What do we know about multimorbidity in the

What do we know about multimorbidity in the UK context and what are the gaps? Avan Aihie Sayer Professor of Geriatric Medicine & Director NIHR Newcastle Biomedical Research Centre Academy of Medical Sciences Wednesday 20 June 2018 The Newcastle upon Tyne Hospitals NHS Foundation Trust

Multimorbidity in UK clinical practice Mr AD Academic Day Unit Newcastle • Multimorbidity: recent fall, mobility impairment, degenerative disease of cervical and lumbar spine, generalised OA, bilateral knee replacements, longstanding hypertension, iatrogenic postural hypotension, longstanding COPD, current smoker, anxiety with depression, small aortic aneurysm, iron deficiency anaemia, prostate cancer, previous coronary heart disease with stenting, hyperlipidaemia • Polypharmacy: aspirin, atorvastatin, bisoprolol, colecalciferol, docusate, finasteride, lansoprazole, losartan, paracetamol, salamol, senna, sertraline, tamsulosin, trazodone, hormonal prostate treatment • Common type of presentation particularly at older ages

Number of papers (in year shown) Mapping of global scientific research in comorbidity and multimorbidity • Systematic literature search to Nov. 2016 • Total 85, 994 papers • Top two countries • US (37, 624) • UK (7, 355) • Me. SH multimorbidity term from 2017 (n=167 currently) Catalá-López F et al PLo. S One 2018

Definitions

Defining multimorbidity • Multimorbidity is the co-existence of two or more long-term conditions (LTCs) • Complex multimorbidity is sometimes defined as four or more LTCs • Differs from co-morbidity where there is an index condition • Characterised eg by simple count, disease score, clinical grouping • Causes polypharmacy and overlaps with generalised frailty Yarnall AJ et al Ageing 2017 Johnston MC et al Eur J Pub Health 2018

Diseases included in 39 different multimorbidity indices Diederichs C et al J Gerontol A Biol Sci Med Sci 2011

Burden

The burden of multimorbidity: number of chronic disorders by age group using data from 314 Scottish medical practices (n=1, 751, 841) Barnett K et al Lancet 2012

Deconstructing complex multimorbidity in the very old: findings from the Newcastle 85+ Study 710 men and women aged 85 Included ageing syndromes Multimorbidity (2+) in 93% Median 4 (IQR, 3 -6) conditions 5 clusters derived mathematically Cluster 1 (third of group) specific diseases with 10 more common than average → • Cluster 2 (third of group) ageing syndromes with 5 more common than average • Healthcare use was high • • • Collerton JC et al Bio. Med Research Int 2016

Risk Factors

Multimorbidity by age group and socio-economic status using data from 314 Scottish medical practices (n=1, 751, 841) Barnett K et al Lancet 2012

Trends in multimorbidity and physical activity • English Longitudinal Study of Ageing • Increasing levels of multimorbidity over time • Inverse relationship between physical activity and multimorbidity Dhalwani NN et al Int J Behav Nutr Phys Activ 2016

Lifestyle risk factors and incident multimorbidity • English Longitudinal Study of Ageing: waves 4, 5 and 6 • Smoking, alcohol, physical activity, fruit & vegetable intake, BMI • Incident multimorbidity (2+ conditions) • Graded association not explained by education or wealth Dhalwani NN et al J Gerontol 2017

Management

Clinical assessment and management of multimorbidity: summary of NICE guidance Farmer C et al BMJ 2016

Gaps

Identifying research gaps and priorities in multimorbidity Multiple Conditions in Later Life

The Priority Setting Process. Steering group formed 15 specialists in older people’s healthcare 4 lay members 1 older person’s charity rep 3 data specialists 1 independent chair from the JLA. 97 questions made it to the shortlist and people were asked to pick their top 10 ? 359 people from across the UK completed a survey or interview. 236 questions were categorised, merged, summarised & checked against existing research evidence. On 25 th April, at the final prioritisation workshop, the top 10 topics were identified. Corner L, Parker S et al

Parker S, Corner L et al Age & Ageing 2018 Submitted for publication

Clusters

Trajectories of functional decline in older adults aged 60 – 101 years with neuropsychiatric and cardiovascular multimorbidity: A Swedish cohort study • Found that older people with 1 or more neuropsychiatric diseases experienced a faster functional decline than those with cardiovascular diseases • However, when these two groups of diseases co-occurred, they played a synergistic role in speeding functional decline Vetrano DL et al PLOS Med 2018

Causes

Frailty and multimorbidity overlap: pooled data from 9 studies including community dwelling people Frailty N=403 (3%) None N=7220 (49%) N=868 (6%) Multimorbidity N=6213 (42%) Vetrano DL et al J Gerontol 2018

Future Approaches to Management

The contribution of risk factors to the predicted probability of developing multimorbidity over 5 -year periods across the life course in Twenty-07 cohort Risk factors • Smoking • BMI • Physical activity • Fruit & veg consumption • Alcohol intake (Adjusted for age, age squared, age cubed, sex, cohort, previous multimorbidity, time between waves, and cohort*sex interaction) Katikireddi SV et al BMC Med 2017

UK Capacity in Translational Research Activity

NIHR Newcastle Biomedical Research Centre 2017 – 2022 Improving lives through world-class research in ageing and long-term conditions

Conclusions • • • Multimorbidity is defined as two or more LTCs and is core business for the NHS Risk factors are well described and there is NICE guidance on assessment & management NICE and the Academy of Medical Sciences have identified research gaps The JLA Priority Setting Partnership on multiple conditions in later life has identified similar priorities for research but also highlighted psychosocial aspects Research gaps include understanding causes, developing effective interventions across the life course, and building capacity in translational research The Newcastle upon Tyne Hospitals NHS Foundation Trust avan. sayer@newcastle. ac. uk @Avan. Sayer #academicgeris https: //www. newcastlebrc. nihr. ac. uk