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New horizons in multimorbidity and frailty

There is increasing political and clinical interest in the concepts of multimorbidity and frailty. For those of us working with older people in primary and secondary care we feel that we intuitively understand these concepts. After all, we have been working towards improvement in caring for people with multimorbidity and frailty for many decades, and in some ways, doing so was the original raison d’être of the specialty of Geriatric Medicine.

However, although I have been working as a geriatrician for over thirty years, armed with my intuition, it is only in recent times that I have begun to truly understand the complexities of these issues. In recent years the concept of multimorbidity, and particularly frailty, have been injected with scientific understanding and explanation.

We have come to understand the great impact that these issues have on health and social care, and the pressures that they bring to bear. The complexity of multimorbidity in the context of frailty, dementia and polypharmacy particularly bears a substantial healthcare burden. If, like me, you struggle to understand the full picture of the relationship between frailty and multimorbidity, it is worth reading the article on New Horizons on Multimorbidity in Older Adults1. This overview helps explain the link between the concepts of multimobility and frailty and their relevance to the healthcare of older people.

Although many people live with multimorbidity in midlife, particularly contributed to by social deprivation, it is important to understand that complex multimorbidity increases with increasing age. The majority of older people have two or more long term conditions with care home residents having significant levels of multimorbidity.

Much of the discussion in the article centres on the recent and National Institute for Health and Care Excellence (NICE) guideline on multimorbidity2. The NICE multimorbidity guideline received supporting editorials in both Age and Ageing3 and the Journal of the American Geriatrics Society4 highlighting the importance of multimorbidity to both clinicians and researchers, and emphasised the role of geriatricians and specialist practitioners in its recognition and management.

The guideline provides a framework in which to consider the need for a tailored approach to complex care people with multimorbidity. Frailty is a key issue in the identification of people who might best suit a tailored approach to care. The New Horizons article teases out the complex interrelationship between frailty and multimorbidity with both leading to accumulation of health deficits.

Geriatricians therefore have a great role to play in the prevention and management of multimorbidity, working closely with our colleagues in primary care. The management of multimorbidity in all adults might best be described as a form of Comprehensive Geriatric Assessment (CGA) and this model of care has been the basis of research in multimorbidity. The review lays down the importance of the development a cohesive research strategy in order to meet the future needs of older people with multimorbidity.

As outlined by Dr Andy Clegg at the spring meeting the British Geriatrics Society in Newcastle earlier this year, there are many opportunities for research in multimorbidity. He laid down the challenge, reiterated in the New Horizons article, for trainees and researchers in geriatric medicine to actively engage with these exciting research priorities in order to improve the future care of older adults living with multimorbidity. The call is to take up that challenge!

John V Hindle
Senior Clinical Lecturer in Care of the Elderly
School of Medical Sciences
Bangor University School of Psychology

1. New Horizons in Multimorbidity in Older Adults. Age and Ageing Yarnall A, et al. 2017
2. NICE. Multimorbidity: clinical assessment and management. CG56. https://wwwniceorguk/guidance/ng56. 2016
3. Stott DJ, Young J. ‘Across the pond’-a response to the NICE guidelines for management of multi-morbidity in older people. Age Ageing. 2017;10.1093/ageing/afx031.
4. Applegate WB. Across the Pond. J Am Geriatr Soc. 2017(10.1111/jgs.14803).

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