Multiple Diseases and Polypharmacy in the Elderly: Challenges for the Internist of the Third Millennium

Abstract

The pattern of patients admitted to internal medicine wards has dramatically changed in the last 20–30 years. Elderly people are now the most rapidly growing proportion of the patient population in the majority of Western countries, and aging seldom comes alone, often being accompanied by chronic diseases, comorbidity, disability, frailty, and social isolation. Multiple diseases and multimorbidity inevitably lead to the use of multiple drugs, a condition known as polypharmacy. Over the last 20–30 years, problems related to aging, multimorbidity, and polypharmacy have become a prominent issue in global healthcare. This review discusses how internists might tackle these new challenges of the aging population. They are called to play a primary role in promoting a new, integrated, and comprehensive approach to the care of elderly people, which should incorporate age-related issues into routine clinical practice and decisions. The development of new approaches in the frame of undergraduate and postgraduate training and of clinical research is essential to improve and implement suitable strategies meant to evaluate and manage frail elderly patients with chronic diseases, comorbidity, and polypharmacy.Journal of Comorbidity 2011;1:28–44

An elderly, urban population: Their experiences and expectations of pharmaceutical services in community pharmacies

“…They are more likely to experience medicine-related problems due to multi-morbidities and the associated polypharmacy. These problems are compounded by low levels of education and language, and cultural differences between healthcare professional and patients (Nobili, Garanttini, & Mannucci, 2011). In the light of the increased risk of medicine-related problems in elderly patients, the role of the community pharmacist should be examined.…”

Prescribing for patients with multimorbidity: aiming to tailor to patient-set goals

“…6 Drugs are more prone to causing toxicity when a disease, such as chronic renal failure, means they are not properly processed or eliminated. 6 Our desktop and electronic formularies may not be sufficiently sophisticated to dictate how to prescribe in complex situations, so utilisation of clinical experience or seeking specialist advice may be required. 3 An increasing number of conditions, with the associated increase in prescribed drugs, leads to a potentially increased chance of adverse drug effects.…”

“…3 Additionally, iatrogenically precipitated problems such as falls and confusion, may lead to yet further morbidity to add to the patient's load. 6 guidelines National guidelines are available to provide evidenced-based recommendations on how drugs should be used in the majority of single diseases and their use when prescribing is generally expected by professional regulatory bodies. 2 The literature on multimorbidity is critical of these single-disease guidelines when it comes to treating a patient with multiple conditions.…”

Trusting internal medicine in hard times

“…In view of the unavoidable recourse to cost-effective strategies, internal medicine represents an appropriate model for intervention because of the priority attributed to clinical reasoning over technical ability and technological instruments, and of its proved flexibility both in the various health-care settings (outpatient clinics, hospital wards, intensive care units) as well as in relation to the transformations in clinical medicine, e.g., the shift from infectious diseases to chronic degenerative diseases as the main cause of morbidity and mortality, and the consequent increase in multimorbidity and polytherapy in geriatric [8] and pre-geriatric age [9]. Noteworthy, the Royal College of Physicians has recently produced a document dedicated to the Future Hospital, based on a more general vision of care and, therefore, more suitable for patients with multimorbidity, where internal medicine is responsible for all medical services within the hospital [10].…”