Multimorbidity in dependent community-dwelling older adults: prevalence and associated factors

Abstract

Objective  To analyze the prevalence and factors associated with multimorbidity in dependent community-dwelling older adults.

Methodology  A cross-sectional study was conducted involving 197 dependent older adults selected by probabilistic sampling, registered at a primary care unit. Data were collected using a semi-structured questionnaire, and scales of independence for activities of daily living, the Hwalek-Sengstock Elder Abuse Screening Test, and a Visual Analog Scale, assessing functional capacity, risk of violence, and pain in older adults, respectively. Data were analyzed using descriptive statistics, inferential statistics, and binary logistic regression analysis, by the enter method.

Results  Multimorbidity was found in 57.9% of participants, 66.0% of whom were women, with predominance among individuals aged 80 or over (65.0%), with less than one year of education (56.2%), no partner (65.3%), and income of up to one minimum wage (89.6%). There was a greater chance of multimorbidity among participants with one year or more of education (OR=2.3), taking four or more medications (OR=3.7), and showing signs of domestic violence (OR=1.3).

Conclusion  Polypharmacy, risk of violence, and education, were significantly associated with multimorbidity in the individuals studied. These results highlight the need for proper management of polypharmacy, implementation of health interventions to reduce abuse, and close monitoring of chronic diseases in the older population with greater social vulnerability, through educational actions that take into account level of education.

Keywords
Frail Older Adults; Aging; Multimorbidity; Primary Care; Chronic Disease.

Resumo

Objetivo  Analisar a prevalência e os fatores associados à multimorbidade em pessoas idosas dependentes residentes na comunidade.

Métodos  Estudo transversal realizado com 197 pessoas idosas dependentes selecionadas por amostragem probabilística e cadastradas em uma unidade básica de saúde. Os dados foram coletados por meio de um questionário semi-estruturado, escalas de independência em atividades de vida diária, <italic>hwalek-sengstock elder abuse screening test</italic> e visual analógica, que avaliam a capacidade funcional, o risco de violência e a dor na pessoa idosa, respectivamente. Os dados foram analisados por meio da estatística descritiva, inferencial e análise de regressão logística binária, método enter.

Resultados  A multimorbidade ocorreu em 57,9% das pessoas idosas, sendo 66,0% mulheres, com predomínio de indivíduos com 80 anos ou mais (65,0%), menos de um ano de estudo (56,2%), sem companheiro (65,3%) e renda de até um salário mínimo (89,6%). Houve maior chance de multimorbidade entre os participantes com um ano ou mais de estudo (OR=2,3), que utilizavam quatro ou mais medicamentos (OR=3,7) e apresentavam indícios de violência doméstica (OR=1,3).

Conclusão  A polifarmácia, o risco de violência e a escolaridade foram significativamente associadas à multimorbidade dos voluntários do estudo. Nesse sentido, ressalta-se a necessidade de um manejo adequado da polifarmácia, implementação de intervenções em saúde para reduzir os maus-tratos e intensificação no monitoramento das doenças crônicas na população idosa com maior vulnerabilidade social, por meio de ações educativas que considerem o seu nível de escolaridade.

Palavras-chave
Idoso Fragilizado; Envelhecimento; Multimorbidade; Atenção Primária à Saúde; Doença Crônica.

INTRODUCTION

Multimorbidity can be defined as the co-occurrence of two or more chronic non-communicable diseases (NCDs) in the same individual¹, a condition found predominantly in older adults. This complex multifactorial condition is associated with older age, female gender², pain³, risk of violence⁴, low socio-economic level, unhealthy lifestyle, and difficulty accessing health services⁵.

In the aging population, the existence of multiple chronic conditions can lead to functional decline, reduced autonomy, poor perceived quality of life⁶ and double the chances of being hospitalized compared with young adults⁷. Although controllable by lifestyle changes and proper treatment, managing multimorbidity is challenging and requires specialist medical care and social support, while generating high costs for health systems across all levels of care¹.

The prevalence of multimorbidity is higher in dependent older adults, posing greater difficulties in terms of financial burden for both the family and public authorities, with higher use of health services and expenditure on medications. Being dependent also limits social participation, rendering the individual more frail, vulnerable, and reliant on caregivers for survival. This dependence on others for assistance in performing basic activities, bathing, feeding, administering medications, getting to consultations and exams, can evoke negative feelings such as sadness, loneliness, impotence and uselessness ⁹.

In Brazil, the overall prevalence of multimorbidity in older adults is 53.¹%¹⁰. However, it is important to distinguish particularities of the older population in different geographic contexts to inform a more meaningful discussion⁶, especially among physically-dependent older individuals, a group that has a higher rate of multimorbidity¹¹. Most related studies published to date have been conducted in major cities where the availability of health services and economic development indexes are generally higher, and whose multimorbidity rates are similar to national levels, e.g. 54.0% in Rio Grande do Sul state¹², 69.4% in the Federal District (Brasilia)¹³ and 67.8% in the city of Montes Claros (Minas Gerais state)¹⁴. By contrast, the older population in the Northeast region remains little studied.

These data reveal that multimorbidity is a serious public health problem¹⁵ and the literature reports the need for studies centering on regional particularities, such as the cultural context, social and economic conditions, environmental factors, besides the availability of and access to health services. Identifying the factors associated with multimorbidity can help devise public policies that take these particularities into account, with comprehensive approaches for management of this condition and health surveillance, promoting healthy aging with better quality of life for this population in different settings.

Therefore, the objective of the present study was to analyze the prevalence of multimorbidity and its associated factors in dependent community-dwelling older adults.

METHODS

This study was part of a larger project called “Condições de saúde de pessoas adultas e idosas: um estudo prospectivo” (“Health status of young and older adults: a prospective study”), scheduled to run between January 2023 and January 2028. A cross-sectional, epidemiological analytical study, with a temporal cut-off for data collected between February and August 2024, involving dependent, community-dwelling older adults, was conducted in accordance with the criteria of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool.

The study venue was the city of Guanambi (Bahia state, Brazil), situated in the Southwest region of the state, with an estimated population of 87,817 people, of which 13,511 are aged 60 or older¹⁶. Health care of dependent older adults is delivered in two ways. Firstly, via the Associação Benemérita de Caridade (local philanthropic association) which caters for institutionalized residents and is funded by users of the service, and through assistance provided by the municipal authorities. The second and main form of care provided under the healthcare system is the Family Health Strategy, whose care coverage was 98.01% in December 2020 (last records), with data publicly available at https://relatorioaps.saude.gov.br/cobertura/ab.

Functional capacity is a key marker for rating health of older adults, covering physical, cognitive and sensory domains. This study included only individuals aged 60 or older, with at least one type of physical dependence¹⁷, and that signed the informed consent form.

Exclusion criteria were individuals unable to communicate due to severe hearing, visual or speech deficits, as perceived by the interviewer through observation or informed by guardians. In addition, data collection was halted when community health workers (CHWs) were unavailable, because these professionals facilitated access to households and guaranteed the safety of the researchers in areas of high social vulnerability. Hence, no individuals with the above-mentioned impairments were included in the sample selected, and all CHWs were on duty during data collection. Thus, after signing the informed consent form, participants were deemed lost to follow-up when they could not be located after three attempts (n=28), had died (n=40), refused to continue participating in the study (n=19), or had changed address (n=11).

To locate participants, nurses at the primary care units (UBS) of the urban zone were asked to provide lists from electronic medical records, containing the names of all users registered at the health units by sub-area. Using this list, interviewers were accompanied by CHWs to the participants´ residences to assess their level of physical dependence in self-care for basic activities of daily living¹⁷. In order to ensure the privacy of the older adults, and to reduce study bias, caregivers were politely asked to leave the room during data collection.

The study population comprised 295 dependent older adults that met the eligibility criteria. The sample size was estimated using online software, based on a finite population formula for epidemiological studies, 95% confidence interval, 5% sampling error, and 50% expected accuracy, with a 20% addition for potential losses, giving an estimated sample of 168 individuals. Thus, a total of 197 older adults took part in the study.

All research instruments applied had previously undergone transcultural adaptation, and validated versions in Brazilian Portuguese were used. A pilot test was conducted involving some older individuals not included in the sample. Research assistants were previously trained by the principal investigator, and the following instruments applied:

1) Physical functional capacity was assessed using the Independence in Activities of Daily Living (Katz) Index, containing 6 biologically hierarchized items that measure whether a person is dependent on assistance or otherwise for: feeding, continence, transferring, toileting, dressing and bathing¹⁷. Each activity is scored as 0 or 1, for a maximum total of 6 points. Thus, participants were classified as independent or dependent for 1 to 6 functions. Level of dependence can also be classified into low (<3 points), moderate (3-4 points) or high (5-6 points)¹⁸.

2) The Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST) is a scale translated and adapted for use in Brazil, that identifies signs of presence or suspected abuse, neglect or risk of violence. The tool contains 15 items, with 1 point given for each “yes” answer, except for items 1, 6, 12 and 14, for which a point is given for a “no” answer. A score of 3 or above on the test may indicate a greater risk or suspicion of abuse or neglect¹⁹.

3) The Visual Analog Scale (VAS) assessed the intensity of pain, on a scale of 0 to 10, with 0 representing “no pain” and 10 “worse pain imaginable”. Participants indicated their level of pain at the time of data collection. The scale displays faces simulating the pain felt, allowing individuals who are illiterate to show their level of pain using the faces. Each face on the scale corresponds numerically to pain intensity. Hence, pain was rated using these two methods²⁰.

In addition to these scales, a form devised by the principal investigator was used to collect details on sociodemographics and health status of participants, namely: age, sex, education, marital status, income, polypharmacy (≥4 medications) and self-reported diseases, categorized as multimorbidity when ≥2 diseases were present. Therefore, multimorbidity was the dependent variable, dichotomized into “yes” or “no”, while the remaining variables were independent.

For data analyses, descriptive and inferential statistics were used. Categorical variables were expressed as absolute frequencies (n) and percentages (%), and numeric variables as measures of central tendency (mean), dispersion (standard deviation), and 95% confidence interval. The Chi-square and Student´s t-tests were applied in the bivariate analyses, where only variables with a p-value <0.20 were included in the multiple model. Subsequently, a hierarchical multiple model was constructed using binary logistic regression, applying the enter method for each variable. The entry sequence and organization levels of blocks of independent variables were determined according to their theoretical importance. Blocks were entered sequentially, and more distal-level variables exhibiting a statistically association with the outcome were retained for model adjustment.

The magnitude of associations was estimated by the Odds Ratio (OR), for a 5% level of significance (α<0.05). The Hosmer–Lemeshow test was used to assess the goodness of fit.

The study complied with the ethics aspects set forth in Resolution no. 466 of 2012 and 510 of 2016, and was approved by the Research Ethics Committee of the Universidade do Estado da Bahia, with substantiated opinion number 7.504.301 and Certificate of Presentation for Ethical Appreciation (CAAE) number 67049623.6.0000.0057.

DATA AVAILABILITY

The full dataset underpinning the study results are available upon request from the corresponding author.

RESULTS

A total of 197 older adults took part in the study, with most participants octogenarian, female, low-educated, with no partner, income <1 minimum wage, mild-to-moderate pain, signs of abuse/neglect by their caregivers, taking <4 medications, and predominantly low level of dependence (Table 1).

Table 1
Sociodemographic characteristics and health status associated with multimorbidity of dependent older adults (N=197). Guanambi, Bahia state, 2024.

Variables	Multimorbidity		p-value	valid n
	No	Yes
Age group (years)*			0,607	193
60-69	7 (33.3)	14 (66.7)
70-79	22 (45.8)	26 (54.2)
≥80	50 (40.3)	74 (59.7)
Sex*			0.495	193
Female	55 (42.6)	74 (57.4)
Male	24 (37.5)	40 (62.5)
Education (years)*			0.131a	190
< 1	49 (45.8)	58 (54.2)
≥1	29 (34.9)	54 (65.1)
Marital status*			0.165a	186
No partner	56 (45.5)	67 (54.5)
With partner	22 (34.9)	41 (65.1)
Income (minimum wagesd)*			0.154a	188
≤ 1	65 (38.2)	105 (61.8)
≥2	10 (55.6)	8 (44.4)
Polypharmacy*			<0.001b	176
No	56 (56.0)	44 (44.0)
Yes	16 (21.1)	60 (78.9)
Painb	2.6*** [95% CI 1.75-3.40]c	3.6*** [95% CI 2.86-4.36]c	0.072a	188
Risk of abuse/neglect**	5.2*** [95% CI 4.88-5.60]c	5.7*** [95% CI 5.29-6.03]c	0.178a	190
Level of dependence*			0.713	192
Low	40 (38.5)	64 (61.5)
Moderate	19 (44.2)	24 (55.8)
High	20 (44.4)	25 (55.6)

• *Chi-square test and values expressed as absolute frequency (n) percentage (%); **Student´s t-test; ***Mean; ^ap<0.20; ^bp<0.05; ^c95% Confidence Interval; ^dMinimum wage in 2024 (RTable 1). ,412.00). Source: Data from survey, 2024.

On the bivariate analysis, 5 variables were found to be associated with the outcome (p<0.20) and selected for construction of the multiple model in the following order of entry: polypharmacy, education, income, risk of abuse/neglect, pain, and marital status (Table 1).

The prevalence of multimorbidity in the dependent older adults was 57.9% [95%CI: 51.1-64.7]. The main self-reported diseases were cardiovascular conditions (systemic arterial hypertension, stroke, and heart diseases), followed by diabetes mellitus, musculoskeletal disorders (arthritis, osteoarthritis, osteoporosis, herniated disc, fractures, mobility difficulties, and pain), and neuropsychological alterations (seizures, hydrocephalus, and depression). Other diseases, related to the other human body systems, were also cited, such as pulmonary, visual, auditory, gastrointestinal, and hormonal alterations, and cancer in different organs (Table 2).

Table 2
Distribution of diseases self-reported by the dependent older adults (N=197). Guanambi, Bahia state, 2024.

Self-reported diseases	N (%)
Cardiovascular*	156 (79.2)
Diabetes Mellitus	53 (26.9)
Musculoskeletal	40 (20.3)
Neurologic and Psychological	30 (15.2)
Other diseases	42 (21.4)

• *Stroke and systemic arterial hypertension. Source: Data from survey, 2024.

Multiple hierarchical analysis revealed that the chance of multimorbidity among participants was influenced by higher number of medications taken and by education, and was associated with signs of abuse/neglect by caregivers (Table 3).

Table 3
Final model of hierarchical binary logistic regression analysis of factors associated with multimorbidity in dependent older adults (N=197). Guanambi, Bahia state, 2024.

Variables	OR**	p-value	95% CI
Education (years)
< 1	1
≥ 1	2.3	0.032*	1.07 - 4.77
Marital status
No partner	-	-	-
With partner	-	-	-
Income (minimum wages)***
≤ 1	1
≥ 2	0.3	0.073	0.10 - 1.10
Polypharmacy
No	1
Yes	3.7	<0.001*	1.76 - 7.70
Pain	-	-	-
Risk of abuse or neglect	1.3	0.039*	1.01 - 1.55

• *p<0.05. Omnibus Test p<0.001; **Odds Ratio; ***Minimum wage in 2024 (RTable 3). ,412.00); Hosmer–Lemeshow Test p=0.539; Pseudo R²: 20.6%. Source: Data from survey, 2024.

DISCUSSION

The results of present study showed a prevalence of multimorbidity among the dependent older adults of 57.9% With regard to associated factors, the results showed that participants with more education, taking ≥4 medications, and showing signs of abuse or neglect. had higher chances of having multimorbidities.

However, international studies report conflicting results, such as investigations in India and Nepal, which found multimorbidity prevalence rates of 24.1%8 and 22.⁸%²¹, respectively. These studies⁸,¹³,¹⁴,²¹ adopted different methods and included both independent and dependent community-dwelling older adults, whereas the present study included only dependent users of primary care units, possibly explaining the disparities observed.

Moreover, developing countries have more limited financial and health resources, and distances between households and clinics can prevent timely diagnosis of chronic diseases²¹. Although Brazil is itself a developing nation, it has a better status in terms of health, education and income, besides a higher human development index²², perhaps favoring early diagnosis of these chronic diseases.

Despite the disparities among national and international studies, systemic arterial hypertension, diabetes mellitus and osteoarticular conditions⁸,¹³,²¹ remain the main morbidities in the older population, as also found in the present investigation. This pattern highlights the global burden of these diseases, which transcends geographic barriers and calls for tighter control to reduce their prevalence. Thus, concerted efforts must be made to improve public health. To this end, health professionals should involve older individuals in planning realistic goals, implementing multi-faceted interventions that promote significant changes in habits and lifestyle.

The analysis of the factors associated with multimorbidity showed that participants with ≥1 year of education had a greater chance of presenting multimorbidity. These findings are similar to the results of another study, showing that risk of multimorbidity was double in high-educated older individuals⁸, because this group has a better socioeconomic level, and tends to seek and understand health-related information more⁶. Conversely, low-educated individuals may have more limited understanding of preventive behaviors and can encounter difficulties accessing health systems, often leading to underdiagnosis⁶.

In the present study, polypharmacy was also found to be associated with multimorbidity, mirroring other investigations¹³,²³. Polypharmacy is common among older individuals and represent a growing concern in geriatrics because of its association with adverse outcomes such as drug-drug interactions, hospitalizations²⁴ and cognitive impairment. In addition, polypharmacy can mask symptoms of other clinical conditions, hampering accurate diagnosis and promoting a vicious cycle of unnecessary prescribing²³. These results highlight the need for a more thorough approach to prescribing medications and an assessment of their impacts on the health of older patients as these drugs are introduced in the treatment of multiple morbidities.

Although medications are essential for controlling chronic diseases, care in treating older adults should not be limited to the use of drugs. Non-pharmacological measures, such as occupational therapy, physiotherapy, psychosocial support and incentives for developing autonomy, despite functional limitations, play a fundamental role in reducing the negative impacts of polypharmacy and are essential for improving perceived health, wellbeing and quality of life²⁵.

Multimorbidity in dependent older adults leads to the need for assistance to perform daily activities, provided by voluntary family or paid formal caregivers. In this scenario, one of the main challenges is caregiver burnout, whose exhausting routine can lead to high levels of stress²⁶, predisposing these individuals to aggressive and neglectful behaviors and contributing to acts of violence against the older individuals in their care.

The literature shows that violence can not only promote worsening of pre-existing chronic conditions among older adults, but also lead to new illnesses²⁷. In this context, a study identified a significant association between risk of abuse and the presence of four or more chronic diseases in less active older women, showing that multimorbidity was a conditioning factor for acts of abuse or neglect perpetrated by caregivers²⁸.

These findings emphasize the importance of scrutinizing the impact of violence on the health of older adults, where experiencing abuse can negatively impact quality of life and multimorbidity control. Psychological abuse, for example, is directly linked to greater risk of depression, anxiety and post-traumatic stress disorder²⁹. Moreover, neglect in care can hamper the management of chronic non-communicable diseases, reducing treatment adherence, and increasing the likelihood of clinical complications³⁰. Domestic violence can also lead to malnutrition, stress and worse quality of life³¹. Therefore, implementing preventive and support measures is pivotal to ensuring physical and mental wellbeing of older adults.

The rising prevalence of multimorbidity in this population calls for a comprehensive individualized approach by health professionals, taking into account the complexity of care and challenges associated with polypharmacy, educational level, and violence against older individuals. Key among these professionals is the nursing team which, besides preventing complications and monitoring health, play a crucial role in coordinating multidisciplinary care, handling complex cases, and supporting caregivers, ensuring more effective humanized care.

This study has some limitations: (i) multimorbidity was assessed based on self-reports of chronic diseases, possibly leading to under-reporting due to recall bias (common in older adults) and to diagnosis biases, given that no checks against medical records were made. Nevertheless, most health studies use similar data collection techniques; (ii) these results may differ if compared against different settings, such as individuals that are hospitalized or institutionalized, in as far as the present sample comprised dependent community-dwelling older adults; and lastly (iii) the study had a cross-sectional design, precluding any causal inferences, a common issue in epidemiological designs of this kind. However, in order to ensure methodological rigor for this study type, the internationally recommended STROBE guidelines were applied.

CONCLUSION

The rate of multimorbidity in the older adults assessed was 57.9%. There was a significant association of higher educational level, taking multiple medications, and signs of neglect/abuse from caregivers, with the presence of multimorbidity. Hence, educational interventions that take into account educational level, aimed at improving management of polypharmacy and reducing abuse in this group should be conducted.

• Funding
  Fundação de Amparo à Pesquisa do Estado da Bahia (FAPESB). Tender 019/2023. Scientific Initiation scholarship.

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Edited by

• Edited by
  Camila Alves dos Santos

Publication Dates

• Publication in this collection
  29 Sept 2025
• Date of issue
  2025

History

• Received
  19 Apr 2025
• Accepted
  18 July 2025