What is multimorbidity?
Multimorbidity refers to the presence of two or more long-term, chronic conditions in one person. [1] This includes life-limiting conditions such as heart disease, chronic kidney disease, chronic pulmonary obstructive disease, and dementia. As people age, their likelihood of developing chronic conditions increases, making multimorbidity common among older adults. [2] In Australia, an estimated 73% of people over the age of 75 live with multimorbidity. [3]
Why multimorbidity matters in aged care
Multimorbidity is common among older people living in the community and even more so in residential care facilities, where the average age on entry is 84 years. [4] With increasing numbers of older people with multimorbidity predicted, residential facilities are likely to become the setting for more complex end-of-life care over the coming years. [5,6]
Multimorbidity can significantly affect quality of life [7] and may add a heavy symptom burden. [8] Some people with multimorbidity may experience progressive functional loss and increased frailty and dependency across the disease trajectory, particularly for activities of daily living. [9] Multimorbidity can also increase the risk of safety issues and hospitalisations, being closely linked to the use of multiple, potentially incompatible medications (polypharmacy). [10] Older people with multimorbidity and their carers often find care burdensome and uncoordinated when each condition is managed separately, which may also result in higher out-of-pocket costs. [11]
Multimorbidity, with its varying rates of disease progression and interactions, can make it difficult for aged care staff to identify when a person’s health is declining. This calls for a more flexible, person-centred approach to care that prioritises the person’s individual needs. [12,13] Early conversations about end-of-life preferences [14] can also help guide care plans that aim to minimise the treatment burden for both the individual and their family. [15]
People with multimorbidity have high medical and care needs that usually require the services of a multidisciplinary team. The Aged Care Quality Standards stipulate that providers have systems and processes in place to support coordinated, comprehensive, and multidisciplinary clinical care services and means to identify early and respond to the changing clinical needs that often typify older people with multiple chronic conditions (Outcome 5.3). [16]
What the evidence tells us
Multimorbidity care is complex but can be directed by a set of guiding principles that support a comprehensive assessment of health needs, treatments, and personal preferences and priorities for care. [17,18] The ultimate goal should be to agree on an individualised care plan for improving quality of life and reducing burden of treatment. [19]
Starting palliative care need not always require a change in a person’s multimorbidity management and this can often worsen symptoms. [20] However, medications might be changed as the end of life approaches because of alterations in the way the body metabolises drugs, swallowing difficulties, or interactions with other drugs or conditions. [20]
Needs assessment
A comprehensive assessment of a person’s health status involves reviewing symptoms and their severity and interactions between different conditions and treatments. [18] An overall decline in function can indicate problems. Mental health assessment is especially relevant, as people with multimorbidity may experience depression due to health challenges and care limitations. [21] The degree of frailty, pain, or sensory impairment is also an important consideration. [17]
As the end of life approaches, this is also the time to question the person’s medication needs and reduce treatments that are no longer offering benefits. A GP can request a medication review to assess all prescriptions across different health providers with a view to deprescribing those that may be less beneficial or potentially harmful based on the person’s health status, age, and overall care goals. [22]
Understanding the likely progression of each condition is also important, though challenging, in tailoring the care plan. [13] Tools such as the Supportive and Palliative Care Indicators Tool (SPICT) [23] and the Gold Standards Framework Proactive Identification Guidance (GSF-PIG) [24] can help staff identify palliative care needs—physical, emotional, spiritual, or social—which can improve quality of life and reduce symptom burden when addressed early. [25] In the home care setting, the needs of family carers are also important. For more on this topic, read our Needs assessment evidence summary.
Prioritising the person’s goals
Managing multimorbidity means considering the overall impact of all conditions on the person’s daily life, rather than focusing solely on individual issues. Engaging the person in discussions about the burden of illness and treatment helps them identify their own care priorities. Tools such as the ICAN Discussion Tool [26] and the REDMAP Framework [27] encourage people to consider questions like ‘Where do you find most joy in your life?’ or ‘What is important to you and your family?’ These questions can guide management plans that align with the person’s goals, which may be symptom management, maintaining functional independence, or receiving emotional and spiritual support.
Treatment can then be planned that incorporates what is most meaningful to the person and their stated goals. It also provides a basis for reducing any forms of care that do not support these goals. [12] This person-centred approach to care aligns with Outcome 1.1 of the Aged Care Quality Standards. [16]
Reducing treatment burden
Older adults are vulnerable to adverse drug reactions, yet polypharmacy (more than five medications) is common in multimorbidity. [28] Medication reviews conducted by credentialled pharmacists can help reduce the risks associated with polypharmacy by identifying potentially inappropriate or non-beneficial medications. [29] Reducing medication burden can enhance quality of life, particularly for those nearing the end of life for whom long-term preventive medications may no longer be necessary. [13] Tools like STOPP/START can support polypharmacy management in both home and residential care settings. [30] For more on this topic, read our Reducing care burden evidence summary.
The individualised care plan
Caring for older adults with multimorbidity and palliative care needs often requires collaboration among healthcare professionals, including GPs, medical specialists, nurses, pharmacists, physiotherapists, occupational therapists, and dietitians. [20] An individualised care plan, supported by effective communication among all care team members, enables coordinated, person-centred care that prioritises quality of life across physical, emotional, and psychosocial domains, above professional boundaries and care settings. [31]
Care of people with dementia
Around 70–80% of people diagnosed with dementia in primary care have at least two other chronic illnesses, [32] increasing their risks of impaired vision, falls, weight loss, incontinence, anxiety, delirium, poor oral health, and seizures. [33, 34] Dementia complicates multimorbidity care, as individuals may forget symptoms, have difficulty reporting them, find it hard to follow care plans, and may struggle with basic needs like drinking and eating. [32]
In Australia, people with dementia typically have an average of five comorbidities, a higher rate than those without dementia. [35] In residential aged care settings, they are also likely to have complex medication regimens, with an average of 10 medications, [36] which may increase unplanned hospital admissions due to adverse drug interactions. [37]
Cultural considerations
Some population groups are more likely to experience multimorbidity, including people who are socioeconomically disadvantaged [15], or living in a rural or remote areas. [38] Veterans, people from culturally and linguistically diverse backgrounds, and those identifying as Aboriginal or Torres Strait Islander also appear to be at higher risk. [19]
It is therefore important that aged care staff understand and respect each client or resident’s cultural background, beliefs, and traditions, as these may influence care preferences. Spiritual care and cultural needs may be of great importance to people, particularly as they approach the end of life. They may find it meaningful to have access to religious leaders as well as safe spaces that protect their privacy and dignity. Some people may wish to engage with staff in discussions on cultural practices and rituals. [25]
Considerations for families/carers
Older people with multimorbidity living at home often rely on the support of a family carer. This caregiving role be substantial and become increasingly challenging if the person is dependent on help with daily activities, attending appointments, and managing multiple conditions. Over time, a carer may experience a decline in their own physical, emotional, and mental health, affecting their ability to continue to provide care. [39]
Service providers can support family carers by connecting them with respite services, social support, and training resources to help them balance caregiving with their own needs. [25] The Carer Support Needs Assessment Tool Intervention (CSNAT-I) and Needs Assessment Tool for Carers of People with a Chronic Condition (NAT-CC) may be useful in helping carers identify their own concerns.
Page updated 14 March 2025