Patient‐Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society

One of the greatest challenges in geriatrics is the provision of optimal care for older adults with multiple chronic conditions, or “multimorbidity.” More than 50% of older adults have three or more chronic diseases, with distinctive cumulative effects for each individual. Multimorbidity is associated with higher rates of death, disability, adverse effects, institutionalization, use of healthcare resources, and poorer quality of life. Comprehensive strategies and interventions for common syndromes and organization of care in this population show promise, but what the best clinical management approaches are remains unclear. Most clinical practice guidelines (CPGs) focus on the management of a single disease, but CPG-based care may be cumulatively impractical, irrelevant, or even harmful for such individuals. CPG deficiencies are not based solely on shortcomings of guideline development and implementation. Older adults with multimorbidity are regularly excluded or underrepresented in trials and observational studies, which translates to less focus on older adults in meta-analyses, systematic reviews, and guidelines and affects appropriate interpretation of results. Clinical management is defined as representing all types of care for chronic conditions, including pharmacological and nonpharmacological treatment and interventions (e.g., referral to specialists, physical and occupational therapy, use of pacemakers), screening, prevention, diagnostic tests, follow-up, and advanced illness care. The best strategies for prioritizing specific aspects of this management spectrum in a particular older adult with multimorbidity are unknown. Clinicians need a management approach that will consider the challenges particular to each individual, including the often-limited available evidence; interactions among conditions or treatments; the patient’s preferences, goals, and prognosis; multifactorial geriatric problems and syndromes; and the feasibility of each management decision and its implementation. The American Geriatrics Society (AGS) convened a panel with expertise in these topics. The goal was to develop an approach by which clinicians can care optimally for older adults with multimorbidity. This document is not a guideline. Therefore, it does not issue recommendations based on rigorous evaluation of the quality of evidence for specific clinical questions with assessments of harms and benefits. Rather it sets out guiding principles that, taken together, provide an approach to clinical management for older adults with multimorbidity. Older adults with multimorbidity are heterogeneous in terms of illness severity, functional status, prognosis, personal priorities, and risk of adverse events even when diagnosed with the same pattern of conditions. Not only the individuals themselves, but also their treatment options will differ, necessitating more-flexible approaches to care in this population. This executive summary presents important points from a full-length document, published in the online edition of this issue of the Journal of the American Geriatrics Society, and includes a minimal reference list. The full-length document, Guiding Principles for the Care of The American Geriatrics Society is developing professional tools and public information to support implementation of these principles in clinical care. All tools can be found at www.americangeriatrics.org. *The American Geriatrics Society Expert Panel and their affiliations are given at the end of the article.