Medical Management of Multimorbidity and Polypharmacy
The optimal medical management requires a systematic medication review with deprescribing of potentially harmful medications, optimization of remaining therapies based on patient-specific goals, and implementation of non-pharmacological interventions prioritized over pharmacological ones. 1, 2
Immediate Assessment and Risk Stratification
Conduct a comprehensive medication reconciliation that includes all prescriptions, over-the-counter medications, supplements, and herbal remedies to identify discontinued, missing, or incorrectly taken medications 3. Document all diagnoses with severity assessment, existing laboratory results, and medication-related problems 4, 3.
Identify high-risk patients using prognostic models, either opportunistically during routine care or through systematic screening, focusing on those with multiple conditions taking multiple medications who face increased complexity in care management 2.
Evaluate for potentially inappropriate medications using validated tools like Beers Criteria or STOPP/START, paying special attention to high-risk drug classes including sedatives/hypnotics, opioids, anticholinergics, benzodiazepines, and hypoglycemics 3.
Patient-Centered Goal Setting
Elicit patient preferences and expectations regarding their care through shared decision-making about treatment options and level of involvement 1, 2. Discuss the purpose of medication optimization to improve quality of life and function, encouraging patients to express their personal values, aims, and priorities regarding treatment 2, 3.
Consider treatment burden, complexity, and feasibility when choosing therapies that optimize benefit, minimize harm, and enhance quality of life 1. Be aware that studies in younger patients without multimorbidity and polypharmacy with short follow-up times may overestimate benefits and underestimate harms 1.
Systematic Deprescribing Approach
Follow a systematic deprescribing process that includes: 1
- Identification and prioritization of medicines to be discontinued
- Stopping one medication at a time
- Consideration of tapering dosage rather than abrupt cessation
- Planning and communicating with patients and caregivers
Target medications from which patients no longer derive reasonable benefit, or when potential harm outweighs benefit 3. When prescribing medications such as statins and bisphosphonates, be aware that they may only provide benefit to elderly patients who have estimated survival greater than five years 1.
Medication Optimization Strategy
Evaluate drug-drug and drug-disease interactions using interaction databases, paying particular attention to QT prolongation risks, anticoagulant interactions, and serotonin syndrome potential 3. Identify medications that may worsen existing conditions, such as NSAIDs in heart failure, chronic kidney disease, or hypertension 3.
Consider the applicability and quality of evidence including study population, study duration, benefits in terms of absolute risk reduction, and time horizon, as these factors may not reflect the multimorbid elderly population 1.
Non-Pharmacological Interventions
Prioritize non-pharmacological modalities first based on availability, cost, safety issues, and patient preference 1. For patients with chronic multisymptom illness, consider cognitive-behavioral therapy, mindfulness-based treatments, and exercise 2.
Care Coordination and Support
Develop individualized care plans that address ongoing medical and social care needs while focusing on enhancing social connectedness and community involvement 1, 2. Ensure there is community-based multidisciplinary support for patients with social care needs, which might include a physiotherapist, occupational therapist, mental health social worker, or psychiatrist 1.
Consider using named care coordinators who can agree on a course of action with patients and their carers, particularly important at times of transition, such as when considering moving to a care home 1.
Recommend selection of a primary pharmacy to support coordination of self-administered drugs with regard to dosage instructions and overall medication regimens, particularly when there are multiple prescribers 1.
Medication Plan Documentation
Create an individualized patient-held medication plan that includes: 1, 2
- Information on drugs and specific instructions for usage
- For "as needed" dosages: exact information about indication and individual dosage (single dose, interval, and maximal daily dosage)
- For short-term prescriptions: prospective end date
- Information about medication history and reduced renal function when indicated
Monitoring and Follow-Up
Schedule regular follow-up appointments to assess medication effectiveness and adverse effects, monitoring treatment effects, clinical parameters, and side effects 2, 3. Review and update medication/care plans regularly to recognize and record changes in needs 2.
Increase monitoring frequency during care transitions including hospital admission, transfers between wards, and discharge 3. Enhanced monitoring of signs, symptoms, and laboratory parameters can determine whether an adverse event has only mild and short-term consequences or major long-term effects on morbidity and mortality 5.
Implementation Support
Utilize computerized decision support systems (CDSS) that support decision making and prescribing, but recognize these should not replace clinical judgment 1, 2. Implement a multidisciplinary team approach, especially involving clinical pharmacists when available 2, 3.
Critical Pitfalls to Avoid
Do not apply single-disease guidelines rigidly to patients with multimorbidity, as adhering to multiple disease-specific guidelines simultaneously can result in excessive polypharmacy, drug-drug interactions, and treatment burden that outweighs benefits 6. Current clinical practice guidelines often fail to address older patients with multiple comorbidities, goals of treatment, interactions between recommendations, burden to patients and caregivers, patient preferences, life expectancy, and quality of life 6.
Avoid routine urinary catheterization unless the benefits outweigh the risks of infection and longer-term complications related to continence 1.