1. 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.
-Also supplement with the Geriatrics Evaluation & Management (GEM) Tools: “Multimorbidity”
-See GRS9 questions 9, 13, 43, 70, 214, 275, 283, and 294 for case vignettes on multimorbidity.

2. 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

3. TOPICS COVERED
Introduction to Multimorbidity
Approach to the Older Adult with Multimorbidity: 5 Domains
Controversies and Challenges to Caring for Older Adults with Multimorbidity

4. INTRO TO MULTIMORBIDITY (1 of 2)
Defined as ≥3 chronic diseases
Affects more than 50% of older adults
Has distinctive cumulative effects for each individual
Associated with increased rates of:
Death
Disability
Adverse treatment effects
Institutionalization
Use of health care resources
Decreased QOL

5. 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
Clinicians need a management approach that will consider the issues particular to each individual, including the often limited available evidence, interactions among conditions or treatments, the patient’s own preferences and goals, prognosis, multifactorial geriatric issues and syndromes, and the feasibility of proposed management approaches and their implementation.

6. LIMITATIONS OF CLINICAL PRACTICE GUIDELINES (CPGs)
Most focus on management of only 1 disease
Older adults with multimorbidity are excluded or under-represented in clinical trials and observational studies, which translates to less representation in meta-analyses, systematic reviews, and guidelines
CPG-based care may be cumulatively impractical, irrelevant, or even harmful for individuals with multimorbidity

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

8. 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 additional 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 5 domains apply at various steps in the process, and because differing approaches for addressing this population have not been compared, there is no justification for insisting on a particular sequence. Patient preferences, for example, are often best elicited in the context of a discussion of prognosis, rather than as an initial subject of inquiry.
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.

9. 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.

10. PATIENT PREFERENCES
Guiding principle: Elicit and incorporate patient preferences into medical decision-making
Care provided in accordance with CPGs may not adequately address patients’ individual preferences
Older adults with multimorbidity should have the opportunity to evaluate choices and prioritize their preferences for care, within personal and cultural contexts
Example: An 80-year-old woman with atrial fibrillation has an indication for warfarin therapy by traditional algorithms. She does not wish to undergo regular blood monitoring and does not feel safe taking newer anticoagulants. She understands the trade-offs and elects to take daily aspirin.

11. INTERPRETING THE EVIDENCE
Guiding principle: Recognize the limitations of the evidence base, and interpret and apply medical literature specifically to older adults with multimorbidity
Key element of interpreting evidence-based medicine: whether the information applies to the individual under consideration
Significant evidence gaps exist concerning condition and treatment interactions, particularly in older adults with multimorbidity
Example: An 84-year-old man with hypercholesterolemia has no history of any vascular (cardiac, cerebral, peripheral) events. He has been on a statin for 12 years. You examine the evidence and advise him that he can stop taking the statin, if he wishes, because of lack of evidence that he will benefit from this medicine in primary prevention.

12. 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

13. 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
Example: A 79-year- old woman has diabetes, heart failure, and stage IV renal failure. Her daughter is pushing her to get her regular colonoscopy; she is reluctant. Using the Web-based resource indicates that her estimated life expectancy is <10 years, and she is not likely to experience overall benefit from screening colonoscopy.

14. 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
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.
Example: An 87-year-old man complains of fatigue and feels he takes too many medications. He has dementia, heart failure, osteoarthritis, osteoporosis, insomnia, diabetes, and prostate disease. He is prescribed 16 medications as well as other treatments. He often forgets to take his evening doses and does not monitor his blood glucose. After using tools to assess medication complexity and discussions with the patient and his daughter, you decide to stop 5 of his medications, to modify times of administration, and to recommend a pill box.

15. OPTIMIZING THERAPIES AND CARE PLANS
Guiding principle: Choose therapies that maximize benefit, minimize harm, enhance QOL
Older adults with multimorbidity are at risk of:
Polypharmacy
Suboptimal medication use
Potential harms from various interventions
Reducing the number of meds can lower the risk of adverse drug reactions
Nonpharmacologic interventions may be more burdensome than beneficial, if inconsistent with patient preferences
Example: A 92-year-old widowed man with advanced Alzheimer disease returns home to the care of his daughter, after a hospitalization for systolic heart failure. A cardiologist has proposed implantation of an automatic cardioverter-defibrillator, but the patient’s daughter points out that her father is unable to leave the home without experiencing intense anxiety. You broach the subject of quality of life and ask the daughter if her father—if he were able to speak for himself—would choose an invasive intervention designed only to prolong his life.

16. 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

17. 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

18. 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

19. 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 clinical feasibility
Optimize therapies and care plans

20. CASE 1 (1 of 4)
An 85-year-old woman comes to the office because she is increasingly depressed by her medical conditions and lifestyle.
Because of osteoarthritis, her exercise is limited to housework.
Her discouragement keeps her from participating in activities that she is able to do.
History: diabetes mellitus, stable angina with moderate exertion, COPD, mild cognitive impairment, knee osteoarthritis. Coronary angioplasty 6 years ago

21. CASE 1 (2 of 4) Medications aspirin 81 mg/d atorvastatin 20 mg/d
lisinopril 10 mg/d
atenolol 50 mg/d
ipratropium 1 inhalation four times daily
salmeterol 1 inhalation every 12 hours
albuterol 1 puff every 4–6 hours as needed
acetaminophen 650 mg three times daily
extended-release glipizide 10 mg/d
Laboratory findings:
Normal blood count and thyroid, kidney, and liver function tests
LDL cholesterol: 120 mg/dL
Hemoglobin A1c: 8.1%

22. CASE 1 (3 of 4)
Which one of the following is most likely to improve her quality of life?
Increase glipizide to 20 mg/d.
Add budesonide 1 puff by inhalation twice daily.
Refer to dietitian for a low-fat, diabetic diet.
Add donepezil 5 mg/d and titrate to 10 mg/d in 6 weeks.
Add escitalopram 10 mg/d.

23. CASE 1 (4 of 4)
Which one of the following is most likely to improve her quality of life?
Increase glipizide to 20 mg/d.
Add budesonide 1 puff by inhalation twice daily.
Refer to dietitian for a low-fat, diabetic diet.
Add donepezil 5 mg/d and titrate to 10 mg/d in 6 weeks.
Add escitalopram 10 mg/d.
ANSWER: E
The expected life span of an 85-year-old person with diabetes, coronary artery disease, chronic obstructive pulmonary disease, and cognitive impairment is <5 years. Treating her depression should show benefit in several weeks and may motivate her to address other medical issues (SOE=A).
Dietary interventions are unlikely to improve quality of life in a patient who is having trouble preparing meals. Tighter control of diabetes would not improve her quality of life, raises risk of hypoglycemia, and requires >5 years to benefit life expectancy. Addition of an inhaled corticosteroid to stable chronic obstructive pulmonary disease is unlikely to provide any benefit. Use of donepezil may delay her potential need of a nursing home but would not provide any current benefits.
Adherence to clinical practice guidelines for her various diseases would result in a regimen that would be difficult, if not impossible, to follow. Orders such as sliding scales for diabetes can easily lead to hypoglycemia, with numerous complications. Strict adherence to dietary guidelines could result in relative malnutrition, with no clear-cut benefit.

24. CASE 2 (1 of 3)
An 85-year-old man wants to discuss options regarding metastatic prostate cancer, which has progressed in spite of hormone and radiation therapy. His oncologist has proposed a trial of a new chemotherapy agent.
History: heart failure (ejection fraction, 22%), chronic renal failure (estimated GFR, 25 mL/min), and peripheral vascular disease (walking limited to about 1 block)

25. CASE 2 (2 of 3)
Which one of the following would be most useful in helping the patient decide whether to start the new chemotherapy?
Relative risk reduction for death from prostate cancer
Number needed to treat for benefit from the chemotherapy
Number needed to harm from the chemotherapy
Clinical practice guidelines for the patient’s diseases
Time horizon for benefit from the chemotherapy

26. CASE 2 (3 of 3)
Which one of the following would be most useful in helping the patient decide whether to start the new chemotherapy?
Relative risk reduction for death from prostate cancer
Number needed to treat for benefit from the chemotherapy
Number needed to harm from the chemotherapy
Clinical practice guidelines for the patient’s diseases
Time horizon for benefit from the chemotherapy
ANSWER: E
This patient has multiple morbidities, any of which could cause death or worsen function. It would be most beneficial for the patient to know how long it would take for the chemotherapy to show benefit (SOE=C). The time to benefit, or time horizon, is an important variable for patients whose life expectancy is limited by other competing illnesses. It is highly likely that this patient will die of competing morbidities before he would die of prostate cancer. Guidelines are available that may help to determine the potential life span for the patient. Likewise, the new therapy being proposed should be based on studies that cite the number needed to treat for benefit and the duration of treatment to achieve benefit.
Following clinical practice guidelines for the patient’s various diseases can be difficult, because they usually address a single disease, not how different diseases affect each other or how treatment for one disease may worsen another. The number needed to treat for either benefit or harm is difficult to evaluate for patients with multiple morbidities, because it is difficult, if not impossible, to isolate the effects of each individual disease on the patient.
Knowing the absolute risk reduction for dying or potential spread of cancer may be helpful and more easily understood by the patient. The relative risk reduction may give a seemingly inflated value for the benefit of the intervention. In addition, the relative risk reduction is uninterpretable if the baseline risk is not known.

27. Copyright © 2016 American Geriatrics Society
GRS9 Slides Editor: Tia Kostas, MD
GRS9 Chapter Authors: Cynthia M. Boyd, MD, MPH
Matthew K. McNabney, MD
GRS9 Question Writer: Jerome Epplin, MD, AGSF
Managing Editor: Andrea N. Sherman, MS
Copyright © 2016 American Geriatrics Society
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