MULTIMORBIDITY Suggestions for Lecturer -1-hour lecture -Use GRS slides alone or to supplement your own teaching materials. -Supplement lecture with this handout: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Guiding Principles for the Care of Older Adults with -Multimorbidity: An Approach for Clinicians. J Am Geriatr Soc. 2012;60(10):E1–E25.

OBJECTIVES Know and understand: The definition of multimorbidity and the associated risks Why most clinical practice guidelines are not appropriate for older adults with multimorbidity The 5 guiding principles for evaluating older adults with multimorbidity and managing their care The challenges that clinicians must try to overcome when caring for older adults with multimorbidity

TOPICS COVERED Introduction to Multimorbidity Limitations of Clinical Practice Guidelines Approach to the Older Adult with Multimorbidity: 5 Domains Challenges to Caring for Older Adults with Multimorbidity

INTRO TO MULTIMORBIDITY (1 of 2) Defined as ≥3 chronic diseases Has distinctive cumulative effects for each individual Associated with increased rates of: Death Disability Adverse effects Institutionalization Use of health care resources Impaired QOL

INTRO TO MULTIMORBIDITY (2 of 2) Even when diagnosed with the same pattern of conditions, older adults with multimorbidity are heterogeneous in terms of: Illness severity Functional status Prognosis Personal priorities Risk of adverse events Treatment options also differ So multimorbidity requires a flexible approach to care

LIMITATIONS OF CLINICAL PRACTICE GUIDELINES (CPGs) Most focus on only 1 or 2 conditions and address comorbidities in limited ways, if at all Older adults with multimorbidity are excluded or under-represented in clinical trials, so there is little focus on multimorbidity in the meta-analyses and systematic reviews that inform CPGs CPG-based care may be cumulatively impractical, irrelevant, or even harmful for individuals with multimorbidity

APPROACH TO EVALUATION AND MANAGEMENT (1 of 3) Five domains: Patient preferences Interpreting the evidence Prognosis Clinical feasibility Optimizing therapies and care plans

APPROACH TO EVALUATION AND MANAGEMENT (2 of 3) Inquire about the patient’s primary concern (and that of family and/or friends if applicable) and any objectives for visit Conduct a complete review of care plan for person with multimorbidity or Focus on specific aspect of care for person with multimorbidity What are the current medical conditions and interventions? Is there adherence/comfort with treatment plan? Consider patient preferences Is relevant evidence available regarding important outcomes? The five domains apply at various steps, which can be taken in other sequences with equal validity, because approaches for addressing this population have not been compared. For example, patient preferences are often best elicited in the context of the individual’s prognosis. SOURCE: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians. J Am Geriatr Soc. 2012;60(10):E1–E25.

APPROACH TO EVALUATION AND MANAGEMENT (3 of 3) Consider prognosis Consider interactions within and among treatments and conditions Weigh benefits and harms of components of the treatment plan Communicate and decide for or against implementation or continuation of intervention/treatment Reassess at selected intervals for benefit, feasibility, adherence, alignment with preferences SOURCE: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians. J Am Geriatr Soc. 2012;60(10):E1–E25.

PATIENT PREFERENCES Guiding principle: Incorporate patient preferences into medical decision making Care provided in accordance with CPGs may not adequately address patient preferences Older adults with multimorbidity should have the opportunity to evaluate choices and prioritize their preferences for care, within personal and cultural contexts

INTERPRETING THE EVIDENCE Guiding principles: Recognize the limitations of the evidence base, and interpret and apply medical literature specifically to older adults with multimorbidity Key element of evidence-based medicine: whether the information applies to the individual under consideration Significant evidence gaps may exist concerning condition and treatment interactions, particularly in older adults with multimorbidity

PROGNOSIS (1 of 2) Guiding principle: Frame management decisions within the context of risks, burdens, benefits, and prognosis Prognosis = remaining life expectancy, functional status, QOL Discussion of prognosis can serve as an introduction to difficult conversations Facilitate decision making, advance care planning Address patient preferences, treatment rationales, and therapy prioritization

PROGNOSIS (2 of 2) Prognosis informs, but does not dictate, management decisions within the context of patient preferences The time horizon to benefit for a treatment may be longer than the individual’s projected life span, raising the risk of polypharmacy and drug-drug and drug- disease interactions Screening tests, too, may be non-beneficial or even harmful if the time horizon to benefit exceeds remaining life expectancy, especially because associated harms and burdens increase with age and comorbidity

CLINICAL FEASIBILITY Guiding principle: Consider treatment complexity and feasibility Complex regimen → higher risk of nonadherence, adverse reactions, impaired QOL, economic burden, and caregiver strain and depression Some influences on complexity: number of steps in the task, number of choices, duration of execution, and patterns of intervening distracting tasks Education and assessments must be ongoing, multifaceted, and individualized, and delivered via a variety of methods and settings, because patients generally do not recall discussion with clinicians.

OPTIMIZING THERAPIES AND CARE PLANS Guiding principle: Choose therapies that optimize benefit, minimize harm, enhance QOL Older adults with multimorbidity are at risk of: Polypharmacy Therapeutic omissions Reduced benefit from medications Actual harm Suboptimal medication use Nonpharmacologic interventions may be more burdensome than beneficial, if inconsistent with patient preferences

CHALLENGES TO CARING FOR OLDER ADULTS WITH MULTIMORBIDITY (1 of 2) Ever-changing health status of the patient Multiple clinicians and settings Need for multiple simultaneous decisions Inadequacy of evidence base Scarcity of prognostic tools; conflicting results Treatments meant to improve one outcome may worsen another

CHALLENGES TO CARING FOR OLDER ADULTS WITH MULTIMORBIDITY (2 of 2) Many clinical management regimens are too complex to be feasible in this population Yet as clinicians attempt to reduce polypharmacy and unnecessary interventions, they may fear liability regarding underuse of therapies Patient-centered approaches may be too time- consuming for the already overwhelmed clinician within the current reimbursement structure and without an effective interdisciplinary team

SUMMARY (1 of 2) More than 50% of older adults have 3 or more chronic diseases, referred to as “multimorbidity” Multimorbidity is associated with increased rates of death, disability, adverse effects, institutionalization, use of healthcare resources, and impaired QOL Older adults with multimorbidity are heterogeneous in terms of illness severity, functional status, prognosis, personal priorities, and risk of adverse events

SUMMARY (2 of 2) Treatment of older adults with multimorbidity requires a flexible approach because of heterogeneity among patients and inadequacy of most clinical practice guidelines The 5 domains of evaluating and managing older adults with multimorbidity are to: Consider patient preferences Interpret relevant evidence Consider prognosis Consider treatment complexity and feasibility Optimize therapies and care plans

CASE 1 (1 of 4) An 86-year-old man comes to the office after recent hospitalization for MI. His history includes DM, HTN, CAD, COPD, renal insufficiency, and anemia. His medications include insulin 70/30, lisinopril, metoprolol, aspirin, clopidogrel, simvastatin, mometasone, formoterol, and albuterol. He lives alone; his daughter lives 5 miles away. He is able to do all instrumental activities of daily living and enjoys yard work and fishing.

CASE 1 (2 of 4) On examination, weight is 54.4 kg (120 lb) and BMI is 20 kg/m2. Sitting blood pressure is 98/60 mmHg, and pulse is 60 bpm. Cardiovascular and pulmonary examinations are normal. Laboratory findings include hemoglobin A1c of 8.0% and hemoglobin of 12 g/dL.

CASE 1 (3 of 4) Using the principles outlined in these slides, which of the following is the best next step in managing this patient? Start alendronate weekly with calcium and vitamin D supplements. Discontinue simvastatin because of limited benefit given life expectancy. Intensify insulin therapy and glucose monitoring to achieve better glucose control. Discontinue lisinopril and monitor blood pressure. Switch insulin to metformin.

CASE 1 (4 of 4) Using the principles outlined in these slides, which of the following is the best next step in managing this patient? Start alendronate weekly with calcium and vitamin D supplements. Discontinue simvastatin because of limited benefit given life expectancy. Intensify insulin therapy and glucose monitoring to achieve better glucose control. Discontinue lisinopril and monitor blood pressure. Switch insulin to metformin. ANSWER: D Hypotension in an older adult can result in falls and possibly fractures, especially in a thin older man. Treatment with alendronate would not be appropriate without first determining the patient’s risk of osteo- porosis and possibly ordering bone density imaging. Discontinuation of simvastatin would not improve the patient’s hypotension. In addition, simvastatin is appropriate for a patient with a recent myocardial infarction. Intensifying the insulin regimen would not yield any benefit, given the patient’s overall prognosis. Although metformin is first-line treatment of type 2 diabetes in older adults, the patient has renal disease and has already required insulin for treatment of his diabetes, with a hemoglobin A1c of 8%. Thus, switching to metformin is not appropriate and will not address the patient’s hypotension.

CASE 2 (1 of 4) An 88-year-old man is brought to the clinic by his wife because he has decreased appetite and progressive weight loss. Over the past 2 months, he has not eaten his favorite foods and has lost 3.6 kg (8 lb). His history includes advanced Alzheimer disease, difficulty swallowing, and aspiration pneumonia, as well as HTN, CAD, hearing loss, and anemia. His medications include aspirin, losartan hydrochlorothiazide, metoprolol, simvastatin, iron, multivitamins, donepezil, and memantine.

CASE 2 (2 of 4) The patient requires assistance with all activities of daily living and speaks only 1 or 2 words over 24 hours. His wife is tearful and states that she is not ready to lose him; she wants all recommended treatments for him. Physical examination and laboratory tests are unchanged.

CASE 2 (3 of 4) Which of the following is the next best step in management of this patient? Refer wife to psychiatry for possible depression. Start mirtazapine to treat patient for depression. Discontinue iron and donepezil and taper memantine off. Place feeding tube. Start megestrol for appetite stimulation.

CASE 2 (4 of 4) Which of the following is the next best step in management of this patient? Refer wife to psychiatry for possible depression. Start mirtazapine to treat patient for depression. Discontinue iron and donepezil and taper memantine off. Place feeding tube. Start megestrol for appetite stimulation. Answer: C Progressive weight loss in older adults can be multifactorial, and in advanced dementia it is a sign of poor prognosis. The weight loss in this patient may be due to dementia but may also be a result of drug adverse effects. Donepezil, memantine, and iron all have GI adverse effects and may be discontinued. Memantine should be tapered off to avoid potential psychiatric effects. Other medications may also be decreased or discontinued (eg, simvastatin, aspirin, multivitamins, antihypertensives) to enhance intake of calories in place of medications. The patient’s wife expresses wishes and concerns commonly seen in advanced dementia; there is no evidence given to support a diagnosis of depression. For the patient, antidepressant medications, particularly SSRIs, can cause anorexia and weight loss as well as increased confusion or sedation; it is unclear whether the patient has major depressive disorder. In addition, recent studies have questioned the efficacy of antidepressant medications in the treatment of coexisting depression and dementia. If an antidepressant were indicated, mirtazapine may be the best choice. Feeding tubes have been shown to increase adverse events and not improve survival or other outcomes in advanced depression. Megestrol is an appetite stimulant, but significant safety concerns in older adults include risk of thromboembolic disease and confusion. The evidence supporting the effects of megestrol on appetite primarily stems from studies of younger patients with AIDS and cancer.

Copyright © 2013 American Geriatrics Society GRS8 Slides Editor: Annette Medina-Walpole, MD, AGSF GRS8 Chapter Authors: Cynthia Boyd, MD, MPH Matthew K. McNabney, MD GRS8 Question Writer: Birju B. Patel, MD, FACP Medical Writers: Beverly A. Caley Faith Reidenbach Managing Editor: Andrea N. Sherman, MS Copyright © 2013 American Geriatrics Society Slide 28