Katie Palmer

Time to face the challenge of multimorbidity. A European perspective from the joint action on chronic diseases and promoting healthy ageing across the life cycle (JA-CHRODIS)

Research on multimorbidity has rapidly increased in the last decade, but evidence on the effectiveness of interventions to improve outcomes in patients with multimorbidity is limited. The European Commission is co-funding a large collaborative project named Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) in the context of the 2nd EU Health Programme 2008-2013. The present manuscript summarizes first results of the JA-CHRODIS, focuses on the identification of a population with multimorbidity who has a high or very high care demand. Identification of characteristics of multimorbid patients associated with a high rate of resource consumption and negative health outcomes is necessary to define a target population who can benefit from interventions. Indeed, multimorbidity alone cannot explain the complexity of care needs and further, stratification of the general population based on care needs is necessary for allocating resources and developing personalized, cost-efficient, and patient-centered care plans. Based on analyses of large databases from European countries a profile of the most care-demanding patients with multimorbidity is defined. Several factors associated with adverse health outcomes and resource consumption among patients with multimorbidity were identified in these analyses, including disease patterns, physical function, mental health, and socioeconomic status. These results underline that a global assessment is needed to identify patients with multimorbidity who are at risk of negative health outcomes and that a comprehensive approach, targeting not only diseases, but also social, cognitive, and functional problems should be adopted for these patients.

Multimorbidity care model: Recommendations from the consensus meeting of the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS)

Patients with multimorbidity have complex health needs but, due to the current traditional disease-oriented approach, they face a highly fragmented form of care that leads to inefficient, ineffective, and possibly harmful clinical interventions. There is limited evidence on available integrated and multidimensional care pathways for multimorbid patients. An expert consensus meeting was held to develop a framework for care of multimorbid patients that can be applied across Europe, within a project funded by the European Union; the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS). The experts included a diverse group representing care providers and patients, and included general practitioners, family medicine physicians, neurologists, geriatricians, internists, cardiologists, endocrinologists, diabetologists, epidemiologists, psychologists, and representatives from patient organizations. Sixteen components across five domains were identified (Delivery of Care; Decision Support; Self Management Support; Information Systems and Technology; and Social and Community Resources). The description and aim of each component are described in these guidelines, along with a summary of key characteristics and relevance to multimorbid patients. Due to the lack of evidence-based recommendations specific to multimorbid patients, this care model needs to be assessed and validated in different European settings to examine specifically how multimorbid patients will benefit from this care model, and whether certain components have more importance than others.

Strategies to Improve Medication Adherence in Older Persons: Consensus Statement from the Senior Italia Federanziani Advisory Board

Poor adherence to treatment regimens has long been recognized as a substantial roadblock to achieving better outcomes for patients. Non-adherence to medications affects the quality and length of life and has been associated with negative health outcomes and increasing healthcare costs. The problem of non-adherence is particularly troublesome in older patients who are affected by multiple chronic diseases and for this reason receive multiple treatments. To date, no single intervention strategy has been shown to be effective in improving adherence across all patients, conditions, and settings. Between September and October 2014, a group of experts in geriatrics, pharmacology, epidemiology, and public health applied a modified RAND appropriateness method to reach a consensus on the possible best interventions to improve adherence in older individuals. Seven interventions were identified, classified based on their target (patient, therapy, and public health/society): (1) Comprehensive Geriatric Assessment, (2) patient (and caregiver) education to improve patient empowerment, (3) optimization of treatment, (4) use of adherence aids, (5) physician and other healthcare professionals’ education, (6) adherence assessment, (7) facilitating access to medicine by service integration. For each intervention, experts assessed (a) target population, (b) health professionals potentially involved in the intervention, (c) strategies/instruments needed for implementation, and (d) time of the intervention. Interventions that target adherence must combine different approaches targeting the complex aspects of older adults in a holistic approach. Tackling non-adherence, with its complexity, requires a multi-stakeholder patient-centred approach acting in a defined framework of interactions in which the different players may provide different services but are integrated with one another.

Accounting for frailty when treating chronic diseases

Chronic diseases are considered to be major determinants of frailty and it could be hypothesized that their treatment may counteract the development of frailty. However, the hypothesis that intensive treatment of chronic diseases might reduce the progression of frailty is poorly supported by existing studies. In contrast, some evidence suggests that intensive treatment of chronic diseases may increase negative health outcomes in frail older adults. In particular, if treatment of symptoms related to chronic diseases (i.e. pain in osteoarthritis, dyspnoea in respiratory disease, motor symptoms in Parkinson disease) might potentially reverse frailty, the benefits related to preventive pharmacological treatment of chronic diseases (i.e. antihypertensive treatment) in patients with prevalent frailty is not certain. In particular, several factors might alter the risk/benefit ratio of a given treatment in persons with frailty. These include: exclusion of frail persons from clinical studies, reduced life expectancy in frail persons, increased susceptibility to iatrogenic events, and functional deficits associated with frailty. Therefore, frailty acts as an effect modifier, by modifying the risks and benefits of chronic disease treatments. This hypothesis must be considered and tested in future clinical intervention studies and clinical guidelines should provide specific recommendations for the treatment of frail people, underlining the pros and the cons of pharmacological treatment and possible targets for therapy in this population. Meanwhile, in older patients, the prescribing process should be individualized and flexible.

The relationship between chronic obstructive pulmonary disease and frailty: a systematic review and meta-analysis of observational studies

BACKGROUND: Frailty is common in seniors and is characterized by diminished physiological reserves and increased vulnerability to stressors. Frailty can change the prognosis and treatment approach of several chronic diseases, including COPD. The association between frailty and COPD has never been systematically reviewed. OBJECTIVES: The goal of this study was to conduct a systematic review and meta‐analysis assessing the association of COPD with frailty and pre‐frailty. METHODS: Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines were used when reporting this review. We searched PubMed, Web of Science, and Embase from January 1, 2002, to October 6, 2017. The quality of the studies was evaluated by using the Newcastle Ottawa Scale. Two assessors independently rated each study: scores > 7 were considered a low risk of bias; 5 to 7, a moderate risk of bias; and < 5, a high risk of bias. Pooled estimates were obtained through random effect models and Mantel‐Haenszel weighting. Homogeneity (I2) and publication bias were assessed. RESULTS: A total of 27 studies were selected: 23 cross‐sectional, three longitudinal, and one both. The pooled prevalence of pre‐frailty in individuals with COPD was 56% (95% CI, 52–60; I2 = 80.8%); it was 19% (95% CI, 14–24; I2 = 94.4%) for frailty. Patients with COPD had a two‐fold increased odds of frailty (pooled OR, 1.97 [95% CI, 1.53–2.53]; I2 = 0.0%). Three longitudinal studies, presenting heterogeneous aims and methods, suggested a bidirectional association between COPD and frailty. CONCLUSIONS: Frailty and pre‐frailty are common in individuals with COPD. Older subjects with COPD have a two‐fold increased odds of frailty. These results may have clinical implications, as they identify the need to assess frailty in individuals with COPD and to further investigate any potential negative effects associated with the co‐occurrence of these conditions. Longitudinal research that examines temporal associations between COPD and frailty are needed to further clarify this relationship and to assess if treatment of COPD may prevent the onset of frailty. TRIAL REGISTRY: PROSPERO registration No.: 58302; URL: https://www.crd.york.ac.uk/prospero/

The Relationship Between COPD and Frailty: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND: Frailty is common in seniors and is characterized by diminished physiological reserves and increased vulnerability to stressors. Frailty can change the prognosis and treatment approach of several chronic diseases, including COPD. The association between frailty and COPD has never been systematically reviewed. OBJECTIVES: The goal of this study was to conduct a systematic review and meta‐analysis assessing the association of COPD with frailty and pre‐frailty. METHODS: Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines were used when reporting this review. We searched PubMed, Web of Science, and Embase from January 1, 2002, to October 6, 2017. The quality of the studies was evaluated by using the Newcastle Ottawa Scale. Two assessors independently rated each study: scores > 7 were considered a low risk of bias; 5 to 7, a moderate risk of bias; and < 5, a high risk of bias. Pooled estimates were obtained through random effect models and Mantel‐Haenszel weighting. Homogeneity (I2) and publication bias were assessed. RESULTS: A total of 27 studies were selected: 23 cross‐sectional, three longitudinal, and one both. The pooled prevalence of pre‐frailty in individuals with COPD was 56% (95% CI, 52–60; I2 = 80.8%); it was 19% (95% CI, 14–24; I2 = 94.4%) for frailty. Patients with COPD had a two‐fold increased odds of frailty (pooled OR, 1.97 [95% CI, 1.53–2.53]; I2 = 0.0%). Three longitudinal studies, presenting heterogeneous aims and methods, suggested a bidirectional association between COPD and frailty. CONCLUSIONS: Frailty and pre‐frailty are common in individuals with COPD. Older subjects with COPD have a two‐fold increased odds of frailty. These results may have clinical implications, as they identify the need to assess frailty in individuals with COPD and to further investigate any potential negative effects associated with the co‐occurrence of these conditions. Longitudinal research that examines temporal associations between COPD and frailty are needed to further clarify this relationship and to assess if treatment of COPD may prevent the onset of frailty. TRIAL REGISTRY: PROSPERO registration No.: 58302; URL: https://www.crd.york.ac.uk/prospero/

Frailty and multimorbidity: a systematic review and meta-analysis

Background Multimorbidity and frailty are complex syndromes characteristics of ageing. We reviewed the literature, and provided pooled estimations of any evidence regarding a) the coexistence of frailty and multimorbidity, and b) their association. Methods We searched PubMed and Web of Science for relevant articles up to September 2017. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting. Homogeneity (I2), risk of bias and publication bias were assessed. PROSPERO registration: 57890. Results A total of 48 studies involving 78122 participants were selected, and 25 were included in one or more meta-analyses. Forty-five studies were cross-sectional and 3 longitudinal, with the majority of them including community-dwelling participants (n=35). Forty-three studies presented a moderate risk of bias, and 5 a low risk. Most of the articles defined multimorbidity as having two or more diseases and frailty according to the Cardiovascular Health Study criteria. In meta-analyses, the prevalence of multimorbidity in frail individual was 72% (95% Confidence Interval [95% CI] 63% to 81%; I2=91.3%) and the prevalence of frailty among multimorbid individuals was 16% (95% CI 12% to 21%; I2=96.5%). Multimorbidity was associated with frailty in pooled analyses (OR 2.27; 95% CI 1.97 to 2.62; I2 47.7%). The three longitudinal studies suggest a bidirectional association between multimorbidity and frailty. Conclusions Frailty and multimorbidity are two related conditions in older adults. Most frail individuals are also multimorbid but fewer multimorbid ones present also frailty. Our findings are not conclusive regarding the causal association between the two conditions. Further longitudinal and well-designed studies may help to untangle the relationship between frailty and multimorbidity.

Adherence to selective serotonin and serotonin-norepinephrine reuptake inhibitor prescriptions affects overall medication adherence in older persons: Evidence from the Italian nationwide osmed health-db database

OBJECTIVE This study aimed to evaluate prevalence of prescription of and adherence to selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) and whether adherence to these classes of drugs affects overall medication adherence in older persons. METHODS In a cross-sectional analysis of administrative data comprehensive of all prescribed drugs reimbursed by the Italian national health care system, new prescriptions of SSRIs and SNRIs to persons aged 65 years or older were analyzed (n = 380,400 in 2011; 395,806 in 2012; 409,741 in 2013, from a total sample of 3,762,299 persons aged 65 years or older) as well as prescriptions of antihypertensives, statins, other psychiatric drugs, antidiabetics, antiplatelets, anticoagulants, drugs for chronic obstructive pulmonary disease, and antiosteoporotics. Adherence was estimated by calculating the proportion of days covered by drugs dispensed during a period of 365 days. Adherence was defined as a proportion of days covered of more than 80%. RESULTS Prevalence of SSRI and SNRI prescriptions varied from 11.4% in 2011 to 12.1% in 2013. Adherence to SSRI and SNRI prescriptions ranged from 31.2% in persons aged ≥ 95 years in 2011 to 41.8% in persons aged 75-84 years in 2013. Persons adherent to SSRI and SNRI prescriptions were more likely to be adherent to the other medications, after adjustment for age, gender, and number of drugs prescribed. The highest association was found for adherence to psychiatric drugs (OR = 1.9; 95% CI, 1.8-2.0). CONCLUSIONS Adherence to SSRI and SNRI prescriptions is poor in older persons. However, people adherent to these classes of antidepressants are more likely to be adherent to the other medications they are prescribed. Studies are needed to evaluate the reasons for and the potential benefits of increasing adherence to antidepressants on overall adherence.

Comprehensive geriatric assessment: Benefits and limitations

The traditional disease-oriented model of medicine focuses on the theory that organor system-based pathologies cause disease and, thus, treatment is focused on eliminating the underlying pathology. However, the disease model does not account for complexity of patients that are more often being seen in modern medical settings [1]. Due to increasing life expectancy, health care systems are progressively facing growing populations of older patients, who often have non-disease specific problems such as multimorbidity, frailty, polypharmacy, and disability [2,3]. The comprehensive geriatric assessment (CGA) and Management is an approach that aims to overcome some of the limitations of the disease-oriented model. Generally defined, CGA is a multi-dimensional multi-disciplinary diagnostic process focused on assessing an older persons medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow-up focused on the individuals needs. This assessment is followed by the development of a care plan, based upon the comprehensive assessment. The care plan must state explicitly what goals are being aimed for, who is responsible for achieving them and a timeline for review of progress. There are several benefits related to this approach. First, this assessment specifically examines a wider range of problematic areas of the patient, including co-morbidities, potential polypharmacy, and quality of life, as well as physical and cognitive functioning, that might not always be considered during a disease-oriented medical assessment [4]. Second, it allows for more specific, individualized care planning for the patient, resulting in better overall quality of care [5,6]. A systematic review concluded that the CGA approach in inpatients was associated with a reduction in short-term mortality, improvement in physical and cognitive functioning, and also increased the chance of patients retuning to live at home [7]. Zintchouk et al.s randomized control study published in this issue of the European Journal of Internal Medicine provides an important contribution to the evidence [8]. They identified several benefits of the CGA when administered in an inpatient community rehabilitation unit. First, during the rehabilitation period, the number of daytime GP consultations and visits or phone and email consultations was lower in the intervention (CGA) group compared to those in the control group who did not undergo CGA. Second, more participants in the intervention group improved their overall quality of life over 90 day follow-up. Despite the benefits of CGA, the process could be improved. For example, specific patients should be targeted, in whom the effects of this comprehensive assessment and follow-up may be required more. Persons with multimorbidity [9] or frailty [10] may be suitable patients who would benefit from CGA. Patients presenting with complex conditions such as frailty often have particular clinical needs that are often not being properly addressed, requiring an adaptation of traditional care organization and services. For example, frail patients are significantly less to adhere to pharmacological treatments [11]. This is further complicated by the fact that many patients with chronic diseases such as chronic obstructive pulmonary disease [12] or chronic kidney disease [13] also present with frailty, and vice versa. Interesting, Zintchouk et al.s study did highlight some differences in outcomes depending on certain patient characteristics. The sub-analysis performed showed that in persons with low to moderate comorbidity participants who underwent CGA had greater 90 day improvement in ADL and overall quality of life than the control group who had no CGA, yet in persons with high comorbidity there was no difference in ADL or overall quality of life improvement between the CGA/no CGA group. This underlines the need of better defining the ideal target population that can get benefit from this approach. Despite there being evidence that CGA in certain patients can improve outcomes, there are currently a number of limitations of the process. The first major issue is that there is a lack of standardization in the assessment. The first assessment tools generally focused on single domains, such as cognitive functioning or mood, and lacked comprehensiveness and standardization. More recently, InterRAI [14], a scientific not-for-profit corporation, has developed a range of validated and standardized setting-specific instruments (i.e., home care, long term care etc.) for older patients. These tools, such as the InterRAI Home Care instrument, are internationally validated comprehensive geriatric assessments. They include common items that have the same scorings and definition, and provide ways not just to standardize assessment but also to standardize data collection and comparison, using international data sharing. Second, there is a lack of standardization in the care approach [7]. A systematic review of CGA

Frailty and atrial fibrillation: A systematic review

Atrial fibrillation (AF) is a common cardiac arrhythmia and its prevalence increases with age. There is a significant correlation between frailty, morbidity and mortality in elderly patients with cardiovascular disease, but the relation between AF and frailty is still under debate. The aim of this study is to systematically review evidence on the association between AF and frailty. A systematic review of articles published between 02/01/2002 and 09/28/2017 according to PRISMA recommendations was carried out. PubMed, Web of Science, and Embase were searched for relevant articles. 11 studies were included; one longitudinal, 10 cross-sectional. Only 4 studies assessed the association of frailty with AF, while 7 studies were performed in a sample of participants with AF and did not provide any measure of association between these two conditions. The prevalence of frailty in AF patients ranged from 4.4%-75.4% while AF prevalence in the frail population ranged from 48.2%-75.4%. Selected studies enrolled an overall sample of 9420 participants. Among them, 2803 participants were diagnosed with AF and of these 1517 (54%) were frail and 1286 (46%) were pre-frail or robust. The four studies assessing the association of AF and frailty provided conflicting results. Evidence suggests that frailty is common in persons with AF. More research is needed to better assess the association of these conditions and to identify the optimal therapeutic approach to AF in persons with frailty.