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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 TOPICS COVERED • Introduction to Multimorbidity • Approach to the Older Adult with Multimorbidity: 5 Domains • Controversies and Challenges to Caring for Older Adults with Multimorbidity 4 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 5 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 6 APPROACH TO EVALUATION AND MANAGEMENT (1 of 3) Five domains: • Patient preferences • Interpreting the evidence • Prognosis • Clinical feasibility • Optimizing therapies and care plans 7 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? 8 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 9 10 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 11 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 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 • 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 15 16 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 17 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 18 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 19 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 20 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 21 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% 22 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. 23 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. 24 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) 25 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 26 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 27 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 SlideSlide 27 27