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