Multi-morbidity in Older Adults and Their Healthcare Management
As more Americans age, there is an increasing number of older adults who are still not able to access the care they need for an acceptable quality of life.
Nurses and other healthcare professionals, researchers and policymakers see multimorbidity (MM) in older adults (≥ 60) as a significant public health concern due to a negative impact on function, quality of life, and healthcare use and costs. MM is referred to as the presence of two or more chronic conditions where one is not more central than the others. Globally 55% to 98% of older adults are living with MM.
More than 75% of health is determined by factors outside the healthcare system. These include social determinants of health. A better understanding of MM could also guide future research. These older adults who live with MM often experience reduced life expectancy, avoidable hospitalizations, lower quality of life, poorer mood, frailty, functional decline, problems with medications, and treatment conflicts.
In this study older adults developed social, emotional and practical coping strategies to live successively with MM. one detriment was when caregivers had a lack of social support often led to destabilization increasing the risk of hospitalization. The goal of this review was to examine how the social determinants of health were challenged by the less than comprehensive discussion of the influence on older adults with MM. conducting research from diverse disciplinary perspective would influence the analysis of the detriments of health.
This study found that structural determents of health were considered mutually exclusive and not intersecting. This assumption has created a gap in understanding of the social determinants and how they intersect to promote or disable successful living. Much work is needed to understand the influence of social and public policy as a determinant of health in older adults with MM. this subject is not a new one with the review of the current literature giving direction for further research. Healthcare research on MM provides a structure to help collaboration between older adults and their caregivers, nurses, and other healthcare professionals. By taking a new look at MM it results in a better clinical practice by including those factors that negatively influence MM (Norwood et al, 2017).
MM is now the norm among those people with long-term conditions as well as more people living with multiple conditions rather than just one. Clinical practice guidelines often do not address the balance between the benefit and harms of treatment recommendations for people with more than one condition. And when treated this way MM quickly becomes polypharmacy. This can create a concern of possible drug-drug or drug-disease interactions. In addition, the burden of multiple treatments can be high with people who have MM.
The burden of treatment, as well as the burden of the illness itself, is unmanageable in some people leading them to prioritize their conditions and management. Healthcare providers need to collectively focus on matching the burden of treatment with patients capacity to cope. Despite the prevailing rhetoric of accounting for patient priorities, there are few tools available to help with a patient of MM. Having this issue can significantly reduce the benefit suggested by trial results and this is an ongoing problem.
This study found clinical guidelines do not currently take into account the cumulative impact of treatment recommendations or cumulative harm of treatments. Some doctors have found that the guidelines rarely discuss applicability to the patient whose greatest concern is quality of life, rather than life expectancy. Clinical guidelines that provide clear and comparable information on benefits and risks of different treatments with the effect of no treatment at all would be of benefit for patients with MM.
This information should include an indicator of the magnitude of the benefit, over what time period these usually accrue, the numbers needed to treat and harm, and when to consider stopping or reducing the treatment. There is an added challenge in the drug companies design trials. They tend to select the trial populations and report their results to maximize the benefits/harm ratio and optimize the validity of the study. The trials are usually designed to target the largest group who may benefit from the medication the most. For research to be of benefit a compromise needs to be found between providing clear and concise treatment recommendations and completely ignoring the complexity of patient in the real world (Miller et al, 2018).
The prevalence of multiple chronic conditions (MCC) among older adults is increasing worldwide. It is associated with poor health status and high rates of healthcare utilization and costs. Current health and social services are not addressing the complex needs of this group or their family caregivers. This trend is even more pronounced i8n older adults (≥65). Adults with two or more conditions represent 60.8% of non-institutionalized adults. Effective healthcare for older people with MCC is a global challenge.
This study found there is complexity defined as the gap between an individual's needs and the ability of healthcare services to meet them. Clearly, there is a need to refine, refocus, and improve the delivery of health and social services for older adults with MCC. A vital place to start is to design services with input from the perspective of the patient with MCC, the family caregivers and healthcare providers.
This study showed research is needed on the experiences of MCC from the perspective of a broader sample of older adults, caregivers, and healthcare providers. The results also indicate that the health services for MCC is experienced as piecemeal and fragmented. The healthcare system is focused on a single disease condition not the complexity of multiple disease or conditions. A key problem is often the challenge of linking older adults with MCC and their caregivers with appropriate resources and services to help them with care in the home. Many patients noted not just the difficulty of accessing services but the inadequacy of them. This included the insufficient number of hours of home care services, lack of continuity of care and lack of respite care for caregivers. This study also showed an increasing problem with access to transportation for their multiple appointments. Healthcare providers can be utilized for a formal assessment of caregivers needs by home care providers of help target the actual needs of patient and family (Ploeg et al, 2017).
Treatment burden refers to the personal workload of healthcare, including treatment and self-management of chronic health conditions and the impact of this on patient functioning and well-being. Workload refers to activities that patients are asked to or required to do in order to care for their health (like medications, maintaining appointments, monitoring healthcare status or engaging in physical therapy). Financial challenges, confusion about medical information and challenges with healthcare system can add to the burden felt by the patient.
One in four American adults have MCC and may be especially vulnerable to treatment burdens. In addition, patients are often required to seek care from a variety of providers that can lead to care that is fragmented and poorly coordinated. Substantial burden arises from the complexity of the treatment regimens. This includes self-management that is needed of patients to maintain health and avoid disease progression. Treatment burden has the potential to negatively impact clinical outcomes like adherence so it seems to be an important issue to understand and assess.
This study showed the results of a model they used to help measure the amount of treatment burden for MCC patients. This model appears to provide information about the patients that cannot be gleaned from a review of medical records. Clinical utility of this model could be considerable and remains to be assessed in future trials. Clinicians tend to know little about the burdens then recommendations have on patients and/or family. They also don't recognize how this burden can influence adherence to treatment plan, attendance to visits, and result in poorer outcomes. Currently, there is a problem with the treatment burden. Developing methods to measure this burden is crucial and still in the trial stage. Continued research is needed as the results could help healthcare providers with information on treatment burden to identify patients who are at risk for problems with adherence (Eton et al, 2017).
Eton,D.T. et al. (2017). Development and validation of the patient experience with treatment and self-management (PETS): A patient-reported measure of treatment burden. Quality of Life Research,26(2). Health and Human Services Public Access. Doi:10.1007/s11136-016-1397-0
Miller,E. Dowell, A. Lawrenson, R. Masngin, D. Sarfat, D. (2018). Clinical guidelines: What happens when people have multiconditions. New Zealand Medical Journal, 131(1472). New Zealand Medical Association. http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2018/vol-131-no-1472-23-march-2018/7530
Norwood, M.; Ploeg, J.; Markle-Reed, M.; Sherifall,D. (2017). Integrative review of the social determinates of health in older adults with multimorbidity. Journal of Advance Nursing. Doi:10.1111/jan.13408
Ploeg, J. et al. (2017). Managing multiple chronic conditions in the community: A Canadian qualitative study the experiences of older adults, family caregivers and healthcare providers. BMC Geriatrics doi:10.1186/s12877-017-0431-6