Independence and the pernicious threat of multimorbidity

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Age and Ageing 2019; 48: 472–473
doi: 10.1093/ageing/afz024
Published electronically 27 March 2019
© The Author(s) 2019. Published by Oxford University Press on behalf of the British Geriatrics
Society. All rights reserved. For permissions, please email: journals.permissions@oup.com
EDITORIALS
Independence and the pernicious threat of
multimorbidity
Key points
•Concurrent dementia and sensory impairments can create
a higher level of disability than the individual conditions
alone.
•Concern about lack of expertise in managing comorbid
conditions can lead to an overcautious approach and
excess disability.
•Assessment and intervention should include a focus on
functional ability within the person’s home setting and
social context.
•A person-centred approach to managing dementia and
sensory impairments rests upon effective interdisciplinary
communication.
Multimorbidity, commonly defined as the presence of two or
more chronic medical conditions [1], poses profound challenges
to older adults and care professionals. We know that the cumu-
lative impact of dual or triple impairments is far greater than
that of the individual conditions alone. In the context of demen-
tia, comorbid hearing and vision impairments compound the
risk of loneliness, isolation and disability and, in doing so,
threaten the roles, relationships and activities that give meaning
to individuals’lives [2]. Qualitative research has expounded the
mechanisms through which disability can be formed, illustrating
that sensory impairments can exacerbate disorientation among
people with dementia by depriving them of the visual or audi-
tory cues to anchor them in the here and now. At the same
time, impaired cognition limits compensatory strategies for sen-
sory deficits, hindering the acquisition of new coping strategies,
mobility training and the use of hearing and low vision aids [2].
Perhaps, just as influential is the social context in which
multimorbidity occurs. Hearing, vision and cognitive impair-
ments each increase vulnerability to harm, accentuating the
tension that care professionals encounter when aiming to
reduce risk and empower individuals to live full lives, with all
the risk taking that this involves. Professionals working across
care settings point to a sense of professional isolation in man-
aging multimorbidity and the inadequacy of current disease
specific guidelines, which do not take account of the unique
circumstances of the individual [3–5]. Older people with
comorbid dementia and sensory impairments are likely to be
in frequent contact with health and social care professionals,
yet these practitioners may seek to avoid or minimise risk if
they lack confidence in their ability to make a holistic assess-
ment of the individual and their capabilities. Qualitative find-
ings suggest that specialists working in hearing, vision and
dementia care can adopt an overcautious approach that inad-
vertently discourages independence in activities of daily living
such as preparing meals, manging money, leaving the home
or participating in hobbies and interests [2,3].
Parallels can be drawn with the challenge of sharing care
for people with dementia across specialist and generalist
settings. Though policy promotes collaborative working
across disciplines for people with dementia, a perceived
lack of competency and resources within primary care, and
specific anxieties around the risk of provoking distress or
damaging the doctor–patient relationship, can contribute to
a reluctance to make a diagnosis or manage dementia in the
community [6]. This raises the question of how best to
equip practitioners with the information and skills to sup-
port older adults with comorbid conditions that fall outside
of their core expertise. Hearing and vision deficits are more
common in people with dementia than in healthy older
populations and both act as independent risk factors for
increased cognitive impairment. All three conditions are
increasingly prevalent with age [5]. Thus, a novel response
is urgently needed to reduce excess disability and improve
quality of life among this growing cohort of older adults.
In this issue, Leroi and colleagues engage with the chal-
lenge of assessing and managing concurrent hearing, vision
and cognitive impairments in older adults [7]. Conducted as
part of the EU funded SENSE-COG programme [8], the
article makes clear that adapted, validated assessments that
take account of concurrent deficits are an essential first step
in improving the service provision. Significantly, emphasis
is placed not only on describing the respective impairments,
but on measuring their cumulative impact on an individual’s
functional ability. Disability and physical functioning are
considered integral components in definitions of successful
ageing [9] and interventions that target generic functional
difficulties have shown promise in improving outcomes for
older people with multimorbidity [10]. Successful ageing in
this context is the ability to optimise adaptation in the face
of losses and limitations. From the standpoint of the WHO
International Classification of Functioning, Disability and
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Health, this assessment should encompass measures of
mobility and environmental, social and personal factors that
may exacerbate or mitigate disability [11]. For example,
environmental adaptations, use of assistive technology, and
aids could lessen the effects of activity limitations and help
the person maintain a level of autonomy [12]. A careful
assessment of how a person functions in their everyday life
could simultaneously lead to a more accurate, shared under-
standing of the collective risks associated with an indivi-
dual’s cognitive and sensory impairments.
A person-centred approach to management should not
simply aim to promote independence in task performance
but seek to promote personhood through optimising valued
roles and participation. Within this issue, Leroi et al. remind
us that the provision of ‘person-centred care’rests upon an
interdisciplinary approach that places the person and their
needs rather than the discipline at the centre of the frame of
reference. However, it is well established that communication
between specialists can be poor and can contribute to frag-
mented care [4]. Even where enthusiasm for joint working
exists among mental health and low vision services, other
obstacles, such as a limited understanding of respective roles
and practices, must still be overcome [3]. Tentative proposals
for promoting joint working across hearing, vision and
dementia care include joint training, workshops, team presen-
tations, ‘shadowing’and a role for nominated experts who
could liaise between teams [3]. Leroi et al. have expanded
upon and refined these ideas, proposing a new role for spe-
cially trained sensory support therapists who will provide a
home-based, individualised hearing and vision intervention
and link with other professionals across domains. The sen-
sory support package is derived from existing local resources
and the findings from the subsequent randomised controlled
trial, which is now underway in five European countries [8],
will provide valuable insight into the benefits of this interdis-
ciplinary approach and of conducting home-based functional
assessments and goal setting with people with multimorbidity
across a range of healthcare organisations.
VANESSA LAWRENCE
King’s College London, Institute of Psychiatry, Psychology and
Neuroscience, Health Services & Population Research Department,
De Crespigny Park, London, UK
Address correspondence to: V. Lawrence. Tel: +44 20 7848 5071;
Fax: +44 20 7848 5056. Email: vanessa.c.lawrence@kcl.ac.uk
Declaration of Sources of Funding: None.
Declaration of Conflict of Interest: None declared.
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