April 01, 2014

Lotsa Lumps

Geriatrics would be a good deal easier if every older person suffered from just one medical condition. But most elderly people have more than one chronic disease and the older they are, the more chronic conditions they are likely to have. Since “multiple chronic conditions” is a mouthful, researchers coined the term “multimorbidity,” an only slightly less awkward way of expressing what is probably one of the most critical features of geriatric existence. It’s so critical because the best medical treatment, known as “evidence-based medicine,” is founded on studies of patients who don’t have multimorbidity at all. They are generally perfectly healthy except for the single disease being studied. So when we tell a patient that “studies show’ that blood pressure should be below 140 and that the best medication to take if the blood pressure is elevated is a diuretic, we mean that if the only problem is high blood pressure, then taking the diuretic is the best way to lower the risk of bad outcomes such as strokes and heart attacks. But if the patient also has another chronic condition, say Parkinson’s disease, which is being treated with the medication L-dopa (Sinemet), then giving that patient a diuretic to lower blood pressure could backfire—long before any heart attacks or strokes were prevented, the patient might fall down (both L-dopa and diuretics contribute to sudden falls in blood pressure when a person stands up) and break a hip. Simply assuming it makes sense to apply multiple guidelines to a patient with multiple problems can result in medication lists a mile long that cost a fortune and that cause more problems than they solve. So multimorbidity is a big deal in geriatrics. Now, for the first time, multimorbidity is getting the attention it deserves.

A couple of years ago, the American Geriatrics Society set up a task force to develop an approach to multimorbidity for physicians. This group generated a report that lays out the basic principles that should underlie care for a patient with multiple chronic conditions. And a recent symposium brought together physicians and researchers from a variety of backgrounds to come up with strategies for generating a better evidence base, for designing new guidelines, and for carrying out appropriate systematic reviews for patients with multimorbidity. The results of the symposium are published as 3 articles along with an editorial in the April issue of the Journal of General Internal Medicine. 

I wish I could report that these new guidelines-for-producing- guidelines came up with the solution to the problem of multimorbidity. I wish I could summarize the gist of these papers. They constitute a valiant attempt to find an answer to a vexing problem. They go far in enumerating the many obstacles to a solution. They provide an exhaustive list of all the issues that must be addressed in the future. But in the end, they advocate a technical solution to a dilemma that can only be addressed by eliciting patient preferences and by use of clinical judgment.

There are just too many different clusters of chronic diseases for physicians to come up with recommendations that clearly and unambiguously apply to a given patient. Consider just the 10 most common chronic diseases. For any group of 10 diseases, there are 45 pairs of diseases and 120 groups of 3 diseases and 210 groups of 4 diseases—and that doesn’t include clusters of greater than 4, even though plenty of older people have, say, arthritis, diabetes, heart disease, emphysema, and kidney problems. Even if it were practical to design a guideline for all the most common groupings, which it isn’t, that wouldn’t be good enough. What matters is not just how many diseases you have, but how sick you are and how well you can go about your day to day business (what geriatricians call your functional status). Someone who lives independently and shops and cooks for herself is in far better shape—and able to withstand a new medication or a brief hospitalization—than her counterpart with the same underlying chronic conditions who lives in a nursing home and needs help with all her daily activities.

I tend to agree with an article in the British Medical Journal that argues that “multimorbidity introduces clinical uncertainty in a way that is unlikely to be resolved by ever more sophisticated guidelines.” The authors advocate listening to patients to find out what matters to them and using clinical judgment to try to achieve their ends. A similar recommendation came from the American Geriatrics Society task force,  which even created a pocket card summarizing their key conclusions: consider patient preferences, consider prognosis, consider interactions among treatments, review the entire care plan, and communicate and decide on treatment together with patient and family. 

More research that measures quality of life outcomes as well as survival outcomes is of course important. But empirical studies alone will not solve the multimorbidity problem. Talking to patients about their overall health status and their goals of care, and figuring out together what tests and treatments make most sense in light of their status and their goals, just might.

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