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Multimorbidity is an increasingly problematic issue for healthcare delivery and healthcare professionals. People with multimorbidity are more likely to attend, and to require health and social care assistance more frequently, especially unplanned admissions to hospital, iatrogenic problems from polypharmacy and are at risk of premature death.
The burden of care for these individuals is significant across primary, secondary and community care. The prevalence of multimorbidity is thought to be around 27%.
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Multimorbidity is defined as a person having two or more long-term health conditions.
These can include:
Multimorbidity is an increasingly problematic issue for healthcare delivery and healthcare professionals. People with multimorbidity are more likely to attend and require health and social care assistance more frequently, especially unplanned admissions to hospital, iatrogenic problems from polypharmacy and are at risk of premature death.
The burden of care for these individuals is significant across primary, secondary and community care.
The prevalence of multimorbidity is thought to be around 27%.
Females have a higher prevalence of 30%, compared with 24% for males. Of those affected, 34% have both a physical and mental morbidity.
Younger people with multimorbidity, that is those aged 18–24 years, were more likely to have a physical–mental comorbidity (56.5%), compared with 23.7% of people aged 75–84 years.
The proportion of people with multimorbidity who had a physical–mental comorbidity increased substantially with greater socioeconomic deprivation, it is also clear that the onset of multimorbidity occurred 10-15 years earlier in people in areas of socioeconomic deprivation.
With an ageing population multimorbidity is likely to become more common and an increasing problem for the whole healthcare economy.
The risk factors for multimorbidity include:
The problem of multimorbidity
Multimorbidity has a highly significant effect on a person’s quality of life and life expectancy.
The reasons for this include a high ‘treatment burden’. This means that the inherent difficulties of understanding and self-managing conditions, juggling multiple appointments with different healthcare specialists, managing complex drug regimens and adhering to radically altered lifestyle changes can result in conflict, fragmentation of care and ultimately failure in compliance with treatment.
In addition to this, issues with anxiety and depression are more common in people with multimorbidity, which can have an adverse impact on their ability to manage their conditions.
It is also important to note that people with cognitive impairment are particularly vulnerable and may have added difficulties in managing their conditions.
Also, polypharmacy in these individuals and the inevitable higher rates of adverse drug events are an ever-present danger. These risks are higher again in people who are older (particularly those with renal impairment), disabled, or people with mental health conditions. This can impose further constraints on self-care and adherence to treatment.
All this inevitably imposes an increased use of health services (including unplanned, or emergency care).
Finally, multimorbidity also has a negative impact on the health and wellbeing of carers.
Polypharmacy and multimorbidity
In 2014 a study of 180,815 adults in primary care approximately 20.8% of people with two medical conditions were prescribed 4–9 drugs and 1.1% were prescribed 10 or more. For people with six or more conditions, these were 47.7% and 41.7%, respectively. This type of polypharmacy is associated with an increased risk of adverse effects, drug interactions, potentially inappropriate prescribing, and reduced drug adherence .
It has been noted by NICE that polypharmacy is often driven by the introduction of multiple medicines intended to reduce the risk of future morbidity and mortality in specific health conditions. However, the evidence for implementing NICE recommendations on single health conditions is often drawn from people without multimorbidity who are participating in studies and who are taking fewer regular medicines.
The absolute benefit made by each additional medicine is likely to reduce when a person is taking multiple preventative medicines; conversely, the risk of harms is likely to increase with additional medicines being taken. The greater the number of chronic conditions, the greater the likelihood of patient-reported safety incidents. Evidence from populations aged 65 years or over also suggests that treatment by multiple prescribers is an independent predictor of reports of adverse drug events.
How do I assess someone with multimorbidity?
To assist with a comprehensive risk assessment, we should consider using a validated tool. These include Electronic Frailty Index (eFI), Predicting Emergency Admissions Over the Next Year (PEONY) or QAdmissions to identify adults with multimorbidity who are at risk of adverse events, such as unplanned hospital admission or admission to care homes.
These tools provide prompts and questions enabling users to employ an evidence-based approach to assess and quantify multimorbidity emergency admission risk for individuals.
How do I assess someone with multimorbidity?
Establish the extent of the disease burden. Specifically, ask how the health problems affect their day-to-day life, this should include a discussion of the following areas;
Also ask about, and consider:
Encourage people with multimorbidity to clarify what is important to them, including their personal priorities, which may include:
This is clearly a long list of questions, considerations and detailed inquiry for a single health professional to undertake. It may therefore form part of an overall care plan, over multiple appointments across a multidisciplinary team.
Frailty is defined as a ‘clinically recognisable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day or acute stressors is compromised’ .
Frailty is an essential consideration to be aware of in people with multimorbidity.
When assessing frailty, consider using one of the following:
– Are you more than 85 years old?
– Are you male?
– In general, do you have any health problems that require you to limit your activities?
– Do you need someone to help you on a regular basis?
– In general, do you have any health problems that require you to stay at home?
– If you need help, can you count on someone close to you?
– Do you regularly use a stick, walker or wheelchair to get about?
It is important to note that we should be cautious about assessing frailty in people who are acutely unwell and that we should not use a physical performance tool to assess frailty in people who are acutely unwell.
Management of multimorbidity
When taking a multimorbidity approach, we should focus on how the person's health conditions and their treatments interact and how this affects quality of life. We need to be cognisant of the person's individual needs, preferences for treatments, health priorities, lifestyle and goals.
When dealing with single health conditions we should take into account the benefits and risks of following guidance and recommendations for these conditions. We should aim to improve quality of life by reducing treatment burden, adverse events, and unplanned care – adding ‘life to years’ rather than solely adding ‘years to life’.
We should strive to improve coordination of care across services.
We should always discuss the purpose of a multimorbidity approach with the person. This might include reducing the treatment burden and optimising care and support by identifying:
Consider using a screening tool (for example, the STOPP/START tool in older people) to identify medicine-related safety concerns and medicines the person might benefit from but is not currently taking.
Plan a review to monitor the effects of any treatment changes and to decide whether further changes are required, including potentially restarting treatment.
Discuss with people who have a limited life expectancy or frailty if they wish to continue treatments recommended in guidance on single health conditions that may offer them limited overall benefit.
Develop and agree an individualised management plan with the person, which should include:
Share copies of the management plan in an accessible format with the person and (with their permission) other people involved in care.
Information and advice
When managing someone with multimorbidity we should provide appropriate lifestyle advice depending on their morbidities. For example, for people with cardiovascular disease: increasing exercise, healthy eating, smoking cessation, reducing alcohol intake.
We should also:
Provide written information and signpost to additional sources of information, for example the:
Follow up intervals for people with multimorbidity should be determined using clinical judgement and agreed with the person in the management plan. This should consider their individual circumstances, the range of morbidities and treatments and risk of unplanned admissions and other risks.
Follow up should include:
During this module you have learnt to
Run a report to identify and code adults with multimorbidity
How many of these patients have been assessed for frailty using gait speed, self-reported health status or a validated tool?
What proportion of these patients have recorded in their record that they have been asked about their goals, values and priorities?
How many of these patients have recorded the person who is responsible for the coordination of their care?
How many of these patients have had a review of their medicines and other treatments and recorded whether treatments can be stopped or changed?
Cassell A, et al. The epidemiology of multimorbidity in primary care: a retrospective cohort study. British Journal of General Practice 2018;68(669):e245-e251 bjgp.org/content/early/2018/03/12/bjgp18X695465
Payne RA, et al. Prevalence of polypharmacy in a Scottish primary care population. European Journal of Clinical Pharmacology 2014;70(5):575-581 link.springer.com/article/10.1007%2Fs00228-013-1639-9
Duerden M, Avery T, Payne R. Polypharmacy and medicines optimisation: making it safe and sound. The King's Fund, 2013. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf
NICE Key Therapeutic Topic (KTT18). Multimorbidity and polypharmacy, 2017 https://www.nice.org.uk/advice/ktt18
Xue Q-L. The Frailty Syndrome: Definition and Natural History. Clinics in Geriatric Medicine. 2011;27(1):1-15. doi: 10.1016/j.cger.2010.08.009.
Raiche M, Hebert R, Dubois MF. PRISMA-7: a case-finding tool to identify older adults with moderate to severe disabilities. Arch Gerontol Geriatr 2008;47(1):9-18 www.ncbi.nlm.nih.gov/pubmed/17723247
Academy of Medical Sciences. Multimorbidity: a priority for global health research, 2018 https://acmedsci.ac.uk/file-download/99630838
World Health Organization. Multimorbidity: technical series on safer primary care, 2016. https://www.who.int/patientsafety/topics/primary-care/technical_series/en/
NICE NG22. Older people with social care needs and multiple long-term conditions, 2015. https://www.nice.org.uk/guidance/ng22
NICE Clinical Evidence, Clinical Knowledge Summaries. Multimorbidity, 2018. https://cks.nice.org.uk/multimorbidity
NICE NG56. Multimorbidity: clinical assessment and management. https://www.nice.org.uk/guidance/ng56