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Multimorbidity is increasingly becoming the norm, particularly in the older population, and presents enormous challenges for patients and their doctors. Models of care for chronic disease have been, since the advent of the Quality and Outcomes Framework (QOF) and the drive for evidence-based practice, centred on individual diseases or conditions. Guidelines for single conditions may not apply in a person with more than one of these conditions, and aggressively treating several conditions may do more harm than good. For people with multimorbidity, consideration needs to be given to individualising care and designing it around each person's needs and priorities.
Multimorbidity refers to the presence of more than one long-term health condition co-existing in one person. This may include:
- Physical conditions.
- Mental health conditions.
- Chronic pain syndromes.
- Learning disability.
- Sight or hearing loss.
- Alcohol and substance misuse.
The co-existence of two or more of these conditions describes multimorbidity.
With an ageing population, multimorbidity is heading towards being the norm rather than the exception.
- Worldwide, studies show that multimorbidity increases with age and with socio-economic deprivation.
- One study in primary care in England found one in six people had more than one chronic condition listed in the QOF and that these people use one third of the consultations in general practice. With the definition of chronic conditions widened outside QOF, more than half had multimorbidity and they accounted for more than three quarters of consultations.
- One large Scottish study in 2012 showed that around 65% of those aged more than 65 years and almost 82% of those aged 85 years or more had multimorbidity.
- The likelihood of a mental health disorder increases as the number of physical health conditions increases.
- Multimorbidity is more common in women.
November 2017 - Dr Hayley Willacy recently read the 'When I'm 64 report from the International Longevity Centre. Life for 64-year-olds has changed significantly over the past 45 years. Today’s 64-year-old is much more likely to own their home outright than 64-year old’s in 1972 (69.5% compared with 26.3% in 1972), but 64-year old’s today are more likely to have a chronic illness and disability than those in 1972 (42.1% to 52.3%). The health inequalities are also growing: Inequalities in at 65 life expectancy by local authority have been rising, particularly for women. These inequalities are strongly related to local differences in health and disability, education, skills and training and employment. The average healthy life expectancy for those at 65 in the ten-worst performing English local authorities is 7.4 years. By contrast, the ten best performing local authorities have an average healthy life expectancy that is almost twice as long at 13.6 years. Tower Hamlets is the worst performing local authority with only 6.5 years of healthy life expectancy at 65, while Richmond upon Thames is the best performing local authority with 14.5 additional years of good health expected.
The problems associated with multimorbidity for patients include:
- Fragmentation of care. There are no longer generalists in secondary care, so they may have to see a number of different specialists, including different orthopaedic surgeons for osteoarthritis in different parts of the body.
- Multiple hospital appointments. This is in part due to seeing multiple specialists as above. Transport or time involved may be issues.
- Polypharmacy. Each diagnosis tends to come with a new set of prescriptions. Taking multiple medications is associated with more side-effects and with concordance problems. A 2014 Scottish study found that for patients with two clinical conditions, 20.8 % were receiving 4-9 medications and 1.1 % were receiving ten or more. This increased with increasing numbers of co-existent conditions - in people with six or more comorbidities, these figures were 47.7% and 41.7% respectively. Numbers of medications depended on the conditions, with cardiovascular conditions associated with the most.
- Burden of treatment. Aggressive management of risk factors for more than one condition may confer a huge burden. Differing conditions come with different lifestyle advice. The more conditions, the more it may be difficult to adhere to the advice and the more time-consuming it may become. (For example, a person with diabetes will be given a dietary regime involving reducing sugar intake. If they also have high lipid levels or coronary heart disease, they may be advised to reduce fat intake as well. Many foods which are low in sugar compensate by being high in fat and vice versa, so to reduce both can be a challenge. Exercise restrictions posed by osteoarthritis may make it difficult to exercise advice given for other long-term health conditions.)
- Increased incidence of mental health problems. People with multimorbidity are more at risk of depression and anxiety. This may further affect their ability to manage co-existing conditions.
- Increased risk of emergency admission to hospital.
- Reduced quality of life.
- Increased risk of conditions affecting everyday functioning.
- Increased risk of death at an earlier age than people without multimorbidity .
The challenges for the primary care clinician include :
- Conflicting advice from different specialists. For example, cardiologists may advise medication which adversely affects renal function, and the renal physician may advise stopping medication considered essential by the cardiologist.
- Managing polypharmacy. The more medication the person is on, the more the chance of side-effects and interactions. It may be difficult when assessing a new symptom to establish if it is part of a previously known condition (or the treatment for it) or if it represents a new clinical condition. It is possible to get into a cycle of ever-increasing prescriptions if tablets are prescribed for the side-effects of other tablets.
- Insufficient appointment time to assess and manage multiple complex problems.
- Guidelines for the management of chronic diseases apply to the single condition and may not be relevant for people with other long-term health conditions. This is partly because guidance is based on evidence from clinical trials which often exclude individuals with other morbidity or the elderly.
- Poor communication between specialists and agencies involved.
Principles of care
Increasing recognition of the problems attached to multimorbidity has led the National Institute for Health and Care Excellence (NICE) to release guidance in 2016 for assessment and management of people with multimorbidity. The essential message from this guideline is that care can and must be individualised for each person. The risks and benefits of each treatment recommended for each single condition should be considered in the context of other conditions and discussed with each person, taking into account their priorities and preferences. A report from the Royal College of General Practitioners (RCGP) points out there is an increasing need to organise care around the patient, not the disease.
- Establish the person's aims, goals, priorities, values and preferences. Some may value independence and wish to maintain that as a priority; others may fear stroke and wish to avoid that; some wish to continue to work; some prefer to be on minimal medication; some value quality of life over length of life, etc. Do not assume priorities, as they may well not correlate with those of the GP.
- Record whether the person wishes their spouse/family member/carer, etc, to be involved in decisions and whether information may be shared. Review this decision regularly.
- Establish the level of burden of the conditions and the "treatment burden". How many hospital appointments do they have to attend? How difficult is it to take their medication? Are they having side-effects and if so, how troublesome are they? How much is their quality of life affected? What can't they do which they would like to do? How do the different conditions interact with each other? Are lifestyle changes they have been advised to make troublesome?
- Proactively ask about symptoms of depression or anxiety.
- Assess degree of pain and effectiveness of management.
- Assess the number of medications prescribed and adherence with them. NICE states that adults on more than 15 medicines are at particularly high risk.
- Consider assessing frailty. Informal assessment or tools such as the PRISMA-7 questionnaire may be used.
NICE advises that GP practices actively identify patients with multimorbidity and assign them a named doctor for continuity of care. It advises an approach to care which takes into account multimorbidity if:
- The person requests it.
- The person finds it difficult to manage their treatments or day-to-day activities.
- The person receives care and support from multiple services and needs additional services.
- The person has both long-term physical and mental health conditions.
- The person is assessed as having frailty or has falls.
- The person frequently seeks unplanned or emergency care.
- The person is prescribed multiple medications (10 or more, or fewer than 10 if there is a high risk of adverse events).
Further advice from NICE on specifics of taking an approach to care which takes into account multimorbidity is as follows:
- Consider each treatment for each condition and weigh up the risks and benefits. Discuss these with each individual, taking into account their preferences before coming to a decision together about the appropriateness of each medicine and treatment plan.
- Agree an individualised treatment plan. This should include:
- Stopping treatments which have limited benefit.
- Where possible, stopping treatments and appointments which are a burden and stopping medication with a high risk of adverse effects. (Consider non-pharmacological options if possible.)
- Co-ordinating appointments as much as possible (eg, one appointment for several chronic disease reviews).
- Prioritising appointments in both primary and secondary care.
- Recording of goals and plans for future care (including advance care planning).
- Naming the professional who is responsible for coordination of care.
- Communication of the individualised management plan and the responsibility for coordination of care to all professionals and services involved.
- A plan for regular follow-up.
- Explanation of how to access urgent care.
- Bisphosphonates are the one group of drug singled out specifically. It is advised that there should be a discussion about stopping a bisphosphonate if the person has been on it for three years, as there is no good evidence of benefit for continuing after this time.
The guideline allows GPs to take into account the potentially limited benefit of continuing treatments that aim to reduce future risks, particularly in people with limited life expectancy or frailty. It advises that GPs discuss with people who have multimorbidity and limited life expectancy or frailty whether they wish to continue treatments recommended in guidance on single health conditions which may offer them limited overall benefit.
It does not make any recommendations on the consultation time needed to deal with complex multimorbidity. The inadequacy of the traditional ten-minute appointment is felt nowhere more than for people with multimorbidity. A 2015 review in the British Medical Journal (BMJ) recommends that consultations for those with complex multimorbidity should be longer, or they should have occasional extended consultations to optimise management. A Kings Fund report into polypharmacy in 2013 also recommended longer appointments for people with multiple morbidity on many medications.
Arguably the most useful tools a GP has in managing people with multimorbidity currently are their own judgement and clinical experience, along with their knowledge of, and relationship with, each individual.
NICE suggests other tools which may be useful in the assessment and management of multimorbidity:
- Electronic Frailty Index (eFI), PEONY (Predicting Emergency admissions Over the Next Year) or QAdmissions tools to identify adults with multimorbidity who are at risk of unplanned admission.
- PRISMA-7 tool to assess frailty.
- Use of electronic prescription records to identify people on large numbers of medications.
- The screening tool of older people's prescriptions (STOPP) and screening tool to alert to right treatment (START) - the STOPP/START tool.
- The database of treatment effects within the guideline, for use in assessing the efficacy of treatments and the populations studied in relevant trials, to aid in shared decision making.
In future it is hoped that guidelines will be developed or adapted for common combinations of morbidities, although it would be impossible to cover all combinations. However, evidence upon which to base these recommendations is thus far slim.
Further reading and references
Farmer C, Fenu E, O'Flynn N, et al; Clinical assessment and management of multimorbidity: summary of NICE guidance. BMJ. 2016 Sep 21354:i4843. doi: 10.1136/bmj.i4843.
Muth C, van den Akker M, Blom JW, et al; The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Med. 2014 Dec 812:223. doi: 10.1186/s12916-014-0223-1.
Multimorbidity: clinical assessment and management; NICE Guidance (September 2016)
Violan C, Foguet-Boreu Q, Flores-Mateo G, et al; Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies. PLoS One. 2014 Jul 219(7):e102149. doi: 10.1371/journal.pone.0102149. eCollection 2014.
Salisbury C, Johnson L, Purdy S, et al; Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2011 Jan61(582):e12-21. doi: 10.3399/bjgp11X548929.
Barnett K, Mercer SW, Norbury M, et al; Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012 Jul 7380(9836):37-43. doi: 10.1016/S0140-6736(12)60240-2. Epub 2012 May 10.
When I’m 64 - The ILC-UK factpack on retirement transitions; International Longevity Cente - UK, 2017
Managing patients with multimorbidity in primary care; British Medical Journal (BMJ), 2015350:h176
Managing multi-morbidity in practice … what lessons can be learnt from the care of people with COPD and co-morbidities?; Royal College of General Practitioners (RCGP)
Payne RA, Avery AJ, Duerden M, et al; Prevalence of polypharmacy in a Scottish primary care population. Eur J Clin Pharmacol. 2014 May70(5):575-81. doi: 10.1007/s00228-013-1639-9. Epub 2014 Feb 1.
Guthrie B, Payne K, Alderson P, et al; Adapting clinical guidelines to take account of multimorbidity. BMJ. 2012 Oct 4345:e6341. doi: 10.1136/bmj.e6341.
CGA Toolkit; PRISMA-7 Resources for the Comprehensive Geriatric Assessment based Proactive and Personalised Primary Care of the Elderly
Moffat K, Mercer SW; Challenges of managing people with multimorbidity in today's healthcare systems. BMC Fam Pract. 2015 Oct 1416:129. doi: 10.1186/s12875-015-0344-4.
Martin Duerden et al; Polypharmacy and medicines optimisation: Making it safe and sound, The Kings Fund, 28 Nov 2013
O'Mahony D, O'Sullivan D, Byrne S, et al; STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015 Mar44(2):213-8. doi: 10.1093/ageing/afu145. Epub 2014 Oct 16.
Smith SM, Wallace E, O'Dowd T, et al; Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev. 2016 Mar 143:CD006560. doi: 10.1002/14651858.CD006560.pub3.