Optimizing Care for Multimorbid Adults Through Guiding Principles

Among patients aged 65 years and older, multimorbidity is the norm, rather than the exception. More than half of all older adults have three or more chronic disorders, and this complicates their care significantly. While high quality clinical guidelines have been shown to improve care for individual health problems, this does not appear to be the case when a patient has multiple disorders. A seminal 2005 study, in fact, found that following each of the individual clinical guidelines that would apply to an older patient with multiple chronic health problems would result in the patient taking numerous medications, running significant risks of adverse drug-drug and drug-disorder interactions.¹ Related research has also highlighted the impracticality from a practice management perspective of treating each of the disorders a multimorbid patient has as though it were the only disorder.²

In an important step toward improving the quality of care for multimorbid older adults, the American Geriatrics Society (AGS) recently convened a panel of experts in this area. The outcome of their work, Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians, was published in September’s Journal of the American Geriatrics Society (JAGS). A summary report, Patient-Centered Care for Older Adults with Multiple Chronic Conditions, A Stepwise Approach from the American Geriatrics Society, appears in the same issue of JAGS. I highly recommend reading both of these reports, which can be found on the AGS Website, www.americangeriatrics.org.

The documents note both the relative scarcity of research focusing on the optimal treatment of multimorbid older patients and the heterogeneous nature of this population. Given this, the panelists offer not just guidelines for care, but rather, guiding principles that clinicians can adopt to optimize care. The authors also emphasize the need for the development of a sufficient evidence base to serve as the basis for guidelines in the future, noting that having high-quality evidence upon which to guide clinicians’ decisions is of key importance.

The panel’s guiding principles call for a focus on five “domains,” or elements, of quality care for these complex older adults. Each domain, they note, is essential to meeting each patient’s needs and wishes to the greatest extent possible. The five elements are as follows: 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. The two documents describe in detail how clinicians can incorporate each element into their practice and optimize care.

The thoughtful and comprehensive approach the panelists delineate makes both documents required reading for those of us in the field of geriatrics. If widely adopted, the recommendations in these publications have the potential to significantly improve the well-being of older patients with multiple health problems. Among other things, the recommendations should result in the prescribing of fewer unnecessary medications, more targeted treatments, fewer adverse reactions to treatments, more flexible care tailored to the patient’s needs and wishes, and greater well-being for these patients and their loved ones.

Because older adults with multimorbidity often move through many different sites of care, Guiding Principles for the Care of Older Adults with Multimorbidity and Patient-Centered Care for Older Adults with Multiple Chronic Conditions will be particularly useful for those providing overall care for older adults across settings. The documents will also be especially helpful in settings employing innovative models of primary care and care coordination, such as advanced medical homes, and in collaborative practice arrangements in which geriatricians and other clinicians work closely as a team.

Because older adults with multimorbidity often need assistance with healthcare management tasks and healthcare decision-making, clinicians need to both move away from the single disease approach to care and also better integrate patients’ family members and friends in their care as healthcare partners. The AGS’ excellent Doorway Thoughts: Cross- Cultural Health Care for Older Adults offers insightful advice for discussing care not only with patients but also with family members from diverse ethnic and cultural backgrounds. We need to better understand the importance of these caregivers, and ensure that their needs are addressed along with the needs of our patients.

There is a wide range of things we know we can do to enhance outcomes for complex multimorbid patients, but to have the time to do them all—and to do them well—we will need additional support. Appropriate compensation for the additional time and resources these patients and their families require is necessary. So are appropriate performance criteria that reward clinical management approaches that lead to improved health outcomes overall, improved functional status, and better quality of life.

Guiding Principles and Patient-Centered Care are, I anticipate, destined to become seminal works in our field. Research confirms that focusing on a single disease approach and on single disease guidelines is inappropriate for many older adults and especially for those with multimorbidity.

 References

1.  Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA. 2005;294(6):716-724.

2.  Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004;351(27):2870-2874.