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Making a plan for optimal aging. Balancing guidelines and drugs in those with multimorbidity

The Bottom Line

  • Clinical practice guidelines are important in encouraging evidence-based practice, but they have limitations when they are applied to older adults with multimorbidity. Think beyond individual diseases and be cautious of rigid adherence to CPGs. Take into consideration the impact of your patient’s other comorbidities, medications, prognosis and goals of care. Discuss with your patient and review periodically as their situation and needs change over time.
  • Estimation of prognosis and remaining life expectancy are essential in determining whether your patient is more likely to experience benefit than any known adverse effect from a proposed treatment. Ensure that your patients have realistic expectations about their health and prognosis. Consider whether your patient has the “time to benefit” from an intervention with immediate risks, but delayed benefits.
  • The appropriateness of treatments can vary significantly depending on your patient’s functional priorities, values and beliefs regarding medication-related risk and benefit. Establish an open and common understanding of your patient’s healthcare-related values, goals and priorities. Devising a good plan for optimal aging and knowing what is important to them will ensure that they receive the best and most appropriate care.

Why is this issue important to your practice?

A growing number of Canadians live with multiple chronic health conditions (sometimes referred to as multimorbidity). 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 multimorbidity is associated with:

  • increased healthcare use;
  • polypharmacy;
  • physical disability; and
  • reduced quality of life and life expectancy (2).

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

Managing multimorbidity is challenging for both patients and their healthcare providers. Traditionally, healthcare providers have used Clinical Practice Guidelines (CPGs) to assist them in making diagnostic and treatment decisions for their patients. CPGs are designed for specific health conditions. They are created after a systematic review of the best available research evidence and practice experience. When applied appropriately, CPGs can standardize practice and maximize benefits for patients with a specific health condition. However, they are not currently designed to balance the cumulative impact of treatment recommendations on people with several 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 multimorbidity (2). For example, a recent Canadian review of CPGs for the 10 most common chronic health conditions (e.g., congestive heart failure, chronic obstructive pulmonary disease, diabetes, etc.) found that only three provided specific recommendations for older patients with comorbidities(4).

As a result, clinicians are becoming increasingly concerned about concurrent use of different CPGs for multiple chronic health conditions for the following reasons.  

  • 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 with or contradict each other(5).
  • 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 multimorbidity(6).
  • Rigid adherence to CPGs across a range of health conditions may increase the risk of polypharmacy and adverse drug events (7). (See other blogs on polypharmacy on this website.)
  • 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 health goals and functional priorities 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 chronic conditions is complex. Ideally, medical treatments would improve all health outcomes whether they are symptoms, survival or function. 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 a shift in thinking. They suggest an individualized and holistic goal-oriented approach rather than a disease-focused, strict following of CPG recommendations. This approach aims to optimize decision-making and treatment appropriateness by re-evaluating whether:

  • medications with benefits for specific health conditions are still helpful or potentially harmful when taken with medications for others conditions (see other blogs on polypharmacy and multiple chronic conditions);
  • medications are effective given pharmacokinetic and pharmacodynamic considerations that may have changed due to the aging; and
  • 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 multimorbidity 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).

Clinicians need to establish a common and respectful understanding of their patient’s values and goals of care. Patients place varying degrees of importance on health outcomes (10). These may include quantity versus quality of life, future versus present health, and symptom relief versus disease prevention. Depending on their values, the appropriateness or priority of specific treatments and medications can vary significantly.

For this reason, it is important to know about your patient’s 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 is similar to a financial advisor utilizing an investor’s short and long-term financial goals, risk tolerance and stage of life to determine the appropriate types of investments. This will allow you to prescribe more effectively as your patient’s situation and needs change over time.

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

A number of clinical tools have been developed to help healthcare providers create individualized goal-oriented health plans for their patients. These include tools that will:

  • improve the quality and appropriateness of medication prescribing (e.g. Beers Criteria, START / STOPP Criteria, Medstopper web-based tool) (11-14);
  • help determine prognosis and estimate remaining life expectancy (e.g. ePrognosis) (15;16); and
  • establish health-related values and goals of care (e.g. Health Outcomes Tool, Time and Outcome Preference / Attitude Scale, Now. Vs. Later Tool) (17-19).

You may want to consider using these tools to help you care for your most complex patients.

In the future, look for CPGs that have considered the net benefit of multiple interventions and incorporated issues related to multimorbidity.

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

Many Canadians live with multiple chronic health conditions and most CPGs have not been developed with this clinical reality in mind. Making decisions about treatments for older adults with multimorbidity and limited life expectancy is complex. An individualized approach that takes into account your patient’s values and goals may be the best option for optimal aging.

 


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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/
  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. University of British Columbia. Medstopper. 2015. http://medstopper.com/.
  15. Lee S, Smith A, and Widera E. ePrognosis- Estimating Prognosis for Elders. 9-5-2014. http://eprognosis.ucsf.edu/.
  16. 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.
  17. 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.
  18. 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.
  19. 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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