Advancing Evidence-Based Clinical Care for Older Adults With Multimorbidity

While high-quality clinical practice guidelines can help improve healthcare for many patients, available guidelines typically focus on the treatment of single disorders and, as research indicates, can harm more than help complex older patients with multiple chronic health problems. According to an eye-opening 2005 Journal of the American Medical Association study (JAMA; www.ncbi.nlm.nih.gov/pubmed/16091574), adhering to each of the individual guidelines applicable to a hypothetical older adult with several common chronic health problems would result in the patient taking multiple medications, which is likely to cause a range of adverse drug-drug and drug-disorder interactions.

Multimorbidity is common. More than half of older adults have at least three chronic diseases and, as a result, meet the criteria for this diagnosis. With the needs of these patients in mind, the American Geriatrics Society convened a panel of experts to develop an approach to their care. The panel created two documents: a comprehensive background document titled Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians and a summary report titled Patient-Centered Care for Older Adults With Multiple Chronic Conditions, A Stepwise Approach from the American Geriatrics Society. Both of these documents are a must-read and appear in the early online edition of this month’s Journal of the American Geriatrics Society.

Older patients with multiple health problems are challenging for a number of reasons, noted the panel, which was chaired by Cynthia M. Boyd, MD, MPH, coauthor of the aforementioned 2005 JAMA report, and Matthew K. McNabney, MD, both of whom are from Johns Hopkins School of Medicine. Among other things, these patients run increased risks of institutionalization, disability, adverse side effects, and death. They are also a very heterogeneous group. For these and other reasons, these patients are often excluded from or underrepresented in clinical trials and other research. Not surprisingly, the evidence base for these patients is limited. 

In light of this, the panel set out to develop not a guideline, but guiding principles, an approach that clinicians can follow to provide these patients with optimal, individualized 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 each management decision and its implementation,” the panel writes, calling for the development of an evidence base to further facilitate appropriate care decisions. “Not only the individuals themselves, but also their treatment options will differ, necessitating more flexible approaches to care in this population.”

Central to the care approach, the panel outlines five “domains,” or areas, relevant to providing care tailored to older patients’ needs. These areas include the following: patient preferences; the interpretation of the evidence base; the framing of clinical decisions in the context of risks, patient benefits, burdens, and prognosis; the assessment of clinical feasibility in light of the complexity of treatment options; and the optimization of treatments and care plans.

Both of the panel’s documents explain the importance of each principle and how to incorporate it into practice. In keeping with the guiding principle for the patient preferences domain, for example, the authors noted that clinicians should first acquaint the patient with the benefits and potential harms of available treatment options. Only when the patient is adequately informed, the report explains, should clinicians elicit the patient’s preferences. The documents further note that some patients may prefer to have healthcare providers make treatment decisions, or to share decision-making with family, friends, and others, and that these preferences should be supported. They also underscore the need to revisit care decisions periodically and to identify other resources that may be helpful. The sections dedicated to the other four domains are equally comprehensive.

Clinicians, researchers, payers, public health professionals, policymakers, and others who are interested in the care of these complex older patients will find these new resources to be illuminating. Ultimately, writes the panel, “We hope that they will be replaced by evidence-based care approaches for this population.” In the meantime, these important documents are a significant step forward in the care of these patients.