Emphysema Cancer Stroke
0
2
4
6
8
10
12
14
Fig. 1B – Prevalence of Chronic Illnesses by Age Group and Gender
Perc
ent
(%)
Mean Number of Chronic Illnesses by Selected Variables, Age Group and Gender
Male Female Male Female Male Female Male FemaleMarried Divorced Widowed Single
0
0.5
1
1.5
2
2.5
Fig. 2A - Marital Status
Male 45-64 yrs 65-74 yrs 75+ yrs
Female
45-64 yrs 65-74 yrs 75+ yrs
Odds Ratios for Gender Differences in Mean # of Chronic Illnesses for Selected Outcomes
* Numbers shown in columns are female/male odds ratios for the mean number of chronic illnesses
Married Divorced Widowed Single0.9
0.95
1
1.05
1.1
1.15
1.2
1.25
1.3
1.35
1.141.16
1.3
1.15
1.06
1.12
1.07
1.18
1.09
1.131.15
1
Fig. 2B - Marital Status
45-6465-7475+
Odds Ratios for Age Differences in Mean # of Chronic Illnesses for Selected Outcomes
* Numbers shown in columns are age group A (older)/ age group B (younger) odds ratios for number of chronic illnesses
Male 75+/45-64 yrs
65-74/45-64 yrs 75+/65-74 yrs Female
75+/45-64 yrs 65-74/45-64 yrs 75+/65-74 yrs
Male Female Male Female Male Female Male FemaleMarried Divorced Widowed Single
0
0.5
1
1.5
2
2.5
3
2.522.4
2.09 2.03 2.02
1.791.96
1.7
2.041.9 1.93 1.86 1.92
1.61.69 1.73
1.23 1.27 1.08 1.09 1.05 1.12 1.16
0.98
Fig. 2C – Marital Status
Mean Number of Chronic Illnesses by Selected Variables, Age Group and Gender
Male Female Male FemaleSecondary or Less More than Secondary
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Fig. 2D - Education
Male 45-64 yrs 65-74 yrs 75+ yrs
Female
45-64 yrs 65-74 yrs 75+ yrs
Odds Ratios for Age Differences in Mean # of Chronic Illnesses for Selected Outcomes
Male Female Male FemaleSecondary or Less More than Secondary
0.00
0.50
1.00
1.50
2.00
2.50
3.00
2.172.01
2.51 2.51
1.871.70
2.06 2.03
1.16 1.181.22 1.24
Fig. 2F - Education
Male 75+/45-64 yrs
65-74/45-64 yrs 75+/65-74 yrs Female
75+/45-64 yrs 65-74/45-64 yrs 75+/65-74 yrs
Mean Number of Chronic Illnesses by Selected Variables, Age Group and Gender
Male 45-64 yrs 65-74 yrs 75+ yrs
Female
45-64 yrs 65-74 yrs 75+ yrs
Male
Fem
ale
Male
Fem
ale
Male
Fem
ale
Male
Fem
ale
Poor or Fair Good, Very Good, Excellent Admittance in 12 months No Admittance in 12 months
0
1
2
3
Fig. 2G - Self Perceived Health and Hospital Admittance
SELF PERCEIVED HEALTH HOSPITAL ADMITTANCE
Odds Ratios for Gender Differences in Mean # of Chronic Illnesses for Selected Outcomes
SELF RATED HEALTH
* Numbers shown in columns are female/male odds ratios for the mean number of chronic illnesses
Poor/Fair Good/Very Good/Excellent Within last 12 months No admittance in 12 months0.9
0.95
1
1.05
1.1
1.15
1.2
1.25
1.13
1.23
1.12
1.18
1.04
1.141.11 1.11
1.03
1.16
1.11.12
Fig. 2H – Self Rated Health & Hospital Admittance
45-6465-7475+
HOSPITAL ADMITTANCE
Mean Number of Chronic Illnesses by Selected Variables, Age Group and Gender
Male Female Male Female Male Female Male FemaleCanada Not Canada Caucasian Non-Caucasian
0
0.5
1
1.5
2
2.5
Fig. 2J - Country of Birth and Visible Minority Status Male
45-64 yrs 65-74 yrs 75+ yrs
Female
45-64 yrs 65-74 yrs 75+ yrs
VISIBLE MINORITY STATUSCOUNTRY OF BIRTH
Odds Ratios for Gender Differences in Mean # of Chronic Illnesses for Selected Outcomes
* Numbers shown in columns are female/male odds ratios for the mean number of chronic illnesses
Canada Not Canada Caucasian Non-Caucasian0.9
1
1.1
1.2
1.3
1.4
1.151.18
1.14
1.33
1.09
1.141.11
1.091.11.12
1.1
1.16
Fig. 2K – Country of Birth & Visible Minority Status
45-6465-7475+
COUNTRY OF BIRTH VISIBLE MINORITY STATUS
Mean Number of Chronic Illnesses by Selected Variables, Age Group and Gender
Male
Fem
ale
Male
Fem
ale
Male
Fem
ale
Male
Fem
ale
Requires Help/ Needs Mechanical Support
No Aid Required/ No Prob-lems
Did not assist Assisted
00.5
11.5
22.5
3
Fig. 2M - Mobility and Personal Care Assistance
MOBILITY PERSONAL CARE ASSISTANCE
Male 45-64 yrs 65-74 yrs 75+ yrs
Female
45-64 yrs 65-74 yrs 75+ yrs
Odds Ratios for Gender Differences in Mean # of Chronic Illnesses for Selected Outcomes
Requires Help No Help Required Assisted Did not assist0.9
0.95
1
1.05
1.1
1.15
1.2
1.25
1.3
1.21.18
1.1
1.17
1.04
1.09
0.98
1.12
1.05
1.09
1.26
1.1
Fig 2N – Mobility & Personal Assistance
MOBILITY PERSONAL CARE
* Numbers shown in columns are female/male odds ratios for the mean number of chronic illnesses
Odds Ratios for Age Differences in Mean # of Chronic Illnesses for Selected Outcomes
MOBILITY PERSONAL CARE
Male 75+/45-64 yrs
65-74/45-64 yrs 75+/65-74 yrs Female
75+/45-64 yrs 65-74/45-64 yrs 75+/65-74 yrs
Male Female Male Female Male Female Male FemaleRequires Help No Help Required Assisted Did not Assist
0.00
0.50
1.00
1.50
2.00
2.50
3.00
1.30 1.12
2.402.22
1.79
2.06
2.522.36
1.42 1.22
2.041.90
1.791.60
2.061.96
0.91 0.92
1.18 1.17
1.00
1.28 1.23 1.20
Fig. 2O – Mobility & Personal Care Assistance
Mean Number of Chronic Illnesses by Selected Variables, Age Group and Gender
Male Female Male Female Male Female Male FemaleReceived Did not receive Received Did not receive
0
0.5
1
1.5
2
2.5
Fig. 2P - Care Received: Formal & Informal
FORMAL INFORMAL
Male 45-64 yrs 65-74 yrs 75+ yrs
Female
45-64 yrs 65-74 yrs 75+ yrs
Odds Ratios for Gender Differences in Mean # of Chronic Illnesses for Selected Outcomes
Received Did not receive Received Did not receive0.9
0.95
1
1.05
1.1
1.15
1.2
1.171.16 1.16
1.13
1.02
1.11
1
1.091.11
1.08
1.03
1.08
Fig. 2Q - Care Received: Formal & Informal
45-6465-7475+
FORMAL INFORMAL
* Numbers shown in columns are female/male odds ratios for the mean number of chronic illnesses
Correlations between Chronic Illnesses Scale and Selected Outcomes by Age Group and Gender
Male 45-64 yrs 65-74 yrs 75+ yrs
Female
45-64 yrs 65-74 yrs 75+ yrs
Male Female Male FemaleMedication Use Daily Life Satisfaction
0
0.1
0.2
0.3
0.4
0.5
0.6
Fig. 3A - Medication Use Daily and Life Satis-faction
Pears
on R
Odds Ratios for Age Differences by Correlation Coefficients of Chronic Illness Scale and Selected Variables
Male Female Male FemaleMedication Use Life Satisfaction
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
0.820.92 0.88
0.80.93 0.92
1.43
0.90.881
0.6
0.88
Fig. 3C – Medication Use Daily & Life Satis-faction
Male 75+/45-64 yrs
65-74/45-64 yrs 75+/65-74 yrs Female
75+/45-64 yrs 65-74/45-64 yrs 75+/65-74 yrs
Correlations between Chronic Illnesses Scale and MOS Sub-scales Age Group and Gender
Male Female Male Female Male Female Male FemaleAffection Emotional/ Informational Positive Social Interaction Tangible
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
0.09
Fig. 3D - Social Support
Pears
on R
Male 45-64 yrs 65-74 yrs 75+ yrs
Female
45-64 yrs 65-74 yrs 75+ yrs
Summary
Age effect on chronic illness prevalence
Gender differences depend on specific illness
Analysis of Multiple Chronic Illness Patterns:
Gender difference in multiple morbidity within marital status is largest for widowed boomers (female/male OR= 1.3)
The 75+/boomer age difference is large for males in all marital categories; but only for married females
Education effect on chronic illness is largest for boomers (45-64), declines with age
Gender difference in self-rated health & hospital admittance is largest for boomers
Summary – Con’t
Significantly higher gender difference in multiple morbidity for visible minority boomers
Large gender difference in multiple morbidity and personal care association for those aged 75+
Strong correlations between multiple morbidity and medication use (r=.45 to .55); slightly higher for boomers than seniors
Gender difference in chronic illness and formal and informal care is highest for boomers, smallest for seniors
Small (r=-.15 to -.25) correlations between multiple morbidity and life satisfaction, but boomers and young-old are most likely to be negatively affected
Correlations between multiple morbidity and social support dimensions are very low