Comment
The health-care needs of older people with multimorbidity, and the extent to which these needs are met, are sharp exemplars of the challenges faced by health-care systems across the world in the 21st century. The increase in longevity in developed and developing countries alike is a testament to the success of 20th-century medicine and economic and social development. Research, policy, and action have transformed our ability to prevent infant mortality, to prevent and treat infectious diseases, and to prevent and treat the great killers in midlife such as heart disease and cancer. This is a fantastic success. But such success brings consequences—increased longevity is accompanied by complexity and multimorbidity (two or more long-term disorders). Although multimorbidity is not a problem only for older adults, its prevalence is much higher in older age groups, with 65% of people aged 65–84 years and 82% of people aged at least 85 years affected.1 Dementia is a disorder that draws attention to all the complex challenges of multimorbidity and, indeed, the implications of not addressing them systematically. The rise in the number of people with dementia worldwide—from 44 million now to a projected 135 million in 2050—is a function of population ageing.2 People with dementia have among the highest levels of multimorbidity of any long-term disorder. Data from Scotland3 suggest that only 5·3% of people with a diagnosis of dementia have no other long-term disorder; on average, people with dementia have 4·6 additional chronic illnesses. An analysis of US primary care data4 showed that people with dementia similarly had, on average, four additional chronic medical disorders and were prescribed about five drugs. 82% of the US cohort had hypertension and 39% had diabetes mellitus. As with other disorders, multimorbidity with dementia predicts poor outcomes and poor quality service response. People with chronic illness and dementia report fewer symptoms than do those without dementia,5 and undiagnosed but treatable disease has been reported in almost half of those with dementia.6 So why do older people with multimorbidity in general, and people with dementia in particular, get poor-quality care? A large part of the answer would seem to be that
health systems are providing 20th-century medicine to today’s patient population. General hospitals are increasingly filled with older people with multimorbidity who are admitted as an emergency. The British Geriatric Society quote UK Hospital Episode Statistics showing that people aged older than 65 years comprise 60% of admissions to hospital, 65% of occupied-bed days, 90% of delayed transfers, and 65% of emergency readmissions.7 People aged older than 65 years make up 17% of the UK’s population, but more than 2 million unplanned admissions a year account for 68% of hospital emergency-bed days, and the use of more than 51 000 acute beds at any time.8 Such people are often let down by the services that they are offered. The services and interventions provided are generally designed for young or middle-aged people, with only one disorder and a discrete episode of illness. Research, policy, and health systems, in developed countries particularly, have become specialised in the past 50 years to deliver increasingly technical treatments for individual disorders. This notion of unidisciplinary, technical superspecialism has grown to dominate policy, research, practice, and education. Such notions cast a dense shadow, acting to devalue and impair the growth of generalism and integration of much of primary care and geriatric medicine. The silo-bound services that this generates in hospitals are those that often do not help the frail, older populations with multimorbidity who form most of the patient population, and who find services confusing, impersonal, and challenging.9 Disorders other than that of the specialty, with dementia as a good example, are often seen as complications that are ignored or managed by many specialist referrals, which can be both inefficient and ineffective.10,11 The impression given to patients and families of people with dementia in hospitals is often that the patient has failed by not fitting the service. The working assumption is that the optimum treatment of someone with more than one condition is to add together the treatments for the individual conditions. Clinical guidelines for chronic illnesses almost always focus on one disorder, although most people with those disorders will have multimorbidity,3
www.thelancet.com Published online November 6, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61596-8
Corbis
Multimorbidity—older adults need health care that can count past one
Published Online November 6, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61596-8
1
Comment
which leads to questions about whether treatments and services that are developed in otherwise healthy people work in people with many health problems. Therapeutic and adverse effects of medicines might differ in those with multimorbidity, and dementia provides a clear example of this situation. In people with both depression and dementia, antidepressants that work well in those without dementia seem to have no effect.12,13 Additionally, the use of antipsychotic drugs in patients with dementia has greater mortality than in those without dementia, with an estimated 1400 extra deaths attributable to their use in the UK in 2009.14 What works for those with one disorder does not necessarily work in multimorbidity; what is safe for those with one disorder is not necessarily safe in multimorbidity. National systems should obtain data in a way that enables an understanding of the burden, management, and outcomes of patients with multimorbidity. We need better research to understand multimorbidity from disease mechanisms through to treatment. Equally, evaluative research, including randomised controlled trials, should be undertaken in real-life clinical populations that include multimorbidity, so that data can be generalised. The education of health-care staff from all professional backgrounds does not prepare them well for the challenges of multimorbidity or long-term conditions. Clinical experience is delivered through a series of discrete, time-limited clinical placements in acute and primary-care settings. These placements provide students with a snapshot of different illnesses in different patients, with an emphasis on the acute phase of illness. An example of what might be done in education is the Time for Dementia programme, a longitudinal clerkship that helps students to develop an understanding of the emerging challenges presented by older adults, multimorbidity, and long-term conditions, using dementia as an example. Time For Dementia has been included in the core curricula for medical students at Brighton and Sussex Medical School, UK, and for nursing and paramedic students at the University of Surrey, UK. All students will visit an assigned patient and family every 3–4 months for 24 months, and the focus is on the health and care experience of the person with dementia and their family. The programme, located in people’s homes rather than in a health service, will help students to gain a long-term perspective. 2
The programme’s aim is to support an empathetic relationship between students and people with dementia to enhance their understanding of: dementia itself; the health, social, and family care of people with dementia; the experience of being ill and old in society; the progression of a long-term condition; and the management of chronic diseases from the viewpoint of a patient and his or her family. So what would 21st-century health care that works for those with multimorbidity look like? Such health care would be multidisciplinary and integrative, and value both generalist and technical skills. It would be patient-centred, focused on what works for the patient, not what works for the service, and would draw on the insights and skills of specialists but deliver them in a balanced and seamless manner. The core challenge is the increasing complexity of patient populations. Yet we need to be wary of simple answers to complex problems, because any solution to this complex set of problems is likely to be complex itself. The solution will require a continuation of technical innovation in medicine, and new ways of organising and delivering services to make them work as well for people with several illnesses as they do for those with one illness. In terms of a framework for international delivery, WHO15 is developing a strategy for integrated people-centred care as a means to attain its goal of universal health coverage. This strategy acknowledges that integration needs to happen across disease specialities and the continuum of care, so that older adults with many chronic conditions have them managed together, not separately. WHO and the World Bank16 acknowledge that universal health coverage applies over a whole lifecourse, and to address the challenge of the growing population of older adults, for whom several chronic conditions is the rule rather than the exception, will be key to delivery of the UN’s Sustainable Development Goals.17 At a national level, political imagination and courage are needed, which will result in re-engineering cherished systems and services. The clinical and financial pressures on current systems should, however, provide the impetus to move decisively and quickly. More of what we have already that is demonstrably not working cannot be the solution. We need to develop services to meet the actual needs of our patients now, not those of the past century. This means developing a system that works for multimorbidity, and creating policy, commissioning, services, research, and education to deliver good quality
www.thelancet.com Published online November 6, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61596-8
Comment
care to patients with more than one condition. A good test of success will be how well these services work for those with dementia. We need a 21st-century health care that can count past one. Sube Banerjee Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9RY, UK [email protected] I have received consultancy fees, speakers’ fees, research funding, and educational support to attend conferences from pharmaceutical companies involved in the manufacture of antidepressants, antipsychotics, and antidementia drugs. 1
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Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380: 37–43. Alzheimer’s Disease International. The global impact of dementia 2013–2050. 2013. http://www.alz.co.uk/research/ globalimpactofdementia2013.pdf (accessed Sept 10, 2014). Guthrie B, Payne K, Alderson P, McMurdo ME, Mercer SW. Adapting clinical guidelines to take account of multimorbidity. BMJ 2012; 345: e6341. Schubert CC, Boustani M, Callahan CM, et al. Comorbidity profile of dementia patients in primary care: are they sicker? J Am Geriatr Soc 2006; 54: 104–09. McCormick WC, Kukull WA, van Belle G, Bowen JD, Teri L, Larson EB. Symptom patterns and comorbidity in the early stages of Alzheimer’s disease. J Am Geriatr Soc 1994; 42: 517–21. Larson EB, Reifler BV, Featherstone HJ, English DR. Dementia in elderly outpatients: a prospective study. Ann Intern Med 1984; 100: 417–23. House of Commons Health Committee. Written evidence from the British Geriatrics Society. December, 2011. http://www.publications.parliament.uk/ pa/cm201213/cmselect/cmhealth/6/6vw03.htm (accessed Sept 10, 2014).
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Imison C, Poteliakhoff E, Thompson J. Older people and emergency bed use—exploring variation. London: The King’s Fund, 2012. Mason B, Nanton V, Epiphaniou E, et al. “My body’s falling apart.” Understanding the experiences of patients with advanced multimorbidity to improve care: serial interviews with patients and carers. BMJ Support Palliat Care 2014; published online May 28. DOI:10.1136/ bmjspcare-2013-000639. Wolff J, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med 2002; 162: 2269–76. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83: 457–502. Rosenberg PB, Martin BK, Frangakis C, et al, for the DIADS-2 Research Group. Sertraline for the treatment of depression in Alzheimer’s disease. Am J Geriatr Psychiatry 2010; 18: 136–45. Banerjee S, Hellier J, Dewey M, et al. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. Lancet 2011; 378: 403–11. Banerjee S. The use of antipsychotic medication for people with dementia: time for action. London: Department of Health, 2009. WHO. WHO strategy on people-centered and integrated health services. Geneva: World Health Organization, 2014. WHO, World Bank. Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets. May, 2014. http://apps.who.int/iris/bitstream/10665/112824/1/WHO_HIS_HIA_14.1_ eng.pdf?ua=1 (accessed Sept 10, 2014). UN. Introduction to the proposal of the open working group for sustainable development goals. 2014. http://sustainabledevelopment.un.org/content/ documents/4518SDGs_FINAL_Proposal%20of%20OWG_19%20July%20 at%201320hrsver3.pdf (accessed Sept 10, 2014).
www.thelancet.com Published online November 6, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61596-8
3
The health-care needs of older people with multimorbidity, and the extent to which these needs are met, are sharp exemplars of the challenges faced by health-care systems across the world in the 21st century. The increase in longevity in developed and developing countries alike is a testament to the success of 20th-century medicine and economic and social development. Research, policy, and action have transformed our ability to prevent infant mortality, to prevent and treat infectious diseases, and to prevent and treat the great killers in midlife such as heart disease and cancer. This is a fantastic success. But such success brings consequences—increased longevity is accompanied by complexity and multimorbidity (two or more long-term disorders). Although multimorbidity is not a problem only for older adults, its prevalence is much higher in older age groups, with 65% of people aged 65–84 years and 82% of people aged at least 85 years affected.1 Dementia is a disorder that draws attention to all the complex challenges of multimorbidity and, indeed, the implications of not addressing them systematically. The rise in the number of people with dementia worldwide—from 44 million now to a projected 135 million in 2050—is a function of population ageing.2 People with dementia have among the highest levels of multimorbidity of any long-term disorder. Data from Scotland3 suggest that only 5·3% of people with a diagnosis of dementia have no other long-term disorder; on average, people with dementia have 4·6 additional chronic illnesses. An analysis of US primary care data4 showed that people with dementia similarly had, on average, four additional chronic medical disorders and were prescribed about five drugs. 82% of the US cohort had hypertension and 39% had diabetes mellitus. As with other disorders, multimorbidity with dementia predicts poor outcomes and poor quality service response. People with chronic illness and dementia report fewer symptoms than do those without dementia,5 and undiagnosed but treatable disease has been reported in almost half of those with dementia.6 So why do older people with multimorbidity in general, and people with dementia in particular, get poor-quality care? A large part of the answer would seem to be that
health systems are providing 20th-century medicine to today’s patient population. General hospitals are increasingly filled with older people with multimorbidity who are admitted as an emergency. The British Geriatric Society quote UK Hospital Episode Statistics showing that people aged older than 65 years comprise 60% of admissions to hospital, 65% of occupied-bed days, 90% of delayed transfers, and 65% of emergency readmissions.7 People aged older than 65 years make up 17% of the UK’s population, but more than 2 million unplanned admissions a year account for 68% of hospital emergency-bed days, and the use of more than 51 000 acute beds at any time.8 Such people are often let down by the services that they are offered. The services and interventions provided are generally designed for young or middle-aged people, with only one disorder and a discrete episode of illness. Research, policy, and health systems, in developed countries particularly, have become specialised in the past 50 years to deliver increasingly technical treatments for individual disorders. This notion of unidisciplinary, technical superspecialism has grown to dominate policy, research, practice, and education. Such notions cast a dense shadow, acting to devalue and impair the growth of generalism and integration of much of primary care and geriatric medicine. The silo-bound services that this generates in hospitals are those that often do not help the frail, older populations with multimorbidity who form most of the patient population, and who find services confusing, impersonal, and challenging.9 Disorders other than that of the specialty, with dementia as a good example, are often seen as complications that are ignored or managed by many specialist referrals, which can be both inefficient and ineffective.10,11 The impression given to patients and families of people with dementia in hospitals is often that the patient has failed by not fitting the service. The working assumption is that the optimum treatment of someone with more than one condition is to add together the treatments for the individual conditions. Clinical guidelines for chronic illnesses almost always focus on one disorder, although most people with those disorders will have multimorbidity,3
www.thelancet.com Published online November 6, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61596-8
Corbis
Multimorbidity—older adults need health care that can count past one
Published Online November 6, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61596-8
1
Comment
which leads to questions about whether treatments and services that are developed in otherwise healthy people work in people with many health problems. Therapeutic and adverse effects of medicines might differ in those with multimorbidity, and dementia provides a clear example of this situation. In people with both depression and dementia, antidepressants that work well in those without dementia seem to have no effect.12,13 Additionally, the use of antipsychotic drugs in patients with dementia has greater mortality than in those without dementia, with an estimated 1400 extra deaths attributable to their use in the UK in 2009.14 What works for those with one disorder does not necessarily work in multimorbidity; what is safe for those with one disorder is not necessarily safe in multimorbidity. National systems should obtain data in a way that enables an understanding of the burden, management, and outcomes of patients with multimorbidity. We need better research to understand multimorbidity from disease mechanisms through to treatment. Equally, evaluative research, including randomised controlled trials, should be undertaken in real-life clinical populations that include multimorbidity, so that data can be generalised. The education of health-care staff from all professional backgrounds does not prepare them well for the challenges of multimorbidity or long-term conditions. Clinical experience is delivered through a series of discrete, time-limited clinical placements in acute and primary-care settings. These placements provide students with a snapshot of different illnesses in different patients, with an emphasis on the acute phase of illness. An example of what might be done in education is the Time for Dementia programme, a longitudinal clerkship that helps students to develop an understanding of the emerging challenges presented by older adults, multimorbidity, and long-term conditions, using dementia as an example. Time For Dementia has been included in the core curricula for medical students at Brighton and Sussex Medical School, UK, and for nursing and paramedic students at the University of Surrey, UK. All students will visit an assigned patient and family every 3–4 months for 24 months, and the focus is on the health and care experience of the person with dementia and their family. The programme, located in people’s homes rather than in a health service, will help students to gain a long-term perspective. 2
The programme’s aim is to support an empathetic relationship between students and people with dementia to enhance their understanding of: dementia itself; the health, social, and family care of people with dementia; the experience of being ill and old in society; the progression of a long-term condition; and the management of chronic diseases from the viewpoint of a patient and his or her family. So what would 21st-century health care that works for those with multimorbidity look like? Such health care would be multidisciplinary and integrative, and value both generalist and technical skills. It would be patient-centred, focused on what works for the patient, not what works for the service, and would draw on the insights and skills of specialists but deliver them in a balanced and seamless manner. The core challenge is the increasing complexity of patient populations. Yet we need to be wary of simple answers to complex problems, because any solution to this complex set of problems is likely to be complex itself. The solution will require a continuation of technical innovation in medicine, and new ways of organising and delivering services to make them work as well for people with several illnesses as they do for those with one illness. In terms of a framework for international delivery, WHO15 is developing a strategy for integrated people-centred care as a means to attain its goal of universal health coverage. This strategy acknowledges that integration needs to happen across disease specialities and the continuum of care, so that older adults with many chronic conditions have them managed together, not separately. WHO and the World Bank16 acknowledge that universal health coverage applies over a whole lifecourse, and to address the challenge of the growing population of older adults, for whom several chronic conditions is the rule rather than the exception, will be key to delivery of the UN’s Sustainable Development Goals.17 At a national level, political imagination and courage are needed, which will result in re-engineering cherished systems and services. The clinical and financial pressures on current systems should, however, provide the impetus to move decisively and quickly. More of what we have already that is demonstrably not working cannot be the solution. We need to develop services to meet the actual needs of our patients now, not those of the past century. This means developing a system that works for multimorbidity, and creating policy, commissioning, services, research, and education to deliver good quality
www.thelancet.com Published online November 6, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61596-8
Comment
care to patients with more than one condition. A good test of success will be how well these services work for those with dementia. We need a 21st-century health care that can count past one. Sube Banerjee Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9RY, UK [email protected] I have received consultancy fees, speakers’ fees, research funding, and educational support to attend conferences from pharmaceutical companies involved in the manufacture of antidepressants, antipsychotics, and antidementia drugs. 1
2
3 4 5
6 7
Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380: 37–43. Alzheimer’s Disease International. The global impact of dementia 2013–2050. 2013. http://www.alz.co.uk/research/ globalimpactofdementia2013.pdf (accessed Sept 10, 2014). Guthrie B, Payne K, Alderson P, McMurdo ME, Mercer SW. Adapting clinical guidelines to take account of multimorbidity. BMJ 2012; 345: e6341. Schubert CC, Boustani M, Callahan CM, et al. Comorbidity profile of dementia patients in primary care: are they sicker? J Am Geriatr Soc 2006; 54: 104–09. McCormick WC, Kukull WA, van Belle G, Bowen JD, Teri L, Larson EB. Symptom patterns and comorbidity in the early stages of Alzheimer’s disease. J Am Geriatr Soc 1994; 42: 517–21. Larson EB, Reifler BV, Featherstone HJ, English DR. Dementia in elderly outpatients: a prospective study. Ann Intern Med 1984; 100: 417–23. House of Commons Health Committee. Written evidence from the British Geriatrics Society. December, 2011. http://www.publications.parliament.uk/ pa/cm201213/cmselect/cmhealth/6/6vw03.htm (accessed Sept 10, 2014).
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Imison C, Poteliakhoff E, Thompson J. Older people and emergency bed use—exploring variation. London: The King’s Fund, 2012. Mason B, Nanton V, Epiphaniou E, et al. “My body’s falling apart.” Understanding the experiences of patients with advanced multimorbidity to improve care: serial interviews with patients and carers. BMJ Support Palliat Care 2014; published online May 28. DOI:10.1136/ bmjspcare-2013-000639. Wolff J, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med 2002; 162: 2269–76. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83: 457–502. Rosenberg PB, Martin BK, Frangakis C, et al, for the DIADS-2 Research Group. Sertraline for the treatment of depression in Alzheimer’s disease. Am J Geriatr Psychiatry 2010; 18: 136–45. Banerjee S, Hellier J, Dewey M, et al. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. Lancet 2011; 378: 403–11. Banerjee S. The use of antipsychotic medication for people with dementia: time for action. London: Department of Health, 2009. WHO. WHO strategy on people-centered and integrated health services. Geneva: World Health Organization, 2014. WHO, World Bank. Monitoring progress towards universal health coverage at country and global levels: framework, measures and targets. May, 2014. http://apps.who.int/iris/bitstream/10665/112824/1/WHO_HIS_HIA_14.1_ eng.pdf?ua=1 (accessed Sept 10, 2014). UN. Introduction to the proposal of the open working group for sustainable development goals. 2014. http://sustainabledevelopment.un.org/content/ documents/4518SDGs_FINAL_Proposal%20of%20OWG_19%20July%20 at%201320hrsver3.pdf (accessed Sept 10, 2014).
www.thelancet.com Published online November 6, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61596-8
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