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Multimorbidity

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Overview

Multimorbidity describes the presence of two or more long-term health conditions. These can include physical or mental health conditions (e.g. heart disease or schizophrenia), ongoing conditions (such as learning disability), symptom complexes (e.g. frailty or chronic pain), sensory impairment (e.g. hearing or sight loss), or alcohol or substance misuse.

Multimorbidity can lead to high treatment burdens (such as multiple appointments and complex drug regimes), mental health problems, polypharmacy, and a negative impact on the health and well-being of carers. 

Epidemiology

  • The prevalence of multimorbidity increases significantly with age
  • The prevalence of multimorbidity also increases with socioeconomic deprivation, particularly mental health disorders

Comorbidities

Overview

The ten most prevalent disorders with associated comorbidities are:

  • Hypertension – the most common, associated with pain, diabetes, and hearing loss
  • Anxiety/depression
  • Chronic pain
  • Hearing loss
  • Irritable bowel syndrome
  • Diabetes mellitus
  • Prostate disorders
  • Thyroid disorders
  • Coronary heart disease
  • Asthma

Risk Factors

  • Increasing age
  • Female sex
  • Lower socioeconomic status
  • Smoking
  • Alcohol use
  • Lack of physical activity
  • Poor nutrition
  • Obesity

Assessment

Identifying people with multimorbidity

Identifying people who may benefit from a multimorbidity approach may involve:

  • Directly identifying them:
    • This may be done opportunistically during routine care or proactively using healthcare records (e.g. identifying people who take a large number of regular medications)
  • Identifying them if they:
    • Struggle with managing treatment/day-today activities
    • Receive care and support from multiple services and need additional services
    • Have both long-term physical and mental health conditions
    • Are frail/at risk of falls
    • Frequently seek unplanned/emergency care
    • Are at risk of the effects of polypharmacy:
      • This generally involves people taking 10-14 regular medicines or people who take <10 regular medicines but are at risk of adverse events
  • Using a validated tool:
    • Such as Electronic Frailty Index (eFI), Predicting Emergency admissions Over the Next Year (PEONY), or QAdmissions 

Assessing the impact of multimorbidity

  • How do their health problems affect their day-to-day life?
    • Ensure to include mental health and discuss how their conditions affect their wellbeing, how their health problems interact, and how these affect their life
  • What is their treatment burden?
    • Number and type of appointments and where they take place
    • Number and type of medicines and adverse effects
    • Number and type of non-pharmacological treatment (e.g. diet, physiotherapy, psychotherapy etc.)
    • Any effects of treatment on their wellbeing
  • Further things to explore include:
    • The person’s beliefs regarding potential benefits and harms
    • Social circumstances, financial constraints, living conditions, social support
    • Coping strategies
  • Identify what matters to the patient regarding multimorbidity:
    • Such as maintaining independence, being able to participate in work/social activities, reducing treatment burden, improving quality and length of life, and pain relief
  • Look out for depression, anxiety, and chronic pain
  • Consider assessing frailty through the assessment of gait speed and the PRISMA-7 questionnaire

Management

Overview

Management of multimorbidity involves reducing the treatment burden and maximising the benefits of existing treatments.

Review medicines and other treatments through:

  • Considering screening tools such as STOPP/START (discussed in Polypharmacy)
  • Discussions with the patient regarding the benefits and risks 

Develop action plans with the patient including what actions will be taken, goals and plans for the future (including advanced care planning), prioritising appointments, and exploring other areas that are important to the patient. These can be used to follow up with the patient at agreed points.

For patients >65 years old, they should have an annual review of all of their medications.

Complications

  • Reduced life expectancy
  • Reduced quality of life
  • High treatment burden
  • Mental health difficulties
  • Functional difficulties
  • Polypharmacy and an increased risk of adverse effects
  • Negative impacts on the health and wellbeing of carers

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