Multimorbidity in Older Adults With Cardiovascular Disease

Abstract

Multimorbidity occurs in adults of all ages, but the number and complexity of comorbid conditions commonly increase with advancing age such that cardiovascular disease (CVD) in older adults typically occurs in a context of multimorbidity. Current clinical practice and research mainly target single disease-specific care that does not embrace the complexities imposed by concurrent conditions. In this paper, emerging concepts regarding CVD in combination with multimorbidity are reviewed, including recommendations for incorporating multimorbidity into clinical decision making, critical knowledge gaps, and research priorities to optimize care of complex older patients.

Keywords: aging; frailty; multimorbidity; polypharmacy; quality of life.

Figure 1. Prevalence of multimorbidity by age

Among Medicare fee-for-service beneficiaries, the number of coexisting chronic conditions increases with age (11). Just over half of beneficiaries <65 years have two or more chronic conditions compared to 63% of those 65–74 years, 77% of those 75–84 years and 83% of those ≥ 85 years.

Figure 2. Diseases and medications impacting one another in multimorbidity

Disease and medication interactions may inadvertently induce detrimental effects in the context of multimorbidity. In this schematic, concordant hypertension, heart failure and atrial fibrillation occur in association with discordant osteoarthritis and depression. Whereas the dark lines indicate relatively straightforward intent of treatment in a disease-based model, the orange lines show the many possible interactions between diseases, between drugs, that are likely to escalate instability and adverse outcomes (e.g., inducing secondary renal deterioration, bleeding, anemia, falls, and cognitive decline). Although the figure is complex and difficult to navigate; this mirrors the inherent clinical challenges of managing patients with multimorbidity.

Central Illustration. Redefining cardiovascular disease as a clinical challenge amidst multimorbidity

Differences between current a disease-specific paradigm and the emerging patient-specified goal directed care approach: the latter seeks to address issues emanating from cardiovascular disease in a context of multimorbidity.