Keeping safe on the road

Judith Davey

10/01/2020

If you are at least 74 years old, an AA member and hold a valid driver licence, you will be valid for a free coaching session to help keep you confident and safe behind the wheel. It is a way to check safe driving skills and road rule knowledge (as advertising recently in the AA magazine and on their website). This is one of several recent initiatives aimed at the safety of older drivers – a growing segment of road users in New Zealand.

Another is a 45-page booklet “The road ahead: Transport options for seniors”. published by the NZ Transport Agency (updated edition February 2019).

I have found both sources informative and valuable. I booked a coaching session through 0800 223 748 (aa.co.nz/senior-driver). A friendly AA driving instructor came to my home for a session which took about 45 minutes. First, we sat in the car to ensure it was correctly set up for me as the driver and I outlined my driving concerns – such as right turns into traffic as I emerge from my garage. Then I drove around my local area – on a route of my choice – pointing out where I have difficulty. We talked about “blind spots”, signalling, hazard identification and positioning on the road. After the drive we had a review and I seem to have scored well. I was even congratulated on driving a manual car, which is becoming much less common.

I am apparently eligible for a free coaching session every two years, so I encourage other older drivers to take advantage of this offer. It would be a splendid preparation for people who are obliged to complete an official on-road safety test to renew their licences.

Which brings me to the NZTA booklet.

This is well produced with large fonts and useful illustrations, for example of give-way rules. After questions to self-check driving ability, there are tips for safe driving and keeping up with the road code.

In New Zealand, a driver licence is valid in periods of ten years up to the age of 75. After this, a licence is valid for five years, then must be renewed every two years over the age of 80. At each renewal a medical certificate from a health practitioner is needed, which includes an eye-sight test.

This is not a straight pass-fail as some people may think.

After completing a clinical assessment, the GP may recommend one of the following:

  1. The patient is medically fit to drive and does not require further assessment.
  2. The patient is medically fit to drive with specified conditions.
  3. The patient is medically fit to drive but an on-road safety test with a testing officer is recommended.
  4. The patient needs further assessment before they can be deemed medically fit to drive (the patient may be referred for specialist medical assessment or to an occupational therapist for driving assessment).
  5. The patient is not medically fit to drive.

GPs may recommend that conditions are imposed on a driver’s licence to improve safety such as:

  • using only an automatic vehicle,
  • no night driving,
  • driving only within 10 kilometres of home,
  • driving only after 9.00 a.m. and before 3.00 p.m.

Older age itself is not a barrier to driving – there are thousands of licence holders in New Zealand aged over 90. However, medical conditions that can affect safe driving increase with age, e.g. dementia, stroke and cardiovascular disease. Other age-related factors that may impair driving include earlier onset of fatigue, slowed responses, visual problems, impaired cognitive function and impaired mobility.

So, take up the opportunities offered,

Age Concern New Zealand recently secured the NZTA national contract to deliver free “Staying Safe” driver education refresher courses across New Zealand. Check with your nearest Age Concern to see when the next course is running!http://www.ageconcern.org.nz

 

 

 

 

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Gym. Any place for me?

With guest blogger; Doug Wilson.

I’ve been going to a gym for two years. I joined when I was 80 which suggests I’m slow to make decisions. I was very concerned at what I might meet: finely tuned young bodies, massive weights lifted by young giants and Brunhildes, and young mothers dancing to loud rock music. My chaotic ignorance, bigotry, and fantasy was demolished at the door. Many of the participants where in their 40s 50s and above. Recovering Individuals after strokes and accidents were fighting to get back to fitness. Most appeared to be serious individuals anxious to improve their health. So I joined in, carefully.

I have long had a scientific interest in ageing. I’ve also been intimately involved in the development of drugs for the treatment of diseases of ageing, such as stroke, heart attacks, high blood pressure, chronic bronchitis, and hypertrophy of the prostate. I’ve also been on teams that failed to find a drug for Alzheimer’s disease.  So anything that helps delay the ageing process is of both scientific and deep personal interest to me.

As part of my campaign to improve my personal longer healthy living, exercise is the top player, almost an Elixir of life so powerful is its positive impact. There are two forms of exercise to consider: aerobic exercise where you run and jump, get your heart pounding and your lungs struggling for breath. Multiple studies around the world have confirmed 20 minutes a day, or 150 minutes a week of serious exercise can reduce your risk of premature death by up to 30%, and particularly benefit risks of stroke, and heart attacks. But also cognition, a measure of mental function, is improved, and recent information suggests that the risks of dementia may be reduced. The other form of exercise engages your fading muscles, to improve their strength, and improve your balance, to reduce the risk of falls, which are far more common as we age, with serious consequences such as breaking of hips, and serious brain injury.

For the long-term health benefit, at any age, a proper exercise program is like a godfather deal, and you win anyway.

I have a personal trainer, a fine 60 year old, slight woman, who combines empathy with tough persuasion to follow a plan. Phrases like you’re rolling your eyes indicate a serious disdain for any lack of my commitment. My stability was wobbly, so getting me to walk backwards downstairs as part of my mobility re-education was a terrifying prospect for an old fellow. I’ll catch you she says confidently. I glanced nervously at her slight build. Don’t worry I’ve been a sheep shearer. Now I’m the ageing Merino ram being tugged on to the shearing floor for the final time. When I succeed in going up a stage in some task performance she says kindly good boy, like I’m the sheepdog. Wuff, wuff.

Recently I’ve extended my interaction by joining a group of fit, bouncy 60 and 70-year-olds who leap about like new born lambs to the sound of music, a transplanted 1980s Jane Fonda class. I began to leap and clap my hands above my head, try hopscotch, and running through a zigzag as if I was in a sheepdog trial and toss basket balls at pace. Very fit women in leotards sometimes call at me, get a move on man, with no consideration I’m 82 years. But surprise, I’m beginning to enjoy it, and feel much better after.

The gym gives me motivation, guidance, and periods of guilt when I don’t attend. But as I read the scientific literature it is clear. Avoiding exercise, now termed the sitting disease, carries higher risks of heart attacks, diabetes, stroke, obesity, and dementia. As I look at that list I want to push them all into the distance. Get away, it’s not time yet. So the gym becomes more than a place to exercise, and more and more my physical, mental, and social partner on the positive journey over the next few years.

It’s never too late, and the words better late than never carries serious implications as we age. Put down the remote, get exercising, find a trainer, but not mine as she’s busy.

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Challenges for the hospice movement

The overall challenge that faces the movement, in New Zealand and elsewhere is to maintain the vision that led to the founding of modern hospices – the holistic care of the dying – which was outlined in my previous blog. This is despite growing administrative demands and funding pressures[1].

  • The widespread assisted dying debate has profound implications for the hospice movement and has forced palliative care into a defensive position. Proponents of assisted dying support their case by maintaining that hospice cannot provide effective pain relief and adequate symptom control. The End of Life Choice Bill passed its third reading in the New Zealand Parliament, seeks to give people with a terminal illness the option of requesting assisted dying.
  • Palliative care in New Zealand is currently substantially under-resourced. The Government recognised the need in its 2000 New Zealand Palliative Care Strategy Document. Full implementation of this strategy requires continuing advocacy to ensure that it retains priority among other healthcare needs, especially when obtaining funding for the medical and technical aspects of end of life care may be seen as a high priority.

The Government provides, on average, around 50% of hospice core functions (some hospices receive just 38% of their total budget while others receive up to 75% – Mary Potter 45%). The remaining amount is funded by public donations and bequests, grants, and fundraising, including charity shops. Mary Potter Hospice has 8 shops, which provide 15% of its income – around $2 million a year. Interesting innovations in this area include an agreement with SKY TV, whereby shops in Thorndon and Porirua are drop-off points for SKY decoders, remotes and cables. This additional revenue stream is worth around $30,000 a year. The Hospice has a TradeMe page and shop volunteers keep a lookout for unusual, rare or popular items that might appeal to online shoppers. Recently a grandfather clock was sold for $521 and a Japanese katana sword for $178. Ceramics, vintage glass, and other collectable items have added to hospice income.

A logistics operation is essential for the pickup and delivery of goods. Hospice trucks are on the road seven days a week, providing work for four drivers. All this is in addition to the Mary Potter Hospice Strawberry Festival in November and pop-up shops at festivals and at Christmas.

In 2018 Work on the Mary Potter Apartments site began. These units, adjacent to the Wellington site will be rented out for additional income. 

  • Much of the hospice activity depends on volunteers, for fund-raising but also general activities for in-patients and in the community, so recruitment may also be a challenge as demand grows. The Mary Potter Inpatient Unit offers a family room with kitchen facilities, which is maintained by volunteers.

The Mary Potter 2018 annual report records 676 volunteers, providing 60,132 free hours of work. All the board members are volunteers. In 2018 a Companion Volunteer Programme was started for patients at home and support to their carers. This is likely to expand as more people receive palliative care services at home, but there will be competition for volunteers from other befriending services such as Age Concern’s AVS. Patients have a parade of medical, nursing and support staff coming into their homes, but non-medical social contact is also beneficial.

  • A key goal of the hospice movement is education and training in palliative care for the medical and nursing professions and wider community.

Mary Potter Hospice offers an extensive palliative care education programme to health professionals and the community, as well as to staff and volunteers. This provides specialist workshops, seminars and symposia. Hospice staff are encouraged to engage in postgraduate study and to present their research and case studies at conferences and seminars.

At the community level a series of workshops to provide practical help for carers and patients is being launched. Topics include home alone, managing money, cooking for one, calming the mind and socialising, funeral and advance care planning, time off for carers, holiday season resilience.

  • The recognition of cultural diversity is now an essential part of service planning and delivery. In 2007first Māori Liaison position at Mary Potter was established and in 2016 Pasifika Liaison. Te Pou Tautoko, the Māori support and advice group, helps the hospice to implement the Māori Service Plan. It ensures that services meet the needs of Māori communities and that a Māori voice is maintained through all levels of operation – Board, Executive, patients, whānau, volunteers and in the community. Each of the Mary Potter bases has Māori and Pasifika liaison staff, administrators and volunteers.
  • The multi-disciplinary and holistic approach of hospice calls for a wide range of skills among staff, and recruitment may pose a challenge, as well as issues arising from working together. As well as nursing care and symptom management, services may include (as at Mary Potter) emotional and spiritual support, regardless of religion or beliefs.  Other professionals needed may include social workers, occupational therapists, counsellors, physiotherapist, massage therapists, oral history recorders and music therapists. Some hospices encourage animal visits.
  • Liaison needs to be developed and maintained with other health professionals and therapists. These include workers in Aged Residential Care, regional hospitals and hospital palliative care teams, GP practice teams, district nurses, ambulance services, oncology and other specialist nurses, iwi health services and home support, assistive technology and social care agencies (some in the private sector). Medical students, student nurses and massage students are offered placements in the in-patient and community teams at Mary Potter.

 

[1] http://www.nathaniel.org.nz/bioethics-politics-and-slovenly-language-lessons-from-history/16-bioethical-issues/bioethics-at-the-end-of-life/114-the-hospice-movement-in-new-zealand-25-years-on
Also: https://www.mariecurie.org.uk/blog/what-is-the-hospice-movement/208684

 

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Older People and Oral Health

“In the 1960s, when New Zealand adults smiled, they often displayed a set of dentures” (Te Ara).

A key finding from the 1976 national oral health survey was that New Zealand had one of the highest prevalences of total tooth loss (edentulism) in the world. Adults had very high rates of extraction of permanent teeth, and over one-quarter of the population aged 35–44 had lost all of their natural teeth. Over 80% of adults aged 65 plus had lost all of their natural teeth. Almost half of all adults had some type of denture.

Since then, the focus of dental care and oral health has changed from pulling out decayed teeth to filling, restoring and improving the appearance of natural teeth, as well as efforts to prevent decay and gum disease in the first place. New Zealand has gone from having one of the highest levels of oral disease in the Western world to a low disease level in children and marked reductions in tooth loss in all but the oldest age group.

This means that more and more people are entering old age with their own teeth, rather than full dentures. Given this, and the ageing of the population as a whole, means that the demand for oral health services is likely to increase and to be substantial.

Professor Murray Thomson University of Otago says poor oral health in older people is a “major clinical and public health problem which is going to get worse”.

“In some ways, dentistry has been a victim of its success – we have long emphasised the idea of ‘teeth for life’ without much thought to what happens towards the end of life”. [1]

Why is this important? Dental problems can lead to health problems

Good oral health benefits both individuals and society, yet oral diseases are among the most prevalent chronic diseases in New Zealand and represent a considerable public health burden.  Oral health refers not only to the absence of tooth decay and gum disease but also to the contribution made to overall health and wellbeing, and quality of life. Greater rates of tooth decay can result in dental and facial infections, malnutrition and difficulties in communication. There is international evidence of the links between periodontal disease and cardiovascular disease, diabetes and other chronic illnesses.

What do we know about the oral health of older New Zealanders?

The 2009 New Zealand Oral Health Survey (NZOHS) (published by the Ministry of Health in 2010) provided some insight on the oral health of the ‘usually resident older New Zealanders living in private dwellings’, but older adults in residential care facilities were not included in this survey.

The 2012 New Zealand Older People’s Oral Health Survey (OPOHS) was the first nationwide survey to collect information on the oral health of people living in residential care and those aged 65 years plus living in their own homes but requiring assistance for their day-to-day living.

In 2012, just over half of all older adults in both living arrangements had lost all of their natural teeth. There were concerning levels of untreated decay and many vulnerable older people experience a significant burden of oral disease and unmet treatment need.

One third of dentate (meaning having their own teeth) older people in residential care and one in five living in their own homes reported having difficulty cleaning their teeth. The majority usually visited a dental professional only when they had a problem, rather than for routine check-ups. Cost hindered access to oral health services for 17% living in residential care and 32% living in their own home. Other reasons for not visiting a dental professional in the previous year were difficulties in accessing services and a perceived lack of problems.

Disparities in oral health and access to services

The study findings indicated that older people in residential care experience poorer oral health than those living in their own homes. They were more likely to require extractions and less likely to access oral health services.

Older men were less likely to be edentulous than older women. However, the oral health of dentate older men was poorer than for older dentate women. Subsequently, they had greater actual treatment need. Older men also had poorer self-care and self-reported oral health.

Older Māori, Pacific people, and older adults of lower socioeconomic status shared problems with accessing oral health services and cost was a significant barrier for these groups, who also had high levels of unmet need, making them key priority groups in New Zealand’s oral health strategy.

Slow Progress

Since these surveys were undertaken only “slow progress” is being made according to clinical commentators. Our Older People’s Oral Health, published in December 2015, urged critical policy development around older people’s oral health

“It’s a very complex situation involving a lot of players – the aged care sector, the Ministry of Health, the dental profession, and the public. An encouraging sign is the inclusion of oral health in the Healthy Ageing Strategy. That’s a starting point, but there is a lot of work to be done.”

The Healthy Ageing Strategy sets out plans to improve oral health in all community and service settings, developing clinical pathways for optimal dental care through to the end of life; and providing information and advice on dental care to aged care providers and older people’s families and carers. Let’s hope this leads to speedy implementation.

The “AWESSoM”proposal  – Ageing Well through Eating, Sleeping, Socialising and Mobility,

Given this background it is good to see that the National Science Challenge – “Ageing Well” has funded a research programme, which aims to optimise healthy ageing, maintaining function and independence.  This includes co-designed strategies to increase activity, improve nutrition, improve oral health and enhance social support and networks.

It recognises the importance of oral health in maintaining overall wellbeing. Self-management will be prompted, and delivery of health and social services improved for Maori, Pasifika and non-Maori non-Pacific older New Zealanders. We have great hopes for this research initiative.

 

[1] Research paper: ‘Oral status, cognitive function and dependency among New Zealand nursing home residents’ by W. Murray Thomson, Moira B. Smith, C. Anna Ferguson, Ngaire M. Kerse, Kathryn Peri, Barry Gribben. Gerodontology 35(3), p. 185-191, September 2018.

 

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Caring rather than curing – the role of the hospice movement

Although the hospice movement does not cater solely for older people, with an ageing population and the fact that deaths are concentrated in the older age groups, its activities are very relevant to the wellbeing of older people and positive ageing[1].

What is hospice? 

The focus of the movement is palliative care – defined by the WHO as “the active total care of patients and their families by a multi-professional team when the patient’s disease is no longer responsive to curative treatment”.  Palliative care affirms life, but accepts death as inevitable. It provides relief for patients from pain and other distressing symptoms and integrates the psychological, social and spiritual aspects of care, helping patients to come to terms with their own death as constructively as possible. It provides a support system that enables patients to live as actively as they can until death and offers support for families both during the patient’s illness and in bereavement. This differentiates hospice from hospital care, where the focus is to cure and return people to health.

In this context, hospice is a philosophy of care rather than a type of building or service. Its philosophy is that there is always something to be done to help patients. The movement has had a major impact around the world in promoting palliative care and improving care standards.

 

Hospice history

The roots of the words hospice and hospital are the same and date as far back as the 4th century AD when hospitality was provided for the poor, travellers, hungry, thirsty and sick[2]. They were also the places where the pilgrims on their journeys received food and medical care.

In later periods, hospice programmes emphasised inpatient care of the terminally ill – patients were admitted to a residential facility, where they received comfort and care from a multidisciplinary team of caregivers until they died.

The modern hospice movement started in the mid nineteenth century, mainly by religious orders, and has since spread all over the world. Pioneers in the twentieth century included Cicely Saunders and Elisabeth Kubler-Ross. Saunders used her experiences as a nurse, social worker and doctor, to integrate these skills, and opened the first modern hospice, St. Christopher’s, in London in 1967. In the United States, in the 1960s, Kubler-Ross wrote a book “On death and dying” which brought death to the public awareness. These women accelerated the spread of hospice in the UK, USA and the whole world.

A worldwide movement

Hospice programmes now provide a wide range of residential and home-based services[3]. Although there are different models and systems of palliative care, they have common attributes.

An average voluntary hospice consists of an inpatient unit; a day care centre; home care and outpatient clinics and a bereavement support service. They aim to offer a home-like atmosphere, in contrast to the rush of hospital wards. For example, staff usually do not wear uniforms and the décor and processes are as informal as possible. They may share facilities with hospitals to reduce costs. Palliative home care teams allow patients, who prefer to do so, to remain at home. Although many hospices cater mainly for cancer sufferers, they also cover other chronic and terminal illness such as renal, respiratory or cardiac failure, HIV/AIDS, motor neuron disease, etc.

The Hospice Movement in New Zealand

New Zealand’s first hospice, Mary Potter Hospice, was opened in Wellington in 1979. Later that year, Te Omanga Hospice in Lower Hutt, and Saint Joseph’s Mercy Hospice in Auckland, were also opened. Since then hospices have gained widespread respect in the community. But initially there was tension between the movement’s aims and the medical system that it sought to reform and inspire. For example, in the United States healthcare tended to be dominated by technology and the physical components of care overshadowed emotional and spiritual support.

 

Why do we need hospices?

Over the past 50 years, treatments have improved dramatically for illnesses which would have led to early deaths for many people in the past. These improvements mean we are living longer. But as we get older, we may have to live with more illnesses and disabilities for longer periods of time than was the case for past generations. Our healthcare system is set up by speciality, when patients are seen by several specialists that deal with one condition each. This means people living with multiple conditions may find it difficult to have a coordinated approach to their care. There has also been greater recognition of the value of holistic approaches to care and treatment. That’s where hospices come in.

In my next blog I will look at the challenges now facing the hospice movement, with examples from the situation of the Wellington Mary Potter Hospice. 

[1] These blogs have been prompted by my personal experience of the work of hospice, and the Wellington services in particular, over recent weeks.

[2] Jindrich Polivka (2002) The hospice movement: History and current worldwide situation. Archive of Oncology, Vol.10(1):29-32.

[3] In 2006, the United States-based National Hospice and Palliative Care Organization and the United Kingdom’s Help the Hospices commissioned an independent, international study of worldwide palliative care practices. They found that 15% of countries offered palliative care services with integration into major health care institutions, while an additional 35% offered some form of palliative care services, though these might be localised or limited. In 2009, there were an estimated 10,000 programmes internationally intended to provide palliative care, although the term hospice is not always employed to describe such services (Wikipedia).

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Some innovative ideas about Dementia

No, nothing about a miracle cure, just some good ideas about how we may be able to cope with the growing challenge of dementia (until a cure emerges). The majority of recommended interventions for people with dementia are certainly pharmacological, but, increasingly, treatment guidelines recognise the need for psycho-social interventions and acknowledge the importance of relationships and interactions between the person with dementia and others.

Men’s Sheds

The first positive thing I heard about dementia was from a lecture given by Hal Kendig, on the (then) new initiative of Men’s Sheds in Australia. At that time, group meetings were held in actual sheds, moving around the garden sheds on each members’ property. One of the members of this particular group was a man– call him Bob – who had dementia and who had not spoken for many months. The meeting convened in a shed which had photos of sports teams on the walls. Bob went up to one photo and began naming the team members. It had awoken a part of his memory which was previously sealed.

Dementia-friendly cities and communities

Much later, when I was writing about the Age Friendly movement for the Office for Seniors, I found that dementia-friendly cities and communities (DFCC) is a part of this.

The Alzheimer’s Society defines a DFC as “a city, town or village where people with dementia are understood, respected and supported, and confident they can contribute to community life. “

I was especially impressed by the concept of “legibility”; which includes the importance of the outside environment, the character of street networks and the presence of landmarks. People with dementia prefer short, narrow and gently winding streets rather than long, wide or straight streets. The latter have the potential to cause a loss of concentration leading to disorientation.

Different shapes, features and colours and a variety of doors, windows and gardens are useful tools for successful navigation. Practical and decorative items, such as public seating and bus shelters, trees or planters all act as landmarks to help people with dementia to clarify their location and to determine which route they need to take.

Group Singing

Dementia and caring responsibilities can affect spousal relationships, leading to  loss of emotional intimacy, reduced relationship quality and loss of communication. An important aspect in preserving the couple relationship is the idea of doing things together, especially in a social context. A recent study examined how group singing benefits people with dementia and their partners[1]. Some research has suggested that musical memory is preserved above other types of memory. And several studies have reported positive feelings of achievement, belonging, and decreased social isolation through group singing. Singing is frequently perceived to be an activity that most people have had experience of. And singing is an accessible activity regardless of ability level or singing history.

The study noted that, while singing, differences between the people with dementia, facilitators, and caregivers become less important. Participation in group singing brings beneficial sense of belonging to a social group and sharing an experience. A number of those with dementia described increased confidence, for themselves and other members of the group. On their part, caregivers experienced a “release” from caring responsibilities. One caregiver described how “it was something we could do together, where I wasn’t responsible…”  Caregivers also reported that this allowed for equal participation between themselves and their partners.

In one case, reminiscent of the Men’s Shed example, one caregiver began singing a familiar tune to their partner, a person with advanced dementia, who had mostly lost the capacity for speech. But she audibly attempted to join in with the words of the song.

The Restaurant of Mistaken Orders

This restaurant has just opened in Tokyo and it only hires waiters and waitresses with dementia. The staff may get orders wrong but “if you go there knowing that, you won’t dwell on it too much – and it might change your perception about those suffering from the illness”. It also shows that dementia patients can be functioning members of society.  One commentator ordered a hamburger, but dumplings came instead. ‘I’m fine – dumplings came and I had a good laugh.’ [2] One older woman shows her guests to a table and then sat down with them. Another serves a hot coffee with a straw. Yet another older woman struggles to twist a large pepper mill. Everybody at the table pitched in to help, and with cries of “We did it!”

japanse chef

The creator, Shiro Oguni, says “Like everybody else, my awareness of dementia at first tended towards negative images of people who were ‘radically forgetful’ and ‘aimlessly wandering about.’ But actually, they can cook, clean, do laundry, go shopping and do other ‘normal’ things for themselves. The restaurant is not about whether orders are executed correctly or not. The important thing is the interaction with people who have dementia.”

Two out of three Japanese with dementia live at home, conditions conducive to isolation. Many would rather be useful to the community than receive assistance. The restaurant gives them a cheery place to do just that.

 

[1] Shreena Unadkat, Paul M. Camic, Trish Vella-Burrows (2017) Understanding the Experience of Group Singing for Couples Where One Partner Has a Diagnosis of Dementia. The Gerontologist, Volume 57, Issue 3, 1 June 2017, Pages 469–478.

[2]  http://www.mistakenorders.com/en/home.html

 

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How many conditions – and how to manage them?

We ask people regularly – “How are you?” – but generally do not expect a recitation of numerous health problems in reply. But when speaking to an older person, the recitation could be long. Increasing survival into old age is certainly to be celebrated, but increased longevity is often accompanied by multimorbidity, meaning the presence of more than one long-term disorder. It is reported that 65% of people aged 65 to 84, and 82% of people aged at least 85 have two or more chronic conditions (this is in contrast to the presence of multimorbidity in only 14% of 35-44-year olds). Moreover, commensurate with overall population ageing, the proportion of older adults with multimorbidity is growing significantly.  Multimorbidity is linked to functional limitations, cognitive impairment or mental health concerns, as well as interactions between the conditions themselves and their treatments. Clearly, multimorbidity presents a problem to health services, but also to society as a whole.

What conditions go together?

A regular topic in the medical literature is how to define multimorbidity, what conditions go together and how they interact. Chronic respiratory diseases increase with age and are linked to many other diseases due to shared risk factors and immune responses,

Patterns of multimorbidity are more clinically meaningful than the number of conditions. A recent review of patterns of multimorbidity reported that most the frequent pairing observed was hypertension and osteoarthritis, followed by other combinations of cardiovascular conditions. But findings on the most common combinations of diseases are limited. Different methods of analysis will produce different patterns.

Multimorbidity affects Quality of Life

Most chronic conditions are associated with reduced quality of life; conditions such as stroke, depression, and anxiety account for the strongest associations. Current studies show that quality of life and functional status decreases as the number of chronic conditions an older adult has increases. They are more likely to be heavy users of medical consultations and multiple medications. Increasing numbers of chronic conditions place older adults at higher risk of hospitalisation and residential care placement. Their ability to adapt to changes that come with ageing and their efforts to self-manage may be challenged when they have multiple chronic conditions with competing demands, for example when coping with chronic obstructive pulmonary disease (COPD) and diabetes at the same time. Older people with physical and mental health multimorbidity may also find it hard to adhere to prescribed treatments and medication regimes.

How to manage Multimorbidity

“Approaches to the management of multimorbidity lack clarity and specificity” seems to be the conclusion. Managing multimorbidity in primary care – by general practitioners – will be challenging, particularly as regards prescribing of medicines. Often multiple medicines are required – described as polypharmacy.

The challenge here is coordinating care and avoiding fragmentation. Prescribers are often asked to reduce medications because of uncertainty about how they will interact, even though the medications, taken alone, are entirely appropriate. This raises the likelihood of iatrogenic illness – an illness that is caused by a medication or a physician. The literature suggests that inappropriate polypharmacy can be improved with “complex, multifaceted, pharmaceutical care-based interventions.” Easier said than done! Despite recent emphasis on patient-centred approaches, it is going to be hard the individualise treatment in the context of multimorbidity. Another challenge is how to apply single-condition regimes in a multimorbidity context.

An important suggestion is to have someone to ‘connect the dots’ for people with multiple conditions – a core coordinator or case manager. The general practitioner might be the first to spring to mind, but to save the GP’s time, such roles could be effectively undertaken by nurse practitioners, nurses and community social workers as well as unpaid family and friend caregivers or volunteers. The problem with this approach may be the “silo” effect in hospitals and health agencies which can make interaction between different service sectors difficult – working across boundaries to meet the diverse needs of patients – home care, food, social connection as well as medication and therapy. Informal carers may know more about the social context, but not be well up on medical aspects.

Trading Off

Management regimes for multimorbidity (as for all eldercare) require trade-offs and perhaps the most important of these is between safety and independence. While both attributes are important, patient safety is often prioritised over patient independence – increasing safety while restricting independence. Achieving the right balance is difficult both for clinicians and informal caregivers. It often produces guilt and uncertainty about the decisions and actions which need to be made. Caregivers face worry when those they care for wish to do activities that place them at risk.

Applying a multimorbidity approach”[1]

The New Zealand Ministry of Health provides advice, mainly directed at clinicians. This aims:

  • To get the most out of current treatments, considering which alternatives meet people’s needs and goals. – reviewing the pros and cons of medications and other treatments.
  • To consider how a person’s health problems affect their day to day life, their mental health and their wellbeing.
  • To discuss the level of family and whānau involvement people want in any planning and ongoing treatment.
  • To discuss overall benefits of preventative treatments in people with multimorbidity, taking their views of harms and benefits into account.
  • To agree an individualised care plan, identifying who is responsible for care coordination, follow-up regimes, and reviews. And deciding how the plan will be shared across all involved in the person’s care.

[1] https://www.health.govt.nz/our-work/diseases-and-conditions/long-term-conditions/management-multimorbidity

 

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