Relationship between hemoglobin and specific cognitive domain among older adults using network analysis.

OBJECTIVES: Hemoglobin (Hgb) is associated with cognitive function, with low and high levels of Hgb leading to impaired cerebral oxygenation and perfusion. Yet, current studies focused on understanding the association between Hgb and cognitive function without consideration for each cognitive domain. Thus, this study aims to identify and visualize potentially interactive associations between Hgb and specific cognitive domains among older adults. METHOD: This is a secondary data analysis using Wave II data from the National Social Life, Health, and Aging Project (NSHAP) and included 1022 older adults aged between 65 and 85 years. The network structure of three different models was estimated to understand the association between specific cognitive domains and Hgb in a mixed graphical model using the R-package 'mgm'. Model 1 did not adjust for any covariates, Model 2 adjusted for age and gender, and Model 3 adjusted for all covariates. RESULTS: Among all cognitive domains, the visuospatial (edge weight = 0.06-0.10) and memory domains (0.04-0.07) were associated with Hgb in all three models Though not present in Model 3, the attention domain was associated with Hgb in Model 1 and Model 2 (0.08-0.11). In addition, the predictability of Hgb was the highest (8.1%) in Model 3. CONCLUSION: Findings from this study suggest that cognition should be considered as a multidimensional construct, and its specific cognitive domain should be carefully assessed and managed in relation to Hgb among older adults.

Network Psychometrics of the 10-Item Perceived Stress Scale Among Patients With High Cardiovascular and Type 2 Diabetes Risk Using Exploratory Graph Analysis.

BACKGROUND: No studies have explored the internal structure of the 10-item Perceived Stress Scale in patients with high cardiovascular and diabetes risk. OBJECTIVE: We scrutinized the dimensionality of the scale in this patient group using exploratory graph analysis, a technique within the developing field of network psychometrics. METHODS: Analyses were conducted on 200 primary care patients. A bootstrap version of exploratory graph analysis assessed the stability of the dimensions based on structural consistency, item stability, and network loadings. RESULTS: Exploratory graph analysis revealed a 2-dimensional structure; structural consistency of the first dimension was high (0.863), whereas that for the second was low (0.667). Items belonging to the latter dimension did not cluster consistently with each other (ie, low item stability) and were not strongly associated with any particular dimension (ie, weak network loadings). CONCLUSION: Exploratory graph analysis offers unique outputs, making it easy to assess the dimensional integrity of scales. Further research is warranted regarding the second dimension of the Perceived Stress Scale.

Interactions Between Serotonin Transporter Gene and Adverse Childhood Experience in a Generalized Additive Model: A Pilot Study.

BACKGROUND: While most people experience potentially traumatic events (PTEs), including Adverse Childhood Experiences (ACEs), the stress reactions to PTEs on mental health outcomes are highly heterogeneous. Resilience is influenced by a complex biopsychosocial ecological system, including gene serotonin transporter-linked promoter region or 5-HTTLPR /rs25531 by ACEs interactions. AIMS: This pilot study investigated the gene-by-environment interactions on mental health outcomes in adults enrolled in a health care profession program using a generalized additive model (GAM). METHODS: Seventy health care college students (mean age = 27.4 years, 67.1% women) participated in this cross-sectional study. Saliva samples were collected from students to analyze 5-HTTLPR/rs25531. Participants completed the ACE Questionnaire and the Mental Health Inventory. GAMs with different interaction terms were built adjusting for age, gender, and race. The value of the effective degree of freedom (EDF) quantifies the curvature of the relationship. RESULTS: Among participants with the long allele of 5-HTTLPR/rs25531, a linear pattern was found between the total ACE score and mental health outcomes (EDF = 1). Conversely, among participants with the short allele, EDF was approximately 2, indicating a curved association suggesting that mental health worsens in individuals exposed to up to four types of ACEs. CONCLUSIONS: The impact of up to four ACEs on mental health was stronger among individuals with the short allele of 5-HTTLPR/rs25531 than those with the long allele. Although this study does not claim to provide a definite approach to analyzing gene-by-environment interactions, we offer a different perspective to explore the relationship.

Leveraging network analysis to determine sex differences in factors associated with frailty among older adults living alone.

BACKGROUND: Frailty is a complex geriatric syndrome typically characterized by multiple underlying etiological factors. We determined the contributing factors, by sex, using a network analysis. METHODS: The study sample consisted of a cross-sectional cohort of community-dwelling older adults aged ≥ 65 years living alone in a Korean city (N = 1,037). Frailty was assessed via the Korean Frailty Index. Participants were assessed for sociodemographic, health-related, mental and cognitive, and social characteristics. Mixed graphical models including all variables were estimated using the R-package mgm discretely by sex. We also used the Walktrap cluster algorithm to identify differences in the network structure in terms of connectivity around frailty between the sex groups for further insights. RESULTS: In both the networks for males and females, frailty correlated most strongly with nutritional status, presence of complex chronic disease, and self-efficacy, and exhibited proximity to decreased sleep quality and loneliness. However, frailty showed an association with suicidal ideation and the number of falls per year only in males, whereas it showed an association with functional disabilities only in females. The overall network connectivity around frailty was stronger with dense interactions (more edges) in the network for females than for males. CONCLUSIONS: The results signify the need for sex-group customized multi-domain assessments and interventions for the prevention and improvement of frailty among community-dwelling older adults.

Nonlinear Relationship Between C-Reactive Protein and Depression Among Obese Middle-Aged Adults.

BACKGROUND: Despite the agreement on the significance of the relationship between the C-reactive protein (CRP) and depression, research results have been discrepant by gender. OBJECTIVE: We attempted to address this uncertainty via a generalized additive model and more carefully analyzed the shape of the CRP-depression relationship in terms of sex. METHODS: This is a secondary data analysis using the National Health and Nutrition Examination Survey (2017-2020) data targeting 1,581 obese middle-aged adults (40-70 years, 51.4% women) with CRP ≤ 10 mg/L. The study outcome was depression severity, assessed by the nine-item Patient Health Questionnaire. Several models were built, adjusting for relevant sociodemographic, lifestyle, and clinical covariates. The value of the effective degree of freedom (EDF) quantifies curvature of the relationship. The threshold effect was investigated using a two-piecewise linear regression model, when needed. RESULTS: Among men, an increasing linear pattern was found (EDF ≈ 1). Contrastingly among women, the EDF value was > 2 in all unadjusted and adjusted models, indicating the smooth (curved) association. The threshold level affected the association pattern particularly for women, among whom the depression severity related to CRP significantly increased as the CRP level increased to an inflection point of 3.6 mg/L but decreased thereafter. DISCUSSION: Assuming linearity for the CRP association with depression may not be appropriate for middle-aged obese women. Although we do not claim to provide a definite method of assessing the CRP-depression relationship, we hope to offer a different perspective when exploring this relationship. Thus, the results should be interpreted cautiously, and future studies on this topic should replicate this approach with generalized additive models.

The application of clique percolation method in health disparities research.

AIMS: Clique percolation, one of the joint community detection algorithms in network science, is a novel and efficient approach to detecting overlapping communities in real networks. The current study illustrated how clique percolation can help to identify overlapping communities within the complex networks underlying health disparities, particularly highlighting nodes with strong associations with more than one community. DESIGN: A cross-sectional study. METHODS: The study used a dataset on Latinx populations (N = 1654; mean age = 43.3 years; 53.1% women) as an example to demonstrate the role of such overlapping nodes in the network of syndemic conditions and their common risk factors. Syndemic conditions in the network included HIV risk, substance abuse (smoking, heavy alcohol consumption and marijuana use) and poor mental health. Moreover, the risk factors encompassed individual (education and income) and sociostructural (adverse childhood experiences [ACEs] and access to services) factors. The network was estimated using the R-package bootnet. Clique percolation was conducted on the estimated network using the R-package CliquePercolation. RESULTS: A total of three communities were detected, with HIV risk and poor mental health not being assigned to any community. In general, Community 1 was comprised of ACE categories, Community 2 included education, income and access to services and Community 3 included other syndemic conditions. Of note, two nodes were assigned to two communities: 'household dysfunction' to Communities 1 and 2 and 'smoking' to Communities 2 and 3. CONCLUSION: Household dysfunction might be the key connector, among other ACEs, to individual and structural barriers. Such barriers further exposed Latinx individuals to risky behaviours, especially smoking, which further linked to marijuana use and heavy alcohol consumption. IMPACT: Clique percolation facilitated our understanding of the complex systems of factors shaping health disparities. The overlapping nodes are promising intervention targets for reducing health disparities in this historically marginalized population. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Identification of Relationships Among Resilience Factors Using Network Analysis: A Pilot Study.

BACKGROUND: Although college life can be fulfilling, it can be stressful, particularly for health professional students. In addition, they may have had Adverse Childhood Experience (ACE) that increases their sensitivity to academic stress. Yet, students need to overcome challenges to become successful professionals. The literature suggests the following factors may be associated with resilience: ACE and academic stress as the antecedents; ego-resilience, emotion regulation, resources, social support, inflammatory markers, and genes as the defining attributes; and mental health and sense of coherence (SOC) as the consequences. AIMS: The purpose is to identify the relationships among factors associated with resilience using network analysis. METHODS: A total of 70 college students participated in this cross-sectional pilot study. They completed measures of psychosocial variables and provided saliva samples, which were analyzed for Serotonin Transporter-Linked Promoter Region (5-HTTLPR)/rs25531 and inflammatory markers. Mixed graphical models including all variables were estimated using the R-package mgm. RESULTS: Network analysis revealed positive associations between (1) mental health and SOC; (2) mental health and resources; (3) mental health and social support; (4) SOC and reappraisal of emotion regulation; (5) resources and reappraisal of emotion regulation; and (6) resources and social support. In addition, SOC and academic stress were negatively associated. Furthermore, the short variant of 5-HTTLPR/rs25531 was associated with stronger suppression of emotion regulation and fewer resources compared with the long variant. CONCLUSION: Resilience may be influenced by biopsychosocial factors, notably SOC and 5-HTTLPR/rs25531. However, longitudinal research is needed with a larger sample size to better understand how these and other factors may affect resilience.

Sex Differences in Depressive Symptom Networks Among Community-Dwelling Older Adults.

BACKGROUND: Compared to male individuals, an increased prevalence of depression has been reported in older female individuals consistently over time. Sex (male/female) differences in depressive symptom networks may help explain the underlying causes of this increased vulnerability for female individuals. OBJECTIVE: This cross-sectional study investigated the sex (male/female) differences in depressive symptom networks among community-dwelling older adults in South Korea. METHODS: The analysis was based on the 2019 Korean Community Health Survey data targeting adults aged 65 years or older. Using network analysis, depressive symptom networks were constructed according to the items listed in the Patient Health Questionnaire-9 for propensity score-matched male and female groups. Strength centrality and network stability were tested. A network comparison test was performed to investigate the difference between the networks based on the invariance of global strength, network structure, edge strength, and specific centrality measures. RESULTS: Symptoms central to the network were similar between sexes, which were suicidal ideation, hopelessness, and psychomotor retardation/agitation. However, the global structure and network structure differed between sexes. The female symptom network showed more strengthened edges. Notably, four edges-loss of interest-hopelessness, sleep disturbance; low energy/fatigue; loss of interest-concentration difficulty; and worthlessness-concentration difficulty-were more pronounced in the female network. Strength centrality did not differ between the two networks. DISCUSSION: Our results may help guide future research and clinical interventions for female depression. In addition, educating health professionals on the differences in depressive symptom presentation will be crucial to ensuring that older female adults receive appropriate treatment.

Latent Profile/Class Analysis Identifying Differentiated Intervention Effects.

BACKGROUND: The randomized clinical trial is generally considered the most rigorous study design for evaluating overall intervention effects. Because of patient heterogeneity, subgroup analysis is often used to identify differential intervention effects. In research of behavioral interventions, such subgroups often depend on a latent construct measured by multiple correlated observed variables. OBJECTIVES: The purpose of this article was to illustrate latent class analysis/latent profile analysis as a helpful tool to characterize latent subgroups, conduct exploratory subgroup analysis, and identify potential differential intervention effects using clinical trial data. METHODS: After reviewing different approaches for subgroup analysis, latent class analysis/latent profile analysis was chosen to identify heterogeneous patient groups based on multiple correlated variables. This approach is superior in this specific scenario because of its ability to control Type I error, assess intersection of multiple moderators, and improve interpretability. We used a case study example to illustrate the process of identifying latent classes as potential moderators based on both clinical and perceived risk scores and then tested the differential effects of health coaching in improving health behavior for patients with elevated risk of developing coronary heart disease. RESULTS: We identified three classes based on one clinical risk score and four perceived risk measures for individuals with high risk of developing coronary heart disease. Compared to other classes we assessed, individuals in the class with low clinical risk and low perceived risk benefit most from health coaching to improve their physical activity levels. DISCUSSION: Latent class analysis/latent profile analysis offers a person-centered approach to identifying distinct patient profiles that can be used as moderators for subgroup analysis. This offers tremendous opportunity to identify differential intervention effects in behavioral research.

Socioeconomic Disparities in Cardiovascular Health in South Korea: A Systematic Review.

BACKGROUND: To improve the cardiovascular health of those with socioeconomic disadvantages, the nature of their disparities must be explored to inform targeted interventions for this group. However, these efforts have been scarce in all areas of nursing research and practice in South Korea. OBJECTIVE: This systematic review aims to examine the nature of socioeconomic disparities in cardiovascular health in South Korea. METHODS: Multiple electronic databases including PubMed, CINAHL, EMBASE, and Cochrane (2009-2019.06) were searched. A total of 42 articles published in English or Korean that examined socioeconomic disparities in cardiovascular health in South Korea were selected, reviewed, and analyzed using a narrative synthesis. RESULTS: Socioeconomic disparities existed in cardiovascular health among Korean populations across the disease continuum from risk factors to mortality. The magnitudes, directions, and significance of the observed associations between socioeconomic status and cardiovascular health varied by socioeconomic status indicators, gender, and age groups. Five studies (12%) explained the mediation and moderation of multiple factors to the associations. CONCLUSION: This body of knowledge will serve as a basis to inform strategies, interventions, or policies to reduce disparities in cardiovascular health.

Health Behavior Trajectories in High Cardiovascular Risk Populations: Secondary Analysis of a Clinical Trial.

BACKGROUND: The application of latent class growth analysis (LCGA) has been limited in behavioral studies on high-cardiovascular-risk populations. AIM: The current study aimed to identify distinct health behavior trajectories in high-cardiovascular-risk populations using LCGA. We also examined the baseline individual characteristics associated with different health behavior trajectories and determined which trajectory is associated with improved cardiovascular risk outcomes at 52 weeks. METHODS: This secondary analysis of a clinical trial included 200 patients admitted to primary care clinics. Latent class growth analysis was conducted to identify the trajectories of physical activity and dietary intake; these were measured at 4 different time points during a 52-week study period. Analysis of variance/χ2 test was used to assess the associations between baseline individual characteristics and trajectories, and logistic regression analysis was used to identify associations between trajectories and cardiovascular risk outcomes at 52 weeks. RESULTS: Three trajectories were identified for physical activity (low-, moderate-, and high-stable). Risk perception, patient activation, and depressive symptoms predicted the trajectories. High-stable trajectory for physical activity was associated with better cardiovascular risk outcomes at the 52-week follow-up. Two trajectories (low-stable and high-decreasing) were identified for percent energy from fat, but the factors that can predict trajectories were limited. CONCLUSIONS: Interventions are needed to target patients who begin with a lower physical activity level, with the goal of enhanced cardiovascular health. The predictors identified in the study may facilitate earlier and more tailored interventions.

The Contribution of Material, Behavioral, Psychological, and Social-Relational Factors to Income-Related Disparities in Cardiovascular Risk Among Older Adults.

BACKGROUND: Understanding the factors underlying health disparities is vital to developing strategies to improve health equity in old age. Such efforts should be encouraged in Korea. OBJECTIVE: This study explored how material, behavioral, psychological, and social-relational factors contribute to income-related disparities in cardiovascular risk among Korean adults 65 years and older. METHODS: This was a secondary analysis of Korean National Health and Nutrition Examination Survey data (2013-2017), targeting 7347 older adults (≥65 years). Socioeconomic position, defined as income, was the primary indicator. The outcome was binary for predicted cardiovascular risk (<90 vs ≥90 percentile). Disparities were measured using relative index of inequality (RII). The contributions of material, behavioral, psychological, and social-relational factors were estimated by calculating percentage reduction in RII when adjusted for these factors. RESULTS: Among men aged 65 to 74 years and women 75 years or older, the largest reductions in RII were achieved after adjusting for social-relational factors. Among men 75 years or older and women aged 65 to 74 years, adjusting for material factors resulted in the largest reductions in RII. Adjustments for behavioral factors also reduced RII for both genders aged 65 to 74 years. CONCLUSIONS: Improving the social, material, and behavioral circumstances of lower-income older adults may help address income-related disparities in cardiovascular risk in old age.

Enhancing the Isolation and Performance of Control Planes for Fog Computing.

Fog computing, which places computing resources close to IoT devices, can offer low latency data processing for IoT applications. With software-defined networking (SDN), fog computing can enable network control logics to become programmable and run on a decoupled control plane, rather than on a physical switch. Therefore, network switches are controlled via the control plane. However, existing control planes have limitations in providing isolation and high performance, which are crucial to support multi-tenancy and scalability in fog computing. In this paper, we present optimization techniques for Linux to provide isolation and high performance for the control plane of SDN. The new techniques are (1) separate execution environment (SE2), which separates the execution environments between multiple control planes, and (2) separate packet processing (SP2), which reduces the complexity of the existing network stack in Linux. We evaluate the proposed techniques on commodity hardware and show that the maximum performance of a control plane increases by four times compared to the native Linux while providing strong isolation.

Accumulation and toxicity of intravenously-injected functionalized graphene oxide in mice.

Graphene and its functionalized derivatives have recently emerged as interesting nanomaterials with promising applications in biomedicine. In this study, the long-term in vivo biodistribution of intravenously injected nanographene oxide (NGO) functionalized with poly sodium 4-styrenesulfonate (PSS) was systematically examined and the potential toxicity over 6 months of NGO-PSS nanoparticles was investigated. Our results showed that the nanoparticles mainly accumulate in the lung, liver and spleen, where they persist for at least 6 months. These nanoparticles result in acute liver injury and chronic inflammation of the lung, liver and spleen, as evidenced by blood biochemistry results and histological examinations.

Electron field emission enhancement of vertically aligned ultrananocrystalline diamond-coated ZnO core-shell heterostructured nanorods.

Enhanced electron field emission (EFE) behavior of a core-shell heterostructure, where ZnO nanorods (ZNRs) form the core and ultrananocrystalline diamond needles (UNCDNs) form the shell, is reported. EFE properties of ZNR-UNCDN core-shell heterostructures show a high emission current density of 5.5 mA cm(-2) at an applied field of 4.25 V µm(-1) , and a low turn-on field of 2.08 V µm(-1) compared to the 1.67 mA cm(-2) emission current density (at an applied field of 28.7 V µm(-1) ) and 16.6 V µm(-1) turn-on field for bare ZNRs. Such an enhancement in the field emission originates from the unique materials combination, resulting in good electron transport from ZNRs to UNCDNs and efficient field emission of electrons from the UNCDNs. The potential application of these materials is demonstrated by the plasma illumination measurements that lowering the threshold voltage by 160 V confirms the role of ZNR-UNCDN core-shell heterostructures in the enhancement of electron emission.

Mediatorless N(2) incorporated diamond nanowire electrode for selective detection of NADH at stable low oxidation potential.

The electrocatalytic properties of a N2 incorporated diamond nanowire (N-DNW) unmodified electrode towards the oxidation of nicotinamide adenine dinucleotide (NADH) was critically evaluated. The electrochemical behavior of the N-DNW unmodified electrode was examined and compared with that of boron-doped diamond, glassy carbon electrode, and graphite electrodes. The N-DNW electrode had high selectivity and high sensitivity for the differential pulse voltammetric detection of NADH in the presence of ascorbic acid at the lower and stable oxidation potential. Moreover, it exhibited strong stability after prolonged usage. The oxidation peak potential at the N-DNW electrode remained unchanged even after exposure to the solution, followed by washing, drying, and storage in laboratory air for 20 days, with minimization of surface contamination. Therefore, the N-DNW unmodified electrode shows promise for the detection of NADH and is attractive for use in a dehydrogenase based biosensor and other analytical applications.

Examining racial differences in the network structure and properties of specific cognitive domains among older adults.

Older adults oftentimes experience cognitive aging which leads to varying degrees of cognitive impairment. Previous studies have found that racial and ethnic disparities exist in the prevalence and severity of cognitive impairment among older adults. Yet, little is known on the relationship among specific cognitive domains and how this relationship differs between African American and White older adults. This is a secondary data analysis of Wave II (2010-2011) data from the National Social Life, Health, and Aging Project (NSHAP). A total of 2,471 older adults aged between 65 and 85 years old (African American n = 452, White n = 2019) were included. Network analysis was used to visualize and characterize the network structure and to examine network stability. Then, network comparison test was conducted to compare the network properties of the cognitive network structure between African American and White older adults. African American older adults had a lower cognitive function in all cognitive domains than White older adults. While there was no significant difference in global strength, there was a significant difference in the network structure and strength centrality measure between the two groups (p < 0.05). The invariance edge strength test found the language-visuospatial edge to be significantly stronger in African American older adults. Clinicians need to understand the different cognitive function across multiple cognitive domains between African American and White older adults and routinely offer targeted and timely cognitive assessment and management in this population.

An Examination of the Non-linear Relationship Between Cognition and Total Hemoglobin Among the Cognitively Normal Older Adults by Gender.

Objectives: This exploratory study aimed to identify the potential non-linear relationship between hemoglobin (Hgb) and cognition among cognitively normal older adults and how this relationship differs in terms of gender in generalized additive models (GAM). Methods: This is a secondary data analysis using Wave II (2010-2011) data from the National Social Life, Health, and Aging Project. A generalized additive model was used to understand the non-linear relationship between Hgb and cognition, and to identify critical Hgb point related to cognition. Results: While both genders had a non-linear association between Hgb and cognition, the degree of non-linearity was more pronounced in male older adults with EDF value close to 2. The inflection point of 15.10 g/dL for male older adults and inflection point of 11.72 g/dL for female older adults were obtained. Conclusion: Further studies are needed to validate these results and develop precision medicine approaches to integrate these results into clinical practice.

How is inflammation biology truly associated with depression in patients with stable coronary heart disease?: Insights from the heart and Soul study.

Depression is known to be associated with inflammation among patients with established coronary heart disease (CHD), but it is unclear whether this is due to individual depression symptoms or to the broader construct of depression. We addressed this gap by using moderated non-linear factor analysis (MNLFA) to determine the extent that inflammation is associated with latent depression and/or individual symptoms in this patient group. We evaluated 1,024 outpatients with stable CHD from the baseline cross-sectional data of the Heart and Soul Study. Depression was assessed using the 9-item Patient Health Questionnaire, while inflammation was evaluated via C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and monocyte chemoattractant protein-1 (MCP-1) levels. MNLFA is based on the concept of model parameter moderation with regard to individual characteristics. Using the MNLFA approach, we simultaneously tested for differences in (1) latent depression, (2) individual depression items, and (3) the factor loading of the item on latent depression as a function of inflammatory markers, with and without covariate adjustment. Higher TNF-α levels were associated with both higher levels of a latent depression factor and greater endorsement of an individual symptom (appetite changes). Increased CRP levels were significantly associated with greater appetite changes, lower concentration difficulty, and greater fatigue. Elevated IL-6 levels were only related to greater fatigue, while increased MCP-1 levels were linked to greater sleep disturbance. After adjusting for covariates, some associations became insignificant. Inflammatory markers were not consistent predictors of factor loadings. This study represents the initial step to discussing how inflammation biology is truly related to depression among patients with established CHD.

A network-based approach to explore comorbidity patterns among community-dwelling older adults living alone.

The detailed comorbidity patterns of community-dwelling older adults have not yet been explored. This study employed a network-based approach to investigate the comorbidity patterns of community-dwelling older adults living alone. The sample comprised a cross-sectional cohort of adults 65 or older living alone in a Korean city (n = 1041; mean age = 77.7 years, 77.6% women). A comorbidity network analysis that estimates networks aggregated from measures of significant co-occurrence between pairs of diseases was employed to investigate comorbid associations between 31 chronic conditions. A cluster detection algorithm was employed to identify specific clusters of comorbidities. The association strength was expressed as the observed-to-expected ratio (OER). As a result, fifteen diseases were interconnected within the network (OER > 1, p-value < .05). While hypertension had a high prevalence, osteoporosis was the most central disease, co-occurring with numerous other diseases. The strongest associations among comorbidities were found between thyroid disease and urinary incontinence, chronic otitis media and osteoporosis, gastric duodenal ulcer/gastritis and anemia, and depression and gastric duodenal ulcer/gastritis (OER > 1.85). Three distinct clusters were identified as follows: (a) cataracts, osteoporosis, chronic otitis media, osteoarthritis/rheumatism, low back pain/sciatica, urinary incontinence, post-accident sequelae, and thyroid diseases; (b) hyperlipidemia, diabetes mellitus, and hypertension; and (c) depression, skin disease, gastric duodenal ulcer/gastritis, and anemia. The results may prove valuable in guiding the early diagnosis, management, and treatment of comorbidities in older adults living alone.