#181 The Multimorbidity Games with Josh Uy MD

November 4, 2019 | By Nora Taranto

Geriatrician Josh Uy Schools us on why multimorbidity is like Juggling and Jenga™

Learn how to approach the geriatric patient with multimorbidity and how to parse through and prioritize a mile-long problem list with Dr Josh Uy, master geriatrician at the University of Pennsylvania. We review different approaches to a clinic visit with a patient who takes fifteen daily medications with just as many chief complaints, all in a thirty minute (or less!) appointment time. We discuss what the term “multimorbidity” even means, how to ask about patient preferences and use them to inform the treatment plan, and what the evidence has to say about adjusting treatment goals of common conditions for individual patients. (Spoiler alert: It all depends on the patient, comorbid conditions and goals!)

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Credits

Producer: Nora Taranto MD 

Writer:  Nora Taranto MD, Leah Witt MD 

Infographic:  Leah Witt MD 

Cover Art: Nora Taranto MD 

Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Leah Witt MD, Paul Williams MD, FACP

Editor: Matthew Watto MD, FACP; Clair Morgan

Guest: Josh Uy MD 

Time Stamps

• 00:00 Pun, Intro, disclaimer, guest bio
• 04:30 Guest one-liner; Career advice; 
• Picks of the Week*: Unbroken (book), Down Dog Yoga (app); Check out Dimash’s music on YouTube; Off Your Rocker (TV show); Finishing Well to the Glory of God (book)
• 12:30 A case of multimorbidity; Where to start?
• 15:30 How to focus the visit; Lumping and the problem list;
• 18:20 Dr Uy’s framework for multimorbidity
• 28:08 Questions (scripts) for eliciting patient preferences
• 30:20 Hypertension; All cause mortality; Number needed to treat; The danger of adding blood pressure medications in the hospital, the Jenga analogy
• 35:30 How to frame  potentially ineffective treatments (e.g. statins for primary prevention of stroke) and align treatments with a patient and family’s goals
• 44:18 Dr Uy runs through common comorbid conditions and time to benefit starting with longevity minded (45:43); Palliative minded approach (47:50)
• 48:49 Afib, anticoagulation and falls; Cancer screening
• 54:30 Take Home Points

Multimorbidity / Geriatric Complexity: Some Clinical Pearls

“a functional goal or a goal of care…is a unifying goal for multiple medical problems…it’s a lot like putting your TV in the living room. It lets you know what you should point all of your furniture at”.

Josh Uy, MD

1. It’s normal to feel overwhelmed when you see the multimorbid patient. Try to prioritize problems and pick a few to focus on per visit. 
2. You and the patient get to share the agenda of the visit.  Always start by asking “What’s most important to you?”  
3. In considering whether to start or stop a treatment, first take into account the patient’s preferences and goals, for the short and long term.  Then, consider the time frame to benefit, the risk (and time frame) of adverse effects, and the number-needed-to-treat for expected benefit.
4. The conversation about stopping preventive screening and medications can be emotionally charged for patients and caregivers. 
5. Our evidence base is limited for evaluating treatments in patients with multimorbidity and frailty. That’s because older and/or medically complex patients have been excluded from many major trials.
6. Disappoint the right people (listen to the first part of the episode, y’all! There’s some profound stuff there). 

Multimorbidity: A definition 

Lots of different terms that are related: multimorbidity, multiple chronic conditions, multi-complexity. Simply put, it means patients who have multiple issues.  The American Geriatrics Society definition suggests that it applies to patients with 3 or more chronic disorders (JAGS 2012).  NICE guidelines broaden it further, to include individuals with 2 or more “long-term health conditions” (NICE 2016).  Even dealing with just two chief complaints can be a challenge when we have 30 minute appointments.  The challenge is to streamline things, and to simplify.

A few different guidelines have come out recently about how to think about multimorbidity.  This year, the American Geriatrics Society Multiple Chronic Conditions recommended Actions (JAGS 2019) came out. In 2016, the NICE (National Institute for Health and Care Excellence) guidelines on “Multimorbidity: clinical assessment and management” were published.  And while these guidelines are useful and meticulously crafted, they tend to be long, and include relatively broad suggestions about practice. But in all of them, there are common themes that can come in handy to think about in structuring your patient visit. 

Josh’s Framework for the Visit 

There are a bunch of different ways to break this down. Per the American Geriatrics Society, the five domains/elements of quality care in complex older patients (JAGS 2012) are:  

1) Patient Preferences 

2) Interpretation of evidence base 

3) Framing of clinical decisions in the context of risk, patient benefits, burdens, and prognosis 

4) Assessment of clinical feasibility in light of treatment options 

5) Optimization of treatments

Dr. Uy uses these values to approach the multimorbid patient, but with slight variation.

Set the Agenda (The patient gets a vote, and you get a vote!) 

First, make sure that you identify the health issue that is most important to the patient (and that may very well be bringing them in), as well as the issue that is most important to you.  Try to focus on these issues during the visit.  Let the patient go first. (And often you’ll have multiple family members who are stakeholders as well participating in this discussion as well). Try to get everything out on the table, early in the visit. You can even go so far as to state that these will be the issues you talk about, to make sure you and your patient are aligned about what the patient will be able to get out of the visit, and what may have to wait.  Acknowledge that not everything will get done today, and try to make the appointment as valuable as possible by asking the patient “What is most important to you? How do you want to spend this time?”  

Patient preferences: Ask about them!  

This goes hand in hand with the agenda-setting. If you don’t know what your patient wants, then the encounter is likely to go far less smoothly.  And, especially early on, you may not know what the patient’s priorities are in terms of quality of life and goals of care. Knowing the patient’s goals in terms of function, health, and happiness is essential in thinking about the multimorbid patient, because it will likely inform how and what you choose to prioritize on a long problem list. There are many ways to get at this, but you need to assess the patient’s goals in terms of longevity, function, and quality of life.

 A few lovely phrases that Dr. Uy uses to get at this: “Tell me, what does a good day look like to you?” or “What do you look forward to when you get up in the morning?” And, conversely, ask “What does a bad day look like to you?”

Now vs. Later:  Is the patient worried about things that will affect them now, or are they worried about their future?  And are the benefits and risks of a given treatment likely to affect the patient now or later? For example, when deciding a diabetes glycemic treatment target, it is important to consider the long time-to-benefit for “tight” glycemic control versus the immediate risk (hypoglycemia!) of tight control.

For Each Problem, Consider the Evidence: 

Next, synthesize. Ask yourself how treating each problem on their problem list would affect their health in the context of their goals regarding longevity, function, and quality of life.  

This involves multiple considerations, for any given disease and potential treatment: 

• Time-to-benefit of a given treatment 
• Potential treatment-related adverse effects (and what the timeline is for these) 
• Discussion with the patient/caregiver about managing handle complexity of care (i.e. multiple medication administrations or complex disease monitoring) 
• The yield of the treatment: how likely is it to benefit the patient 

A great pearl from Dr. Uy: If someone can’t handle complex care, you should cut out low yield treatment. 

“If someone has food insecurity, and they don’t have enough food to eat to begin with, you are not going to tell them about the potential (largely unproven) benefits of organic, expensive asparagus water.” 

Now about that evidence….

It turns out that the exclusion criteria for many of the large trials kept patients with multimorbidity and frailty out of the trials. So it can be a challenge to interpret the guidelines for common medical conditions (e.g. hypertension) in the multimorbid patient on more than ten medications. But there are a few conditions the treatments for which have very clear mortality benefit: atrial fibrillation (tx: anticoagulation) and hypertension (tx: anti-hypertensives). This proven mortality benefit does not apply so clearly to treating other common chronic conditions such as high cholesterol, diabetes, or diastolic heart failure in the elderly. 

Geriatric Conditions, and Numbers Needed to Treat (A few examples)

Briefly, there are not that many conditions for which treatment reduces all-cause mortality (read: hypertension, atrial fibrillation) in the geriatric population. But important to keep in mind that, in the complex older adult, there is not a one-size-fits-all solution.  In this discussion, it’s important to be clear with patients about what treatments will most likely help them now vs. later, and what treatments will make them feel better vs prevent future disease. And re polypharmacy: Be a little bit more scared to add medications.–Dr. Uy 

Hypertension: Treat! But to what goal?  

The SPRINT trial identified a number-needed-to-treat of 63, over three years, to reduce all-cause mortality and morbidity (heart failure, stroke, heart attack) by improving blood pressure control with anti-hypertensives (SPRINT, NEJM 2015) in older adults. This is a relatively low number-needed-to treat, over a relatively short time period, to prevent the composite CV outcome and reduce mortality. Blood pressure control is, as Dr. Uy states, one of the few things we can do in the office that, within a relatively short time frame, can reduce the risk of common causes of death and disability in our population.

Now what about that more intensive blood pressure goal (<120 systolic versus 135-139)? The SPRINT trial excluded folks with frailty, diabetes, prior stroke, or multimorbidity. So, in patients with myriad conditions, it makes less sense to worry about the intensive blood pressure goals. But if you’ve got a two-problem visit that includes hypertension, maybe treat more aggressively. (And think twice (or more) about intensifying anti-hypertensive treatment on discharge from hospitalization. TLDR: short-term harms, no long term benefits (Anderson; JAMA IM 2019)).  

Hyperlipidemia: Maybe? 

There’s significant debate about the use of statins in the multimorbid older adult.  How do we think about treating hyperlipidemia? 

This is where the now vs. later framework can be helpful, because while statins can help to prevent future cardiovascular events, they don’t improve immediate quality of life and contribute to pill burden. While evidence does suggest that in the geriatric population statins do reduce the risk of non-fatal heart attacks, they do not reduce the risk of stroke or overall total mortality (PROSPER; Lancet, 2002).  Time-frame to efficacy for statins is 6 months to several years, depending on the trial–with a number needed to treat of 48 over 3 years to achieve a significant reduction in risk of non-fatal MI.  And they can add to the pill burden of an already overburdened patient, with some risk of side effects. So, if you’re seeing a robust and healthy individual with high cardiovascular risk, statins most likely make sense. But, in the patient with multimorbidity and limited life expectancy, who is already taking myriad other medications, consider very carefully if this treatment makes sense. 

Atrial fibrillation?  

Anticoagulation to prevent strokes and overall mortality is one of a few treatments with a low NNT and a short time frame to benefit (around one year). Among those with a CHADS2 score of 2 (CHF, HTN, Age > 75, DM, stroke/tia previously), there is a NNT of 38 over one year. With a CHADS2 score of 3, there’s a NNT of 26 over the same time frame to prevent stroke.  (Annals IM 2007)

But the decision to start anticoagulation in geriatrics is made more complex for patients with frequent falls. And even though there is research looking at the number of falls needed to have a clinically significant event, that’s population data, not data that applies to the individual (E.g. as the patient, you need fall only once, and hit your head, to have a real problem. So, as always, it’s a balance of pros and cons for the specific patient. Will the patient be able to accept and tolerate the risk of potential complications? Some patients may not accept treatments with small therapeutic windows (like anticoagulation). 

(And a quick primer on Diabetes, even though we didn’t talk about the NNTs for it in the episode…)  

Diabetes? Target A1c goals? 

Well, there are no trials of glucose control and long-term outcomes in the elderly (the closest we get is the ACCORD trial, in which the average age of participants was 62). Dr. Watto points out that tight glycemic control does not conclusively prevent important clinical endpoints (e.g. microvascular disease (blindness, renal failure, symptomatic neuropathy) or macrovascular endpoints (e.g. stroke, all-cause mortality, fatal MI) with the exception of nonfatal MI (Rodriguez-Gutierrez, 2016). The time to benefit for tight control with conventional therapies (metformin, insulin, sulfonylureas) is on the order of 10 years –see episode #96: Diabetes: A1C targets & ACP guidelines controversy. Notably, there are real downsides to tight control (risk of lows and syncope or falls). So, in general, in the multimorbid geriatric population, the goal is to prevent lows, even if that requires increased glycemic targets. Dr Uy cites an A1C goal of 8-9% for older patients with medical complexity at high risk for hypoglycemia.

This is where we come back to the “now vs. later” framework, yet again.  If the patient’s goals are “now” focused, then, simply put, we want to avoid the highs and the lows–avoid the symptomatic hypoglycemia (and falls) and the symptomatic hyperglycemia (polyuria and polydipsia), consider an A1c >7 and pick the safest medications to get into this window. 

Table 1. Number-Needed-to-Treat and Time-to-Benefit for common geriatric conditions. Note: These are rough numbers supplied by Dr. Uy to illustrate the differing time to benefit and number needed to treat (NNT) amongst various treatment interventions.

When (and how) to stop treatments or screenings: 

The discussion about when to stop preventive medicines (or preventive screenings) can be tough (or not! Patient may be waiting for you to bring this up!). 

Framing the conversation is important, de-emphasizing the medical model that lots of care is always good care. This is a conversation that has strong emotional valence for patients and their families, even if it doesn’t seem that way on the surface.

It is important to clarify what treatments will address symptoms and what treatments are preventive. 

If a patient has longevity-focused goals with an eye on preventive medicine, a lipid-lowering medication may be indicated.  But patients can also choose to focus on the “now” goals–the ones that will improve symptoms from a disease now instead of preventing development of disease later.

Time Frame and Goals of Care: It’s ok to choose Now. 

Make sure your patients and their caregivers know that choosing to focus on the “now” goals, and treating the conditions that will make someone feel better, and setting aside the preventive “later” goals, does not mean that they are neglecting their loved one’s health, and it also does not mean that the patient cannot aspire to things for the future.  It’s all about reframing decisions to stop treatment (or continue) within the setting of a patient’s goals, whatever they may be.

Phrases to use in explaining what has benefit and what doesn’t: 

“We’ve Tried”: “We’ve tried our best to prevent death with cholesterol medications, but it’s been disappointing that it hasn’t worked.” 

“I Wish” statements: “I wish that the evidence showed that Medicine X would prolong life and reduce symptoms, but it doesn’t.”  

How to talk about cessation of cancer prevention screenings: 

When a patient’s age or clinical context makes the potential harms of continued cancer screenings greater than the benefits, clinicians must discuss stopping these screenings. Discuss why the patient may derive less benefit. For example, someone with limited life expectancy will not benefit from early cancer detection and has a higher risk of harm from screening. e.g. diagnosis related harms: invasive procedures, anxiety; or treatment related harms: radiation, chemotherapy or surgery. It is critical to convey that you deeply care if your patient gets cancer, but also deeply care about sparing them of tests with higher potential for harm and limited benefit.

A great tool to use in these discussions: 

E-Prognosis has substantial, easy to interpret data about the risks and benefits (and time to benefit) of cancer screening. 

Framing problem lists 

We can use different unifying themes to frame problem lists, based on patient goals and preferences.  

Table 2. How to think about the problem list. Focus on one overall goal, whether Longevity,  Palliative/symptom management, or Simplicity-Minded goal setting. By Josh Uy MD from The Curbsiders Multimorbidity Games

Take Home Points: 

1. Think about the goals of care and the consequences of your treatments. Does treating this achieve a longevity benefit, functional benefit, or a quality of life benefit? Will it benefit the patient NOW or later.
2. Listen to the patient so you can learn about their goals of care. Then align your own treatment goals with a few things that the patient actually cares about. 
3. The goal of geriatrics is to simplify complexity. Simplicity needs to be a goal in our care of patients. 

Goal

Listeners will develop an approach to managing older adults with multimorbidity in primary care  

Learning objectives 

After listening to this episode listeners will… 

1. Define multimorbidity and its implications for triaging multiple chief complaints and chronic conditions
2. Recognize the time frame to benefit of treatments for several chronic conditions
3. Learn to ask patients about health care values and goals of care in order to optimize shared decision-making
4. Identify the barriers to treating multimorbidity and strategize approaches for optimal primary care delivery for patients with multimorbidity

Links*

1. Book recommendations: Unbroken 
2. Leah’s pick of the week: The Down Dog Yoga App. Get that wellness on! 
3. Stuart’s pick of the week: Dimash performs SOS 
4. A great prognostic tool: https://eprognosis.ucsf.edu/
5. Betty White’s Off Their Rockers (TV show!)
6. Another book recommendation: Finishing Well to the Glory of God 

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Disclosures

Dr Uy reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Uy J, Taranto N, Witt LJ, Williams PN, Brigham SK, Watto MF. “#181 The Multimorbidity Games”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list November 4, 2019.