Comorbidity and Multimorbidity
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Comorbidity and Multimorbidity

Key Messages

  • The terms comorbidity and multimorbidity both describe a state of multiple chronic conditions with the terms used interchangeably, however, the distinction between the two is starting to be recognised. [1]
  • Comorbidity and particularly multimorbidity are associated with poorer quality of life, increased use of health services and hospitalisation, and polypharmacy. [1-3]
  • Prioritising treatments requires an assessment across all health issues. [4] This means considering the person’s co-existing illnesses and the ways in which they and their respective treatments interact, the person’s clinical and functional status, treatment burden for the person, and the person’s preferences for care. [5,6]
  • While evidence-based guidelines exist for the management of a single disease, few address comorbidity or multimorbidity particularly in a palliative care context. [2,4]

Background

The prevalence of many diseases increases with age so many older people have more than one illness. Almost two thirds of adults over 80 years of age have three or more chronic diseases. [2]

In Australia, the prevalence of a chronic condition(s) that accompanies a life-limiting condition is high. For example, 82% for cancer, [7] 90% for chronic obstructive pulmonary disease (COPD), [7] and 99.1% for heart failure. [8] Some of the more common conditions include diabetes, heart disease, cancer, hypertension, depression, COPD, stroke, arthritis/osteoarthritis, osteoporosis, and asthma. [9] The Evidence Synthesis describes some of the more common comorbidities to expect with prevalent life-limiting conditions.

The terms multimorbidity and comorbidity both describe a state of multiple chronic conditions, however, the distinction between the two is starting to be recognised. [1] In comorbidity, an index condition (e.g. diabetes, stroke, cancer) takes priority and this index condition will often dominate treatment and management decisions. In contrast, multimorbidity is not dominated by an index condition so that all co-existing conditions are regarded equally with none taking priority. [1]

Progressive diseases like cancer, organ or system failure (e.g. chronic heart failure, chronic obstructive pulmonary disease) and neurological conditions can interfere substantially with life for older adults. In the case of frailty and multimorbidity, predicting when death will occur is often difficult and can impact on timely and person-centred palliative care.

Evidence Summary

More than 50% of older adults have three or more chronic diseases. Comorbidity and particularly multimorbidity are associated with poorer quality of life, increased use of health services and hospitalisation, and polypharmacy. [1-3] For many older people with multimorbidity, it is likely that at least one of their chronic diseases will be life-limiting and progressive. [7] The presentation and severity of symptoms will be varied but produce cumulative effects. [2,3,10]

While evidence-based guidelines exist for the management of a single disease, few address comorbidity or multimorbidity particularly in a palliative care context. [2,4] In addition, there is a low inclusion rate of older adults in comorbidity randomised clinical trials which reinforces the difficulty in creating appropriate clinical protocols for their management. [3] Available guidelines for multimorbidity include:

Clinicians may need to pursue more flexible approaches to care of older adults with co-existing illnesses in a palliative care context where the goals are to provide comfort and maximising quality of life. [4,10] As a person-centred approach to care is central to the Aged Care Quality Standards, [13] discussions about prognosis can serve as a springboard for difficult conversations with older people with multimorbidity, and may thus facilitate shared or supported decision-making and advance care planning. [10]

Tools such as Supportive and Palliative Care Indicators Tool (SPICT) and the Gold Standards Framework Prognostic indicator Guidance are available to help with prognostication, [14] as are established trajectories of decline for major life-limiting illnesses. [15] However, the dynamic, fluctuating nature of multimorbidity can complicate this. [16]

Older people with life-limiting illness and multimorbidity may have considerable palliative care needs associated with the cumulative impact of their disease symptoms and functional impairments. [17] These needs are similar to those of people referred to specialist palliative care. [18] Therefore, timely identification of palliative care needs is important for improving symptom burden and overall quality of life.

Prioritising treatments requires an assessment across all health issues. [4] This means considering the person’s co-existing illnesses and the ways in which they and their respective treatments interact. [5,6] It is guided by the person’s clinical and functional status, treatment burden for the person, and the person’s preferences for care. This means providing opportunities for the older person to discuss their quality of life and changing functional ability [2,10] and incorporating their priorities, goals and preferences into shared decisions. [16] The Instrument for Patient Capacity Assessment (ICAN) Discussion Aid [19] is a tool which can help patients to discuss treatment burden. It has also been shown to help health professionals understand patient capacity, workload, and treatment burden. [20]

Integration of these care considerations through supported decision-making is increasingly seen in Australian care settings. Supported decision-making is defined as "the process of enabling a person who requires decision-making support to make, and/or communicate, decisions about their own life. The decision-making is supported, but the decision is theirs.” [21]

Older adults are particularly prone to adverse drug reactions but despite this, polypharmacy (>5 medications) in the management of multimorbidity is common. [2,22] Regular medication and care plan reviews can help to rationalise medications in light of life expectancy, disease trajectory, and the time it takes for the medication to be affective. [5] Medications may be therapeutically omitted where burden outweighs benefits. [4,10] A European 7-step process [2] and a similar Australian five-step process can be used to manage inappropriate polypharmacy. [23] Both these guidelines advocate consideration of the person’s specific needs and the Australian guidelines encourage consideration of “benefit over the person’s remaining lifespan”, which would include the palliative context. [23]

Similarly, screening procedures or treatments may be discontinued if the harms and burdens outweigh the perceived benefit. [10]

Quality statement

Overall the quality of the evidence was acceptable to high [2-4,9,14], although three studies scored poorly [14,15,20,22] due to the lack of reporting on methodology and quality of included studies. These papers were still included in this review due to their relevancy to the topic. Publications other than systematics reviews were included to provide context. [1,5-8,10-12,16-18,21,23]


Page updated 10 May 2022
 

  • References

  • About PubMed Search

  1. Nicholson K, Makovski TT, Griffith LE, Raina P, Stranges S, van den Akker M. Multimorbidity and comorbidity revisited: refining the concepts for international health research. J Clin Epidemiol. 2019 Jan;105:142-146. doi: 10.1016/j.jclinepi.2018.09.008. Epub 2018 Sep 22.
  2. Stewart D, Mair A, Wilson M, Kardas P, Lewek P, Alonso A, et al. Guidance to manage inappropriate polypharmacy in older people: systematic review and future developments. Expert Opin Drug Saf. 2017 Feb;16(2):203-213. doi: 10.1080/14740338.2017.1265503. Epub 2016 Dec 4.
  3. Nunes BP, Flores TR, Mielke GI, Thume E, Facchini LA. Multimorbidity and mortality in older adults: A systematic review and meta-analysis. Arch Gerontol Geriatr. 2016 Nov-Dec;67:130-8.
  4. Mangin D, Stephen G, Bismah V, Risdon C. Making patient values visible in healthcare: a systematic review of tools to assess patient treatment priorities and preferences in the context of multimorbidity. BMJ Open. 2016 Jun 10;6(6):e010903. doi: 10.1136/bmjopen-2015-010903.
  5. Boyd C, Smith CD, Masoudi FA, Blaum CS, Dodson JA, Green AR, et al. Decision Making for Older Adults With Multiple Chronic Conditions: Executive Summary for the American Geriatrics Society Guiding Principles on the Care of Older Adults With Multimorbidity. J Am Geriatr Soc. 2019 Apr;67(4):665-673. doi: 10.1111/jgs.15809. Epub 2019 Mar 10.
  6. Dumbreck S, Flynn A, Nairn M, Wilson M, Treweek S, Mercer SW, et al. Drug-disease and drug-drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines. BMJ. 2015 Mar 11;350:h949. doi: 10.1136/bmj.h949.
  7. Australian Bureau of Statistics (ABS). National Health Survey: first results 2014-15 (2.13MB pdf). Canberra, ACT: ABS; 2015.
  8. Taylor CJ, Harrison C, Britt H, Miller G, Hobbs FR. Heart failure and multimorbidity in Australian general practice. J Comorb. 2017 Apr 28;7(1):44-49. doi: 10.15256/joc.2017.7.106.
  9. Xu X, Mishra GD, Jones M. Evidence on multimorbidity from definition to intervention: An overview of systematic reviews. Ageing Res Rev. 2017 Aug;37:53-68. doi: 10.1016/j.arr.2017.05.003. Epub 2017 May 13.
  10. 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 Geriat Soc. 2012 Oct;60(10):E1-E25.
  11. The Royal Australian College of General Practitioners (RACGP). RACGP aged care clinical guide (Silver Book) [Internet]. East Melbourne, VIC: RACGP; 2019.
  12. National Guideline Centre (UK). Multimorbidity: Assessment, Prioritisation and Management of Care for People with Commonly Occurring Multimorbidity. London: National Institute for Health and Care Excellence (NICE); 2016 Sep.
  13. Aged Care Quality and Safety Commission. Guidance and Resources for Providers to support the Aged Care Quality Standards. Canberra, ACT: Aged Care Quality and Safety Commission; 2021.
  14. Walsh RI, Mitchell G, Francis L, van Driel ML. What Diagnostic Tools Exist for the Early Identification of Palliative Care Patients in General Practice? A systematic review. J Palliat Care. 2015;31(2):118-23. doi: 10.1177/082585971503100208.
  15. Cohen-Mansfield J, Skornick-Bouchbinder M, Brill S. Trajectories of End of Life: A Systematic Review. J Gerontol B Psychol Sci Soc Sci. 2018 Apr 16;73(4):564-572. doi: 10.1093/geronb/gbx093.
  16. Muth C, van den Akker M, Blom JW, Mallen CD, Rochon J, Schellevis FG, et al. The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Med. 2014 Dec 8;12:223. doi: 10.1186/s12916-014-0223-1.
  17. Luckett T, Agar M, Phillips J. Palliative Care in Chronic Illness and Multimorbidity. In: MacLeod RD, Van den Block L, editors. Textbook of Palliative Care. Springer, Cham. https://doi.org/10.1007/978-3-319-77740-5_64
  18. Nicholson C, Davies JM, George R, Smith B, Pace V, Harris L, et al. What are the main palliative care symptoms and concerns of older people with multimorbidity?-a comparative cross-sectional study using routinely collected Phase of Illness, Australia-modified Karnofsky Performance Status and Integrated Palliative Care Outcome Scale data. Ann Palliat Med. 2018 Oct;7(Suppl 3):S164-S175. doi: 10.21037/apm.2018.06.07. Epub 2018 Jul 18.
  19. Boehmer KR, Dobler CC, Thota A, Branda M, Giblon R, Behnken E, et al. Changing conversations in primary care for patients living with chronic conditions: pilot and feasibility study of the ICAN Discussion Aid. BMJ Open. 2019 Sep 3;9(9):e029105. doi: 10.1136/bmjopen-2019-029105.
  20. Sheehan OC, Leff B, Ritchie CS, Garrigues SK, Li L, Saliba D, et al. A systematic literature review of the assessment of treatment burden experienced by patients and their caregivers. BMC Geriatr. 2019 Oct 11;19(1):262. doi: 10.1186/s12877-019-1222-z.
  21. Sinclair C, Field S, Blake M. Supported decision-making in aged care: A policy development guideline for aged care providers in Australia (1.42MB pdf). 2nd Ed. Sydney: Cognitive Decline Partnership Centre; 2018.
  22. van der Cammen TJ, Rajkumar C, Onder G, Sterke CS, Petrovic M. Drug cessation in complex older adults: time for action. Age Ageing. 2014 Jan;43(1):20-5.
  23. Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015 May;175(5):827-34. doi: 10.1001/jamainternmed.2015.0324.

Definitions

Comorbidity, frailty and falls are predictors for implementing a palliative approach in older adult populations.

Comorbidity definition

The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. (MeSH)

Frail Elderly definition

Older adults or aged individuals who are lacking in general strength and are unusually susceptible to disease or to other infirmity. (MeSH)

Accidental Falls definition

Falls due to slipping or tripping which may result in injury. (MeSH)

Search

(Comorbidity[mh] OR comorbidit*[tiab] OR multimorbidit*[tiab] OR multi-morbidit*[tiab] OR co-morbidit*[tiab] OR multiple morbid*[tiab] OR polymorbid*[tiab] OR Polypathy[tiab] OR Polypatholog*[tiab] OR multiple patholog*[tiab] OR Frail elderly[mh] OR frail*[tiab] OR Accidental falls[mh] OR Accidents, home[mh] OR Falls[ti] OR falling[ti] OR fallers[ti])