Clinical assessment and management of patients with multimorbidity
Authors:
Zdeněk Monhart 1,2
Authors‘ workplace:
Interní oddělení a urgentní příjem, Nemocnice Znojmo
1; Lékařská fakulta Masarykovy Univerzity, Brno
2
Published in:
Vnitř Lék 2023; 69(3): 173-180
Category:
Main Topic
doi:
https://doi.org/10.36290/vnl.2023.030
Overview
Internal medicine specialists, also known as general internal medicine specialists are specialist physicians trained to manage particularly complex or multisystem disease conditions that single-organ-disease specialists may not be trained to deal with. The management of multimorbidity, however, is often complex, and requires specific clinical skills and corresponding experience in appropriate diagnostic and therapeutic procedures. Multimorbidity is associated with a decline in many aspects of health and in consequence with an increase in hospital admissions, polypharmacy, and use of health care and social resouces. When prescribing medicine to patients with multimorbidity, all the risks and benefits, as well as possible interactions should be carefully considered. The prescription appropriateness can be assessed by validated tools like STOPP-START criteria. Beneficial part of good prescribing is deprescribing – planned and supervised process of dose reduction or withdrawal of medications that are no longer needed in the circumstances of the patient.
Keywords:
polypharmacy – deprescribing – multimorbidity
Sources
1. Ho IS, Azcoaga‑Lorenzo A, Akbari A, et al. Variation in the estimated prevalence of multimorbidity: systematic review and meta‑analysis of 193 international studies. BMJ Open 2022;12:e057017.
2. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio‑Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC, Eur Heart J. 2021 Feb 1;42(5):373-498.
3. Farmer C, et al. Clinical assessment and management of multimorbidity: summary of NICE guidance. BMJ. 2016 Sep 21;354:i4843.
4. Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross‑sectional study. Lancet,380,37-43.
5. Valderas JM, Starfield B, Sibbald B et al. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. 2009;7(4):357-363.
6. de Groot V, Beckerman H, Lankhorst GJ, et al. How to measure comorbidity. a critical review of available methods. J Clin Epidemiol. 2003;56(3):221-229.
7. Huntley AL, Johnson R, Purdy S, et al. Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med. Mar‑Apr 2012;10(2):134-41.
8. Newschaffer CJ, Bush TL, Penberthy LT. Comorbidity measurement in elderly female breast cancer patients with administrative and medical records data, J Clin Epidemiol. 1997,50:725-733.
9. Charlson ME, Charlson RE, Peterson JC, et al. The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients. J Clin Epidemiol. 2008;61(12):1234-1240.
10. Salvi F, Miller MD, Grilli A, et al. A manual of guidelines to score the modified cumulative illness rating scale and its validation in acute hospitalized elderly patients.J Am Geriatr Soc. 2008 Oct;56(10):1926-31.
11. Donnan PT, Dorward DW, Mutch B, et al. Development and validation of a model for predicting emergency admissions over the next year (PEONY): a UK historical cohort study. Archives of Internal Medicine. 2008; 168(13):1416-1422.
12. Hippisley‑Cox J, Coupland C. Predicting risk of emergency admission to hospital using primary care data: Derivation and validation of QAdmissions score. BMJ Open. 2013 Aug 19;3(8):e003482.
13. Von Korff M, Wagner EH, Saunders K. A chronic disease score from automated pharmacy data. J Clin Epidemiol. 1992;45(2):197-203.
14. Bernabeu‑Wittel M, Para O, Voicehovska J, et al; EFIM Multimorbidity Working Group. Competences of internal medicine specialists for the management of patients with multimorbidity. EFIM multimorbidity working group position paper. Eur J Intern Med. 2023 Mar;109:97-106.
15. Lyness JM, Niculescu A, Tu X, et al. The relationship of medical comorbidity and depression in older, primary care patients.Psychosomatics. 2006;47(5):435-9.
16. European guide for management of frailty at individual level including recommendations and roadmap. https://www.advantageja.eu/images/D6.2_EuropeanGuide_Management. pdf
17. Butchart A, Kerr EA, Heisler M, et al. Experience and management of chronic pain among patients with other complex chronic conditions. Clin J Pain. 2009 May;25(4):293-8.
18. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA. 2005;294:716-24.
19. Guthrie B, Payne K, Alderson P, et al. Adapting clinical guidelines to take account of multimorbidity. BMJ. 2012;345:e6341.
20. Leśniak W, Morbidoni L, Dicker D, et al. EFIM Clinical practice guidelines adaptation for internists – an EFIM methodology.Eur J Intern Med. 2020;77:1-5.
21. Kostev K, Jacob L. Multimorbidity and polypharmacy among elderly people followed in general practices in Germany. Eur J Intern Med. 2018 Sep;55:66-68.
22. Masnoon N, Shakib S, Kalisch‑Ellett L, et al. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017 Oct 10;17(1):230.
23. Chang TI, Park H, Kim DW, et al. Polypharmacy, hospitalization, and mortality risk: a nationwide cohort study. Sci Rep. 2020 Nov 3;10(1):18964.
24. Burt J, Elmore N, Campbell SM, et al. Developing a measure of polypharmacy appropriateness in primary care: systematic review and expert consensus study. BMC Med. 2018 Jun 13;16(1):91.
25. The 2019 American Geriatrics Society (AGS) Beers Criteria® Update Expert Panel (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694.
26. Naugler CT, Brymer C, Stolee P, et al. Development and validation of an improving prescribing in the elderly tool. Can J Clin Pharmacol. 2000 Summer;7(2):103-7.
27. Barry PJ, Gallagher P, Ryan C, et al. START (screening tool to alert doctors to the right treatment) –an evidence‑based screening tool to detect prescribing omissions in elderly patients. Age and Ageing. 36(6):632-638.
28. O’Mahony D. STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress. Expert Rev Clin Pharmacol. 2020 Jan;13(1):15-22.
29. Pazan F, Weiss C, Wehling M. FORTA. The FORTA (Fit fOR The Aged) List 2021: Fourth Version of a Validated Clinical Aid for Improved Pharmacotherapy in Older Adults. Drugs Aging. 2022 Mar;39(3):245-247.
30. Scott IA, Le Couteur DG. Physicians need to take the lead in deprescribing. Intern Med J. 2015 Mar;45(3):352-6.
Labels
Diabetology Endocrinology Internal medicineArticle was published in
Internal Medicine
2023 Issue 3
Most read in this issue
- JAK inhibition in the treatment of inflammatory rheumatic diseases
- Differential diagnostics of interstitial lung diseases
- Multimorbidity in nephrotic syndrome
- News in gastroenterology, hepatology and digestive endoscopy