1030468

research-article2021
HHCXXX10.1177/10848223211030468Home Health Care Management & PracticeWittenberg et al.

Nursing Article

Home Health Care Management & Practice

Exploring the Association between

1­–11
© The Author(s) 2021
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Multimorbidity and Cognitive Impairment sagepub.com/journals-permissions
DOI: 10.1177/10848223211030468
https://doi.org/10.1177/10848223211030468

in Older Adults Living in the Community: journals.sagepub.com/home/hhc

A Review of the Literature

Grace F. Wittenberg, BS1 , Michelle A. McKay, PhD, RN, CCRN1,

and Melissa O’Connor, PhD, MBA, RN, FGSA, FAAN1

Abstract
Two-thirds of older adults have multimorbidity (MM), or co-occurrence of two or more medical conditions. Mild cognitive
impairment (CI) is found in almost 20% of older adults and can lead to further cognitive decline and increased mortality.
Older adults with MM are the primary users of home health care services and are at high risk for CI development; however,
there is no validated cognitive screening tool used to assess the level of CI in home health users. Given the prevalence of
MM and CI in the home health setting, we conducted a review of the literature to understand this association. Due to the
absence of literature on CI in home health users, the review focused on the association of MM and CI in community-dwelling
older adults. Search terms included home health, older adults, cognitive impairment, and multimorbidity and were applied
to the databases PubMed, CINAHL, and PsychInfo leading to eight studies eligible for review. Results show CI is associated
with MM in older adults of increasing age, among minorities, and in older adults with lower levels of education. Heart disease
was the most prevalent disease associated with increased CI. Sleep disorders, hypertension, arthritis, and hyperlipidemia
were also significantly associated with increased CI. The presence of MM and CI was associated with increased risk for death
among older adults. Further research and attention are needed regarding the use and development of a validated cognitive
assessment tool for home health users to decrease adverse outcomes in the older adult population.

Keywords
older adults, home health, multimorbidity, cognitive impairment, community-dwelling, assessment

Introduction on the health of older adults including decreased quality of

Life expectancy has improved considerably in recent
decades. In nearly 60 countries, the life expectancy of adults
exceeds 75 years.1 In the United States (US), the older adult
population (65 years and older) is projected to double by
2030.2 Therefore, the population of older adults is expected
to outnumber children for the first time in US history.2 In
tandem with the growing population of older adults is the
incidence of multiple chronic conditions. Multimorbidity
(MM) is any co-occurrence of two, but often more than two,
medical conditions within one person.3 Over 1/4 of
Americans and 2/3 of older adults currently have multiple
chronic conditions.4 Based on the 2018 National Health
Interview Survey data, 51.8% of US civilian, noninstitution-
alized adults were diagnosed with at least 1 of 10 chronic
conditions. Approximately 27.2% of adults had multiple
chronic conditions. Over 63% of older adults over 65 years
of age had two or more chronic conditions.5 The presence of
multiple comorbid conditions can have detrimental effects
life, increased poor self-rated health, depression, and limita-
tions in activities of daily living (ADLs).6
Cognitive impairment (CI) is a common chronic condi-
tion in older adults.4 Approximately 15% to 20% of people
age 65 or older living in America have mild cognitive impair-
ment (MCI), a stage between normal cognitive decline of
aging and dementia.7 MCI can affect memory or other think-
ing skills including decision making, judgment, and visual
perception.8 Individuals living with MCI are more likely to
develop dementia.8 As of 2021 in the US, about 6.2 million
people age 65 and older have Alzheimer’s dementia with
72% being 75 years old or older.9 About 50 million people
1
Villanova University, Villanova, PA, USA
Corresponding Author:
Grace F. Wittenberg, College of Liberal Arts and Sciences, Villanova
University, 800 Lancaster Avenue, Villanova, PA 19085, USA.
Email: wittenberggrace@gmail.com
2 Home Health Care Management & Practice 00(0)
have a form of dementia worldwide; this diagnosis is pro-
jected to reach 82 million in 2030 and 152 million in 2050.10
About 5 million adults aged 65 and older were diagnosed
with dementia in 2014 in the US; this diagnosis is projected
to be nearly 14 million by 2060.11 Older adults report recog-
nition of their own CI; however, these reports do not provide
a good estimation of the overall prevalence of CI among
older adults.12
As of 2016, there were an estimated 12,200 home health
agencies in the US.13 In 2015, almost 4.5 million people
received care and were discharged from home health agen-
cies.13 Of these patients requiring home health care services,
81.9% were aged 65 or older.13 Additionally, 60.9% of users
were female and 39.1% were male.13 Most users of home
health care services are older adults with MM and complex
medical conditions such as CI.14 Of all Medicare beneficia-
ries, 59.3% have three or more chronic conditions, specifi-
cally 82.3% of Medicare beneficiaries who use home health
have three or more chronic conditions.15 According to the
2015 to 2016 data from the National Center for Health
Statistics, 32.3% of home health patients had a diagnosis of
Alzheimer’s disease or other dementias in the US.13 The
prevalence of MCI among older adults using home health
care services is unknown. In home health care, the Outcome
and Assessment Information Set (OASIS) is required by the
Centers for Medicare and Medicaid (CMS) and monitors
care quality and patient improvement and serves as the basis
for reimbursement.16 The current OASIS-D includes cogni-
tive screening to assess cognitive functioning, level of alert-
ness, orientation, comprehension, concentration, and
memory using a 5 point Likert scale.17 The revised OASIS-E
includes a Brief Interview for Mental Status (BIMS) as well
as signs and symptoms for delirium.18 However, the OASIS
is not a specific tool for cognitive deficit measurement.
CI is associated with a significantly higher risk of 2-year
mortality in older adults.19 MCI negatively influences the
health outcomes of older adults including higher rates of pro-
gression to dementia when compared to older adults with
normal cognition.8,20 With the increase in number of older
adults living in the community who may need home health
care services for management of not only acute healthcare
needs, but MM and CI, more attention to these factors in
older adults using home health care services is warranted.
Therefore, a review of the literature was conducted to explore
the connection between MM and CI in older adults who live
in the community utilizing home health care services.
Methods
Data Sources, Searches, and Study Selection
PubMed, PsychInfo, and CINAHL databases were searched
for relevant articles using the following search terms: “home
care services, home health, cognition, cognitive decline, cog-
nitive impairment, cognitive dysfunction, older adults,
elderly, seniors, geriatrics, multiple chronic conditions, mul-
timorbidities, multiple comorbidity, disease.” This combina-
tion of searches produced 429 potentially relevant sources
which were screened by the lead author to determine whether
the following initial criteria were met: (1) Published during
the timeframe 2010 to 2020; (2) written in English; (3)
reported on the relationship between MM and CI among
older adults living in the community. The original intention
was to review studies specifically in the home health setting
that investigated CI in community-dwelling older adults who
receive home health services. However, the literature lacks
research on CI and home health services despite the associa-
tion between MM and CI in community-dwelling older
adults. Therefore, the focus shifted to exploring the relation-
ship of MM and CI in community-dwelling older adults.
Screening
Articles pertaining to older adults in the long-term care or
hospital settings were omitted from this review to focus on
applications of MM and CI in older adults living in the com-
munity. The lead author reviewed the remaining full-length
articles (n = 8), and they were further reviewed by the second
and third authors to determine final eligibility for inclusion
(see Figure 1). Articles were organized into a table of evi-
dence and analyzed based on design of study, sample charac-
teristics, and key findings (see Table 1). The seven levels of
evidence21 were applied to each article included in the review
with Level VII being the lowest level of evidence and Level
I as the highest level of evidence, reflecting the most rigor-
ous study design.
Findings
Findings were organized into four subcategories: demo-
graphics, significant chronic conditions, cognitive changes,
and mortality (see Table 2). All articles reported data from
the analysis of large longitudinal cohort studies.22–29 Six
studies were conducted in the US,23,25–29 one study was con-
ducted in the Netherlands22 and another in Italy.24 Across the
eight studies, sample sizes ranged from 37424 to 18, 913.27
Overall, each included study was denoted as Level IV.21
Demographics
Four studies examined the association of MM and CI with
increasing age.22,26,27,29 Aarts and colleagues22 analyzed data
from the Maastricht Aging Study (MAAS), to explore the
determinants of cognitive aging, with participants ranging
from 24 to 81 years old at baseline. The association between
96 chronic diseases and cognition were assessed at baseline
and at 6 and 12 years of follow-up. Verbal memory and psy-
chomotor speed were used to measure cognitive perfor-
mance. In this cohort, increased age negatively influenced
verbal memory and processing speed (p < .002). Fabbri and
Wittenberg et al. 3

Records identified through

database searching
(n = 380) Additional records
258 from PubMed identified through other
108 from CINHAL paper reference sections
14 from PsycInfo (n = 49)

Records after duplicates removed

(n = 425)

Records screened Records excluded

(n = 425) based on review of
title and abstract
(n = 401)

Full-text articles
Full-text articles
assessed for eligibility
excluded for not
(n = 24)
meeting criteria
(n = 16)

Studies included in
systematic review
(n = 8)

Figure 1.  Flow diagram for article search and selection processes.

collaborators29 used data of participants aged 65 and older
without dementia from the Baltimore Longitudinal Study of
Aging (BLSA) to explore the association of increased MM
with decline in cognitive function over time. BLSA partici-
pants were followed on average for 3 years. Measurements
included standardized neurocognitive tests to evaluate exec-
utive function, processing speed, memory, mental status, and
verbal fluency. A faster accumulation of chronic diseases
was significantly associated with a greater decline on cate-
gory (p = .01) and letter (p = .01) fluency tests with similar
but nonsignificant findings in executive function as partici-
pants aged. There was no significant association between a
faster accumulation of chronic diseases and memory decline
as the cohort aged. Both Koroukian et al.27 and Schiltz et al.26
utilized data from the Health and Retirement Study (HRS) to
evaluate MM burden and mortality in adults with no CI, mild
CI, and moderate/severe CI in a representative sample of US
older adults aged 50 or older and reported demographic asso-
ciations such as age, race, and ethnicity. In both studies,
moderate to severe CI increased across age categories and
the number of adults with no CI decreased as age
increased.26,27
Each team26,27 analyzed differences among people of dif-
ferent racial/ethnic backgrounds. In both studies, there were
a higher proportion of adults and older adults from racial/
ethnic minority groups in the mild and moderate/severe CI
categories as compared to the no CI group. Specifically, the
amount of Black non-Hispanic and Hispanic individuals
nearly doubled from the no CI category to the mild and mod-
erate/severe CI categories whereas the white non-Hispanic
group decreased slightly between the lack of CI group and
the CI group.26,27 Similarly, a larger percentage of people
with CI before death were from the same racial/ethnic
minorities.26
Three studies22,23,26 examined the role of sex in the asso-
ciation between CI and MM with conflicting results, and two
studies22,27 observed the role of education. Schiltz and col-
leagues found a greater percentage of mild CI and moderate/
severe CI preceding death in females as compared to males
among respondents to the HRS.26 Yet, opposing results have
also been reported where there is a stronger association of
MM with MCI and dementia in males than females.23
Vassilaki et al.23 followed 70-80-year-old cognitively intact
older adults for 4 years. Participants were assessed for MCI
and dementia at baseline and at 15-month intervals using
neuropsychometric and neuropsychological testing that
assessed performance in the memory, executive function,
language, and visuospatial cognitive domains. Having four
4
Table 1.  Table of Evidence.
Level of
Citation Purpose Design evidence Sample characteristics, size Key findings Strengths and limitations

Aarts et al. To investigate the effect Data was collected as part of the IV Participants are inhabitants in Higher education was associated with a significantly Strengths: first study to incorporate 96
(2010) of multimorbidity over Maastricht Aging Study (MAAS), the South of Limburg, the better performance of memory and processing speed chronic medical conditions, 12-year
a 12-year period of a which explored cognitive aging Netherlands Higher age negatively influenced memory and follow-up in a large population-based
population over a wide Participants of MAAS n = 1763 after screening processing speed sample, more representative result for
age range were recruited from to ensure no baseline The cardiac cluster and malignancies were associated the general population, and includes
the RegistratieNetwerk impairments that would with a significantly lower verbal memory performance data on disease duration
Huisartspraktijken (RNH) interfere with cognition and The cardiac cluster and malignancies were not Limitations: possible misidentification
Of the 4189 eligible participants, dropout among the three significantly associated with verbal memory in creating clusters, overly simplistic
1823 were randomly selected, measurements Cerebrovascular diseases, cardiac diseases, definition of multimorbidity by a simple
stratified for age, sex, and Participants fall within 12 malignancies, and movement disorders were disease count, and possibly missing
occupational achievement discrete groups between 24-81 significantly related to a decrease in processing speed health problems due to lack of self-
years A combination of malignancies and movement disorders report to general practitioner
was related to a faster decline in processing speed
Bratzke et al. To examine the Analysis of the existing longitudinal IV 73% of WRAP children are adult Support for a 4-class solution (depression, sleep, Strengths: found four distinct classes of
(2018) relationship between data from the Wisconsin Registry biological children of persons cardiovascular, and healthy) that included 14 of the chronic illness, new research in limited
multiple chronic for Alzheimer’s Prevention with Alzheimer’s Disease (AD) 40 chronic illnesses literature of relationship between MCC
conditions (MCC) and (WRAP), which included four Healthy controls with no The proportion of new-onset amnestic mild cognitive and cognition, provides new lines of
cognitive decline visits parental history of AD or impairment (aMCI) differed between MCC and thinking about AD risks and insights
Health History Questionnaire dementia developing aMCI into MCC self-management
derived from the National Predominantly female and Participants in class II (sleep) had higher aMCI than Limitations: study does not allow for
Institutes of Health (NIH) Caucasian, mean age of 54 those in class III (cardiovascular) investigation of temporal relationship
Women’s Health Initiative years old Non-amnestic mild cognitive impairment (naMCI) was between MCC and cognitive decline,
Memory Study Total sample n = 1285 not associated with MCC, suggests that relationship lack of a priori designs with attention
Commonly used cognitive tests between MCC and cognition pertains to the memory to MCC, had a relatively young cohort
were utilized at the four visits domain which decreased dementia diagnosis,
Findings consistent with evidence of an association self-reporting may lead to under/over-
between MCC and accelerated cognitive decline in reporting
people with dementia
Suggestive findings that specific MCC classes increase
cognitive aging in memory domain with possible
modifiable risk factor for AD
Fabbri et al. To explore the Baltimore Longitudinal Study of IV BLSA participants aged 65+, Number of chronic diseases increased significantly over Strengths: contributes new insight into the
(2016) association between Aging (BLSA) followed for average of 3 the follow-up period effect of declining physical health to age-
rate of physical Psychometricians administered years and free from dementia Faster accumulation of multimorbidity was significantly associated cognitive decline, longitudinal
deterioration and standard neuropsychological tests or mild cognitive impairment associated with faster rate of decline in category and design is one of the only to explore this
longitudinal decline at each study visit (MCI) at baseline and follow- letter fluency (similar effects on the Trail Making relationship, large community-dwelling
in cognitive function Baseline age and education were up Test-A and Trail Making Test-B) study sample, and the availability of
in elderly without assessed in years along with n = 756 No significant effect was found on visual and verbal multiple cognitive tests
dementia additional covariates Average education was 16.6 ± memory decline Limitations: BLSA population may have
2.5 years Participants who accumulated 1+ disease over the 5 had lower prevalence of some illnesses
Mean number of diseases was years of follow-up had a significantly greater decline and disability due to high demands
2.4 ± 1.6 in fluency to attend a clinic visit for testing, no
Most prevalent diseases were standard methodological approach
hypertension, lower extremity to measuring multimorbidity, and the
joint disease, and chronic average length of follow-up was short/
kidney disease varied

(continued)
 Table 1.  (continued)
Citation Purpose Design
Grande et al. To investigate the Participants were selected if they
(2015) proportion of mild met the outlined diagnostic
cognitive impairment criteria for MCI
(MCI) subjects who Baseline assessment of medical
revert to normal and neurological examination,
cognition (NC), laboratory testing, neuroimaging,
focusing on the role of neuropsychological assessment,
comorbidities and APOE genotyping
Comorbidity assessed using the
Cumulative Illness Rating Scale
(CIRS) comorbidity index
resulting in a total score (TSC)
Baseline and 12-month follow-
up visits assessed the whole
cognitive spectrum including
memory, language abilities,
visuo-spatial and visuo-perceptual
abilities, executive functions and
attention
Global Cognition measured
with the Mini Mental State
Examination (MMSE)
Koroukian To evaluate the burden Data from 2010 health and
et al. (2017) of multimorbidity retirement study (HRS) with
(MM) across people with no CI, mild CI, and
gradients of cognitive moderate/severe CI
impairment (CI) HRS is self-reported by 95% of
respondents and 5% by proxy
respondents every 2 years
Assessed cognitive status with the
35-item telephone interview
cognitive status (TICS) and proxy
respondents were asked directly
about the participant’s memory
MM variable was coded as 4-point
composite measure from MM0
to MM3
Additional biographical/personal
data was gathered
Schiltz et al. To evaluate the Retrospective study using
(2019) distribution of leading the longitudinal Health and
causes of death by Retirement study (HRS)
gradient of cognitive Surveys conducted every 2 years
impairment (CI) and for cognitive ability, chronic
explore the effect of conditions, etc.
the distribution of
death for different
combinations on
multimorbidity by
gradient of CI
5
Level of
evidence Sample characteristics, size
IV Cohort study carried out in
the Center for Research
and Treatment of Cognitive
Dysfunctions of the Luigi Sacco
Hospital, University of Milan
n = 503 who met the outlined
criteria for MCI
Final population = 374 after loss
to follow-up completely and
only telephone follow-up
Subjects were followed for a
mean of 32.0 ± 25.5 months
IV 2010 HRS survey participants (n
= 20,566)
Excluded 1357 people who
were dead at baseline, 193
people with missing values
for CI, 118 who had other
missing covariate values, and
376 people with a nonpositive
sampling weight
Final study participants after
2012 follow up was n =
18,913
Total weighted population
(representative HRS sample
extrapolated to the US
population of adults 50+) was
87,478,731
IV HRS survey participants with a
linked national death index
(NDI) and participated in
HRS survey within 3 years
preceding death (n = 11,822)
Those missing data on CI were
excluded (n = 2131)
9691 deceased people in study
population
Key findings
21 subjects (5.6%) reverted to NC, 110 remained stable Strengths: use of a hard endpoint of
MCI (29.4%), and 243 progressed (65%) to dementia
5.6% of subjects with MCI reverted to a state of NC
Post hoc analyses showed that those who developed
dementia had less comorbidities when compared to
people with stable MCI Limitations: comorbidities are not
The frequency of the APOE-4 genotypes was
statistically significant and higher in subjects who
developed dementia than in those with stable MCI or
who reverted to NC
Higher MMSE forms at baseline are associated with
higher probability to revert to NC than to develop
dementia
Respiratory, urologic, and psychiatric diseases were
more frequently observed in subjects who reverted
to NC than ones who developed dementia
Cardiac, hypertension, vascular/hematological, eye/
ear/nose/throat, upper gastrointestinal, lower
gastrointestinal, hepatic, renal, musculoskeletal/
integumentary, neurological and endocrine/metabolic
were not more frequent in those who reverted to NC
1.93% identified with mild CI and 1.84% identified with
moderate/severe CI
Greater percentage of mild or moderate/severe CI
were 85+ and of racial/ethnic minority
Percentage of people with fair/poor health increased as
CI increased
2-year mortality rate increased as CI increased
Regarding chronic conditions, the most significant
increase occurred for mild heart disease across
gradients of CI
Functional limitations increased across gradients of CI
Increased urinary incontinence among those with
moderate/severe CI
Increase in visual and hearing impairments as well as falls
(but only participants 65+) across gradients of CI
Dose-response association between greater CI and
limitations in IADLs and 2-year mortality
Higher percentage of people with CI before death are
older, female, racial minorities, and single, widowed,
or divorced compared with those without CI
95% of deceased had two or more chronic conditions
People with all levels of CI have significant
multimorbidity burden at their time of death
Higher levels of CI showed greater levels of functional
disability and higher prevalence of most geriatric
syndromes
Distribution of cause of death varies by combination of
morbidity with different levels of CI
Strengths and limitations
NC with precise neuropsychological
assessment, numerous tests to identify
MCI, wide-ranging cognitive assessments
in follow-ups
analyzed as time-dependent variable,
onset of new diseases are not
accounted for in statistical analysis,
small sample size related to the APOE
genotype information, and the potential
selection bias related to the specific
clinical setting weakens generalizations
Strengths: strong dose-response pattern
of increased MM burden and mortality
across gradients of CI, first study to
document increased MM burden in
individuals with higher levels of CI, and
first study to expand the definition
of complex MM beyond chronic
conditions, incorporating functional
limitations and geriatric syndromes
Limitations: unable to establish
temporality between some conditions
and more severe CI, do not account
for care received by individuals with CI,
measures of mild or moderate/severe
CI reflect cognitive functioning rather
than a clinical diagnosis of dementia
Strengths: shows considerable
heterogeneity in leading cause of death
across gradients of CI, provides help with
care management for people with CI,
results can increase clinical awareness
Limitations: misclassification of the
underlying cause of death, CTree
produces one tree compared to the
Random Forest analysis, persons may
have developed additional morbidities/
cognitive decline in gap between
response and death
(continued)
6
Table 1.  (continued)
Citation Purpose Design
Vassilaki et al. To determine the Prospective cohort study
(2015) association between Randomly selected participants
multiple chronic from the community, evaluated
conditions and the by a physician, and had
risk of incident mild neuropsychometric testing
cognitive impairment at baseline and at 15-month
(MCI) and dementia intervals
Information on chronic diseases
was collected using the
Rochester Epidemiology Project
(REP) medical records linkage
system
Defined multimorbidity as having
two or more chronic conditions
Cox proportional hazards
models were used to examine
the association between
multimorbidity and MCI
Wei et al. To better characterize Used data from the health and
(2017) the association retirement study (HRS), included
between incident participants who completed at
multimorbidity and least one interview regarding
cognitive decline physician-diagnosed chronic
over 14 years in conditions, and ≥2 cognitive
older adults by assessments between 200 and
incorporating physical 2014
functioning and to All required baseline measurements
compare a validated Excluded participants with baseline
multimorbidity- dementia based on telephone
weighted index (MWI) interview for cognitive status
and a simple disease (TICSm) and respondents
count in predicting represented by proxy
future rates of Global cognition was assessed with
cognitive decline TICSm
Episodic and working memory
were assessed
Measured multimorbidity using a
validated MWI
Performed covariate assessment on
predictors for multimorbidity and
cognitive functioning followed by
statistical analysis
Level of
evidence Sample characteristics, size
IV n = 2176 cognitively normal
participants in Olmsted
County, MN
Mean age ± standard deviation
78.5 ± 5.2
50.6% male
1884 (86.6%) had multimorbidity
IV Largely national representative
cohort of US adults
At baseline, 18,612 cohort-
eligible adults participated in Demonstrated that MWI provides a wider distribution,
the 2000 interview
Final sample included 14, 265
participants who contributed
73,700 observations over a
mean ± SD of 11 ± 4.2 years Multimorbidity is detrimental in episodic memory
Exclusions include those
with TICSm ≤6, proxy
representation, no follow-up,
missing covariates
At baseline, mean age of
participants was 66.6 ± 9.1
years, MWI 4.4 ± 3.9, TICSm
score 15.9 ± 4.1, immediate
recall 5.7 ± 1.6 words, delayed
recall 4.6 ± 2.0 words, and
serial 7s 3.6 ± 1.6
Key findings
No differences in frequency of multimorbidity, severe
multimorbidity, APOE ε4 allele, or duration of follow-
up according to sex
Mean age, frequency of obesity, and former smoking
were greater with greater comorbidity
APOE ε4 was not related to number of chronic
conditions
Over the median follow-up of 4 years, 583 participants
developed incident MCI or dementia
Multimorbidity was associated with greater risk of
MCI in men and women after accounting for sex and
education
Having four or more chronic conditions significantly
increased MCI risk in both sexes combined and in
men but not women
Five most common co-occurring chronic condition
pairs (dyads) were hypertension and hyperlipidemia,
hypertension and arthritis, hyperlipidemia and
arthritis, coronary artery disease (CAD) and
hyperlipidemia, and hypertension and CAD
Risk of MCI was significantly greater with the presence
of the most common dyads in both sexes
Multimorbidity using a validated MWI was associated
with accelerated and persistent rates of decline in
global cognition and verbal memory over time
more precision, and greater parsimony for predicting
cognition than simple disease count
MWI was associated with an acute decline and faster
rates of decline in cognitive functioning
and working memory, which are sensitive to
neurogenerative disease
Strengths and limitations
Strengths: MCSA is a large, prospective,
population-based study, comprehensive
evaluation by three independent
evaluators to assess MCI or dementia
by a consensus decision, blind follow-up
of evaluators, REP captures medical
information for all Olmsted County
residents who receive care in the
county, REP medical records linkage
system to identify relevant ICD-9
codes of all chronic conditions within
5 years of enrollment reduced temporal
ambiguity in diagnoses, and recall
bias could be eliminated due to data
gathered from ongoing medical care
Limitations: potential misclassification due
to use of ICD-9 codes to define chronic
conditions, limited power for subgroup
analyses according to sex, and primarily
Caucasian participants
Strengths: extends prior studies
of multimorbidity and cognitive
functioning, longest follow-up compared
to prior studies, shows an association
between multimorbidity and cognition
Limitations: MWI was limited to
16 chronic conditions, more
comprehensive assessments of
cognitive functioning were not used,
underdiagnosed and underreported
cases of dementia are likely present
in HRS
 Table 2.  Table of Evidence by Results.
Citation Demographics Significant Chronic Conditions Significant Cognitive Domain Changes Mortality

Aarts et al. (2010) Increased age negatively influenced verbal memory and Decreased processing speed was significantly related to the presence No significant association between the total number of  
processing speed (p < .002) of cerebrovascular diseases (p ≤ .05), cardiac diseases (p ≤ .05), medical conditions and cognitive domains of memory and
Females scored significantly higher in memory and processing malignancies (p ≤ .05), and movement disorders (p ≤ .01) processing speed
speed than males (p = .001) The co-occurrence of malignancies and movement disorders were
Higher education is associated with significantly better memory significant for decline in processing speed (p ≤ .05)
performance (p < .001) Cardiac diseases (p ≤ .05) and malignancies (p ≤ .05) were associated
with a significantly lower verbal memory performance individually
Bratzke et al. Participants with sleep disturbances had increased cognitive aging There was a significant association between multimorbidity  
(2018) within the memory domain as compared to participants in the (MM) and development of changes in memory with
cardiovascular group and healthy controls the highest incidence of new onset memory changes in
participants with sleep disturbances, sleep apnea and
hypercholesterolemia
No significant differences between MM and changes in
executive function
Fabbri et al. (2016) A significant association (p = .01) between a faster  
accumulation of chronic diseases and a greater decline on
category and letter fluency tests
No significant association between multimorbidity and
memory decline
Grande et al. Older adults with respiratory diseases such as COPD and sleep apnea,  
(2015) reverted from MCI back to normal cognition (NC)
Older adults with urologic disorders and mild psychiatric diseases
reverted to NC instead of progressing to dementia
Koroukian et al. Moderate to severe cognitive impairment (CI) increased across An increased prevalence of heart disease, severe stroke, and functional Compared to those without CI, individuals
(2017) age categories. The number of adults with no CI decreased limitations was found in participants with moderate/severe CI as with mild CI had 2 times greater risk
as age increased compared to those with mild CI and an even higher prevalence than of death within 2 years, and those with
There is a higher proportion of adults and older adults from those participants with no CI moderate/severe CI had 4 times greater
racial/ethnic minority groups, specifically Black non-Hispanic Falls and impairments in vision and hearing increased as CI impairment risk of 2-year mortality
and Hispanic individuals, in the mild and moderate/severe CI increased The presence of CI, whether mild, moderate
categories as compared to the no CI group There was a greater association of an individual having co-occurrence or severe, is associated with an increased
A high proportion of people with CI before death were of racial/ of chronic disease, functional limitations, and geriatric syndromes risk for mortality
ethnic minorities as the level of severity of CI increased from mild to moderate/
Of participants with no CI, 94% had more than 9 years of severe CI
education compared to approximately 72% of older adults With a greater level of CI, there was a significant increase in
with mild CI and almost 75.3% with moderate/severe CI who limitations in instrumental activities of daily living (IADLs) (p < .05)
had less years of education
Schiltz et al. Moderate to severe cognitive impairment (CI) increased across Mild heart disease and stroke as well as psychiatric conditions were Participants had significant MM at time of
(2019) age categories. The number of adults with no CI decreased common among those with CI at time of death death with 98% of older adults with mild
as age increased All geriatric syndromes (urinary incontinence, severe pain, hearing CI and 99% of older adults with moderate/
There is a higher proportion of adults and older adults from impairment, vision impairment and moderate/severe depressive severe CI having MM at the time of death
racial/ethnic minority groups, specifically Black non-Hispanic symptoms) and functional limitations in both activities of daily living The cause of death in older adults with no CI
and Hispanic individuals, in the mild and moderate/severe CI (ADLs) and IADLs, were found more often in those with CI was more commonly malignant neoplasm
categories as compared to the no CI group COPD and severe cancer were more common in older adults without as compared to those with mild or
A high proportion of people with CI before death were of racial/ CI moderate/severe CI
ethnic minorities The presence of ten or more chronic conditions was associated with The presence of CI, whether mild, moderate
A larger percentage of females had mild CI and moderate/severe increased CI or severe, is associated with an increased
CI than males preceding death risk for mortality
Vassilaki et al. Having four or more chronic conditions significantly increased The most common co-occurring chronic pairs were hypertension  
(2015) mild CI (MCI) risk in both sexes combined and in males and hyperlipidemia, hypertension and arthritis, hyperlipidemia and
independently (p ≤ .001) arthritis, coronary artery disease (CAD) and hyperlipidemia, and
hypertension and CAD
The presence of any of the dyads increased the risk of MCI in older
adults regardless of the presence of other chronic conditions
Wei et al. (2017) Increased multimorbidity-weighted index (MWI) was  
associated with an acute decline and faster rates of decline
in global cognition, immediate and delayed recall, and
working memory

7
8 Home Health Care Management & Practice 00(0)
or more chronic conditions significantly increased MCI risk
in both sexes combined and in males independently
(p ≤ .001). After adjusting for sex and education, MM was
associated with greater risk of developing MCI in both males
and females (p ≤ .001).23 Aarts et al.22 found that females
scored significantly higher in memory and processing speed
than males, suggesting a smaller rate of cognitive decline in
females (p = .001). In regards to education they reported that
higher education is associated with significantly better mem-
ory performance (p < .001).22 Koroukian et al.27 report simi-
lar results where 94% of participants with no CI had more
than 9 years of education compared to approximately 72% of
older adults with mild CI and almost 75.3% with moderate/
severe CI who had less years of education.
Significant Chronic Conditions
Three studies analyzed the specific significant comorbidities
associated with no CI, mild CI, and moderate/severe CI.22,26,27
Aarts et al.22 found a significant relationship between
decreased processing speed and the presence of cerebrovas-
cular diseases (p ≤ .05), cardiac diseases (p ≤ .05), malig-
nancies (p ≤  .05), and movement disorders (p ≤ .01).
Co-occurrence of malignancies and movement disorders
were significant for decline in processing speed (p ≤ .05) as
well. Cardiac diseases (p ≤ .05) and malignancies (p ≤ .05)
were associated with a significantly lower verbal memory
performance individually. The combined effect of the car-
diac diseases and malignancies did not have a significant
effect on verbal memory performance. Koroukian et al.27
reported that among HRS respondents, there was increased
prevalence of heart disease, severe stroke, and functional
limitations in participants with moderate/severe CI as com-
pared to those with mild CI and even higher prevalence than
those participants with no CI. Falls and impairments in vision
and hearing increased as CI impairment increased as well.
There was a greater association of an individual having co-
occurrence of chronic disease, functional limitations, and
geriatric syndromes as the level of severity of CI increased
from mild to moderate/severe CI. With a greater level of CI,
there was a significant increase in limitations in instrumental
activities of daily living (IADLs) (p < .05).27 Using the same
HRS respondent data, Schiltz et al.26 found similar results to
Koroukian et al.,27 but also investigated the comorbidity
associate with mild and moderate/severe CI at time of death
among participants. Mild heart disease and stroke as well as
psychiatric conditions were common among those with CI at
time of death. Additionally, all geriatric syndromes (urinary
incontinence, severe pain, hearing impairment, vision
impairment and moderate/severe depressive symptoms) and
functional limitations in both ADLs and IADLs, were found
more often in those with CI. Conversely, chronic obstrustive
pulmonary disease (COPD) and severe cancer were more
common in older adults without CI. The presence of ten or
more chronic conditions was associated with increased CI.26
Three additional studies investigated the association of
multiple chronic conditions and the presence of CI.23–25 Both
Vassilaki et al.23 and Bratzke et al.25 assessed the association
of co-occurring diseases on cognition. Vassilaki et al.23
reported 131 co-occurring chronic condition pairs (dyads) in
older adults. The most common co-occurring chronic pairs
were hypertension and hyperlipidemia, hypertension and
arthritis, hyperlipidemia and arthritis, coronary artery dis-
ease (CAD) and hyperlipidemia, and hypertension and
CAD.23 The presence of any of these dyads increased the risk
of MCI in older adults regardless of the presence of other
chronic conditions. Having more than 4 chronic conditions
increased risk of MCI for both males and females. Bratzke
et al.25 analyzed data from the Wisconsin Registry for
Alzheimer’s Prevention (WRAP), which includes data from
late middle-aged adult biological children of persons with
Alzheimer’s Disease (AD) and healthy controls. Data col-
lected included a health history questionnaire and neuropsy-
chological tests that measured working memory, executive
function, and verbal episodic learning and memory. They
identified four comorbidity groups for analysis: depression,
sleep, cardiovascular, and healthy. The presence of CI in
each group was analyzed between groups. The depression
class consisted of hypercholesterolemia, depression, and
arthritis, and the sleep class included hypercholesteremia,
sleep disturbances, and sleep apnea. The cardiovascular class
consisted of hypercholesterolemia, hypertension, and arthri-
tis, and the healthy class included participants with no
chronic illnesses. There were no significant differences in
cognitive decline between participants with MM and the
healthy controls. However, participants with sleep distur-
bances had increased cognitive aging within the memory
domain as compared to participants in the cardiovascular
group and when compared to the healthy controls.25 Grande
et al.24 reports interesting results among its cohort of 374
older adults. The primary purpose of this study was to deter-
mine which chronic conditions are associated with improve-
ment in MCI. Grande found that older adults with respiratory
diseases such as COPD and sleep apnea, actually reverted
from MCI back to normal cognition (NC) potentially due to
treatment of the underlying disease. They also found that
older adults with urologic disorders and mild psychiatric dis-
eases reverted to NC instead of progressing to dementia.
Specific Cognitive Domain Changes
Cognitive abilities encompass several specific cognitive
domains including language, visuospatial abilities, executive
cognitive function, memory, and attention.30 Research con-
firms measurable declines within these domains with increas-
ing age.30 Three previously discussed studies22,25,29 as well as
one additional study28 analyzed specific cognitive changes
associated with MM. Wei et al.28 analyzed HRS data, a cohort
of US older adults ≥ 51 years old. They analyzed global cog-
nition at baseline and at each biennial follow-up wave. The
Wittenberg et al. 9
researchers used the multimorbidity-weighted index (MWI)
as a measure of MM that encompasses cumulative burden of
chronic conditions along with decreased physical function-
ing. Increased MWI was associated with an acute decline
and faster rates of decline in global cognition, immediate and
delayed recall, and working memory.28 Conversely, Aarts
et al.22 did not find a significant association between the total
number of medical conditions and cognitive domains of
memory and processing speed.22
Fabbri et al.29 used data from the BLSA and reported a
significant association (p = .01) between a faster accumula-
tion of chronic diseases and a greater decline on category and
letter fluency tests; however, there was no significant asso-
ciation between MM and memory decline. Bratzke et al.25
also looked at the role of MM with both memory and execu-
tive function as pieces of CI among a cohort of late middle-
aged adults who are biologic children of adults with an
Alzheimer’s diagnosis. There was a significant association
between MM and development of changes in memory with
the highest incidence of new onset memory changes in par-
ticipants with sleep disturbances, sleep apnea and hypercho-
lesterolemia. There were no significant differences between
MM and changes in executive function.25
Mortality
Two studies examined the association of MM and CI with
mortality.26,27 Schiltz et al.26 studied the leading causes of
death with MM and increasing CI. Participants had signifi-
cant MM at time of death with 98% of older adults with mild
CI and 99% of older adults with moderate/severe CI having
MM at the time of death. The cause of death in older adults
with no CI was more commonly malignant neoplasm as
compared to those with mild or moderate/severe CI.26
Similarly Koroukian et al.27 found increased MM burden and
mortality with increased CI. Compared to those without CI,
individuals with mild CI had 2 times greater risk of death
within 2 years, and those with moderate/severe CI had 4
times greater risk of 2-year mortality.27 Both studies con-
clude that the presence of CI, whether mild, moderate or
severe, is associated with an increased risk for mortality.26,27
Discussion
In the home health population specifically, further research and
attention to CI is needed to identify areas for intervention and to
decrease the risk for adverse outcomes. Overall, there are con-
cerning interactions between MM and CI in community-dwell-
ing older adults. MM is associated with CI in different cognitive
domains in this population. CI increases with age22,26,27,29 and is
more common among those of racial and ethnic minorities.26,27
Sex differences vary across studies,22,23,26 but higher education22
is associated with significantly better memory performance.
Particular chronic conditions are more likely associated with
increased CI.22–27 Occurrence of heart disease and stroke26 are
associated with cognitive decline. Other disorders associated
with cognitive decline included sleep disorders,25 hyperlipid-
emia, arthritis, and hypertension.23 Changes in specific cogni-
tive domains are associated with increased MM including
decreased global cognition,28 changes in category and letter flu-
ency tests,29 immediate and delayed recall,28 and working
memory.28 Across all levels of CI, both mild and moderate/
severe, older adults with CI and MM have an increased risk for
death with heart disease being the most common cause of death
among older adults with CI and MM.26,27 Although the review
shows these interactions, the articles were all Level IV evidence,
reflecting large longitudinal cohort studies that lack highly rig-
orous research.21 Understanding levels of evidence is important
in evidence-based nursing when establishing best practice and
the need for additional research. Future research should focus
on more rigorous study designs with Levels I, II, or III evidence
in order to obtain more concrete data regarding the correlation
between MM and CI in older adults using home health
services.
With the population of older adults expected to double by
2030,2 those requiring home health services is also expected to
increase. Literature and research about home health care lacks
the discussion of CI in older adults with MM and the potential
for adverse outcomes. The present review provides evidence
about the concerning outcomes associated with MM and coex-
isting declines in cognitive functioning and the need for further
research to better understand MM and CI in older adults receiv-
ing home health services. MM is common among home health
care users;14 thus, it is imperative to have better screening for
CI to prevent adverse consequences. Currently, the home health
care team utilizes the OASIS-D which gathers data on cogni-
tive functioning, but there is no reliable and valid cognitive
screening tool required for admission of new home health
patients or ongoing recipients of home health. This prevents a
comprehensive understanding of CI in the individual and the
potential risk for poor outcomes. In addition to the OASIS, a
more detailed cognitive standardized screening tool should be
used on admission to the home health service and routinely to
assess CI on a continuum. Mild CI is associated with decreased
quality of life,31 increased incidence of falls,32 and increased
hospitalizations.33 More accurate detection of CI will assist
home health nurses to develop individualized plans of care
including supportive interventions to prevent falls, increase
quality of life, and potentially support caregivers as well.
Additionally, although no pharmacological treatments are
proven to prevent or slow the progression of mild CI to demen-
tia, lifestyle modifications including diet and exercise may be
effective avenues for intervention.34 Making cognitive func-
tioning screening a priority assessment on admission to home
health would ensure concrete follow up on the cognitive func-
tioning of a home health patient, prevention of other adverse
consequences, and proactively support future needs of this
population.
Further educational programs of the home health care
team must be strengthened to prevent the under detection of
10 Home Health Care Management & Practice 00(0)
CI while managing multiple chronic conditions in the home
health patient. First, the home health community must be
aware of the association between CI and MM specifically
upon admission to assist in the development of a compre-
hensive plan of care. While there is a gap in knowledge
regarding the association between CI and MM and home
health patients specifically, there is a distinct connection
among community-dwelling older adults making it neces-
sary to educate the home health care team of the existing
literature. This knowledge could also educate the interdis-
ciplinary team, including outpatient care providers and hos-
pital care providers, because having the knowledge of the
association between MM and CI can help the entire team
adjust an individual’s care plan to prevent adverse out-
comes. Education may be provided through various meth-
ods including mandatory training modules, lectures, and
continuing education credits as part of the existing home
health training through the workplace organization or spe-
cialty organizations. Education will provide the awareness
necessary to screen for CI especially when the patient has
MM. Through education and the use of a standardized
screening tool for CI, the team will be able to recognize
early declines in cognitive functioning and properly inter-
vene before the potential progression to dementia. These
interventions may include better management of a patient’s
multiple chronic conditions24 or memory training and care-
giver support35 to both limit CI progression and reverse
mild CI.
Finally, existing research shows a demographic bias.
Only two studies26,27 commented on the significance of
race and the association between MM and CI. About 76%
of home health care users are non-Hispanic white,13 yet
there needs to be critical research into why there is dispro-
portionate use among races in the US. Minorities in home
health experienced worse outcomes in ADLs as well as
rehospitalizations and ER visits compared to non-Hispanic
whites.36,37 Additional investigation into racial health dis-
parities is essential to ensuring racial justice in research.
Although most home health users are non-Hispanic white,
further research should include accessibility of home
health services to all racial and ethnic groups and the pres-
ence of CI in users of home health from different racial and
ethnic profiles.13 To better serve the home health commu-
nity, further studies on the association of MM and CI in
home health should include individuals of all racial back-
grounds. Focusing on inclusive research will help alleviate
the racism that leads to health care inequalities and assist
in better care overall especially for minority groups.
Although the current literature does not accurately repre-
sent the home health population demographics, this review
provides a snapshot of the existing literature regarding the
association between MM and CI of older adults living in
the community. It provides valuable insight into the con-
cerning association and the foundation for new avenues for
initial research and need for intervention.
Conclusion
The existing literature suggests an association between MM
and CI in community-dwelling older adults. No studies
explored this association within home health, proving an
expansive opportunity for further research. The research
within the community provides a strong foundation for tar-
geted home health research to study the under detection of CI
in older adults with MM. With more knowledge on CI in com-
munity-dwelling older adults with MM, the home health team
will be better prepared to treat these patients. To prevent
adverse outcomes in older adults, research must extend into
education of the home care team. Education will allow for ear-
lier recognition and intervention for CI to promote changes to
the care plan and maximize each patient’s quality of life.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Grace F. Wittenberg https://orcid.org/0000-0001-9862-3107
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