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Comorbidity, Frailty and Prognostics

Key Messages

  • Comorbidities are associated with poorer quality of life, multiple symptoms, increased use of health services and hospitalisation. [1,2] 
  • Frailty with ageing and diagnosis of one or more comorbidities can accelerate the expected decline in health and, as a result, prognostication can become difficult. [3-5]
  • Care planning discussions may be beneficial in reducing polypharmacy and burdensome treatments while optimising individual preferences benefits. [6-9] 
  • Difficulties in assessing symptoms and pain in older adults with cognitive impairment may mean that they are under-prescribed medications. [10]
  • Prioritising treatments requires an assessment across all health issues. [6]
  • Tools and decision-making guides for multimorbidity are being developed. [2,4,6]

Background

Prevalence of many diseases increases with age so many older people have more than one illness (comorbidity). 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 comorbidities, knowing exactly when death will occur is often difficult to predict and can impact on timely and person-centred palliative care.

This evidence summary aims to discuss the implications of comorbidity and frailty in prognostication and management of older adults, and subsequently provision of palliative care services.

Evidence Summary

More than 50% of older adults have three or more chronic diseases, the presentation and severity of symptoms will be heterogeneous, but produce cumulative effects for each individual. [1,7] Comorbidity is associated with poorer quality of life and increased risk of frailty and morbidity. [1] While evidence based guidelines exist for the management of a single disease, few address comorbidities particularly in a palliative care context where polypharmacy is inevitable. [6] In addition there is a low inclusion rate of older adults in comorbidity randomised clinical trials and therefore reinforces the difficulty in creating appropriate clinical protocols for their management. [1]

Clinicians may need to pursue more flexible approaches to care of older adults with comorbidities in a palliative care context where the medical goals are to provide comfort and quality of life. [6,7]

Clinical goals may vary according to prognosis, however prognostication is additionally difficult for those with the frailty of old age and no overriding diagnosis but multiple comorbidities or ‘multimorbidity’ and often a degree of cognitive impairment. [2,4,5] Clinicians often find discussing end-of-life preferences and advance care planning more difficult where prognostication is not clear-cut and as a result older adults may be subjected to unnecessary treatment and side effects. [2,8,9]

Prioritising treatments requires an assessment across all health issues. Identifying patient priorities and preferences for care is important in providing patient-centred care over time in the context of polypharmacy and multimorbidity. [6] Older adults with comorbidities are at particular risk of adverse reactions from polypharmacy and in the case of symptom review and setting health priorities, some medications may be therapeutically omitted where burden outweighs benefits. [6-9] Currently there is insufficient evidence or guidelines to facilitate prognostication, appropriate polypharmacy and symptom management for older adults with multimorbidity.

Older adults with comorbidity of cognitive impairment may be under-prescribed as a result of the difficulties in assessing symptoms and pain. [10] Development of tools or decision-making guides is being conducted but as yet only single-disease-specific guidance exists. [2,4,6]

Quality statement

Overall the quality of the evidence was acceptable – high, [1,2,4,6,9-11] although four studies scored poorly [3,5,8,12] 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.

Page updated 24 May 2017
 
  • References

  • About PubMed Search

  1. 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.
  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.
  3. Brown MA, Sampson EL, Jones L, Barron AM. Prognostic indicators of 6-month mortality in elderly people with advanced dementia: A systematic review. Palliat Med. 2013 May;27(5):389-400.
  4. de Decker L, Annweiler C, Launay C, Fantino B, Beauchet O. Do not resuscitate orders and aging: impact of multimorbidity on the decision-making process. J Nutr Health Aging. 2014 Mar;18(3):330-5.
  5. Sharp T, Moran E, Kuhn I, Barclay S. Do the elderly have a voice? Advance care planning discussions with frail and older individuals: a systematic literature review and narrative synthesis. Br J Gen Pract. 2013 Oct;63(615):e657-68.
  6. 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.
  7. American Geriatrics Society Expert Panel on the Care of Older Adults with M. Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians. J Am Geriat Soc. 2012 Oct;60(10):E1-E25.
  8. 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.
  9. Tjia J, Velten SJ, Parsons C, Valluri S, Briesacher BA. Studies to reduce unnecessary medication use in frail older adults: a systematic review. Drugs Aging. 2013 May;30(5):285-307.
  10. Drageset J, Corbett A, Selbaek G, Husebo BS. Cancer-related pain and symptoms among nursing home residents: a systematic review. J Pain Symptom Manage. 2014 Oct;48(4):699-710.e1.
  11. Veronese N, Cereda E, Solmi M, Fowler SA, Manzato E, Maggi S, et al. Inverse relationship between body mass index and mortality in older nursing home residents: A meta-analysis of 19,538 elderly subjects. Obes Rev. 2015 Nov;16(11):1001-15.
  12. Salpeter SR, Luo EJ, Malter DS, Stuart B. Systematic review of noncancer presentations with a median survival of 6 months or less. Am J Med. 2012 May;125(5):512.e1-6.

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])