Caring for Patients With Multiple Chronic Conditions

Multimorbidity, the coexistence of multiple chronic conditions, is common among all adults receiving health care and the norm among older adults. Almost 15 years ago, we raised concerns about the limitations of disease-focused, guideline-based medication prescribing (and the randomized clinical trials that inform it) for older adults with multimorbidity (1, 2). At that time, we noted the following 9 limitations of such care: Results observed in younger study participants without multimorbidity may not apply to older adults with multimorbidity, prescribing based on survival or disease-specific outcomes may be inadequate for patients with competing risks from multiple diseases and whose quality of life and functional status may take priority over other outcomes, it may be difficult to identify harms or benefits of medications that we expect patients to receive over many years on the basis of trials lasting only a few months or years, attention to the potential harms of following individual disease recommendations in the face of multiple coexisting conditions may be lacking, adhering to guidelines for multiple conditions may diminish benefits and increase burdens, the time to treatment benefit in the context of limited life expectancy may not be considered, the tradeoffs between better short-term quality of life without treatment and the long-term benefits of treatment may not be recognized, following multiple guidelines creates risk for drug–drug and disease–drug interactions, and methods for incorporating patients' preferences and priorities into guidelines are not available.

We concluded that “The proliferation of multidrug regimens demands that we consider health...