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Independence and the pernicious threat of multimorbidity

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Age and Ageing 2019; 48: 472473
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 persons home setting and
social context.
A person-centred approach to managing dementia and
sensory impairments rests upon effective interdisciplinary
communication.
Multimorbidity, commonly dened 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 individualslives [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 decits, hindering the acquisition of new coping strategies,
mobility training and the use of hearing and low vision aids [2].
Perhaps, just as inuential 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
specic guidelines, which do not take account of the unique
circumstances of the individual [35]. 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 condence in their ability to make a holistic assess-
ment of the individual and their capabilities. Qualitative nd-
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
specic anxieties around the risk of provoking distress or
damaging the doctorpatient 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 decits 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 decits are an essential rst step
in improving the service provision. Signicantly, emphasis
is placed not only on describing the respective impairments,
but on measuring their cumulative impact on an individuals
functional ability. Disability and physical functioning are
considered integral components in denitions of successful
ageing [9] and interventions that target generic functional
difculties 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 Classication 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-
duals 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 carerests 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, shadowingand a role for nominated experts who
could liaise between teams [3]. Leroi et al. have expanded
upon and rened 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 ndings from the subsequent randomised controlled
trial, which is now underway in ve European countries [8],
will provide valuable insight into the benets 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
Kings 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 Conict of Interest: None declared.
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Independence and the pernicious threat of multimorbidity
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... Multimorbidity poses further critical challenges at local and national levels. There is an almost exponential relationship between the number of health conditions, healthcare resources and supports required (Barnett et al. 2012;McWilliams et al. 2017;2018;ONS 2018;Lawrence 2019). Multimorbidity has been variably defined and often used interchangeably, or conflated with, comorbidity (Nicholson et al. 2019). ...
... This may enhance inequalities in clinical outcomes, healthcare and survival rates already associated with dementia (Scrutton and Brancati 2016;Cooper et al. 2017;Witham et al. 2017;Martin et al. 2019;Nelis et al. 2019). Much evidence has focused on dementia alone or on direct-care experiences in nursing and care homes (Lawrence 2019). There is a dearth of evidence considering the challenges of living with dementia and multimorbidities at home and the more complex care and skills required. ...
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Dementia is recognised as the biggest health crisis of our time in terms of high personal and social costs and wider impact on health and social care systems. Increases in people living with dementia and multi-morbidities presents critical challenges for home care worldwide. Health-care systems struggle to provide adequate home-care services, delivering limited care restricted to a single-condition focus. This study explored the experiences and expectations of home care from the multiple perspectives of people living with dementia and multi-morbidities and home-care workers providing support. Findings draw from qualititative semi-structured interviews with people with dementia (N = 2 ), their partners (N = 2 ), other partners or family carers (N = 6 ) and home-care workers (N = 26 ). Three themes are identified: (a) the preference for and value of home; (b) inadequate home-care provision and enhanced care burden; and (c) limited training and education. Despite continued calls for home-care investment, the focus on reduction in costs hides key questions and further dialogue is required exploring how people with dementia can be supported to live independently and flourish at home. This study considers these complex experiences and care requirements through the prism of disability and human rights frameworks. This paper concludes with consideration of more recent human social rights debate. We discuss critically what this may mean for people living with dementia and consider the implications for co-requisite policy development to optimise available home-care support.
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Background: Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity. Objectives: To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. Search methods: We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies. Selection criteria: Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting. Data collection and analysis: Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types. Main results: We identified 17 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 11 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) -0.41, 95% confidence interval (CI) -0.63 to -0.2). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited. Authors' conclusions: This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression in people with co-morbidity.
Chapter
Background: Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity. Objectives: To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. Search methods: We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies. Selection criteria: Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting. Data collection and analysis: Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types. Main results: We identified 18 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 12 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) -2.23, 95% confidence interval (CI) -2.52 to -1.95). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence) although two studies that specifically targeted functional difficulties in participants had positive effects on functional outcomes with one of these studies also reporting a reduction in mortality at four year follow-up (Int 6%, Con 13%, absolute difference 7%). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited. Authors' conclusions: This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression, or specific functional difficulties in people with multimorbidity.
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dementia and visual impairment are common in older adults, and both conditions create a high risk of disability. Care professionals lack evidence on how best to support older adults with both conditions. the study investigated attitudes towards working with older adults with concurrent sight loss and dementia, the challenges involved and suggestions for service development. a qualitative study was conducted comprising 18 in-depth interviews and two focus groups with care professionals within mental health and low vision services. care professionals were alert to the high levels of risk among patients with joint sight loss and dementia. In-depth interviews revealed that insufficient time and expertise can lead to an overcautious approach that prioritises the reduction of risk rather than the promotion of independence. Focus groups highlighted the role that joint working can play in supporting older adults' valued roles and activities. Barriers to joint working were identified alongside strategies to assist the process. it is essential that care professionals and service providers acknowledge and respond to the complex needs of this population. Joint working was considered key to assessing risks and targeting interventions. The research workshop presented here provides a useful format for improving practice across inter-professional boundaries.