Download Multimorbidity.GRS9

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MULTIMORBIDITY
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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
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TOPICS COVERED
• Introduction to Multimorbidity
• Approach to the Older Adult with
Multimorbidity: 5 Domains
• Controversies and Challenges to Caring for
Older Adults with Multimorbidity
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INTRO TO MULTIMORBIDITY (1 of 2)
• Defined as ≥3 chronic diseases
 Affects more than 50% of older adults
• Has distinctive cumulative effects for each
individual
• Associated with increased rates of:






Death
Disability
Adverse treatment effects
Institutionalization
Use of health care resources
Decreased QOL
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INTRO TO MULTIMORBIDITY (2 of 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
LIMITATIONS OF CLINICAL
PRACTICE GUIDELINES (CPGs)
• Most focus on management of only 1 disease
• Older adults with multimorbidity are excluded or
under-represented in clinical trials and observational
studies, which translates to less representation in
meta-analyses, systematic reviews, and guidelines
• CPG-based care may be cumulatively impractical,
irrelevant, or even harmful for individuals with
multimorbidity
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APPROACH TO EVALUATION
AND MANAGEMENT (1 of 3)
Five domains:
• Patient preferences
• Interpreting the evidence
• Prognosis
• Clinical feasibility
• Optimizing therapies and care plans
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APPROACH TO EVALUATION
AND MANAGEMENT (2 of 3)
Inquire about the patient’s primary concern (and that of family and/or friends if
applicable) and any additional 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?
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APPROACH TO EVALUATION
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
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PATIENT PREFERENCES
• Guiding principle: Elicit and incorporate patient
preferences into medical decision-making
• Care provided in accordance with CPGs may not
adequately address patients’ individual preferences
• Older adults with multimorbidity should have the
opportunity to evaluate choices and prioritize their
preferences for care, within personal and cultural
contexts
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INTERPRETING THE EVIDENCE
• Guiding principle: Recognize the limitations of the
evidence base, and interpret and apply medical
literature specifically to older adults with
multimorbidity
• Key element of interpreting evidence-based
medicine: whether the information applies to the
individual under consideration
 Significant evidence gaps exist concerning
condition and treatment interactions, particularly
in older adults with multimorbidity
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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
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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
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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
• Education and assessments must be ongoing,
multifaceted, and individualized, and delivered via a
variety of methods and settings, because patients
generally do not recall discussion with clinicians.
OPTIMIZING THERAPIES
AND CARE PLANS
• Guiding principle: Choose therapies that maximize
benefit, minimize harm, enhance QOL
• Older adults with multimorbidity are at risk of:
 Polypharmacy
 Suboptimal medication use
 Potential harms from various interventions
• Reducing the number of meds can lower the risk of
adverse drug reactions
• Nonpharmacologic interventions may be more
burdensome than beneficial, if inconsistent with
patient preferences
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CHALLENGES TO CARING FOR OLDER
ADULTS WITH MULTIMORBIDITY (1 of 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
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CHALLENGES TO CARING FOR OLDER
ADULTS WITH MULTIMORBIDITY (2 of 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
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SUMMARY (1 of 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
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SUMMARY (2 of 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 clinical feasibility
 Optimize therapies and care plans
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CASE 1 (1 of 4)
• An 85-year-old woman comes to the office because she is
increasingly depressed by her medical conditions and
lifestyle.
 Because of osteoarthritis, her exercise is limited to housework.
 Her discouragement keeps her from participating in activities that
she is able to do.
• History: diabetes mellitus, stable angina with moderate
exertion, COPD, mild cognitive impairment, knee
osteoarthritis. Coronary angioplasty 6 years ago
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CASE 1 (2 of 4)
• Medications
aspirin 81 mg/d
atorvastatin 20 mg/d
lisinopril 10 mg/d
atenolol 50 mg/d
ipratropium 1 inhalation four times daily
salmeterol 1 inhalation every 12 hours
albuterol 1 puff every 4–6 hours as needed
acetaminophen 650 mg three times daily
extended-release glipizide 10 mg/d
• Laboratory findings:
Normal blood count and thyroid, kidney, and liver function tests
LDL cholesterol: 120 mg/dL
Hemoglobin A1c: 8.1%
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CASE 1 (3 of 4)
Which one of the following is most likely to improve her
quality of life?
A. Increase glipizide to 20 mg/d.
B. Add budesonide 1 puff by inhalation twice daily.
C. Refer to dietitian for a low-fat, diabetic diet.
D. Add donepezil 5 mg/d and titrate to 10 mg/d in 6
weeks.
E. Add escitalopram 10 mg/d.
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CASE 1 (4 of 4)
Which one of the following is most likely to improve her
quality of life?
A. Increase glipizide to 20 mg/d.
B. Add budesonide 1 puff by inhalation twice daily.
C. Refer to dietitian for a low-fat, diabetic diet.
D. Add donepezil 5 mg/d and titrate to 10 mg/d in 6
weeks.
E. Add escitalopram 10 mg/d.
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CASE 2 (1 of 3)
• An 85-year-old man wants to discuss options regarding
metastatic prostate cancer, which has progressed in
spite of hormone and radiation therapy. His oncologist
has proposed a trial of a new chemotherapy agent.
• History: heart failure (ejection fraction, 22%), chronic
renal failure (estimated GFR, 25 mL/min), and
peripheral vascular disease (walking limited to about 1
block)
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CASE 2 (2 of 3)
Which one of the following would be most useful in helping the
patient decide whether to start the new chemotherapy?
A. Relative risk reduction for death from prostate cancer
B. Number needed to treat for benefit from the chemotherapy
C. Number needed to harm from the chemotherapy
D. Clinical practice guidelines for the patient’s diseases
E. Time horizon for benefit from the chemotherapy
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CASE 2 (3 of 3)
Which one of the following would be most useful in helping the
patient decide whether to start the new chemotherapy?
A. Relative risk reduction for death from prostate cancer
B. Number needed to treat for benefit from the chemotherapy
C. Number needed to harm from the chemotherapy
D. Clinical practice guidelines for the patient’s diseases
E. Time horizon for benefit from the chemotherapy
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GRS9 Slides Editor:
Tia Kostas, MD
GRS9 Chapter Authors:
Cynthia M. Boyd, MD, MPH
Matthew K. McNabney, MD
GRS9 Question Writer:
Jerome Epplin, MD, AGSF
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2016 American Geriatrics Society
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