Italian guidelines on management of persons with multimorbidity and polypharmacy

Onder, Graziano; Vetrano, Davide Liborio; Palmer, Katie; Trevisan, Caterina; Amato, Laura; Berti, Franco; Campomori, Annalisa; Catalano, Lucio; Corsonello, Andrea; Kruger, Paola; Medea, Gerardo; Nobili, Alessandro; Trifirò, Gianluca; Vecchi, Simona; Veronese, Nicola; Marengoni, Alessandra

doi:10.1007/s40520-022-02094-z

Cited by 25 publications

(38 citation statements)

References 11 publications

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“…The limited available evidence on the treatment of multimorbidity makes it challenging for clinical guideline development, although a small number of guidelines have been developed internationally 181,188,232 . The consensus across these guidelines is presented in Box 2 (reF.…”

Section: Evidence-based Clinical Guidelinesmentioning

confidence: 99%

Multimorbidity

Skou

Mair

Fortin

et al. 2022

Nat Rev Dis Primers

451

283

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Interest in multimorbidity -commonly defined as the co-occurrence of at least two chronic conditions in the same individual 1 -has increased in the past few years owing to its substantial effect on the individual and the individual's family, as well as on health systems and on society, particularly in resource-poor settings 2-4 . Multimorbidity is distinct from the related concept of comorbidity, which refers to the combined effects of additional conditions in relation to the index condition in an individual [5][6][7][8] . By contrast, care for multimorbidity is patient-centred and does not routinely give priority to any single condition, although in clinical care, patients and clinicians will usually focus on the most pressing problems that the patient is experiencing.People with multimorbidity are more likely to die prematurely, be admitted to hospital and have an increased length of stay than people with a single chronic condition 9,10 . Multimorbidity is also associated with poorer function and health-related quality of life (HRQOL), depression and intake of multiple drugs (polypharmacy) and greater socioeconomic costs [11][12][13][14][15][16][17][18] . Most health care is designed to treat individual conditions rather than providing comprehensive, person-centred care 2,19,20 , which often leads to fragmented and sometimes contradictory care for people with multimorbidity and increases their treatment burden 21 Moreover, treating one condition at a time is inefficient and unsatisfactory for both people with multimorbidity and their health-care providers [22][23][24] .Multimorbidity is increasingly common owing to changes in lifestyle risk factors, notably physical inactivity and obesity, and population ageing that in part reflects improvements in survival from acute and chronic conditions 2,19,25,26 . Multimorbidity is associated with socioeconomic status and age 3,19,25,27 . However, although age is the strongest driver of multimorbidity, in absolute numbers, more people <65 years of age have multimorbidity than people ≥65 years of age, partly because more people in the general population are in that age group. Moreover, this emphasizes that multimorbidity is not just a feature of ageing 19,26 .Multimorbidity is further complicated in low-income and middle-income countries (LMICs) by the overlap of compounding factors, including adverse environmental and early life stressors linked to poverty, limited social infrastructure and poorer family coping mechanisms, that translate into chronic diseases occurring at earlier ages [28][29][30][31] . LMICs also have a higher prevalence of multimorbidity-related financial burden 32,33 and have weaknesses in health systems including a greater focus Treatment burdenThe workload associated with managing treatments and health-care recommendations and the impact of this on an individual and their supporters.

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Section: Evidence-based Clinical Guidelinesmentioning

confidence: 99%

Multimorbidity

Skou

Mair

Fortin

et al. 2022

Nat Rev Dis Primers

451

283

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“…To note, the NICE guidelines on multimorbidity underline the need of assessing frailty in order to identify people who may benefit from an approach to care that takes account of multimorbidity, suggesting that frailty is a key condition that should influence the approach to the care of chronic conditions [13]. This concept was also pointed out by the recently published Italian guidelines on multimorbidity and polypharmacy [14]. In the heart diseases and dementia and sensory impairments patterns frailty and patterns expression seem having an additive effect in determining prognosis.…”

Section: Discussionmentioning

confidence: 99%

“…It has been hypothesized that frailty can influence the management of chronic diseases and modulate the effect of multimorbidity on health outcomes [12]. In this context, guidelines focusing on multimorbidity suggest to use frailty instruments to identify persons at high risk of negative health outcomes and in need of specific care approaches [13,14].…”

Section: Introductionmentioning

confidence: 99%

Frailty, multimorbidity patterns and mortality in institutionalized older adults in Italy

et al. 2022

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Background Little is known on how frailty influences clinical outcomes in persons with specific multimorbidity patterns. Aims To investigate the interplay between multimorbidity and frailty in the association with mortality in older individuals living in nursing homes (NH). Methods We considered 4,131 NH residents aged 60 years and over, assessed through the interRAI LTCF instrument between 2014 and 2018. Follow-up was until 2019. Considering four multimorbidity patterns identified via principal component analysis, subjects were stratified in tertiles (T) with respect to their loading values. Frailty Index (FI) considered 23 variables and a cut-off of 0.24 distinguished between high and low frailty levels. For each pattern, all possible combinations of tertiles and FI were evaluated. Their association (Hazard Ratio [HR] and 95% confidence interval) with mortality was tested in Cox regression models. Results In the heart diseases and dementia and sensory impairments patterns, the hazard of death increases progressively with patterns expression and frailty severity (being HR T3 vs. T1 = 2.36 [2.01-2.78]; HR T3 vs. T1 = 2.12 [1.83-2.47], respectively). In heart, respiratory and psychiatric diseases and diabetes, musculoskeletal and vascular diseases patterns, frailty seems to have a stronger impact on mortality than patterns' expression. Discussion Frailty increases mortality risk in all the patterns and provides additional prognostic information in NH residents with different multimorbidity patterns. Conclusions These findings support the need to routinely assess frailty. Older people affected by specific groups of chronic diseases need a specific care approach and have high risk of negative health outcomes.

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“…The total score (0-28) is obtained by adding the resulting partial scores of two sections, namely, Balance and Gait. The total score classifies the subject in the following way: not able to walk (<2); high fall risk (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19); moderate fall risk (20-23); and not increased fall risk (≥24) (27).…”

Section: Assessmentmentioning

confidence: 99%

“…More articles in scientific literature deepen the specifics of assessment markers and how predictive tools can assist in improving these patients' quality of life (1,3,4). In this regard, Comprehensive Geriatric Assessment (CGA) represents a specialistic tool that takes a deep look into several areas, i.e., cognitive, mood, functional status, nutrition, social and interpersonal relationship, and caregivers' status in order to holistically frame, and thus help, the patient, where possible (3)(4)(5)(6). The years have yielded evidence that make CGA essential in clinical practice, as long as it is exploited when there is still room for maneuver; otherwise, it may turn into a useful tool to take note of a critical clinical condition and, where appropriate, the receipt of indemnity, but mournfully not to significantly improve the patient's health and quality of life (7).…”

Section: Introductionmentioning

confidence: 99%

Comprehensive Geriatric Assessment: Application and correlations in a real-life cross-sectional study

et al. 2022

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BackgroundThe assessment process of elderly people considers all aspects of an individual’s life, including physical, mental, and social aspects. Frailty refers to a decline in physiological functions or strengths leading to increased vulnerability to stressors and decreased ability to cope with them. Comprehensive Geriatric Assessment (CGA) is a validated and useful tool in this context to holistically study elderly people. The primary aim of this study was to determine the prevalence of impaired health status in a large geriatric population turning to outpatient service, based on the components of the CGA, and thus to describe its usefulness in real-life clinical practice. The secondary aim of this study was the evaluation of the association between nutritional status, assessed with Mini Nutritional Assessment (MNA)—within the CGA—and cognitive-affective and functional capacities, and multimorbidity.Materials and methodsThis real-life, retrospective cross-sectional study included subjects consecutively evaluated from January 2009 to December 2020 at the Geriatric Outpatient Service, University Hospital of Monserrato, Cagliari, Italy. A sum of 3,260 patients were subjected to CGA.ResultsOnly a small proportion of the sample (2.24%) showed an absence of impairment in cognitive-affective, functional, and nutritional domains. Moderate correlations were found between MNA and several other CGA variables, namely, Geriatric Depression Scale (GDS; ϱ = −0.41, p < 0.0001), Barthel Index of Independence in Activities of Daily Living (ADL) (ϱ = 0.51, p < 0.0001), Instrumental Activities of Daily Living (IADL) (ϱ = 0.43, p < 0.0001), and Performance-Oriented Mobility Assessment (ϱ = 0.44, p < 0.0001). A multiple regression also highlighted these variables as significant regressors of MNA. Finally, malnutrition showed a significant association with depression (odds ratio [OR]: 4.97), dependence on ADL (OR: 19.8) and IADL (OR: 7.04), and falling risk (OR: 5.16).ConclusionThis study has figured out the complex situation in which geriatric care finds itself the complexity and severe impairment of elderly people. The possibilities of intervention are often limited, but the literature confirms the benefits of good nutritional status on the general health status. The data that emerged from our study fit into this assumption, highlighting the close association between the nutritional domain and the other CGA domains.

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Italian guidelines on management of persons with multimorbidity and polypharmacy

Cited by 25 publications

References 11 publications

Multimorbidity

Multimorbidity

Frailty, multimorbidity patterns and mortality in institutionalized older adults in Italy

Comprehensive Geriatric Assessment: Application and correlations in a real-life cross-sectional study

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