Saudi Cultural Missions Theses & Dissertations
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Item Restricted Progress of multimorbidity among older adults and the role of Oral Health(King's College London, 2024-08-14) Mira, Rolla; Sabbah, WaelThe world's ageing population has rapidly increased because of the demographic shift that has occurred over the last several decades. Multimorbidity is one of the most significant effects of the ageing population on public health. When a person has more than two chronic conditions, this is known as multimorbidity. Furthermore, multimorbidity is common, increases with age, and is more prevalent in those from lower socioeconomic backgrounds, according to all current studies. Multimorbidity is linked to worse outcomes such as lower quality of life, increased mortality, polypharmacy, high treatment burden, higher rates of adverse drug events, and much higher use of health services, including emergency hospital admissions. The mechanism of multimorbidity development is a multifactorial dynamic process, oral health could be associated with multimorbidity through different pathways. One of the most plausible pathways is the impact of poor oral health on nutritional status. Aim: The thesis aimed to explore socioeconomic inequalities in the progress of multimorbidity, among older adults. The second aim is to assess whether tooth loss is associated with the progress of multimorbidity. The objectives of the thesis were to (1) examine socioeconomic inequalities in the progress of multimorbidity among older adults in the U.S.A. (2) Assess whether tooth loss is longitudinally associated with the progress of multimorbidity and (3) explore the nutritional pathway between tooth loss and the progress of multimorbidity. (4) Examine the relationship between allostatic load and the progress of multimorbidity and whether it mediates socioeconomic inequalities in multimorbidity. Methods: Seven waves were used (2006-2018) of the Health and Retirement Study, a longitudinal survey of older Americans. Multimorbidity was indicated by self-reported diagnosis of 5 conditions: diabetes, heart conditions, lung diseases, cancer, and stroke. Socioeconomic indicators were ethnicity, education, wealth, and income. Behavioural factors were smoking, excessive alcohol consumption, physical activity, and body mass index. Allostatic load was used as a biomarker of stress and was indicated by high-density lipoprotein, glycosylated haemoglobin, c-reactive protein, waist circumference, and high blood pressure. Nutritional intake was calculated in 2013 by summing 10 nutrients (Protein, Vitamins C, D, B12, E, Calcium, Zinc, Polyunsaturated fatty acids, Folate and ß- carotene). Finally, edentulism (total tooth loss) was assessed in three waves (2006, 2012, and 2018). Multilevel models for the analysis of longitudinal data were used to assess the association between socioeconomic factors and multimorbidity and whether behavioural factors mediate this association. Multilevel models were used to examine the relationship between oral health and multimorbidity and whether nutritional intake mediates this association. The association between allostatic load as a marker of chronic stresses with progress of multimorbidity was also assessed using multilevel models for longitudinal panel data. Results: Socioeconomic indicators showed different significant associations with the progress of multimorbidity demonstrating social gradients. However, after adjusting for behavioural factors these associations were attenuated. Incidence rate ratios (IRR) of multimorbidity was considerably higher in those who did not finish high school (IRR 1.21; 95% CI 1.18, 1.23) compared to those who attended college. After adjusting for behaviours, IRR decreased to 1.11 (95% CI 1.07, 1.14). Furthermore, IRR of multimorbidity was greater in the lowest quartiles of total wealth and income, with IRR 1.47 (95% CI 1.44, 1.51) and 1.25 (95% CI 1.22, 1.28), respectively. These IRRs decreased to 1.31 (95% CI 1.26, 1.36) and 1.22 (95% CI 1.18, 1.27), respectively, after accounting for behaviours. Moreover, longitudinal associations were found between edentulism in the years 2006 and 2012 and the progress of multimorbidity. After adjusting for behavioural factors, and total nutrients, the IRR for multimorbidity among edentate individuals was 1.12 (95%CI 1.06, 1.18) and 1.10 (95%CI 1.05, 1.16) in 2006 and 2012, respectively. Moreover, the analysis showed an association between edentulism (in 2006 and 2012) and total nutrition (2013) adjusting for age and gender. Total nutrients in 2013 were lower among those who were edentate in 2006 [IRR 0.97 (95%CI 0.95, 0.99)] and in 2012 [IRR 0.98 (95% CI 0.96, 0.99)]. A positive association was found between allostatic load and multimorbidity even after accounting for socioeconomic and behavioural factors. Conclusion: This thesis illustrated that socioeconomic factors were associated with the progress of multimorbidity, and behavioural factors appeared to mediate the association. It also demonstrated that the association between socioeconomic factors and multimorbidity was slightly attenuated after adjusting the allostatic load. Additionally, the allostatic load was significantly associated with multimorbidity even after accounting for socioeconomic and behavioural factors. Moreover, edentulism in 2006 and 2012 showed a statistically significant association with multimorbidity, although. The association between total nutrition and multimorbidity was significant only in the unadjusted models.18 0Item Restricted Multimorbidity and Polypharmacy: A Health Informatics Approach(Saudi Digital Library, 2023) Aldhobaie, Ghadah; Pirmohamed, Munir; Coenen, Frans; Walker, LaurenIntroduction: Multimorbidity is increasing in prevalence, and is more common in older age groups. All bodily systems can be affected by multimorbidity (or multiple long-term conditions), and this is associated with increased healthcare utilisation and increased mortality. Additionally, people living with multiple long-term conditions are often on many drugs, which has been termed polypharmacy. This puts them at risk of adverse drug reactions, drug-drug interactions and poor adherence, all of which can increase healthcare costs. In this thesis, I have focused on cardiovascular and gastrointestinal drugs in order to understand the changes which have occurred in the usage of these drugs over the last two decades. Objective: The thesis aims to describe the changing patterns of medication prescription practice over the last two decades in older people with cardiovascular and/or gastrointestinal diseases using the Clinical Practice Research Datalink (CPRD). Methods: We extracted one million patient records from CPRD. Among these patients, we have included cardiovascular (CV) and gastrointestinal (GI) patients with two or more years of follow-up. These patients were then filtered further based on the second chronic condition and the patient’s age (whether they were 50 years and above). After adjusting for the range between the years 2001 and 2020, the number of eligible patients for this study was reduced further (used for the first group analysis). An association rule mining was applied to investigate the prescription pattern between 2001 and 2020. When this is filtered to those who had 20 years of follow-up appointments, it reduced the number and was analysed accordingly for the second group analysis to examine the change in the prescription patterns by applying specifically the Apriori algorithm Association Rules Mining. Results: For the first analysis, the extracted eligible CV and GI patients were 228,376 and 111,355, respectively. The eligible patients for the second analysis with continuous and constant 20 years follow-up were 17,075 and 3,110, respectively. In cardiovascular disease, the most commonly prescribed drug classes were statins followed by calcium channel blockers. The study also showed that there was a statistically significant increase (P-value <0.0001) in the mean number of total cardiovascular drugs prescribed in 2020 in comparison to 2001 (mean 2.201-1.581, standard deviation 1.153-0.860 respectively). In gastrointestinal disease, the most commonly prescribed drug classes were proton pump inhibitors followed by corticosteroids. In the same study period, there was a statistically significant increase (P-value <0.0001) in the mean number of total gastrointestinal drugs prescribed (mean 1.284-1.152, standard deviation 0.586-0.424 respectively). Evaluation of the 20 year follow-up data allowed association rule mining to be applied and the top 10 rules were identified. Conclusions: There was a statistically significant difference in prescription patterns during the study period. In particular, the total number of drugs increased significantly in 2020 when compared to 2001. A limitation of the studies is that only drugs associated with CV and GI diseases were evaluated, and further studies on all systems are needed. Researchers and clinicians need to better understand drug prescribing patterns overall in patients with multiple long-term conditions to develop strategies to overcome the possible adverse consequences of polypharmacy.30 0