Approach to the evaluation and management of the older adult with multimorbidity.

Inquire about the patient’s primary concern (and that of family and friends, if
applicable) and any additional objectives for visit.

Conduct a complete review of care plan for person with multimorbidity.

OR
Guiding Principles for the Care of Older Focus on specific aspect of care for person with multimorbidity.

Adults with Multimorbidity Pocket Card What are the current medical conditions and interventions?
Is there adherence to and comfort with treatment plan?
FROM THE AMERICAN GERIATRICS SOCIETY

This Clinical Tool, based on the 2012 Patient-Centered Care for Older Adults with Multiple
Chronic Conditions: A Stepwise Approach from the American Geriatrics Society, has been Consider patient preferences.
developed to assist healthcare providers implement the 5 Guiding Principles in taking
care of an Older Adults with Multimorbidity.
Is relevant evidence available regarding important outcomes?
“More than 50% of older adults have three or more chronic diseases.”1 By definition,
older adults with multimorbidity are heterogeneous in terms of severity of illness,
functional status, prognosis, and risk of adverse events even when diagnosed with the
same pattern of conditions. Priorities for outcomes and health care also vary. Thus, not Consider prognosis.
only the individuals themselves, but also the treatments that clinicians consider for them
will differ.
Consider interactions within and among treatments and conditions.
The adoption of these guiding principles may improve healthcare and outcomes for
older adults with multiple conditions. Patients should be evaluated, and care plans
should be designed and implemented according to the individual needs of each patient,
with the recognition that few studies are currently available that have rigorously Weigh benefits and harms of components of the treatment plan.
evaluated the effectiveness of approaches related to these guiding principles.

The full document, together with accompanying resources, can be viewed online at Communicate and decide for or against implementation
americangeriatrics.org. or continuation of intervention/ treatment.

Reassess at selected intervals: for benefit, feasibility, adherence,

alignment with preferences.

AGS AGS
THE AMERICAN GERIATRICS SOCIETY 40 Fulton Street, 18th Floor • New York, NY 10038 THE AMERICAN GERIATRICS SOCIETY 40 Fulton Street, 18th Floor • New York, NY 10038
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Leading change. Improving care for older adults. PAGE 1 Leading change. Improving care for older adults. PAGE 2
 Guiding Principle I: Patient Preferences Domain Guiding Principle II: Interpreting the Evidence Domain
Elicit and incorporate patient preferences into medical decision-making for older Recognizing the limitations of the evidence base, interpret and apply the medical
adults with multimorbidity. literature specifically to older adults with multimorbidity.
How to Use in Clinical Practice How to Use in Clinical Practice
Goal Implementation Strategies & Resources Goal Implementation Strategies & Resources
Elicit patient preferences Keep in Mind:: Consider certain key Consider:
according to the individual • Less complex situations require abbreviated decision-making; principles in evaluating clinical • Applicability and quality of evidence;
situation. evidence. • Outcomes;
• More complex situations with multiple options may require several • Harms and burdens;
steps. • Absolute risk reduction;
• Time horizon to benefit.
Recognize when decisions are • Know which factors are most important to each patient;
Ascertain whether the Key questions:
“preference-sensitive” for the • Examples of preference-sensitive decisions: evidence applies to older • Does the individual being considered resemble the research
patient. adults with multimorbidity population?
1. therapy that may improve one condition but make another worse;
and whether it has been • Does multimorbidity modify the effect of the intervention?
2. therapy that may confer long-term benefits but cause short-term rigorously evaluated. • Were older adults with or without multimorbidity included in the
harm; study?
3. multiple medications with benefits and harms that must be • Are the design and analysis of the study of high quality?
balanced. • If the evidence comes from a randomized clinical trial, are the results
applicable to older adults with multimorbidity? (Observational studies
Ensure that patients are • Consider effects of treatments and interventions, particularly side often can provide additional information, but have challenges related to
adequately informed about effects, which may be seen as important outcomes for the patient. confounding.)
benefits and harms of • Provide numerical likelihoods of specific outcomes if available:
treatment options. Focus on outcomes. Key considerations:
1. include probabilities of the outcome occurring or not occurring; • clear identification of expected treatment outcomes;
2. present absolute rather than relative risk; • importance of outcomes to the patient;
• variations in baseline risk (in order to validate expectations for
3. use visual aids. treatment);
• Assess patient understanding of the information, e.g., using a “teach • risks and side effects of interventions in older patients with
back” technique. multimorbidity (to avoid exacerbation of co-morbidities);
• comparator treatments or strategies;
Elicit patient preferences Decision aids are available, but may not be able to accommodate different • time to benefits;
only after the individual is comorbidity and risk factor profiles; • precision and confidence limits of analyses.
sufficiently informed, using
appropriate tools. Weigh anticipated benefits Key considerations:
Resources: against potential harms and • Studies may be too short-term to give adequate assessment of harms;
• Decision analysis: a “decision tree” can facilitate decisions by identifying burdens. • Treatment burdens experienced by patients are rarely included in
and quantifying all potential treatment outcomes; study reports;
• Exacerbation of coexisting conditions may be caused by following
• Conjoint analysis: assigns scores to characteristics of treatment treatment guidelines for another condition;
outcomes to assess which are most important to individual patients; • Adherence may be impacted by financial costs and difficulties of
• Patient prioritization: The patient chooses among sets of universal regimens;
health outcomes to identify those most important to the individual, • Treatment interactions in older adults with multimorbidity may occur
e.g., living as long as possible, being pain-free, maintaining function, and Clarify risk reduction. Key considerations:
then chooses treatment options based on most desired outcomes. • Results expressed as relative risk reduction (RRR) are not the same as
those expressed by absolute risk reduction (ARR).
Accommodate the individual’s Decision styles include: • ARR is based on the risk of an outcome without treatment minus
decision-making style, while 1. Patient prefers to make decisions; outcome with treatment, or on the difference of two comparative
acknowledging that all treatments.
2. Patient prefers that healthcare provider decides;
patients want their opinions • RRR usually appears much more impressive than ARR.
to guide choices. 3. Shared decision-making preferred; • If baseline risk is not reported, RRR is uninterpretable since the
4. Patient prefers involvement of family, friends, caregivers in decision- baseline risk may be different for older multimorbid adults compared
making; to the general population, and there may be greater variability.
• Baseline risks may be reported in single-disease guidelines,
observational studies, prognostic indices, or control groups of single
Keep in Mind: disease trials.
• Patients with cognitive impairment may rely on significant others as Identify time horizon to Key questions:
surrogates to act with healthcare providers to make decisions for benefit. • What is the sample size of the study?
them. • What is the duration of follow-up?
• Preferences may change over time, and should be re-examined, • If evidence is expressed in number needed to treat (NNT) or number
needed to harm (NNH), is a time period to outcome reported?
especially with a change in health status. • Is the older adult with multimorbidity at risk of dying from a
• Patients cannot demand any and all treatments if these options do not comorbidity before benefitting from a treatment (e.g., tight glucose
have a reasonable expectation of some benefit. control in diabetes).

AGS AGS
THE AMERICAN GERIATRICS SOCIETY 40 Fulton Street, 18th Floor • New York, NY 10038 THE AMERICAN GERIATRICS SOCIETY 40 Fulton Street, 18th Floor • New York, NY 10038
Geriatrics Health Professionals. 800-247-4779 or 212-308-1414 • americangeriatrics.org Geriatrics Health Professionals. 800-247-4779 or 212-308-1414 • americangeriatrics.org
Leading change. Improving care for older adults. PAGE 3 Leading change. Improving care for older adults. PAGE 4
 Guiding Principle III: Prognosis Domain Guiding Principle IV: Clinical Feasibility Domain
Frame clinical management decisions within the context of risks, burdens, benefits, Consider treatment complexity and feasibility when making clinical management
and prognosis (e.g., remaining life expectancy, functional status, quality of life) for older decisions for older adults with multimorbidity.
adults with multimorbidity. How to Use in Clinical Practice
How to Use in Clinical Practice Goal Tools, Resources, Strategies
Goal Tools, Resources, Strategies Assess ability of the older Consider:
Incorporate prognosis into • Frame a focused clinical question; person with multimorbidity to • Treatment complexity increases with multimorbidity.
clinical decision-making. • Determine the outcome being predicted (e.g., remaining life expectancy, adhere to the treatment plan
functional ability, quality of life, or a condition-specific risk such as • Assessments must be individualized.
on an ongoing basis.
stroke); • Patient-centered discussions must occur in collaboration with the
• Select a prognosis measure, while recognizing its strengths and support system (family, caregivers).
weaknesses;
• Estimate prognosis;
• Integrate this information into the decision-making process. Tools available to measure medication management capacity:
Prioritize decisions based Minimize treatments or interventions unlikely to provide benefit and limit • Medication Management Ability Assessment (MMAA) (1)
on life expectancy or other harms without benefit by making decisions based on prognosis categories :
relevant outcomes. • short-term (death expected within the next year/highest priority) – • Drug Regimen Unassisted Grading Scale (DRUGS) (2)
address issues such as advance directives, need for aggressive glucose • Hopkins Medication Schedule (HMS) (3)
control, physical therapy;
• mid-term (death expected within the next 5 years) • Medication Management Instrument for Deficiencies in the Elderly.
• long-term (death expected beyond five years). (MedMaIDE) (4)
Offer to discuss prognosis. Many older adults wish to discuss prognosis but some do not.
Offer clinical information within the context of specific ethnic and cultural
considerations for older patients, addressing principles of:
• patient autonomy (e.g., self-determination);
• beneficence (e.g., promotion of patient well-being);
• non-maleficence; Clinical feasibility and Key considerations:
• justice. individual preferences should • Evidence-based medicine alone is not an adequate guide;
Identify situations in which a • When making decisions about treatment or prevention (e.g., whether inform treatment choices.
determination of prognosis to start/stop a medication or insert/replace a device); • Reliance on condition-specific guidelines results in overly complex
may help inform clinical • Disease screening (e.g., for cognitive decline, cancer, osteoporosis); regimens that reduce adherence.
decision-making. • Change in clinical status of patient (e.g., weight loss, functional decline,
after a fall);
• Change of health service utilization (e.g., decisions about
hospitalization or initiation of aggressive ICU care).
Choose an appropriate Examples of measures for specific diseases (1)
prognostic measure, based on • The Seattle Heart Failure Model (2)
its relevance to the individual • The BODE Index (3)
patient. • ADEPT (4)
• STOPP/START (Screening Tool to Alert to Right Treatment Identify treatment complexity • Discuss adherence and individual preferences with the older adult with
and Screening Tool of Older Persons’ potentially inappropriate with patient participation. multimorbidity;
Prescriptions) (5) • Suggest education programs that teach patients self-management skills
• Cancer screening (6)
for setting realistic goals and learning how to reach them.
Life tables:
• Prognostic index based on 6 risk factors for the year following acute
hospitalization (7)
• Planning for final years of life (8)

Measures based on functional status:

• Role of gait speed in survival (9) Address conflicts between • Discussion and re-evaluation must be ongoing;
• Chronic disability as the strongest negative risk factor for survival (10) wishes of prescribers versus • Patient education should be provided;
Integrated measures: those of the older adult with • Care transitions offer good opportunities to re-evaluate adherence
• 4-year prognostic index (11) multimorbidity. and treatment complexity.
• 5- and 9-year survival indices (12)
• Vulnerable Elders-13 Survey (VES-13) (13)

Measures based on advanced illness:

• Palliative Prognostic Score (PaP) (14)
• Palliative Performance Scale (PPS) (15, 16)
Decide what prognostic Base choice of measure on:
information to share with • patient-stated preferences
patient and family. • overall evaluation of evidence.

AGS AGS
THE AMERICAN GERIATRICS SOCIETY 40 Fulton Street, 18th Floor • New York, NY 10038 THE AMERICAN GERIATRICS SOCIETY 40 Fulton Street, 18th Floor • New York, NY 10038
Geriatrics Health Professionals. 800-247-4779 or 212-308-1414 • americangeriatrics.org Geriatrics Health Professionals. 800-247-4779 or 212-308-1414 • americangeriatrics.org
Leading change. Improving care for older adults. PAGE 5 Leading change. Improving care for older adults. PAGE 6
 1
Anderson G. Chronic Care: Making the Case for Ongoing Care. Robert Wood Johnson Foundation, 2010 [on-line]. Available at http://www.rwjf.
Guiding Principle V: Prognosis Domain org/files/research/50968chronic.care.chartbook.pdf Accessed June 19, 2012.

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Badinelli S, Harris T, Newman AB, Cauley J, Ferrucci L, Guralnik J. Gait speed and survival in older adults. JAMA. 2011 Jan 5;305(1):50-8.

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(falls, impaired cognition). Successful validation of the palliative prognostic score in terminally ill cancer patients. Italian multicenter study group on palliative care. J
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3. Carlson MC, Fried LP, Xue QL, Tekwe C, Brandt J.Validation of the Hopkins Medication Schedule to identify difficulties in taking medications.
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2. Gallagher P, et al. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment).
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AGS AGS
THE AMERICAN GERIATRICS SOCIETY 40 Fulton Street, 18th Floor • New York, NY 10038 THE AMERICAN GERIATRICS SOCIETY 40 Fulton Street, 18th Floor • New York, NY 10038
Geriatrics Health Professionals. 800-247-4779 or 212-308-1414 • americangeriatrics.org Geriatrics Health Professionals. 800-247-4779 or 212-308-1414 • americangeriatrics.org
Leading change. Improving care for older adults. PAGE 7 Leading change. Improving care for older adults. PAGE 8