What is it?
Multimorbidity is the presence of multiple diseases and medical conditions – chronic or acute – in the one person.1 A recognition of multimorbidity requires these multiple diseases and conditions to be treated concurrently without a hierarchical order.2
Aspects of the patient’s context – biopsychosocial factors, risk factors, support networks, health care consumption and the patient’s coping strategies – may function as modifiers of the effects of multimorbidity.3 Multimorbidity requires a holistic approach which puts the patient, not the disease, at the centre of the plan.4
Why is it important?
- Multimorbidity is associated with more complex clinical management, poor treatment outcomes, longer hospital stays, increased healthcare costs and increased risk of readmission.
- The prevalence of multimorbidity increases substantially with age.5 More than half of older people have three or more chronic diseases.4 These may include cancer, diabetes, asthma, arthritis, pain and mental illness.
- Current clinical guidelines have a single disease focus and rarely consider the cumulative impact of multimorbidity. This can lead to inefficient care which is inconvenient and unsatisfactory to both patients and clinicians.6,7
- Older people with multimorbidity are more likely to have a poorer quality of life, experiencing depression, premature mortality and frequent hospital admissions.6,8
- Older people with multimorbidity are often prescribed multiple medications (polypharmacy). Those on five or more medications are three times more likely to be taking inappropriate medications and are at greater risk of an adverse drug reaction or medication errors. Non-adherence to prescribed regimes, and the interaction of drugs and multiple diseases can affect the burden of care.6
- Eighty per cent of older people report having poor health literacy that impacts on their ability to understand and use health information.9
How can you respond to the needs of older people with multimorbidity?
All hospital staff have a shared role in identifying and responding to multimorbidity in patients.
To provide best care:
- Ensure that the patient’s medical history is complete and that medication safety and quality systems are in place to monitor the management of multimorbidity.
- Check that mental health issues such as depression and cognitive issues such as dementia are recognised as multimorbidity.
- Consult with the patient and their family and carers to determine what the patient’s primary concerns are.
- Engage an interdisciplinary team to manage the patient’s multimorbidity.
Involve patients, their family and carers in the management of multimorbidity
- Find out what is most important to the patient, their family and carers in determining the treatment or care plan.
- Ask the patient about their experience of their multimorbidity, and what they want from their treatment.
- Consider the patient’s health literacy level and their understanding of multimorbidity.
- Encourage shared decision-making so the patient and their family or carer are engaged in the management of their conditions.
- Encourage the discussion of advance care planning with the patient and their family or carer.
Assess medication safety in older people with multimorbidity
- Discuss the need for a medication review with the patient, their family or carer, the multidisciplinary team and the patient’s GP.
- Check the patient’s understanding of their medication needs.
- Minimise the risks to the patient associated with polypharmacy and medication non-adherence.
Ensure continuity of care for patients with multimorbidity
- Engage the patient’s other care providers such as pharmacists, specialists, case managers and GPs to provide a coordinated service.
- Make sure the patient and their family or carers are involved in the management of multimorbidity and care plan processes.
- Ensure there are mechanisms in place to monitor older people with multimorbidity and escalate their care when required.
- Review and ongoing appraisal of the revised care plan is required when the patient’s circumstances and goals of care change. Ideally this should be coordinated through a single clinician who intimately knows the patient, the issues and the care goals.
1. Akker Mvd, Buntinx F & Knottnerus JA 1996, ‘Comorbidity or multimorbidity’, The European Journal of General Practice, 2(2):65.
2. Akker Mvd, Buntinx F, Roos S & Knottnerus JA 2001, ‘Problems in determining occurrence rates of multimorbidity’, Journal of Clinical Epidemiology 54(7):675-679.
3. Le Reste JY, Nabbe P, Manceau B, Lygidakis C, Doerr C, Lingner H, Czachowski S, Munoz M, Argyriadou S, Claveria A, Le Floch B, Barais M, Bower P, Van Marwijk H, Van Royen P & Lietard C 2013, ‘The European General Practice Research Network presents a comprehensive definition of multimorbidity in family medicine and long term care, following a systematic review of relevant literature’, Journal of the American Medical Directors Association, 14(5):319-25.
4. Boyd C, McNabney M, Brandt N, Correa-de-Araujuo R, Daniel M, Epplin J, Fried T, Goldstein M, Holmes H, Ritchie C & Shega J 2012, ‘Guiding principles for the care of older adults with multimorbidity: an approach for clinicians: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity’ J Am Geriatr Soc, 60(10):E1-E25.
5. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S & Guthrie B 2013, ‘Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study’, Lancet, 380(9836):37-43.
6. Salisbury C 2013, ‘Multimorbidity: time for action rather than words’, British Journal of General Practice:64-65.
7. Vitry A & Zhang Y 2008, ‘Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions’, MJA, 189(7):360-365.
8. Australian Institute of Health and Welfare 2012, Australia's Health 2012, Australian Institute of Health and Welfare Canberra, Australia.
9. Department of Health 2012, Best care for older people everywhere – The toolkit, State Government of Victoria, Melbourne.