The Co-Occurrence of Chronic Diseases and Geriatric Syndromes:
The Health and Retirement Study
Pearl G. Lee, MD,?zChristine Cigolle, MD, MPH,wzand Caroline Blaum, MD, MS?z
OBJECTIVES: To analyze the co-occurrence, in adults
aged 65 and older, of five conditions that are highly
prevalent, lead to substantial morbidity, and have evidence-
based guidelines for management and well-developed
measures of medical care quality.
DESIGN: Secondary data analysis of the 2004 wave of the
Health and Retirement Study (HRS).
SETTING: Nationally representative health interview sur-
PARTICIPANTS: Respondents in the 2004 wave of the
HRS aged 65 and older.
MEASUREMENTS: Self-reported presence of five index
conditions (three chronic diseases (coronary artery disease,
congestive heart failure, and diabetes mellitus) and two ge-
riatric syndromes (urinary incontinence and injurious falls))
and demographic information (age, sex, race, living situa-
tion, net worth, and education).
RESULTS: Eleven thousand one hundred thirteen adults,
representing 37.1 million Americans aged 65 and older,
were interviewed. Forty-five percent were aged 76 and
older, 58% were female, 8% were African American, and
4% resided in a nursing home. Respondents with more
conditions were older and more likely to be female, single,
and residing in a nursing home (all Po.001). Fifty-six per-
cent had at least one of the five index conditions, and 23%
had two or more. Of respondents with one condition, 20%
to 55% (depending on the index condition) had two or
more additional conditions.
CONCLUSION: Five common conditions (3 chronic dis-
eases, 2 geriatric syndromes) often co-occur in older adults,
suggesting that coordinated management of comorbid con-
Care guidelines and quality indicators, rather than consid-
ering one condition at a time, should be developed to
address comprehensive and coordinated management of
Soc 57:511–516, 2009.
Key words: disease; incontinence; fall
health and functional status, greater utilization of health
single diseases.1Multimorbidity is common in the older
adult population. It has been reported that 65% of Med-
icare beneficiaries have two or more chronic diseases and
43% have three or more;2other studies have found that
more than 50% of older adults have multimorbidity.3,4
Furthermore, having newly reported chronic diseases has
been associated with risk of functional dependency.5The
research reported in this article adds to the study of mul-
timorbidity by examining the co-occurrence of chronic dis-
eases with geriatric syndromes.
Geriatric syndromes, such as falls and urinary inconti-
nence (UI), are conditions that have not traditionally been
considered to be chronic diseases; nonetheless, geriatric
syndromes have been shown to be as prevalent as chronic
diseases and to be associated with functional dependency in
older adults.6A number of studies have suggested potential
associations between geriatric syndromes and certain
chronic diseases (e.g., coronary artery disease (CAD), con-
but population-based investigations of the co-occurrence of
chronic diseases and geriatric syndromes are not available.
To understand how many older adults are potentially
managing co-occurring chronic diseases and geriatric syn-
set was analyzed. Three chronic diseases (CAD, CHF, and
DM) and two geriatric syndromes (UI, falls) were chosen to
function as index conditions to illustrate how frequently
older adults may be faced with simultaneous management
of diseases and syndromes. Each of these index conditions
is highly prevalent in older adults;12,13is associated with
lder adults with multimorbidity, or co-occurrence of
multiple chronic diseases, have poorer self-rated
Address correspondence to Pearl G. Lee, Department of Internal Medicine,
University of Michigan 300 N. Ingalls, Room 920, Ann Arbor, MI 48109-
2007. E-mail: firstname.lastname@example.org
From the?Departments of Internal Medicine;wFamily Medicine, University
of Michigan, Ann Arbor, Michigan; andzVeterans Affairs Ann Arbor
Healthcare System Geriatric Research, Education and Clinical Center, Ann
r 2009, Copyright the Authors
Journal compilation r 2009, The American Geriatrics Society
substantial morbidity, disability, and healthcare utiliza-
tion;12,14–16is the focus of well-developed disease manage-
ment guidelines; and has well-defined quality measures to
assess its quality of care.17,18The goal of the study was to
investigate the co-occurrence of these diseases and syn-
dromes in the older adult population. It was hypothesized
that substantial co-occurrence of CAD, CHF, DM, UI, and
falls exists in adults aged 65 and older.
Data were obtained from respondents in the 2004 wave of
the Health and Retirement Study (HRS), a longitudinal
health interview survey of adults aged 51 and older in the
United States. In 1992, the HRS began interviewing adults
who were community-dwelling at baseline to obtain de-
tailed self-report information on physical and mental
health, financial status, and family support systems.19Re-
spondents are surveyed every 2 years and continue to be
followed upon moving into long-term care facilities. Inter-
views are conducted face to face or over the telephone ac-
cording to study protocols. If individual respondents are
unable to complete the interview, most often because of
medical or cognitive conditions, a proxy informant familiar
with the respondent’s medical conditions and financial sta-
tus is then interviewed. African-American and Hispanic
minority groups are oversampled. For this study, the ana-
lyses were limited to respondents aged 65 and older.
The National Institute on Aging sponsors the HRS,
which the Institute for Social Research at the University of
Michigan conducts.20The Health Sciences Institutional
Review Board at the University of Michigan approved the
HRS. The data used for this analysis are publicly available
and contain no unique identifiers, thus assuring respondent
Variables and Their Measurement
Index Conditions. The 2004 wave of the HRS ob-
tained self-report information on respondents’ chronic dis-
eases and geriatric syndromes. Respondents were asked
whether a physician had diagnosed them with each disease
or whether they had symptoms of each syndrome. For this
study, diseases and syndromes were specified as follows:
CAD: physician diagnosis of heart attack or myocar-
dial infarction at any time previously or angina pectoris (or
chest pains due to the heart) in the previous 2 years.
CHF: physician diagnosis of CHF in the previous 2
DM: physician diagnosis of DM (or high blood sugar)
at any time previously.
UI: loss of urine beyond the respondent’s control in the
Falls: two or more falls or any injurious fall requiring
medical attention in the previous 2 years.
race, marital status, living situation (lives alone, with oth-
ers, or in a long-term care facility), educational attainment,
and net worth (total household assets minus current debt).
The HRS was designed to differentially select for partici-
pants so as to be nationally representative. To adjust for its
complex sample design, including the differential probabil-
ity of selection and nonresponse, all analyses were weighted
and adjusted using the statistical package STATA (Release
9.2, StataCorp, College Station, TX). Standard descriptive
methods were used to estimate the prevalence of and de-
termine confidence intervals for respondents with different
numbers of index conditions. Associations between index
conditions and demographic characteristics were estimated
using the chi-square test.
Of the 20,129 respondents interviewed in the 2004 wave of
the HRS, 11,113 were aged 65 and older, representing 37.1
million older adults nationally. Table 1 shows the sociode-
weighted to be nationally representative. The respondents
were classified according to their number of index condi-
tions (0, 1, 2, ?3). Respondents with more conditions were
older; more likely to be female, unmarried, living alone or
residing in a nursing facility; and had less education and a
lower net worth. No association was found between the
number of index conditions and race.
Table 2 shows the prevalence of each index condition
and its frequency of co-occurrence with other four condi-
tions. The prevalence of each index condition was: CAD
15.9%, CHF 4.8%, DM 19.4%, UI 25.0%, and falls
23.2%. In general, the chronic diseases and the geriatric
syndromes demonstrated substantial co-occurrence. Of the
three chronic diseases, CHF had the largest burden of co-
For respondents not reporting any of the three chronic
diseases, the prevalence of the two geriatric syndromes was
lower (data not shown). Sixty-four percent did not report
either geriatric syndrome, 15% reported only incontinence,
12% reported only falls, and 8% reported incontinence and
Figure 1 illustrates, for each index condition, the prev-
alenceof havingno, one,two, orthree otherconditions.For
each index condition, the prevalence of having at least one
additional condition exceeded 50%; the prevalence of hav-
ing two or more additional conditions exceeded 20%. Most
striking is the finding that more than 80% of respondents
with CHF had at least one other condition.
of thestudy population,
This cross-sectional study examined the prevalence of the
co-occurrence of three chronic diseases and two geriatric
syndromes in the older adult population. These diseases and
syndromes are important causes of morbidityin older adults
and are targets of management guidelines and clinical qual-
ity measures. Previous studies have shown that co-occurring
chronic diseases are common in older adults.3The current
study, using nationally representative data, furthers these
findings by demonstrating that the co-occurrence of chronic
diseases with geriatric syndromes is also common. Espe-
cially remarkable is the finding that more than 25% of older
adults with any one of the three chronic diseases also had at
least one of the two geriatric syndromes.
LEE ET AL.
MARCH 2009–VOL. 57, NO. 3 JAGS
The combination of chronic diseases and geriatric syn-
dromes can have a substantial effect on older adults’ func-
tional status and specifically on their ability to manage their
overall health. As has been demonstrated, the association
between geriatric syndromes and functional disability is as
strong as that between chronic diseases and functional dis-
ability.6The current study, although employing only five
common conditions, highlights that a substantial propor-
Table 2. Prevalence of Individual Co-Occurring Index Conditions
(Population Prevalence %)
Prevalence of Other Conditions in Respondents with Index Conditions
(%, 95% Confidence Interval)
CAD CHFDM UIFalls
All prevalence percentages were derived using the Health and Retirement Study (HRS) respondent population weights to adjust for the complex sampling design
of the HRS survey.
Percentages indicate the prevalence of the other four conditions in respondents with the index condition listed in the first column. For example, in respondents
with coronary artery disease (CAD), 17.3% also have congestive heart failure (CHF), 28.6% diabetes mellitus (DM), 28.9% urinary incontinence (UI), and
Table 1. Respondent Characteristics According to Number of Index Conditions
Number of Index Conditions, Weighted % (N511,113)
0 (n54,861)1 (n53,715)2 (n51,777)?3 (n5760)
6.9 Overall Prevalence
White or other (87%)
African American (8%)
Net worth, $
With others (67%)
Nursing home residence (4%)
Weightedpercentages derived usingtheHealthandRetirement Study(HRS)respondentpopulationweightsto adjustforthecomplexsamplingdesignof theHRS
Numbers represent row percentages (i.e., 48.1% of the respondents aged 65–75 had no index conditions).
?P-values are from chi-square test for association between the indicated variable and number of index conditions.
CO-OCCURRING DISEASES AND GERIATRIC SYNDROMES
513JAGS MARCH 2009–VOL. 57, NO. 3
tion of older adults have geriatric syndromes co-occurring
with their chronic diseases. Although geriatric syndromes
are not routinely considered to be comorbidities, their
prevalence, their effect on the functional status of older
adults, and their associated risk for poor quality of life
suggest that clinically they may be as important as other
comorbidities. Thus, physicians should address older
adult patients’ geriatric syndromes as well as their chronic
The prevalencerates of thechronic diseases in the study
were compared with those reported in the literature. The
prevalence of DM in older adults according to HRS data
compared favorably with data from the National Health
and Nutrition Examination Survey (NHANES, 1999–
2004).21Of adults aged 60 and older in the NHANES,
21% had DM; 19% of adults aged 65 years and older had
DM in the HRS. In contrast, the prevalence rates for CAD
and CHF in the HRS were lower than those for other pop-
ulation-based studies. In the HRS, 16% of adults aged 65
and older reported CAD, and 5% reported CHF. In the
National Health Interview Survey (2006), 22% of adults in
the same age group reported CAD, and 31% reported some
form of heart disease (CAD and other heart diseases).22
For NHANES data, the prevalence of CAD was 32% for
adults aged 80 and older; the prevalence of CHF was 5% to
12% for adults aged 60 and older.21The lower prevalence
in the HRS may in part be due to limiting the self-report
of angina pectoris and of CHF to the previous 2 years,
thereby not including respondents who reported angina
pectoris or CHF before this time period. The aim was to
minimize recall bias for these symptoms and diagnoses and
thus to make a conservative estimate of the prevalence of
CAD and of CHF.
The prevalence rates for the geriatric syndromes in this
study were similarly compared with those reported in the
literature. The current study found that 25% of adults aged
65 and older reported having any degree of UI in the pre-
vious year, whereas NHANES data yielded a prevalence of
12% for daily UI for women aged 60 to 64 and 21% for
women aged 85 and older.23The current study found the
prevalence of falls to be 23% of HRS respondents. (Falls
previous 2 years, similar to the criteria for falls in the Phy-
sicians QualityReporting Initiative quality measure used by
the Centers for Medicare and Medicaid Services.) Other
studies have reported that nearly one-third of older adults
fall at least once each year.24,25
From a physician and healthcare policy perspective,
patients’ healthcare quality appears to improve as their
number of medical conditions increases,26,27but from a
patient perspective, adherence to multiple management
guidelines can lead to undue burden for the older adult with
multiple diseases and syndromes. It has been found that
most health management guidelines do not modify their
recommendations or address the applicability of the rec-
ommendations for older adults with multiple chronic
Current indicators of clinical quality are likewise based
on individual diseases. Physicians caring for patients with
multiple diseases may be motivated to focus on single dis-
eases rather than to provide comprehensive and coordi-
nated care for all of their patients’ conditions. Guidelines
and clinical performance quality indicators for the geriatric
syndromes of UI and falls have been developed and are
beginning to be implemented. Although this is an important
step, with the potential to improve detection and manage-
syndrome at a time’’ management philosophy rather than
the integration and coordination of management interven-
tions for patients with complex health status. The current
study’s findings support the need for the implementation of
comprehensive management guidelines and quality indica-
CAD DM UI Falls
Prevalence of Co-Occurring Conditions (%)
Figure 1. Prevalenceofmultipleco-occurring indexconditions.wWeightedpercentages derivedusingtheHealthandRetirementStudy
(HRS) respondent population weights to adjust for the complex sampling design of the HRS survey. The percentages of respondents
with coronary artery disease (CAD), congestive heart failure (CHF), diabetes mellitus (DM), urinary incontinence (UI), or falls who
also had no, one, two, or three of the four other index conditions. Y-axis scale is 0 to 50.
LEE ET AL.
MARCH 2009–VOL. 57, NO. 3 JAGS
tors for physicians caring for older adults with multiple dis-
eases and syndromes; such guidelines and indicators of com-
prehensive clinical quality are now under development.28
Finally, from a research standpoint, the co-occurrence
of chronic diseases and geriatric syndromes in the cur-
rent study suggests that they may have shared risk factors.
The pathophysiological relationship between DM and
heart disease is well known, but the pathways relating
chronic diseases to geriatric syndromes have not been
fully explored. Future research investigating the causes of
the ‘‘clustering’’ of diseases and syndromes would have
benefit for prevention, early recognition, and manage-
ment of accumulating comorbid diseases and syndromes.
Such research might lead also to eventual prevention or
attenuation of functional disability and decreased quality
A key strength of this study is its use of HRS data. The
HRS is a nationally representative survey and includes de-
tailed information on chronic diseases and geriatric syn-
dromes. Although the HRS primarily collects self-report
data, it is one of the few nationally representative studies to
syndromes. Self-report data may be less reliable for certain
chronic diseases, although research suggests that good
agreement exists between validated evidence of myocardial
infarction, angina pectoris, CHF, and DM and the self-
report of these diseases.29
The current studyemploys cross-sectional analysis, and
causality cannot be determined, although respondents in
the HRS are interviewed every 2 years, making possible
future longitudinal studies to further evaluate the relation-
ship between chronic diseases and geriatric syndromes. In
addition, the prevalence of other common chronic diseases,
such as chronic lung disease or arthritis, and other geriatric
syndromes, such as delirium, were not analyzed. Rather,
diseases and syndromes with well-developed clinical per-
formance indicators, ones on which physicians are now
being measured, were selected to highlight the substantial
co-occurrence of these five diseases and syndromes. For
most primary care physiciansandother providers, these five
conditions occur commonly in their practices, and these are
the most common conditions for which payers and health
plans are measuring the quality of clinical care. Future re-
search is needed to more fully explore the effect of multiple
other geriatric syndromes on patients with multiple chronic
It has been convincingly argued that medical practice
should evolve to match the changes of an aging population
with a longer life expectancy.30Consistent with that view,
the results from the current study suggest that, as greater
numbers of older adult patients present with multiple co-
occurring diseases and geriatric syndromes, physicians will
be required to provide comprehensive care to address com-
plex health status. Clinical guidelines and measures of
the quality of clinical care must be developed that address
coordinated and comprehensive management of multiple
co-occurring diseases and syndromes rather than focus on
We would like to thank Ms. Zhiyi Tian for her assistance in
Conflict of Interest: The editor in chief has reviewed the
conflictof interestchecklistprovided bythe authorsandhas
determined that the authors have no financial or any other
kind of personal conflicts with this manuscript.
Financial Disclosure: Dr. Lee was supported by the
Veterans Affairs (VA) Special Fellowships Program in Ad-
vanced Geriatrics through the VA Ann Arbor Healthcare
System Geriatric Research, Education and Clinical Center
(GRECC); the John A. Hartford Foundation; and the Uni-
versity of Michigan Claude D. Pepper Older Americans In-
dependence Center. Dr. Cigolle was supported by a Ruth L.
Kirschstein National Research Service Award from the Na-
tional Institute on Aging (NIA; 1F32AG027649-01), the
National Institutes of Health, National Center for Research
Resources K12 Mentored Clinical Scholars Program at the
University of Michigan, the VA Ann Arbor Healthcare Sys-
tem GRECC, and the John A. Hartford Foundation. Dr.
Blaum was supported by NIA Grant R01 AG021493A and
the VA Ann Arbor Healthcare System GRECC. An early
version of this paper was presented as a poster at the Ge-
rontological Society of America’s Annual Scientific Meeting
in November 2007.
Author Contributions: All authors were involved in
study concept and design, data analyses, interpretation of
data, and preparation of manuscript.
Sponsor’s Role: None.
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