Geriatric Medicine

Managing Multiple Morbidities

Erbil, November 2022
Assistant prof. Ali D. Dauod
CLINICAL OBJECTIVES:

To focus on more effective identification and management of

multi-morbidity and long-term chronic disease
 CASE STUDY
A 65-Year-Old Woman with Multiple diseases
Note: Measures and targets

• Measures, e.g., BMI, blood pressure, blood

glucose, lipid profile, CBC, RFT, etc.
• Targets: goals to achieve for these measures
• Aging population
• Increase in long term conditions
• Unhealthy lifestyles/obesity epidemic

Leading to:
• Growth in emergency hospital admissions
• Pressure on services/waiting times and lists

Compounded by:
• Remote and rural dimension
• Deprivation and inequalities
• Increasing public expectations
• Technological advances/cost pressures
Three (at least) huge challenges

• Defining targets and goals

• Note: Once comorbidities come into play, determining what
goals/targets are suitable for a given patient parameter becomes
difficult, e.g., if a patient has a HTN and DM, the blood pressure
target would be <140/90 simply, but once something like chronic
kidney impairment comes into play, the matter differs.
• Encourage new/better practices (note: both in doctors and
patients)
• Improve our understanding (note: of how having multiple
diseases and being on multiple medications affects
management decisions like whether or not a medication is
appropriate)

… in a system where person-doctor interaction is at a

stretching point
• Multi-morbidity, is a major challenge for many health systems

• One in three adults in the UK has a long-term condition, which accounts for
half of GP appointments, 70% of inpatient bed days, and 70% of the acute care
budget; in other words, over two-thirds of NHS expenditure for one-third of
the population.
• Managing patients with multiple morbidities is one of the primary problems
threatening the healthcare system in the twenty-first century.

• This problem is especially well suited for the skill set of primary care
physicians. Complexities increase as problems multiply, and dealing with
complexity is a particular skill set of future physicians.
The specific skills needed to deal with
patients with multiple morbidities include:
1. The capacity to thrive in managing complex medical problems (note:
Ability to assess and determine goals for each disease in a patient with
multimorbidity)
2. The ability to integrate all of the medical and personal issues facing an
individual and his or her family members
3. The ability to break down medical terms and complex medical issues to
make it easier for patients to understand
4. The capacity to develop long-term healing relationships with patients
(note: The patient should be involved in treatment decisions)
5. The capacity to know and understand people’s limitations, problems, and
personal beliefs when deciding on a treatment
6. The ability to provide care that includes long-term behavioral change
interventions that lead to better health
7. The ability to empower patients with information and guidance that are
needed to maintain health
• Modifying the practice to equip all members to contribute to the problem of
managing patients with multiple morbidities is important, as is developing
systems and processes to monitor practice performance.

• Effective methodologies include the use of patient disease registries to monitor

populations in need of particular care and the use of audits and feedback to
assess practice and physician performance with respect to particular conditions
or groups of conditions.
 CLINICAL CASE PROBLEM:
A 65-Year-Old Woman with
Multiple diseases
• A new patient presents to your office after moving to your community from
a different city.
• She is a 65-year-old, recently divorced retired with a history of recent-onset
diabetes, long-standing hypertension, moderate obesity, and depression.
• She smokes half a pack of cigarettes per day, gets insufficient exercise, travels
often, and follows an erratic diet.
• She complains of headaches that are worsening with stress and seasonal
allergies, intermittent fatigue with snoring and daytime somnolence, and hot
flushes.
• She is taking six medications from six different physicians she has irregularly
seen in her previous city, but she has not been seen in follow-up by any of them
for the past 4 months.
Note: list of problems in the previous case

• Obesity
• Hypertension
• Diabetes
• Depression
• Snoring and daytime somnolence: Sleep apnea is a secondary cause
of hypertension
• Hot flushes (post-menopausal)
• Liable for infections (frequent travel)
SELECT THE BEST ANSWER TO THE FOLLOWING QUESTIONS

1. Given her symptom complex, at this time she is likely to need the services of
which of the following subspecialists?
A. cardiologist
B. psychiatrist
C. sleep specialist
D. endocrinologist
E. none of the above

You are a long way from consulting or referring to anyone. You must first get a
clearer understanding of this patient’s problems and how they interrelate. As the
family physician, you are in the best position to do so, and it is your responsibility to
do so

Note: Measures are first done (blood glucose, BP, etc.) so you know where the issues are and
where to refer them if needed or manage it at primary care, e.g., a slightly abnormal A1c may
only need lifestyle changes (diet and exercise) to control and doesn’t require referral, weight
gain may simply be due to hypoglycemic agents, and so on
SELECT THE BEST ANSWER TO THE
FOLLOWING QUESTIONS
• On PE, vital signs are BP 150/85 and PR 85/minute. BMI is 30. She appears
well-developed, over-nourished, and well-spoken. There are boggy nasal
passages, nicotine staining on her buccal mucosa, clear lungs, and a
normal-sounding heart. The abdomen is obese; the skin is warm and dry.
Extremities are without clubbing, cyanosis, or edema. Peripheral pulses
are normal and symmetrical. The mood seems depressed.
What laboratory data would you like to obtain at this time?
A. Complete blood count (CBC), comprehensive metabolic profile (CMP),
lipid profile, and electrocardiogram (ECG)
B. CBC, CMP, lipid profile, hemoglobin A1c, and ECG
C. CBC, CMP, lipid profile, hemoglobin A1c, ECG, and thyroid-stimulating
hormone
D. CBC, CMP, lipid profile, hemoglobin A1c, and chest radiograph
E. No new testing is necessary at this time; obtain old records first
SELECT THE BEST ANSWER TO THE
FOLLOWING QUESTIONS
What laboratory data would you like to obtain at this time?
A. Complete blood count (CBC), comprehensive metabolic profile (CMP), lipid
profile, and electrocardiogram (ECG)
B. CBC, CMP, lipid profile, hemoglobin A1c, and ECG
C. CBC, CMP, lipid profile, hemoglobin A1c, ECG, and thyroid-stimulating
hormone
D. CBC, CMP, lipid profile, hemoglobin A1c, and chest radiograph
E. No new testing is necessary at this time; obtain old records first

Normally, it would be best to get old records before obtaining laboratory tests.
particularly if the situation is not urgent. However, in the case of the previously
fracture care experienced by this patient and the time since the last visit to all the
subspecialists, the likelihood of receiving information in a timely manner in the
absence of a shared electronic record is limited. Therefore, obtaining baseline
information in this patient's situation is most appropriate. Of the combinations
listed, that of CBC, CMP, lipid profile, hemoglobin A1c, and ECG is most
reasonable to cover this patient's multiple morbidities listed in the history.
Notes on the previous case
• Sleep apnea: nasal hygiene and weight control to see if that resolves the issue. The
obesity (high BMI) and the abnormal nasal passages may be responsible for sleep
apnea; a sleep study doesn’t need to be done if managing these risk factors and
seeing if they’ll control the issue will do.
• As it seems there are no cardiovascular or pulmonary complications, referral to
specialists is not needed.
• BP: The focus is on managing lifestyle, smoking, and obesity to reach the desired
goal of <140/90
• DM: targets for A1c, LDL, TG, TC, etc. are determined. Say her HbA1c is 8.7%: in
addition to lifestyle changes, the first line would be metformin, but given the high
HbA1c and other diseases such as HTN, combining it with SGLT-2 inhibitor due to its
renoprotective (the patient is liable for renal damage due to HTN and DM),
cardioprotective, and weight reducing effects. The combination can be used from
the beginning or after a 3 month trial of metformin.
• Smoking + depression: bupropion addresses both.
• The obesity is managed by lifestyle changes and SLGT-2 inhibitor. Saxenda (GLP1 and
2 agonist; liraglutide) can be used, though the obesity is not severe enough to justify
it.
Note: Assessing smoking/drug addiction: CAGE (to
see if they need pharmacological assistance for
smoking cessation [?? Dr. Kawa])
SELECT THE BEST ANSWER TO THE FOLLOWING
QUESTIONS
For elderly patients in chronic care facilities, which of the following statements regarding medication use is (are)
true?
A. elderly patients in chronic care facilities are usually taking fewer medications than are elderly patients living
on their own
B. elderly patients in chronic care facilities are usually taking between 8 and 13 different medications at any one
time
C. elderly patients in chronic care facilities are likely to experience iatrogenic side effects from medications at
one time or another
D. b and c are true
E. a, b, and c are true

Patients in chronic care facilities have the following characteristics with respect to medication use:
• They are usually taking multiple medications. The average number of medications used by the institutionalized
elderly is 8 — 13 per day (note: The higher number of medications increases the risk of ADR)
• The most usual scenario is that medications are always added but never subtracted. Thus, the number simply
continues to increase.
• Iatrogenic side effects from medication use in chronic care facilities are extremely common, more likely to
experience at least one ADR per year than not.
• In comparison to senior citizens living on their own in the community, the number of medications used by
institution-based elderly patients is greater.
SELECT THE BEST ANSWER TO THE FOLLOWING QUESTIONS

Results from the Medical Outcomes Study suggest which of the following is (are) true regarding systems
of care for this patient?
A. Optimal clinical outcomes are best achieved when care is provided by a generalist
B. Optimum clinical outcomes are best achieved when care is provided by subspecialists
C. Costs of care and resource use tend to be lower when care is provided by generalists
D. Similar clinical outcomes are achieved when care is provided by either a generalist or subspecialist
E. C and d

• The Medical Outcomes Study is a classic well-designed comprehensive study that compared outcomes
of care by generalists and subspecialists after controlling for the patient mix.
• Reported in The Journal of the American Medical Association and other medical journals, the
comprehensive study found no difference in outcomes between generalists and subspecialists for
patients with diabetes and hypertension who were observed for 7 years.
• Outcomes included measures of physical and emotional (functional) health, mortality, and disease-
specific physiologic markers. However, there were significant differences with regard to lower
resource use and cost for patients of primary care physicians because of more judicious use of tests,
procedures, drugs, office visits, and hospitalizations.
SELECT THE BEST ANSWER TO THE FOLLOWING
QUESTIONS
In addition to reviewing all her current medications, obtaining any previous medical
records you can, and ordering some laboratory data, your next step in management
should I include which of the following?
A. assessing the patient's understanding of her health problems
B. getting a sense of the patient's priorities in dealing with her health problems
C. reordering all her medications and stressing the importance of compliance
D. identifying community resources that can be brought to bear in a treatment
plan
E. a, b, and d
• Without a clear knowledge of the patient's understanding of her medical
conditions or an assessment of the patient's priorities in dealing with her health
problems, reordering of all her medications is likely to be a wasted opportunity to
identify and prioritize the patient's needs and conditions.
• Without this information, stressing the importance of compliance is a waste of
time.
• This is also an opportunity to identify community resources that can be brought to
bear in a treatment plan.
Note: C is not that important yet, it’s a later step
SELECT THE BEST ANSWER TO THE
FOLLOWING QUESTIONS
You decide to enter your patient in your office-based disease registry. Which of the following is
(are) true regarding disease registries?
A. they are a useful way for tracking practice adoption of disease- and patient-centered
guidelines
B. they require the use of an electronic medical record
C. they can facilitate population-based interventions such as hemoglobin A1c tracking or
influenza immunizations
D. a and c
E. they are primarily a research tool of little use clinically
• Disease registries are a useful way for tracking practice adoption of disease- and patient-
centered guidelines.
• It is a common misunderstanding that to have a disease registry you need an electronic
medical record. This is not the case.
• Registries can facilitate population-based interventions such as hemoglobin Alc tracking or
influenza immunizations as well as facilitate and track other patient-centered interventions.
• Although some have been used in practice-based research, their primary application is in
clinical care.