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Editors

HeidiAlenius
JukkapekkaJousimaa

Multimorbidity

Essentials

  • This article concentrates on working-age patients and elderly patients who are in relatively good condition.
  • Multimorbid patients have multiple diseases, injuries or organ failures.
  • Depression may be either a consequence of multimorbidity or its cause, affecting the quality of life significantly.
  • Continuity of care increases trust, improves the experienced quality of life and reduces mortality.
  • Treatment should be based on a plan drawn up together with the patient and based on the patient's needs.
    • Find out what is important for the patient: values, aims, priorities.
  • The physician's assessment of the achievable health benefit is a means of guiding multiprofessional treatment.
  • Lifestyle changes can often be used to influence the root causes of diseases.

Definitions and concepts

  • A person with at least 2 chronic diseases, injuries or organ failures is defined as multimorbid.
  • Assessment of functional capacity is essential. The functional capacity of a person classified as multimorbid may be normal or good.
  • It is particularly important to identify the multimorbid patients with increased risk of premature death, hospitalization or need for residential care (high-risk patients).
  • The following typical features can help to identify high-risk patients (NICE guideline for the care of patients with multimorbidity http://www.nice.org.uk/guidance/ng56).
    • Both physical and mental conditions
    • High service use
    • Polypharmacy
    • Frailty syndrome
    • Difficulty coping with daily life
  • Patients with high service use are often defined as those belonging to the ten per cent using the most services in their age and gender group. They are often multimorbid but not necessarily.
  • There are many definitions of polypharmacy in the international literature but it is most commonly defined as being on 5 or more long-term drugs.
  • Concepts
    • Concepts are inconsistent.
    • Comorbidity: The patient has a chronic disease (such as diabetes or coronary artery disease) and his/her other diseases are considered from the perspective of that disease.
    • Multimorbidity: The patient's diseases or conditions may be independent of each other and are not considered from the perspective of any one disease.
      • In practice, in multimorbidity various diseases are very often interconnected either aetiologically or by one aggravating the other. The diseases may therefore be interdependent but cannot be considered from the perspective of any one chronic disease.
      • For example, if a patient has depression, diabetes, overweight and osteoarthritis, and smokes, treatment and follow-up may concentrate on blood glucose and cholesterol, but the fundamental problems may not receive adequate attention.
    • Patient's complexity means cultural, socioeconomic, cognitive or interactive factors, for example, that add to the disease burden and make treatment more complex.

Prevalence

Disease clusters

  • Diseases, symptoms and risks are clustered in aetiological chains that are often interconnected.
  • Treatment should be targeted at the factors with the greatest influence on the disease cluster.
    • The most common influencing factors include overweight, smoking, depression, substance abuse and social deprivation, for instance. Treatment should focus on these.
  • The most common diseases include hypertension, diabetes, metabolic syndrome, depression, osteoarthritis or other significant musculoskeletal problem, and sleep problems.
  • The most commonly described clusters
    • Cardiovascular diseases and risk factors
    • Metabolic syndrome, tobacco and substance dependence and pulmonary diseases
    • Musculoskeletal diseases, diseases causing pain, and mental symptoms
    • Diseases with prevalence increasing with age
  • The risk may be high in a youngish person with a high cardio- and cerebrovascular risk score projected to the age of 60 years even if he/she does not have any diseases yet. See e.g. http://www.terveyskirjasto.fi/pgt00016 and calculator(s) relevant for the local population.
  • By changing habits, high-risk patients can achieve significant health benefits (see below for the assessment of health benefit).

Depression

  • As the number of diseases increases, the probability of depressive symptoms and mental disorders increases and these, in turn, are associated with a poorer quality of life.
  • Depression is an independent risk factor for type 2 diabetes (T2D).
  • On the other hand, T2D doubles the risk of depression. As many as 30% of women and 20% of men with T2D have depression.
  • Depression is often underdiagnosed and untreated.

Central principles of treatment

  • Continuity of care
    • One physician should be responsible for the treatment and its coordination.
      • The physician should guide and provide instructions for the work of the multiprofessional team.
    • A designated contact person, usually a nurse whom the patient can easily reach, as necessary, should keep in touch with the patient proactively.
      • Dividing the treatment between several staff members should be avoided.
    • Proceeding in this manner will increase trust, improve the experienced quality of life and reduce mortality , and may decrease the need of older patients for emergency and hospital services, in particular .
    • Information should pass smoothly between the different professionals and organizations (such as mental health units, social services, guidance centres).
      • An agreement can be made with the patient to allow a person involved in treatment to contact other organizations, or a networking meeting can be arranged (attended, maybe through remote access, by a person involved in treatment in another unit).
  • Health and care plans should be made together with the patient according to his/her needs (patient-centredness).
    • Need: ask what is important. “When you think about your health and wellbeing, what is important for you?”
      • By asking an unconventional question like this you can lead the patient to look at the situation genuinely from his/her perspective. Things have usually been approached focusing on disease (speaking about the patient's diabetes or cholesterol, for instance).
    • Aim: “How would you like things to be?”
      • Common answers: “I would like to cope at home, be relatively healthy / see my grandchild's confirmation / retire as healthy as I am now.”
    • Means: “How can you achieve this?”
      • “I should be physically more active / lose weight / quit smoking.”
    • Support and coaching particularly for lifestyle changes
      • Offer the next appointment and to begin treatment immediately.
      • “I will call you next week / the day after tomorrow...”
      • Support can be provided by phone, too, and the frequency can vary greatly depending on the circumstances (daily, twice a week, once a month, etc.).
      • The health and care plan will show whether the patient has expressed a wish to change his/her habits, i.e. his/her motivation. The change may be hindered by difficulty implementing it in practice or by lack of energy (”I just don't seem to be able to get it done”) The Role of Motivational Interviewing in Changing Lifestyles and in Treatment. The problem is usually not lack of knowledge.
    • It should be agreed locally who will draw up the health and care plan.
      • Having it drawn up by a nurse is recommended, because in practice it is nurses who keep in touch with the patients.
      • A health and care plan can be drawn up quickly (5-10 min) and also by phone.
      • The physician should make sure that the plan conforms to what was agreed.
      • The need, aim and means expressed by the patient should be recorded in the plan using the patient's wording.
    • The patient's situation and the burden of disease and treatments experienced by the patient (treatment burden) should be examined. Does the patient currently have the energy to stop smoking, for instance?
    • Disease-specific care guidelines can often not be applied as such for multimorbid patients but need individual adjustment.
  • Medical assessment (health benefit assessment)
    • Before assessing the health benefit, the physician must know what permanent diagnoses have been made, what treatments are being used, the essential risks to the patient's wellbeing and the patient's life situation, as well as what kind of things the patient considers important and what he/she is prepared to do.
    • Knowing all this, the physician can assess the need for treatment, see how it can be implemented and suggest a suitable division of labour among the team based on the patient's health risks, estimated life expectancy and wishes.
    • Assessment of total risk: permanent diagnoses,cardio- and cerebrovascular risk score applicable to local population (find out about locally available tools), indicators (smoking, blood pressure, LDL cholesterol, HbA1c, BMI, Audit, BDI, MMSE, caries, gingivitis)
    • Patients with multimorbidity often have undiagnosed and undertreated - but also overtreated - diseases.
      • Investigation and treatment of latent depression, in particular, may improve the prognosis and results of treatments significantly.
      • In elderly people, it is common to adhere mechanically to the target values for HbA1c, LDL and blood pressure, even though it might be wiser to shift the focus to quality of life.
    • In younger high-risk patients, in particular, significant health benefits can be achieved by lifestyle changes and medication.
    • Functional capacity affects the prognosis significantly.
    • Since in very old, infirm and frail people the health benefit will be minor (short life expectancy), the focus in these patients should be more on maintaining functional capacity and quality of life. See Assessment of Functional Capacity in the Elderly Managing the Medication of Elderly People Depression in the Elderly Falls of the Elderly Hypertension in Elderly Patients Special Issues in Long-Term Care of Elderly Persons in Assisted Living Facilities.
  • Assessment of medication (including OTC drugs and natural drugs)
    • The whole medication should be assessed considering the health benefit (e.g. high-risk patients with a high probability of benefiting from intensive treatment).
    • When assessing the health benefit, the health problem or risk should be considered in relation to the effectiveness and adverse effects of the drug and the cost of treatment.
      • For adverse event load and drug interactions, see locally available drug databases.
      • Total assessment of medication is integrated in many electronic health record (EHR) systems. Find out about locally available tools.
    • If the patient would benefit from lifestyle changes and is interested in and prepared to make them, intensive support and coaching should be provided.
    • Non-pharmacological treatment
    • Medication
      • Start or continue beneficial medication (such as cardioprotective medication and medication improving the prognosis, antihyperlipidaemic drugs).
      • Withdraw unnecessary drugs and drugs that are still taken or prescribed for no particular reason.
      • Look at use of symptomatic drugs, the need for them, benefits and harms
    • Use of preventive and symptomatic drugs; see Table T1

Aspects worth special attention in prevention

Not elderlyElderly (biological age > 70 yrs, for instance)Elderly, frail
Primary preventionSensible if the intervention is cost-effective
  • Cardiovascular risk factors
  • Mood
  • Substance abuse
Sensible if the intervention is cost-effective
  • Maintenance of muscle strength and coordination
  • Prevention of falls
Few interventions are cost-effective
  • Review of polypharmacy
Secondary preventionVery important
  • Risk factors for arterial disease
  • COPD, cancers (smoking)
Significance decreases due to decreased effectiveness.
  • Treatment of osteoporosis after low-energy fracture
Minor significance
Tertiary preventionExtremely important
  • Actual arterial disease, COPD, depression, substance abuse
Significance decreasingMust be considered carefully
Use of symptomatic medicationsBenefits generally decrease and risks increase with age.
For the definitions of primary, secondary and tertiary prevention, see Wonca International Dictionary for General/Family Practice http://www.ph3c.org/ph3c/docs/27/000092/0000052.pdf
Documenting the care plan and medical assessment
  • These should be documented clearly in the agreed place.
  • The chosen line of treatment should be justified particularly if it deviates from generally agreed lines of treatment or disease-specific aims.

    References

    • Kuan V, Denaxas S, Patalay P, et al. Identifying and visualising multimorbidity and comorbidity patterns in patients in the English National Health Service: a population-based study. Lancet Digit Health 2023;5(1):e16-e27. [PubMed]
    • Read JR, Sharpe L, Burton AL et al. Preventing depression in older people with multimorbidity: 24-month follow-up of a trial of internet-delivered cognitive behaviour therapy. Age Ageing 2021;50(6):2254-2258. [PubMed]
    • Blum MR, Sallevelt BTGM, Spinewine A et al. Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial. BMJ 2021;374():n1585. [PubMed]
    • Stewart M, Fortin M, Brown JB et al. Patient-centred innovation for multimorbidity care: a mixed-methods, randomised trial and qualitative study of the patients' experience. Br J Gen Pract 2021;71(705):e320-e330. [PubMed]
    • 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 2021;1():CD006560. [PubMed]
    • Dibato JE, Montvida O, Zaccardi F et al. Association of Cardiometabolic Multimorbidity and Depression With Cardiovascular Events in Early-Onset Adult Type 2 Diabetes: A Multiethnic Study in the U.S. Diabetes Care 2021;44(1):231-239. [PubMed]
    • Butterworth JE, Hays R, McDonagh ST et al. Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations. Cochrane Database Syst Rev 2019;2019(10):. [PubMed]
    • NICE guideline (NG56): Multimorbidity: clinical assessment and management, 2016. http://www.nice.org.uk/guidance/ng56/resources/multimorbidity-clinical-assessment-and-management-pdf-1837516654789
    • Wagner EH, Austin BT, Davis C et al. Improving chronic illness care: translating evidence into action. Health Aff (Millwood) 2001;20(6):64-78. [PubMed]
    • Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74(4):511-44. [PubMed]
    • Wonca International Dictionary for General/Family Practice http://www.ph3c.org/ph3c/docs/27/000092/0000052.pdf

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