Balancing guidelines and drugs in those with multiple health conditions

Why is this issue important to your health?

A growing number of Canadians live with multiple chronic health conditions (sometimes referred to as multi-morbidity). According to the Canadian Institute for Health Information (CIHI), 33% of community-living seniors have three or more chronic conditions (1).

Scientific evidence suggests that multiple chronic health conditions are associated with:

1. increased healthcare use
2. treatment with multiple medications (polypharmacy)
3. physical disability
4. reduced quality of life and life expectancy (2).

In fact, the driving force in healthcare use appears to be patients' multiple chronic health conditions rather than aging itself. In Ontario, for example, it is the most complex 10% of seniors (the frail and those with multiple chronic health conditions) that account for 60% of the provincial healthcare spending (3).

Managing multiple chronic health conditions is challenging for both patients and their health care providers. Traditionally, doctors and other health care providers have used Clinical Practice Guidelines (CPGs) to assist them in making medical test and treatment decisions for their patients. CPGs are sets of recommendations for specific health conditions. They are created after an exhaustive review of the best available research evidence and practice experience. When applied appropriately, CPGs can maximize benefits for patients with a specific health condition. However, they can sometimes create new problems when applied to seniors with multiple chronic health conditions.

What are the limitations of clinical practice guidelines?

Several research studies have shown that most CPGs do not consider how their recommendations might affect older patients with multiple health conditions (2). For example, a recent Canadian review of CPGs for the ten most common chronic health conditions (e.g., diabetes, heart problems, etc.) found that only three provided specific recommendations for older patients with multiple health conditions (4).

As a result, clinicians are becoming increasingly concerned about using different CPGs for the multiple health conditions of their patients. This is because:

1. CPGs are typically designed for a single health condition. They may not take into account signs, symptoms and treatments related to other health conditions. As a result, the recommendations made in each CPG (for individual health conditions) may interact or contradict each other (5).
2. Most CPGs are based on scientific evidence that does not include studies of older adults. When studies of seniors are included, they usually exclude or under-represent patients with multiple health conditions (6).
3. Rigidly following CPGs across a range of health conditions may increase the risk of polypharmacy and drug complications (7). [See other blogs on polypharmacy on the website]
4. CPG recommendations rarely consider other life issues important to older adults. Seniors often have different priorities than young adults (2). These priorities or goals of care are rarely considered in older people with limited life expectancy. This means that many life issues important to seniors may not be factored into the recommendations made within the CPG.

Prescribing for the patient versus prescribing for the disease

Making decisions and prescribing medications for older adults with multiple conditions is complex. Ideally, medical treatments would improve all health outcomes whether they improve your symptoms, daily function, or how long you live. However, these treatment outcomes are often at odds with one another. There can be a dilemma where the improvement of one outcome (e.g. symptoms of breathlessness) may worsen the other (e.g. survival).

Many experts in elder care recommend an individualized, holistic approach rather than a strict following of CPG recommendations. This approach aims to optimize decision-making and patient treatments by re-evaluating whether:

1. medications with benefits for specific health conditions are still helpful or potentially harmful when taken along medications for others conditions [see the other blogs on polypharmacy].
2. medications are effective given all health conditions of a patient
3. medications are sensible given a patient's age and circumstance (e.g. remaining life expectancy and goals of care)

Using this information, patients and healthcare providers must decide whether a medication is more likely to help (provide the proposed or expected benefit) or harm (produce any known adverse effect) in their lifetime. This is known as the 'time to benefit' or 'payoff time' model. This model is a reminder that many patients with multiple health conditions may not live long enough to reap the rewards from medical treatments. This occurs because many medications have the potential to cause immediate discomfort or harm, but the health benefits may take years to appreciate (8;9).

Patients and healthcare providers also need to have a common and respectful understanding of each other's values and goals of care. Patients place varying degrees of importance on health outcomes (10). These may include quantity vs. quality of life, future vs. present health, and symptom relief vs. disease prevention. Depending on one's values, the appropriateness or priority of specific treatments and medications can vary significantly.

For this reason, healthcare providers should know about your priorities and beliefs regarding medication-related risk and benefit. Once this has been established, a good plan for healthy living, optimal aging and end-of-life concerns can be developed. This will allow them to prescribe more effectively as your situation and needs change over time.

What tools are available to help patients and their health care providers?

A number of clinical tools have been developed to help your healthcare provider develop your health plan. These include tools that will:

1. improve the appropriateness of medication prescribing (e.g. Beers Criteria, START / STOPP Criteria) (11-13),
2. help estimate remaining life expectancy (e.g. ePrognosis) (14;15) and
3. establish health-related values and goals of care (e.g. Health Outcomes Tool, Time and Outcome Preference / Attitude Scale, Now. Vs. Later Tool) (16-18)

You may want to ask your doctor about some of these clinical tools as you work on your health plan.

What is the bottom line about clinical practice guidelines, medications, and multi-morbidity?

Many Canadians live with multiple chronic health conditions and most CPG have not been developed for older adults in this situation. Making decisions about your care and your medications are complex. An individualized approach, that takes into account your values and goals may be the best option for older adults with multiple chronic health conditions.