Despite the challenges intrinsic to caring for someone with multimorbidity, provision of higher quality, more gratifying care can occur when a few guiding principles are taken into account. These guiding principles were initially developed by a national expert panel on multimorbidity of the American Geriatrics Society. The panel performed an extensive review of the literature and synthesized these findings into practical perspectives for clinicians. We discuss 3 steps that can support clinicians in their care of older adults with multimorbidity: ascertainment of prognosis, elicitation of patient preferences, and assessment and management of treatment complexity.
Because, in older adults with multimorbidity, tension exists between benefit from a particular intervention and possible harm from complications or interactions with other conditions, it is very important to ascertain as best as possible the older person’s prognosis. Prognosis ideally should be considered not just for survival but also for function and quality of life (see Chapter 3, “Goals of Care & Consideration of Prognosis,” for more details). Determination of prognosis can provide the appropriate context for elicitation of preferences for particular treatments. It offers the backdrop for decisions related to (a) disease prevention or treatment (eg, whether or not to start or stop a medication or insert or replace a device); (b) disease screening (eg, cancer); and (c) use of specific services (eg, whether or not to admit a patient to the hospital or enroll them into hospice).
Elicitation of patient preferences can help guide the management of older adults with multimorbidity. Patient preferences take many forms: preferences regarding the importance of any one condition over another, preferences regarding states of being and how much burden is acceptable in order to achieve a particular state of being (also called an outcome; eg, survival, higher functional status, or better quality of life), and preferences regarding particular treatments in light of potential benefits and burdens associated with that treatment.
Involving patients and their caregivers (when appropriate) is particularly important when treatment decisions are preference-sensitive. Preference-sensitive decisions are those that (a) relate to therapies that might help one condition but lead to worse outcomes in another (antiinflammatory agents that might reduce pain but increase risk for gastrointestinal bleeding); (b) therapies that may be beneficial over the long term but are at risk for causing short-term harm (anticoagulants for stroke prevention); or (c) therapies that may include multiple medications with potential harmful interactions (such as heart failure medications and medications for chronic obstructive pulmonary disease). Table 10–1 offers some language for elicitation of preferences.
Table 10–1.Language for eliciting patient preferences. ||Download (.pdf) Table 10–1. Language for eliciting patient preferences.
|Question Purpose ||Question |
|To understand patient’s view of their quality of life ||How would you consider your current quality of life? |
|To understand patient’s view of their future ||What sort of things have you been thinking about especially as you think about the future? |
|To learn patient’s values ||What kinds of things are important to you now? (Or if surrogate: If your loved one were able to tell us what she is thinking, what things would she think are important now?) |
|To learn patient’s preferences ||Some people want to live as long as possible no matter the risks, including being willing to accept hospitalizations and less independence. Other people are less willing to compromise their quality of life or independence and would defer [treatment] knowing this may limit their survival. Do you have an idea of what kind of person you might be? |
It is also important that patients and their caregivers understand as well as is possible the potential benefits and harms of a particular treatment. Unfortunately, the evidence base for risks and benefits for many treatments are not evaluated in the context of multimorbidity and must be extrapolated from single condition studies and observational studies. Regardless, it is incumbent on clinicians to communicate what is known in language that makes sense to patients. Table 10–2 provides some general suggestions for ways to communicate benefits and harms.
Table 10–2.Strategies to communicate risks and benefits of treatments or diagnostic tests. ||Download (.pdf) Table 10–2. Strategies to communicate risks and benefits of treatments or diagnostic tests.
|Do ||Don’t |
|Use numerical likelihoods ||Use words like “rarely” and “frequently” |
|Provide the likelihood of an event both occurring and not occurring ||Provide the likelihood in only 1 direction either in favor of benefit or harm |
|Provide absolute risks ||Provide relative risks |
|Offer visual aids and assess understanding ||Assume the patient understands |
Treatment complexity is common in patients with multimorbidity. The Medication Regimen Complexity Index (MRCI) captures some of the elements of complexity by capturing (a) the steps in the task, (b) the number of choices, (c) the duration of execution, (d) the process of administration, and (e) the patterns of intervening and potentially distracting tasks. It highlights the multiple dimensions of treatment patients have to contend with when managing their conditions. For clinicians who strictly follow individual clinical practice guidelines, regimens for patients can be both complex and also onerous and costly. Boyd et al described the implications of following individual practice guidelines for an older woman with the following conditions of moderate severity: chronic obstructive pulmonary disease (COPD), hypertension (HTN), diabetes mellitus (DM), osteoporosis, osteoarthritis. If clinical practice guidelines were followed, the patient would be taking 19 doses per day at 4 different time points. Assuming no prescription drug coverage, this regimen would cost $407 per month and $4877 per year. Complex treatment regimens increase risk for nonadherence, adverse reactions, reduced quality of life, financial burden, and caregiver stress.
Given the problems associated with complex treatment regimens, it is worthwhile to consider ways to reduce or mitigate treatment burden or complexity. A number of tools have been developed that can assist the provider in both identifying complex medication regimens that pose potential difficulties for patient self management along with strategies to reduce treatment complexity and optimize outcomes. Table 10–3 lists tools that can be used to assess treatment complexity and ability to manage it. Table 10–4 lists a few approaches that can be used by a patient’s clinical team to address candidate medications to discontinue to decrease treatment complexity.
Table 10–3.Tools to identify treatment complexity. ||Download (.pdf) Table 10–3. Tools to identify treatment complexity.
|Tool ||Description |
|Medication Management Ability Assessment ||Role-play task that simulates a prescribed medication regimen, similar in complexity to one to which an older person is likely to be exposed |
|Drug Regimen Unassisted Grading Scale ||DRUGS- (1) identification: showing the appropriate medications, (2) access: opening the appropriate containers, (3) dosage: dispensing the correct number per dose, and (4) timing: demonstrating the appropriate timing of do |
|Hopkins Medication Schedule ||Role play that includes the following: “Read the medication instructions below. Assume that you eat breakfast, lunch, and dinner at the following listed times. Please indicate at what times you should take each medication and how many you need to take. Also, indicate when your should drink water and eat any snacks.” |
|Medication Management Instrument for Deficiencies in the Elderly ||Twenty item assessment that covers three domains relevant to medication adherence (knowledge of medications, how to take medications, and procurement) and yields a total score of 13 or less. |
Table 10–4.Strategies to reduce treatment complexity and burden. ||Download (.pdf) Table 10–4. Strategies to reduce treatment complexity and burden.
|Tool ||Description |
|Screening Tool to Alert to Right Treatment and Screening Tool of Older Persons’ potentially inappropriate Prescriptions (START/STOPP) ||Algorithm of medications that should be considered in certain conditions and medications that may be inappropriate to use in certain conditions |
|Good-Palliative Geriatric Practice (GP-GP) algorithm ||Series of questions that can provide guidance of the ongoing utility or value of continuing a medication based on the patient’s prognosis or the underlying evidence base |