Caring for older adults with multiple chronic conditions can create challenging situations. For example, some treatments may be harmful to older adults who live with and manage several chronic conditions. In some cases, several treatments might be available but healthcare providers may not know which are best for a particular individual. In other cases, older adults and caregivers could even receive different treatment recommendations depending on the healthcare providers who offer guidance. Most important of all, managing care for multiple chronic conditions can make it difficult to focus on what matters most to us as individual--a key priority when we think about the high-quality, person-centered care we all want and need as we age.
In 2010, the American Geriatrics Society (AGS) convened a panel of medical experts to address how to provide the best care for older adults living with multiple chronic conditions. The panel reviewed a host of clinical studies and developed the AGS Guiding Principles for the Care of Older Adults with Multimorbidity as a result.
The expert panel identified five "key principles" that healthcare providers should follow to support the best care for older adults with multiple chronic conditions:
1. Include personal preferences in care decision-making. Older adults who have multiple chronic health conditions should be asked how they wish to make medical decisions affecting their care. Whenever appropriate, caregivers and family members should also be involved in these discussions.
2. Understand the limits of evidence on treatment options. Clinicians must understand that specific, evidence-backed answers to questions about the best medical choices for individual older adults may not exist. That's because every older adult and every health situation is unique.
3. Weigh benefits versus harms. When addressing multiple chronic conditions for an older individual, clinicians must consider how a person might be burdened by one medical plan or treatment versus others. They also must weigh the benefits of treatment options, as well as information on the person's functional status (their ability to perform daily activities such as bathing and eating), life expectancy (how long they are likely to live), and quality of life.
4. Consider if treatment is manageable. When sharing recommendations, clinicians must account for the complexity of a treatment and whether it suits an older adult's particular situation.
5. Make the best informed choice possible. Ultimately, healthcare professionals also must try to choose therapies that have the most benefit, pose the least harm, and will work to enhance an older person's quality of life.
Now, an expert group of geriatricians, cardiologists, and general physicians have identified a set of action steps based on those guiding principles to help healthcare providers work with older adults and caregivers to make the best treatment choices possible when addressing multiple chronic conditions.
These steps include:
1) Identify and communicate your health priorities.
* Health Priorities and Decision-Making. There are many reasons we might make a decision about different health tests or treatments, but the best care possible supports decisions based on our personal needs and preferences. The first step toward supporting that type of care is identifying those needs and preferences.
Sitting down for a frank conversation with your health professionals, family, and caregivers can help you identify and communicate what matters most to you in your health and health care. We all prioritize things differently when we are faced with tradeoffs, which are common when we have multiple chronic conditions. The more you and those who care for you understand what matters most, the better you can align your healthcare to help achieve what matters most. For some people, what matters most may mean living as long as possible (even if our quality of life isn't the same as it once was). For others, it may mean living independently as long as we can (even if that means choosing less aggressive treatments because they might impact our ability to live on our own). Some people make health decisions for religious reasons. Others may be most concerned about staying in a particular location. And others may make decisions based on additional, personal factors. It's important to remember that none of these decision-making strategies are "right" or "wrong," but they can only be implemented when you take the time to identify and discuss them with partners like your caregivers and health professionals.
* Health Trajectory & Your "Health Future." Work with your health professionals to assess and take into consideration your anticipated future health when it comes to deciding on treatments. As older adults, our "health trajectory" and "health future" anticipate how likely it is that we will live for a given number of years, and how likely it is for us to continue performing our daily activities during that same timeframe. Discussing how our health and function may change over time helps identify the most beneficial treatments.
2) Stop, Start, or Continue Care Based on Health Priorities, Potential Benefits/Harms, and Health Trajectory.
* Understanding "Harmful Treatments" and "Medical Uncertainty." "Do no harm" is a guiding principle for all of our health care. It's also a principle that's especially important for people who may be managing multiple treatment plans and how they interact (especially if they may result in unintended consequences when managed together). Since having more than one chronic condition means one health concern (or even its treatment) can worsen another, older adults need to work closely with their health professionals to assess all treatment options (including any treatments you may buy "over the counter" from a pharmacy or supermarket). We should consider the risks of each individual treatment plan in light of all the other care we may be receiving. It's also important that we understand what potential outcomes from treatment may be "uncertain." While research and health expertise gives our health professionals a solid sense of how safe and effective various treatment options may be, care is always personal (and not all research involves older adults specifically). That means that what's very effective for one individual may not work for another. Knowing about uncertainties in advance can help us make educated decisions about the potential benefits and harms of different treatment options.
* Understanding "Beneficial Treatments." Many beneficial treatments exist for older adults with multiple chronic diseases. Some are preventive (meaning they help us avoid a potential disease, such as getting an annual flu vaccine to avoid the flu virus). Some are diagnostic (meaning they help determine if we are living with a condition, such as a chest x-ray to see if you have pneumonia). Others, such as diuretics (water pills), control the symptoms of a chronic disease. And others are palliative (meaning they are designed to help make us feel better), rehabilitative (meaning they work to restore our function or quality of life), or supportive (meaning they help us to live as best as we can with a care condition or concern).
Though many of us may only think about "cures" when we consider treatment, it's important to think about all these beneficial options when it comes to our care--especially because some options (like rehabilitation) may be even more helpful in promoting what we most want and need from care.
* Minimizing "Treatment Burden." Older adults and caregivers managing multiple chronic conditions spend an average of two hours daily on healthcare-related activities. They also spend up to two hours at each healthcare visit--and there can be many visits to coordinate when you have multiple health concerns. This much care risks causing what health professionals refer to as "treatment burden" (the term for feeling overwhelmed or incapable when it comes to carrying out our treatment plans). When we consider all the options available for multiple chronic conditions, it's important to consider which treatments may be most helpful in light of our abilities, and which--conversely--may be more difficult for us to follow or implement (especially when we may need assistance from a caregiver). Removing healthcare that is burdensome and not beneficial creates the opportunity to start care that is helpful and consistent with our own personal health priorities.
3) Align Decisions and Care for Us, Our Caregivers, and Our Clinicians Based on Our Health Priorities and Health Trajectory.
* Seeking Agreement on Health Priorities & Health Information. Two critical steps for anyone living with multiple chronic conditions are (1) identifying our own health priorities and (2) getting information on how treatment options can help us achieve our health priorities. To make the most of these actions, however, we need to make sure everyone involved in our care understands our care priorities and can help us make sense of health information based on our needs. Everyone involved in our care should be using the same information when it comes to decisions about treatment plans.
* Promoting Communication. Seeing a number of specialists for multiple chronic conditions can lead to fragmented healthcare (the term for care that feels uncoordinated or "choppy"). In some cases, fragmented care can lead to conflicting treatment recommendations from different providers, as well as burdensome treatments that may not be focused on what matters most to us individually. Decision-making and communication must fit into our care decisions and care plans. This means keeping an open, honest, and ongoing dialogue with our health providers, as well as any individuals (such as our caregivers) who we may want to play a role in our care. If you're worried about coordinating care with different providers/offices, it may also be helpful to identify a primary point-of-contact (such as your geriatrician), who can gather information from all your providers and help you understand and assess different options.