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 Table of Contents  
EDITORIAL
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 35-37

Multimorbidity in the elderly: Are we prepared for it!


Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission10-Dec-2019
Date of Decision30-Dec-2019
Date of Acceptance05-Jan-2020
Date of Web Publication20-Feb-2020

Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_1_20

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How to cite this article:
Grover S. Multimorbidity in the elderly: Are we prepared for it!. J Geriatr Ment Health 2019;6:35-7

How to cite this URL:
Grover S. Multimorbidity in the elderly: Are we prepared for it!. J Geriatr Ment Health [serial online] 2019 [cited 2020 Aug 9];6:35-7. Available from: http://www.jgmh.org/text.asp?2019/6/2/35/278730



Globally, more so in developing countries, the elderly population is rising. The increasing elderly population is posing its own challenges. One of the major challenges is multimorbidity. Multimorbidity is defined as “existence of multiple medical conditions in a single individual.”[1] Others have tried to define multimorbidity as an accumulation of two or more chronic diseases, whereas others have considered it to be the accumulation of three or more diseases.[2],[3] In terms of chronicity, various diseases which have been included in the definition of multimorbidity include those which are considered to have permanence, are associated with disability, are associated with irreversible pathological changes in the body's system, require long-term supervision, observation, and care and are associated with special training needs for the patient's rehabilitation.[2] Other authors have used the term long-term conditions instead of chronic and defined the long-term conditions like those, which cannot be cured but can be controlled by the use of medications or other treatments.[4] It is suggested that compared to those without multimorbidity, those with multimorbidity have a higher chance of functional decline, poorer quality of life, and more often use of health-care services.[4] Some of the authors also suggest that there is a significant overlap between multimorbidity and frailty.[4] There are also some data to suggest that multimorbidity is associated with increased mortality.[5] Accordingly, those with multimorbidity are considered to be patients with complex healthcare needs, who have significantly higher healthcare needs, and pose a significant burden on the available health-care services.[6]

In high-income countries (HIC), multimorbidity is considered as a norm rather than the exception. It is also suggested that multimorbidity is increasing in low- and middle-income countries (LMIC) too.[1] A recent review which reported the prevalence of multimorbidity among the elderly from 7 studies reported it to vary from 30.7% to 57%.[2] Another review of 70 community-based studies, with sample size varying from 264 to 162,464 elderly patients, reported a pooled prevalence rate of 33.1%, with significantly higher prevalence in HIC (37.9%), when compared to LMIC (29.7%).[3] One study from India evaluated the multimorbidity among the elderly from seven states of India (Kerala, Tamil Nadu, Punjab, Himachal Pradesh, Maharashtra, Orissa, and West Bengal) and reported a prevalence rate of 30.7% among 9852 elderly.[7]

In terms of the incidence of multimorbidity, one study evaluated the 3-year incidence of multimorbidity (defined as the development of ≥2 chronic diseases) in persons, who were free from the same and reported incidence rate of 33.6% in those without any disease and 66.4% in those with one disease at the baseline, which amounted to an incidence rate of 12.6 and 32.9/100 person-years, respectively.[8] A study from the United Kingdom evaluated multimorbidity for the year 2015 and projected that by 2035, the prevalence of multimorbidity is going to increase significantly, with the percentage of patients with 4 or more diseases going to double from 9.8% in 2015 to 17% in 2035. It was further suggested in this study that the prevalence of multimorbidity in those aged 65–74 years will increase from 45.7% in 2015 to 52.8% in 2035. Further, this study showed that two-thirds of those with 4 or more diseases would have mental illnesses in the form of depression, dementia, and cognitive impairment not amounting to dementia.[9]

Different studies have evaluated the factors associated with multimorbidity and data from cross-sectional studies suggest that smoking, alcohol consumption, living in rural locality, poor education, female gender, low income, older age, living away from children, use of health services in the preceding week, polypharmacy, and negative self-perception of health are associated with the development of multimorbidity.[2] In contrast, studies from India suggest that older age, high socio-economic status, female gender, and ever use of alcohol and tobacco are associated with the development of multimorbidity.[7] In the incidence study of multimorbidity, after adjusting for various confounders, poorer cognitive functioning at the baseline was associated with a higher risk of the development of multimorbidity in those who were free from any disease at the baseline.[8] However, in those with at least one disease at the baseline, older age was the only predictor of the development of multimorbidity.[8]

Based on these findings, it can be concluded that multimorbidity is a reality in the geriatric practice and psychiatric issues contribute significantly to the development of multimorbidity either in the form of risk factors or a component of multimorbidity.

In terms of etiology, it is suggested that multimorbidity is an outcome of progressive loss of resilience and dysfunction of the multisystem homeostatic regulatory system with progressive age. In fact, it is suggested that multimorbidity is an outcome of the dysfunction of the same mechanisms which are associated with aging. Accordingly, it is suggested that improving the understanding of the processes associated with multimorbidity will actually help in understanding the mechanisms associated with aging.[10]


  Why it Is Important to Bother About Multimorbidity among the Elderly? Top


At present, although there are multiple guidelines for the management of different chronic conditions, most of these guidelines, focus on single morbidity. Further, these guidelines are often formulated by keeping the adult patients in mind, who have a single disorder with a good physiological reserve. If different specialists attempt to manage single morbidity on their own, it invariably leads to polypharmacy and high chances of drug-drug interactions and its consequences (in the form of reduction in efficacy or increase in the cumulative side effects).[4] These can have serious implications for the elderly who are frail and have cognitive impairment.[4] One of the authors estimated that if the guidelines as formulated for single diseases by the National Institute for Health and Care Excellence (NICE) are applied to an elderly with five conditions (type 2 diabetes, history of myocardial infarction, osteoarthritis, chronic obstructive pulmonary disease, and depression), it will result in prescription of at least 11 medications (with up to 10 other drugs routinely recommended), 8–10 routine primary care appointments and 4–6 general practitioner appointments, as well as multiple self-care/lifestyle modifications.[11]


  What Is Being Done to Address Multimorbidity? Top


Taking note of the impact of multimorbidity, Academy of Medical Sciences, United Kingdom, concluded that there is an urgent need to understand the challenges being posed by multimorbidity. It is recommended that there is a need to carry out more research on multimorbidity. Some of the areas identified include to assess the rates and understand the nature of multimorbidity and how it is changing over time, which cluster of morbidities have biggest problems for patients, factors associated with multimorbidity, approaches required to prevention, how to increase the beneficial effects of treatments and reduce the risks of treatments for patients experiencing multimorbidity, reorganization of services to address the need of the elderly with multimorbidity, and how to use technology to improve care of patients experiencing multimorbidity.[1] Further, taking note of the implications of multimorbidity, NICE has issued guidelines on the assessment and management of multimorbidity defined as the presence of ≥2 long-term health conditions.[12] The guidelines also make recommendations to improve awareness.[10]

It is, in general, suggested that the management of multimorbidity should include a proactive assessment, which should be individualized and deciding about the plan of care, which can enhance the quality of life of the person by minimizing the treatment burden, adverse events, and unplanned or uncoordinated care.[4]


  Indian Scenario Top


Like other developing countries, India is also aging and the elderly population is increasing at a faster pace compared to other age groups. According to the United Nations, India is among the five countries which accounted for half of the elderly population in the year 2015, and India alone accounted for the world's 13% of the elderly population. It is projected that in India, from 2015 to 2030, the elderly population will increase by 64%. It is projected that the proportion of elderly persons in India is going to increase from 8.9% in 2015 to 19.4% by 2050, which in absolute terms will mean increase from 116.5 million to 330 million.[13] If one goes by the Indian study which evaluated multimorbidity in seven states,[7] with the prevalence of 30.7%, the older persons with multimorbidity by the year 2050 will be 101.3 million.

In India, at present, geriatric care is limited to a handful of geriatricians and most of the care provided to the elderly is fragmented and patients with multimorbidity are expected to visit different specialists, who in their busy clinics have no time to review the ongoing prescriptions of patients with multimorbidity and this often leads to polypharmacy and prescription of 2–3 medications of the same class. This problem is further compounded by over the counter medications. Hence, multimorbidity among the elderly is associated with increased number of hospital visits, over-prescription of medications, increase treatment cost and increased burden on the families. Accordingly, it can be said that at present, the health-care services are not elderly friendly. Hence, there is an urgent need to focus on multimorbidity among the elderly and reorganize the services to provide holistic care to the elderly under one roof. In terms of training of doctors, there is a need to develop more training programs for providing good health-care services to the elderly. In terms of the policy, there is an urgent need at the level of the government to develop policies to reorganize health-care services for the elderly. Various professional organizations working in the area of geriatric healthcare should join hands to develop guidelines to manage multimorbidity, in Indian setup, which can be translated into practice. The government also need to fund more research in the area of geriatrics, especially, multimorbidity, to understand the impact of multimorbidity on the health-care services, develop service models, understand the impact of multimorbidity on the family, training of health professionals, and impact of multimorbidity on the outcome of the elderly.



 
  References Top

1.
Academy of Medical Sciences. Multimorbidity: A Priority for Global Health Research. Academy of Medical Sciences; 2018. Available from: https://acmedsci.ac.uk/policy/policy-projects/multimorbidity. [Last accessed on 2019 Dec 10].  Back to cited text no. 1
    
2.
de Melo LA, Braga LC, Leite FP, Bittar BF, Oseas JM, Lima KC. Factors associated with multimorbidity in the elderly: An integrative literature review. Rev Bras Geriatr Gerontol Rio de Janeiro 2019;22:E180154.  Back to cited text no. 2
    
3.
Nguyen H, Manolova G, Daskalopoulou C, Vitoratou S, Prince M, Prina AM. Prevalence of multimorbidity in community settings: A systematic review and meta-analysis of observational studies. J Comorb 2019;9:2235042X19870934.  Back to cited text no. 3
    
4.
Yarnall AJ, Sayer AA, Clegg A, Rockwood K, Parker S, Hindle JV. New horizons in multimorbidity in older adults. Age Ageing 2017;46:882-8.  Back to cited text no. 4
    
5.
Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: A systematic review of the literature. Ageing Res Rev 2011;10:430-9.  Back to cited text no. 5
    
6.
Buja A, Claus M, Perin L, Rivera M, Corti MC, Avossa F, et al. Multimorbidity patterns in high-need, high-cost elderly patients. PLoS One 2018;13:e0208875.  Back to cited text no. 6
    
7.
Mini GK, Thankappan KR. Pattern, correlates and implications of non-communicable disease multimorbidity among older adults in selected Indian states: A cross-sectional study. BMJ Open 2017;7:e013529.  Back to cited text no. 7
    
8.
Melis R, Marengoni A, Angleman S, Fratiglioni L. Incidence and predictors of multimorbidity in the elderly: A population-based longitudinal study. PLoS One 2014;9:e103120.  Back to cited text no. 8
    
9.
Kingston A, Robinson L, Booth H, Knapp M, Jagger C; MODEM project. Projections of multi-morbidity in the older population in England to 2035: estimates from the population ageing and care simulation (PACSim) model. Age Ageing 2018;47:374-80.  Back to cited text no. 9
    
10.
Fabbri E, Zoli M, Gonzalez-Freire M, Salive ME, Studenski SA, Ferrucci L. Aging and multimorbidity: New tasks, priorities, and frontiers for integrated gerontological and clinical research. J Am Med Dir Assoc 2015;16:640-7.  Back to cited text no. 10
    
11.
Hughes LD, McMurdo ME, Guthrie B. Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age Ageing 2013;42:62-9.  Back to cited text no. 11
    
12.
National Institute of Health and Care Excellence. Multimorbidity: Clinical Assessment and Management NICE Guideline. National Institute of Health and Care Excellence; 21 September, 2016. Available from: https://www.nice.org.uk/guidance/ng56/resources/multimorbidity-clinical-assessment-and-management-pdf-1837516654789. [Last accessed on 2019 Nov 15].  Back to cited text no. 12
    
13.
United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2015 (ST/ESA/SER.A/390); 2015.  Back to cited text no. 13
    



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