1
MULTIMORBIDITY
2
OBJECTIVES
Know and understand:
• The definition of multimorbidity and the associated
risks
• Why most clinical practice guidelines are not
appropriate for older adults with multimorbidity
• The 5 guiding principles for evaluating older adults
with multimorbidity and managing their care
• The challenges that clinicians must try to overcome
when caring for older adults with multimorbidity
3
TO P I C S C O V E R E D
• Introduction to Multimorbidity
• Limitations of Clinical Practice Guidelines
• Approach to the Older Adult with
Multimorbidity: 5 Domains
• Challenges to Caring for Older Adults with
Multimorbidity
4
I N T R O TO M U LT I M O R B I D I T Y ( 1 o f 2 )
• Defined as ≥3 chronic diseases
• Has distinctive cumulative effects for each
individual
• Associated with increased rates of:






Death
Disability
Adverse effects
Institutionalization
Use of health care resources
Impaired QOL
5
I N T R O TO M U LT I M O R B I D I T Y ( 2 o f 2 )
• Even when diagnosed with the same pattern of
conditions, older adults with multimorbidity are
heterogeneous in terms of:
 Illness severity
 Functional status
 Prognosis
 Personal priorities
 Risk of adverse events
• Treatment options also differ
• So multimorbidity requires a flexible approach to care
L I M I TAT I O N S O F C L I N I C A L
PRACTICE GUIDELINES (CPGs)
• Most focus on only 1 or 2 conditions and address
comorbidities in limited ways, if at all
• Older adults with multimorbidity are excluded or
under-represented in clinical trials, so there is little
focus on multimorbidity in the meta-analyses and
systematic reviews that inform CPGs
• CPG-based care may be cumulatively impractical,
irrelevant, or even harmful for individuals with
multimorbidity
6
A P P R O A C H TO E VA L U AT I O N
AND MANAGEMENT (1 of 3)
Five domains:
• Patient preferences
• Interpreting the evidence
• Prognosis
• Clinical feasibility
• Optimizing therapies and care plans
7
A P P R O A C H TO E VA L U AT I O N
AND MANAGEMENT (2 of 3)
Inquire about the patient’s primary concern
(and that of family and/or friends if applicable) and any objectives for visit
Conduct a complete review of care plan for person with multimorbidity
or
Focus on specific aspect of care for person with multimorbidity
What are the current medical conditions and interventions?
Is there adherence/comfort with treatment plan?
Consider patient preferences
Is relevant evidence available regarding important outcomes?
8
A P P R O A C H TO E VA L U AT I O N
AND MANAGEMENT (3 of 3)
Consider prognosis
Consider interactions within and among treatments and conditions
Weigh benefits and harms of components of the treatment plan
Communicate and decide for or against implementation
or continuation of intervention/treatment
Reassess at selected intervals for benefit, feasibility,
adherence, alignment with preferences
9
10
PAT I E N T P R E F E R E N C E S
• Guiding principle: Incorporate patient preferences
into medical decision making
• Care provided in accordance with CPGs may not
adequately address patient preferences
• Older adults with multimorbidity should have the
opportunity to evaluate choices and prioritize their
preferences for care, within personal and cultural
contexts
11
INTERPRETING THE EVIDENCE
• Guiding principles: Recognize the limitations of the
evidence base, and interpret and apply medical
literature specifically to older adults with
multimorbidity
• Key element of evidence-based medicine: whether
the information applies to the individual under
consideration
 Significant evidence gaps may exist concerning
condition and treatment interactions, particularly
in older adults with multimorbidity
12
PROGNOSIS (1 of 2)
• Guiding principle: Frame management decisions within
the context of risks, burdens, benefits, and prognosis
• Prognosis = remaining life expectancy, functional
status, QOL
• Discussion of prognosis can serve as an introduction to
difficult conversations
 Facilitate decision making, advance care planning
 Address patient preferences, treatment rationales,
and therapy prioritization
13
PROGNOSIS (2 of 2)
• Prognosis informs, but does not dictate,
management decisions within the context of patient
preferences
 The time horizon to benefit for a treatment may be
longer than the individual’s projected life span, raising
the risk of polypharmacy and drug-drug and drugdisease interactions
 Screening tests, too, may be non-beneficial or even
harmful if the time horizon to benefit exceeds
remaining life expectancy, especially because
associated harms and burdens increase with age and
comorbidity
14
CLINICAL FEASIBILITY
• Guiding principle: Consider treatment complexity and
feasibility
• Complex regimen → higher risk of nonadherence,
adverse reactions, impaired QOL, economic burden,
and caregiver strain and depression
• Some influences on complexity: number of steps in the
task, number of choices, duration of execution, and
patterns of intervening distracting tasks
OPTIMIZING THERAPIES
AND CARE PLANS
• Guiding principle: Choose therapies that optimize
benefit, minimize harm, enhance QOL
• Older adults with multimorbidity are at risk of:





Polypharmacy
Therapeutic omissions
Reduced benefit from medications
Actual harm
Suboptimal medication use
• Nonpharmacologic interventions may be more
burdensome than beneficial, if inconsistent with
patient preferences
15
16
CHALLENGES TO CARING FOR OLDER
A D U LT S W I T H M U LT I M O R B I D I T Y ( 1 o f 2 )
• Ever-changing health status of the patient
• Multiple clinicians and settings
• Need for multiple simultaneous decisions
• Inadequacy of evidence base
• Scarcity of prognostic tools; conflicting results
• Treatments meant to improve one outcome
may worsen another
17
CHALLENGES TO CARING FOR OLDER
A D U LT S W I T H M U LT I M O R B I D I T Y ( 2 o f 2 )
• Many clinical management regimens are too complex
to be feasible in this population
• Yet as clinicians attempt to reduce polypharmacy and
unnecessary interventions, they may fear liability
regarding underuse of therapies
• Patient-centered approaches may be too timeconsuming for the already overwhelmed clinician
within the current reimbursement structure and without
an effective interdisciplinary team
18
S U M M A RY ( 1 o f 2 )
• More than 50% of older adults have 3 or more
chronic diseases, referred to as “multimorbidity”
• Multimorbidity is associated with increased rates of
death, disability, adverse effects, institutionalization,
use of healthcare resources, and impaired QOL
• Older adults with multimorbidity are heterogeneous in
terms of illness severity, functional status, prognosis,
personal priorities, and risk of adverse events
19
S U M M A RY ( 2 o f 2 )
• Treatment of older adults with multimorbidity requires
a flexible approach because of heterogeneity among
patients and inadequacy of most clinical practice
guidelines
• The 5 domains of evaluating and managing older
adults with multimorbidity are to:
 Consider patient preferences
 Interpret relevant evidence
 Consider prognosis
 Consider treatment complexity and feasibility
 Optimize therapies and care plans
20
CASE 1 (1 of 4)
• An 86-year-old man comes to the office after recent
hospitalization for MI.
• His history includes DM, HTN, CAD, COPD, renal
insufficiency, and anemia.
• His medications include insulin 70/30, lisinopril,
metoprolol, aspirin, clopidogrel, simvastatin,
mometasone, formoterol, and albuterol.
• He lives alone; his daughter lives 5 miles away. He is
able to do all instrumental activities of daily living and
enjoys yard work and fishing.
21
CASE 1 (2 of 4)
• On examination, weight is 54.4 kg (120 lb) and BMI is
20 kg/m2. Sitting blood pressure is 98/60 mmHg, and
pulse is 60 bpm.
• Cardiovascular and pulmonary examinations are
normal.
• Laboratory findings include hemoglobin A1c of 8.0%
and hemoglobin of 12 g/dL.
22
CASE 1 (3 of 4)
Using the principles outlined in these slides, which of
the following is the best next step in managing this
patient?
A.
Start alendronate weekly with calcium and vitamin D
supplements.
B.
Discontinue simvastatin because of limited benefit given
life expectancy.
C.
Intensify insulin therapy and glucose monitoring to
achieve better glucose control.
D.
Discontinue lisinopril and monitor blood pressure.
E.
Switch insulin to metformin.
23
CASE 1 (4 of 4)
Using the principles outlined in these slides, which of
the following is the best next step in managing this
patient?
A.
Start alendronate weekly with calcium and vitamin D
supplements.
B.
Discontinue simvastatin because of limited benefit given
life expectancy.
C.
Intensify insulin therapy and glucose monitoring to
achieve better glucose control.
D.
Discontinue lisinopril and monitor blood pressure.
E.
Switch insulin to metformin.
24
CASE 2 (1 of 4)
• An 88-year-old man is brought to the clinic by his wife
because he has decreased appetite and progressive
weight loss. Over the past 2 months, he has not eaten
his favorite foods and has lost 3.6 kg (8 lb).
• His history includes advanced Alzheimer disease,
difficulty swallowing, and aspiration pneumonia, as well
as HTN, CAD, hearing loss, and anemia.
• His medications include aspirin, losartan
hydrochlorothiazide, metoprolol, simvastatin, iron,
multivitamins, donepezil, and memantine.
25
CASE 2 (2 of 4)
• The patient requires assistance with all activities of daily
living and speaks only 1 or 2 words over 24 hours.
• His wife is tearful and states that she is not ready to lose
him; she wants all recommended treatments for him.
• Physical examination and laboratory tests are
unchanged.
26
CASE 2 (3 of 4)
Which of the following is the next best step in
management of this patient?
A. Refer wife to psychiatry for possible depression.
B. Start mirtazapine to treat patient for depression.
C. Discontinue iron and donepezil and taper
memantine off.
D. Place feeding tube.
E. Start megestrol for appetite stimulation.
27
CASE 2 (4 of 4)
Which of the following is the next best step in
management of this patient?
A. Refer wife to psychiatry for possible depression.
B. Start mirtazapine to treat patient for depression.
C. Discontinue iron and donepezil and taper
memantine off.
D. Place feeding tube.
E. Start megestrol for appetite stimulation.
28
GRS8 Slides Editor:
Annette Medina-Walpole, MD, AGSF
GRS8 Chapter Authors:
Cynthia Boyd, MD, MPH
Matthew K. McNabney, MD
GRS8 Question Writer:
Birju B. Patel, MD, FACP
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society
SlideSlide
28 28