Chapter 10. Multimorbidity and geriatric syndromes

People often live with many health conditions. Ageing populations and the increase in long-term conditions mean that the number of people with multiple health conditions is set to rise. Ageing is associated with impaired functioning at different levels, which manifests in morphofunctional age-related involution of different organs. These changes lead to the development of multimorbidity and geriatric syndromes. To improve safety in primary care, it is essential to take into account care of people with multiple health conditions.

Multimorbidity and geriatric syndromes

Multimorbidity is the coexistence of multiple conditions (most commonly defined as two or more conditions) a combination of two or more chronic diseases or conditions in an individual that contribute to a decrease in a person’s functional abilities, quality of life and an increase in the cost of provided medical care.

According to the guidelines of the National Institute of Health and Medical Care of the United Kingdom, the concept of multimorbidity includes:

Multimorbidity is highly correlated with geriatric syndromes.

Geriatric syndrome is a multifactorial age-associated clinical condition that worsens the quality of life, increases the risk of death, dependence on outside help, repeated hospitalizations and functional disorders. Geriatric syndrome is not a manifestation of the disease, but reflects a complex of changes in several systems. The occurrence of one geriatric syndrome increases the risk of deve­loping other geriatric syndromes.

Geriatric syndromes include:

• frailty (a key geriatric syndrome);
• fall;
• dementia;
• delirium;
• depression;
• osteoporosis;
• sarcopenia;
• reduced mobility and imbalance;
• dizziness;
• orthostatic syndrome (orthostatic hypotension, orthostatic tachycardia with or without symptoms);
• sensory deficits (impaired vision, hearing loss);
• urinary fecal incontinence;
• constipation syndrome;
• poor nutrition (malnutrition);
• chronic pain syndrome.

Frailty is an age-related decline leading to reduced reserves of physical and mental health capacity, resulting in vulnerability to stressors and an increased risk of poor health outcomes.

Multiple concomitant pathology can accelerate frailty and its progression.

The difficulties of managing a multimorbid patient at the outpatient stage are displayed in fig. 10.1.

Fig. 10.1. Difficulties of managing a multimorbid patient

Multimorbidity is closely related to polypragmasy (“poly” — a lot and “pragma” — an object, a thing), and prescription of a large number of drugs for a long period of time, in most cases, increases the risk of undesirable interactions and reduces the response to treatment.

Sometimes, patients deliberately skip the dose, while receiving treatment for concomitant diseases, as they are afraid of unfavorable outcome due to drug interactions.

At least two of any chronic diseases are present in 62% of patients aged 65–74 years and in 82% — aged 85 years and older. The following combi­nations of diseases are most common in people aged 65 years and older:

• hypertension and arthritis;
• hypertension, arthritis and other CVD;
• hypertension, arthritis and diabetes mellitus.

Causes of multimorbidity:

• anatomical proximity of the organs involved in the pathological process;
• a single pathogenetic mechanism for the development of several diseases;
• temporary cause-and-effect relationship between different diseases;
• one disease as a complication of another.

The development of many diseases, especially cardiovascular diseases, is closely related to lifestyle characteristics and risk factors: smoking, unhealthy diet, insufficient physical activity, overweight, arterial hypertension, psychosocial factors, etc. (table 10.1).

Table 10.1. Risk factors

Source: M. Piepoli et al., 2016.

Factors affecting multimorbidity development:

• chronic infection;
• systemic inflammation;
• metabolic changes;
• iatrogenic;
• low social status;
• unfavorable environment;
• genetic predisposition.

The problem of comorbid pathology becomes relevant not only due to an increase in life expectancy, but also the presence of non-communicable inflammation — one of the main links in pathogenesis of various diseases — both directly and indirectly through other body systems.

Presence of two or more diseases simultaneously may be an accidental phenomenon; however, quite often the combination of diseases is an interconnected pathological process, which is proven for arterial hypertension, cardiovascular diseases that are based on the processes of atherosclerosis (co­ro­nary heart disease, ischemic cerebral circulation disorders, vascular dementia, obliterating atherosclerosis of peripheral arteries), diabetes mellitus and chronic kidney disease. The presumed pathogenesis of multimorbidity is displayed in fig. 10.2.