Multisystem Cases: Deciding Where to Start

Most clinical guidelines are written for a single disease. Most patients over middle age have more than one. A person with type 2 diabetes, hypertension, osteoarthritis, depression, chronic kidney disease and sleep apnoea may, if every guideline is followed, be advised to take a dozen medicines, attend several clinics, follow multiple diets and complete daily self monitoring for each condition. The result can be a treatment burden that overwhelms the patient and conflicts that no single guideline resolves. Integrated Functional Medicine is well suited to these patients, but only if practitioners start in the right place.

The scale of multimorbidity

Multimorbidity is the norm rather than the exception in older adults, and increasingly common in middle age, particularly in socioeconomically deprived populations, where it tends to occur earlier. It is associated with poorer quality of life, more frequent healthcare use, polypharmacy and higher mortality. Clinical guidance on multimorbidity, such as that from NICE, recommends an approach that considers the person as a whole, their priorities and the burden of their treatment, rather than applying single disease guidelines in parallel.

Treatment burden

Treatment burden describes the work patients must do to manage their conditions: taking medicines, attending appointments, monitoring, following diets and exercise plans, coordinating between services. The concept of minimally disruptive medicine argues that care should fit the patient’s capacity to manage it. When burden exceeds capacity, adherence falls, conditions worsen and patients become exhausted. Adding more, even good things, can make matters worse.

A starting sequence

1. Ask what matters most

Patient priorities care, developed for older adults with multiple conditions, begins by identifying the patient’s health outcome goals, such as staying independent, walking to the shops or reducing pain, and their care preferences, such as how many medicines or appointments they are willing to accept. Decisions are then aligned with those priorities. This often reveals that the patient’s most pressing concern is not the one clinicians have focused on.

2. Assess safety

Check red flags, dangerous interactions, recent falls, hypoglycaemia, adverse drug effects and safeguarding concerns.

3. Map the conditions together

Placing all conditions on one matrix shows how they connect. Many share mediators.

4. Identify hub mediators

Some factors influence several conditions at once. Improving them can benefit many problems with a single change.

5. Review medicines

Structured medication review identifies medicines that are no longer needed, duplicated, interacting or causing harm. Tools such as the STOPP and START criteria help in older adults. Anticholinergic burden, sedatives, drugs affecting glucose or blood pressure excessively, and medicines affecting nutrition deserve particular attention. Deprescribing decisions belong with the prescriber.

6. Reconcile conflicting advice

Conflicts are common: a diabetes diet may conflict with a kidney diet; exercise advice for heart failure may differ from that for osteoarthritis; tight glucose targets may increase fall risk in frailty. Resolving these requires prioritisation guided by the patient’s goals and coordination between clinicians. Individualised targets, for example less stringent HbA1c targets in frail older adults, are supported by guidelines.

7. Choose 1 or 2 first steps

Select changes that address a hub mediator, fit the patient’s priorities and capacity, and are safe. Build from there.

Conditions that often coexist

Certain clusters are common and shape where to start.

• Cardiometabolic cluster: diabetes, hypertension, dyslipidaemia, fatty liver, chronic kidney disease, heart disease. Weight, activity, diet and sleep are central.
• Pain and mood cluster: chronic pain, depression, anxiety, insomnia, fatigue. Sleep, activity, psychological support and medication review are central.
• Autoimmune cluster: thyroid disease, coeliac disease, type 1 diabetes, rheumatoid arthritis, psoriasis. Specialist treatment, associated condition screening and nutritional status matter.
• Frailty cluster: sarcopenia, falls, cognitive decline, polypharmacy, undernutrition. Protein, strength, medication review and social support are central.

An illustrative case

A 76 year old widow has type 2 diabetes, hypertension, knee osteoarthritis, chronic kidney disease stage 3, depression and insomnia. She takes 11 medicines, including a sulphonylurea, 3 blood pressure medicines, an anticholinergic bladder medicine and a sleeping tablet. She has fallen twice in 6 months. Her HbA1c is 51 mmol/mol, her blood pressure 118/64 lying and lower standing.

Her priority: “I want to stay in my own home and keep going to my Thursday lunch club.”

Safety: falls, possible hypoglycaemia from the sulphonylurea, postural hypotension, anticholinergic and sedative burden.

Hub mediators: polypharmacy, inactivity and deconditioning, low mood and loneliness since her husband died, poor sleep.

Plan, coordinated with her doctor: a medication review that stops the sulphonylurea given her HbA1c and fall risk, reduces blood pressure medicines, and tapers the sleeping tablet and anticholinergic; a home based strength and balance programme with a physiotherapist; protein at each meal, given sarcopenia risk and kidney function, planned with a dietitian; support for grief and mood; and help to attend her lunch club weekly.

At 3 months she takes 7 medicines, has had no further falls, is sleeping as well without the tablet and is attending her lunch club. Her HbA1c is 55 mmol/mol, appropriate for her. Fewer interventions, better chosen, produced more benefit.

Starting where it counts

In multimorbidity, the question is rarely what else could be added. More often it is what matters most to the patient, what connects their conditions, what is causing harm and what single change would help most. Starting there makes integrated care manageable for the patient and effective for their health.