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Balancing guidelines and drugs in those with multiple health conditions

The Bottom Line

  • Clinical practice guidelines are important in encouraging evidence-based practice among practitioners, but they have limitations when they are applied to seniors with multiple health conditions.
    • As a patient, you should be aware of the risk and benefits of your current treatments. Discuss them with your family doctor and specialists. Some of the benefits, though important, may not be as relevant to you in your current life stage. Based on these discussions, some of the treatments for your multiple health conditions may change.
  • Estimation of prognosis and remaining life expectancy are keys to determine whether you are more likely to experience benefit than any known adverse effect from a proposed treatment.
    • As a patient, it may be helpful to ask your doctor how you compare relative to the average patient with similar health conditions. Discuss what you should expect in the future.
  • When you have multiple health conditions, the appropriateness of treatments can vary significantly. This depends on your functional priorities, values and beliefs regarding medication-related risk and benefit.
    • As a patient, it is important for you to establish an open and common understanding of your healthcare-related values, goals and priorities with your health care providers. Devising a good plan for optimal aging and knowing what is important to you will ensure that you receive the best and most appropriate care.

Why is this issue important to your health?

A growing number of Canadians live with multiple chronic health conditions (sometimes referred to as multi-morbidity). According to the Canadian Institute for Health Information (CIHI), 33% of community-living seniors have three or more chronic conditions (1).

Scientific evidence suggests that multiple chronic health conditions are associated with:

  1. increased healthcare use
  2. treatment with multiple medications (polypharmacy)
  3. physical disability
  4. reduced quality of life and life expectancy (2).

In fact, the driving force in healthcare use appears to be patients' multiple chronic health conditions rather than aging itself. In Ontario, for example, it is the most complex 10% of seniors (the frail and those with multiple chronic health conditions) that account for 60% of the provincial healthcare spending (3).

Managing multiple chronic health conditions is challenging for both patients and their health care providers. Traditionally, doctors and other health care providers have used Clinical Practice Guidelines (CPGs) to assist them in making medical test and treatment decisions for their patients. CPGs are sets of recommendations for specific health conditions. They are created after an exhaustive review of the best available research evidence and practice experience. When applied appropriately, CPGs can maximize benefits for patients with a specific health condition. However, they can sometimes create new problems when applied to seniors with multiple chronic health conditions.

What are the limitations of clinical practice guidelines?

Several research studies have shown that most CPGs do not consider how their recommendations might affect older patients with multiple health conditions (2). For example, a recent Canadian review of CPGs for the ten most common chronic health conditions (e.g., diabetes, heart problems, etc.) found that only three provided specific recommendations for older patients with multiple health conditions (4).

As a result, clinicians are becoming increasingly concerned about using different CPGs for the multiple health conditions of their patients. This is because:

  1. CPGs are typically designed for a single health condition. They may not take into account signs, symptoms and treatments related to other health conditions. As a result, the recommendations made in each CPG (for individual health conditions) may interact or contradict each other (5).
  2. Most CPGs are based on scientific evidence that does not include studies of older adults. When studies of seniors are included, they usually exclude or under-represent patients with multiple health conditions (6).
  3. Rigidly following CPGs across a range of health conditions may increase the risk of polypharmacy and drug complications (7). [See other blogs on polypharmacy on the website]
  4. CPG recommendations rarely consider other life issues important to older adults. Seniors often have different priorities than young adults (2). These priorities or goals of care are rarely considered in older people with limited life expectancy. This means that many life issues important to seniors may not be factored into the recommendations made within the CPG.

Prescribing for the patient versus prescribing for the disease

Making decisions and prescribing medications for older adults with multiple conditions is complex. Ideally, medical treatments would improve all health outcomes whether they improve your symptoms, daily function, or how long you live. However, these treatment outcomes are often at odds with one another. There can be a dilemma where the improvement of one outcome (e.g. symptoms of breathlessness) may worsen the other (e.g. survival).

Many experts in elder care recommend an individualized, holistic approach rather than a strict following of CPG recommendations. This approach aims to optimize decision-making and patient treatments by re-evaluating whether:

  1. medications with benefits for specific health conditions are still helpful or potentially harmful when taken along medications for others conditions [see the other blogs on polypharmacy].
  2. medications are effective given all health conditions of a patient
  3. medications are sensible given a patient's age and circumstance (e.g. remaining life expectancy and goals of care)

Using this information, patients and healthcare providers must decide whether a medication is more likely to help (provide the proposed or expected benefit) or harm (produce any known adverse effect) in their lifetime. This is known as the 'time to benefit' or 'payoff time' model. This model is a reminder that many patients with multiple health conditions may not live long enough to reap the rewards from medical treatments. This occurs because many medications have the potential to cause immediate discomfort or harm, but the health benefits may take years to appreciate (8;9).

Patients and healthcare providers also need to have a common and respectful understanding of each other's values and goals of care. Patients place varying degrees of importance on health outcomes (10). These may include quantity vs. quality of life, future vs. present health, and symptom relief vs. disease prevention. Depending on one's values, the appropriateness or priority of specific treatments and medications can vary significantly.

For this reason, healthcare providers should know about your priorities and beliefs regarding medication-related risk and benefit. Once this has been established, a good plan for healthy living, optimal aging and end-of-life concerns can be developed. This will allow them to prescribe more effectively as your situation and needs change over time.

What tools are available to help patients and their health care providers?

A number of clinical tools have been developed to help your healthcare provider develop your health plan. These include tools that will:

  1. improve the appropriateness of medication prescribing (e.g. Beers Criteria, START / STOPP Criteria) (11-13),
  2. help estimate remaining life expectancy (e.g. ePrognosis) (14;15) and
  3. establish health-related values and goals of care (e.g. Health Outcomes Tool, Time and Outcome Preference / Attitude Scale, Now. Vs. Later Tool) (16-18)

You may want to ask your doctor about some of these clinical tools as you work on your health plan.

What is the bottom line about clinical practice guidelines, medications, and multi-morbidity?

Many Canadians live with multiple chronic health conditions and most CPG have not been developed for older adults in this situation. Making decisions about your care and your medications are complex. An individualized approach, that takes into account your values and goals may be the best option for older adults with multiple chronic health conditions.


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References

  1. Canadian Institute for Health Information. Seniors and the Health Care System: What is the Impact of Multiple Chronic Conditions. Ottawa, Canada; 2011.
  2. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005 Aug 10;294(6):716-24.  
  3. Sinha SK. Living Longer, Living Well. 2013. http://www.health.gov.on.ca/en/common/ministry/publications/reports/seniors_strategy/docs/seniors_strategy.pdf.  
  4. Mutasingwa DR, Ge H, Upshur RE. How applicable are clinical practice guidelines to elderly patients with comorbidities? Can Fam Physician 2011 Jul;57(7):e253-e262.
  5. Upshur RE, Tracy S. Chronicity and complexity: is what's good for the diseases always good for the patients? Can Fam Physician 2008 Dec;54(12):1655-8.  
  6. Nobili A, Garattini S, Mannucci PM. Multiple diseases and polypharmacy in the elderly:challenges for the internist of the third millenium. J Comorbidity 2011;1:28-44.
  7. Mazowita G, Kozak JF. "First do no harm". Reflections on the application of consensus guidelines for diabetes and other chronic conditions in residential care. BCMJ 2013;55:80-4.  
  8. Holmes HM, Min LC, Yee M, Varadhan R, Basran J, Dale W, et al. Rationalizing prescribing for older patients with multimorbidity: considering time to benefit. Drugs Aging 2013 Sep;30(9):655-66.  
  9. Braithwaite RS, Concato J, Chang CC, Roberts MS, Justice AC. A framework for tailoring clinical guidelines to comorbidity at the point of care. Arch Intern Med 2007 Nov 26;167(21):2361-5.  
  10. Tinetti ME, Bogardus ST, Jr., Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004 Dec 30;351(27):2870-4.  
  11. Campenelli C. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geratr Soc 2012;60:616-31.
  12. Gallagher P, O'Mahony D. STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria. Age Ageing 2008 Nov;37(6):673-9.  
  13. Barry PJ, Gallagher P, Ryan C, O'Mahony D. START (screening tool to alert doctors to the right treatment)--an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing 2007 Nov;36(6):632-8.  
  14. Lee S, Smith A, and Widera E. ePrognosis- Estimating Prognosis for Elders. 9-5-2014. http://eprognosis.ucsf.edu/.  
  15. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA 2012 Jan 11;307(2):182-92.  
  16. Fried TR, Tinetti M, Agostini J, Iannone L, Towle V. Health outcome prioritization to elicit preferences of older persons with multiple health conditions. Patient Educ Couns 2011 May;83(2):278-82.  
  17. Fried TR, Tinetti ME, Iannone L, O'Leary JR, Towle V, Van Ness PH. Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Arch Intern Med 2011 Nov 14;171(20):1854-6.  
  18. Case SM, Towle VR, Fried TR. Considering the balance: development of a scale to assess patient views on trade-offs in competing health outcomes. J Am Geriatr Soc 2013 Aug;61(8):1331-6.

DISCLAIMER: The blogs are provided for informational purposes only. They are not a substitute for advice from your own healthcare professionals.

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