Patient-centered care for older adults with multiple chronic conditions: A stepwise approach from the American Geriatrics Society: American Geriatrics Society expert panel on the care of older adults with multimorbidity

Journal of the American Geriatrics Society

Volumn 60, Issue 10, 2012, Pages 1957-1968

  Ickowicz, Elvy ^a  

^a American Geriatrics Society   (United States)

Author keywords

comorbidity; guiding principles; multimorbidity; older adults

Indexed keywords

ARTICLE; CHRONIC DISEASE; CLINICAL PRACTICE; EVIDENCE BASED PRACTICE; GERIATRIC CARE; HEALTH CARE PLANNING; HUMAN; MEDICAL DECISION MAKING; MEDICAL EDUCATION; MORBIDITY; NURSING HOME; PATIENT CARE; PATIENT CENTERED CARE; PRACTICE GUIDELINE; PRIMARY MEDICAL CARE; PROGNOSIS;

EID: 84867476224     PISSN: 00028614     EISSN: 15325415     Source Type: Journal    
DOI: 10.1111/j.1532-5415.2012.04187.x     Document Type: Article

References (103)

1. Boyd CM, Fortin M,. Future of multimorbidity research: How should understanding of multimorbidity inform health system design? Public Health Rev 2011; 32: 451-474.
2. Mercer SW, Smith SM, Wyke S, et al. Multimorbidity in primary care: Developing the research agenda. Fam Pract 2009; 26: 79-80.
3. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA 2005; 294: 716-724.
4. Anderson G,. Chronic Care: Making the Case for Ongoing Care. Robert Wood Johnson Foundation, 2010 [on-line]. Available at http://www.rwjf.org/files/ research/50968chronic.care.chartbook.pdf Accessed June 19, 2012.
5. Boult C, Wieland GD,. Comprehensive primary care for older patients with multiple chronic conditions: "Nobody rushes you through." JAMA 2010; 304: 1936-1943.
6. Tinetti ME, Bogardus ST Jr, Agostini JV,. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004; 351: 2870-2874.
7. Lugtenberg M, Burgers JS, Clancy C, et al. Current guidelines have limited applicability to patients with comorbid conditions: A systematic analysis of evidence-based guidelines. PLoS ONE 2011; 6: e25987.
8. Chong CA, Chen IJ, Naglie G, et al. How well do guidelines incorporate evidence on patient preferences? J Gen Intern Med 2009; 24: 977-982.
9. Fried TR, Tinetti ME, Iannone L,. Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med 2011; 171: 75-80.
10. Durso S,. The next frontier: Quantifying risks for interventions with no end in sight. Arch Intern Med 2008; 168: 1230-1231.
11. Reuben DB, Tinetti ME,. Goal-oriented patient care-an alternative health outcomes paradigm. N Engl J Med 2012; 366: 777-779.
12. Loke YK, Cavallazzi R, Singh S,. Risk of fractures with inhaled corticosteroids in COPD: Systematic review and meta-analysis of randomised controlled trials and observational studies. Thorax 2011; 66: 699-708.
13. Abd TT, Jacobson TA,. Statin-induced myopathy: A review and update. Expert Opin Drug Saf 2011; 10: 373-387.
14. Agostini JV, Han L, Tinetti ME,. The relationship between number of medications and weight loss or impaired balance in older adults. J Am Geriatr Soc 2004; 52: 1719-1723.
15. Fried TR, McGraw S, Agostini JV, et al. Views of older persons with multiple morbidities on competing outcomes and clinical decision-making. J Am Geriatr Soc 2008; 56: 1839-1844.
16. Nakao MA, Axelrod S,. Numbers are better than words. verbal specifications of frequency have no place in medicine. Am J Med 1983; 74: 1061-1065.
17. McNeil BJ, Pauker SG, Sox HC Jr, et al. On the elicitation of preferences for alternative therapies. N Engl J Med 1982; 306: 1259-1262.
18. Apter AJ, Paasche-Orlow MK, Remillard JT, et al. Numeracy and communication with patients: They are counting on us. J Gen Intern Med 2008; 23: 2117-2124.
19. O'Connor AM, Bennett CL, Stacey D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2009; 3: CD001431.
20. Fraenkel L, Fried TR,. Individualized medical decision making: Necessary, achievable, but not yet attainable. Arch Intern Med 2010; 170: 566-569.
21. Assessing desirability of outcome states for medical decision making and cost-effectiveness analysis [on-line]. Available at http://painconsortium.nih. gov/symptomresearch/chapter-24/index.htm Accessed June 19, 2012.
22. Pauker SG, Kassirer JP,. Decision analysis. N Engl J Med 1987; 316: 250-258.
23. Farrar S, Ryan M, Ross D, et al. Using discrete choice modelling in priority setting: An application to clinical service developments. Soc Sci Med 2000; 50: 63-75.
24. Fried TR, Tinetti M, Agostini J, et al. Health outcome prioritization to elicit preferences of older persons with multiple health conditions. Patient Educ Couns 2011; 83: 278-282.
25. Deber RB,. Physicians in health care management: 8. The patient-physician partnership: Decision making, problem solving and the desire to participate. Can Med Assoc J 1994; 151: 423-427.
26. Levinson W, Kao A, Kuby A, et al. Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med 2005; 20: 531-535.
27. Fried TR, Byers AL, Gallo WT, et al. Prospective study of health status preferences and changes in preferences over time in older adults. Arch Intern Med 2006; 166: 890-895.
28. Luce JM,. Physicians do not have a responsibility to provide futile or unreasonable care if a patient or family insists. Crit Care Med 1995; 23: 760-766.
29. Guyatt G, Rennie DE, eds. Users' Guides to the Medical Literature: A Manual of Evidence-Based Clinical Practice. Chicago, IL: AMA Press, 2002.
30. Institute of Medicine. Clinical practice guidelines we can trust [on-line]. Available at http://www.iom.edu/~/media/Files/Report%20Files/2011/ Clinical-Practice-Guidelines-We-Can-Trust/ Clinical%20Practice%20Guidelines%202011%20Insert.pdf Accessed June 19, 2012.
31. McClellan MB, McGinnis JM, Nabel EG, IOM (Institute of Medicine) et al. Evidence-Based Medicine and the Changing Nature of Health Care: 2007 IOM Annual Meeting Summary. Washington, DC: The National Academies Press, 2008.
32. Cox L, Kloseck M, Crilly R, et al. Underrepresentation of individuals 80 years of age and older in chronic disease clinical practice guidelines. Can Fam Physician 2011; 57: e263-2269.
33. Fortin M, Contant E, Savard C, et al. Canadian guidelines for clinical practice: An analysis of their quality and relevance to the care of adults with comorbidity. BMC Fam Pract 2011; 12: 74.
34. GRADE Working Group [on-line]. Available at http://www.gradeworkinggroup. org/index.htm Accessed June 19, 2012.
35. AHRQ Effective Health Care Program Stakeholder Guide. Evidence-Based Medicine and the Changing Nature of Health Care: 2007 IOM Annual Meeting Summary. Rockville, MD: Agency for Healthcare Research and Quality, 2011.
36. Kent DM, Hayward RA,. Limitations of applying summary results of clinical trials to individual patients: The need for risk stratification. JAMA 2007; 298: 1209-1212.
37. Walter LC, Covinsky KE,. Cancer screening in elderly patients: A framework for individualized decision making. JAMA 2001; 285: 2750-2756.
38. Welch HG, Albertsen PC, Nease RF, et al. Estimating treatment benefits for the elderly: The effect of competing risks. Ann Intern Med 1996; 124: 577-584.
39. Koller MT, Raatz H, Steyerberg EW, et al. Competing risks and the clinical community: Irrelevance or ignorance? Stat Med 2011; 31: 1089-1097.
40. Blaum CS, Cigolle CT, Boyd C, et al. Clinical complexity in middle-aged and older adults with diabetes: The Health and Retirement Study. Med Care 2010; 48: 327-334.
41. Reuben DB,. Medical care for the final years of life: "When you're 83, it's not going to be 20 years." JAMA 2009; 302: 2686-2694.
42. Covinsky KE, Hilton J, Lindquist K, et al. Development and validation of an index to predict activity of daily living dependence in community-dwelling elders. Med Care 2006; 44: 149-157.
43. U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 150: 396-404.
44. Brown AF, Mangione CM, Saliba D, et al. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc 2003; 51: S265-280.
45. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363: 733-742.
46. Adler R, Kamel H,. Doorway Thoughts: Cross-Cultural Health Care for Older Adults, vol. III. Sudbury, MA: Jones and Bartlett Publishers 2009.
47. Yourman LC, Lee SJ, Schonberg MA, et al. Prognostic indices for older adults: A systematic review. JAMA 2012; 307: 182-192.
48. Minne L, Ludikhuize J, de Rooij SE, et al. Characterizing predictive models of mortality for older adults and their validation for use in clinical practice. J Am Geriatr Soc 2011; 59: 1110-1115.
49. Harrold J, Rickerson E, Carroll JT, et al. Is the palliative performance scale a useful predictor of mortality in a heterogeneous hospice population? J Palliat Med 2005; 8: 503-509.
50. Covinsky KE, Eng C, Lui LY, et al. The last 2 years of life: Functional trajectories of frail older people. J Am Geriatr Soc 2003; 51: 492-498.
51. Kavanagh BP,. The GRADE system for rating clinical guidelines. PLoS Med 2009; 6: e1000094.
52. Nolan TW,. System changes to improve patient safety. BMJ 2000; 320: 771-773.
53. George J, Phun Y-, Bailey MJ, et al. Development validation of the medication regimen complexity index. Ann Pharmacother 2004; 38: 1369-1376.
54. George J, Vuong T, Bailey MJ, et al. Medication regimen complexity and adherence in patients at risk of medication misadventure. J Pharm Pract Res 2006; 36: 99-102.
55. Cherubini A, Ruggiero C, Gasperini B, et al. The prevention of adverse drug reactions in older subjects. Curr Drug Metab 2011; 12: 652-657.
56. Giovannetti ER, Wolff JL, Xue QL, et al. Difficulty assisting with health care tasks among caregivers of multimorbid older adults. J Gen Intern Med 2012; 27: 37-44.
57. Morris RL, Sanders C, Kennedy AP, et al. Shifting priorities in multimorbidity: A longitudinal qualitative study of patient's prioritization of multiple conditions. Chronic Illn 2011; 7: 147-161.
58. Brown MT, Bussell JK,. Medication adherence: WHO cares? Mayo Clin Proc 2011; 86: 304-314.
59. Farris KB, Phillips BB,. Instruments assessing capacity to manage medications. Ann Pharmacother 2008; 42: 1026-1036.
60. Nobili A, Licata G, Salerno F, et al. Polypharmacy, length of hospital stay, and in-hospital mortality among elderly patients in internal medicine wards. The REPOSI study. Eur J Clin Pharmacol 2011; 67: 507-519.
61. Kripalani S, Yao X, Haynes RB,. Interventions to enhance medication adherence in chronic medical conditions: A systematic review. Arch Intern Med 2007; 167: 540-550.
62. Weiss M, Britten N,. What is concordance? Pharm J 2003; 271: 493.
63. Moen J, Norrgård S, Antonov K, et al. GPs' perceptions of multiple-medicine use in older patients. J Eval Clin Pract 2010; 16: 69-75.
64. Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA 2011; 306: 840-847.
65. Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic disease in primary care. JAMA 2002; 288: 2469-2475.
66. Steinman MA, Landefeld CS, Rosenthal GE, et al. Does the number of coexisting chronic diseases affect the adverse association between polypharmacy and prescribing quality in older adults? Response J Am Geriatr Soc 2007; 55: 803-804.
67. Lampert R, Hayes DL, Annas GJ, et al. HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm 2010; 7: 1008-1026.
68. Hanlon JT, Wang X, Handler SM, et al. Potentially inappropriate prescribing of primarily renally cleared medications for older Veterans Affairs nursing home patients. J Am Med Dir Assoc 2011; 12: 377-383.
69. Garfinkel D, Mangin D,. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: Addressing polypharmacy. Arch Intern Med 2010; 170: 1648-1654.
70. Rudolph JL, Salow MJ, Angelini MC, et al. The Anticholinergic Risk Scale and anticholinergic adverse effects in older persons. Arch Intern Med 2008; 168: 508-513.
71. Morandi A, Vasilevskis EE, Pandharipande PP, et al. Inappropriate medications in elderly ICU survivors: Where to intervene? Arch Intern Med 2011; 171: 1032-1034.
72. Holmes HM, Hayley DC, Alexander GC, et al. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006; 166: 605-609.
73. Fitzgerald SP, Bean NG,. An analysis of the interactions between individual comorbidities and their treatments-implications for guidelines and polypharmacy. J Am Med Dir Assoc 2010; 11: 475-484.
74. Rochon PA, Gurwitz JH,. Optimising drug treatment for elderly people: The prescribing cascade. BMJ 1997; 315: 1096-1099.
75. Schiff GD, Galanter WL, Duhig J, et al. Principles of conservative prescribing. Arch Intern Med 2011; 171: 1433-1440.
76. Modig S, Kristensson J, Ekwall AK, et al. Frail elderly patients in primary care-their medication knowledge and beliefs about prescribed medicines. Eur J Clin Pharmacol 2009; 65: 151-155.
77. Graves T, Hanlon JT, Schmader KE, et al. Adverse events after discontinuing medications in elderly outpatients. Arch Intern Med 1997; 157: 2205-2210.
78. Bain KT, Holmes HM, Beers MH, et al. Discontinuing medications: A novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc 2008; 56: 1946-1952.
79. Doucette WR, McDonough RP, Klepser D, et al. Comprehensive medication therapy management: Identifying and resolving drug-related issues in a community pharmacy. Clin Ther 2005; 27: 1104-1111.
80. Wolff JL, Rand-Giovannetti E, Palmer S, et al. Caregiving and chronic care: The Guided Care Program for Family and Friends. J Gerontol A Biol Sci Med Sci 2009; 64A: 785-791.
81. Turner J, Pugh J, Budiani D,. "It's always continuing": First-year medical students' perspectives on chronic illness and the care of chronically ill patients. Acad Med 2005; 80: 183-188.
82. Giovannetti ER, Xue Q, Reider L, et al. Factors Associated with Change in Health Care Task Difficulty Among Multimorbid Older Adults. Presented at the American Geriatrics Society Annual Meeting, May 2011, National Harbor, MD.
83. Mir G, Sheikh A,. 'Fasting and prayer don't concern the doctors... they don't even know what it is': Communication, decision-making and perceived social relations of Pakistani Muslim patients with long-term illnesses. Ethn Health 2010; 15: 327-342.
84. Thorne SE,. Ternulf Nyhlin K, Paterson BL. Attitudes toward patient expertise in chronic illness. Int J Nurs Stud 2000; 37: 303-311.
85. Ostbye T, Yarnall KS, Krause KM, et al. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005; 3: 209-214.
86. Multiple Chronic Conditions. A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. Washington, DC: U.S. Department of Health and Human Services, 2010.
87. The American Geriatrics Society. Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012; 2012 (60): 616-631.
88. Fick DM, Mion LC, Beers MH, et al. Health outcomes associated with potentially inappropriate medication use in older adults. Res Nurs Health 2008; 31: 42-51.
89. Dedhiya SD, Hancock E, Craig BA, et al. Incident use and outcomes associated with potentially inappropriate medication use in older adults. Am J Geriatr Pharmacother 2010; 8: 562-570.
90. Akazawa M, Imai H, Igarashi A, et al. Potentially inappropriate medication use in elderly Japanese patients. Am J Geriatr Pharmacother 2010; 8: 146-160.
91. Gnjidic D, Le Couteur DG, Abernethy DR, et al. Drug Burden Index and Beers criteria: Impact on functional outcomes in older people living in self-care retirement villages. J Clin Pharmacol 2011; 52: 258-265.
92. Sakuma M, Morimoto T, Matsui K, et al. Epidemiology of potentially inappropriate medication use in elderly patients in Japanese acute care hospitals. Pharmacoepidemiol Drug Saf 2011; 20: 386-392.
93. Barnett K, McCowan C, Evans JM, et al. Prevalence and outcomes of use of potentially inappropriate medicines in older people: Cohort study stratified by residence in nursing home or in the community. BMJ Qual Saf 2011; 20: 275-281.
94. Harugeri A, Joseph J, Parthasarathi G, et al. Potentially inappropriate medication use in elderly patients: A study of prevalence and predictors in two teaching hospitals. J Postgrad Med 2010; 56: 186-191.
95. Corsonello A, Pedone C, Lattanzio F, et al. Potentially inappropriate medications and functional decline in elderly hospitalized patients. J Am Geriatr Soc 2009; 57: 1007-1014.
96. Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011; 365: 2002-2012.
97. Gallagher P, Ryan C, Byrne S, et al. STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment) consensus validation. Int J Clin Pharmacol Ther 2008; 46: 72-83.
98. Gallagher PF, O'Connor MN, O'Mahony D,. Prevention of potentially inappropriate prescribing for elderly patients: A randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther 2011; 89: 845-854.
99. Samsa GP, Hanlon JT, Schmader KE, et al. A summated score for the Medication Appropriateness Index: Development and assessment of clinimetric properties including content validity. J Clin Epidemiol 1994; 47: 891-896.
100. Hellstrom LM, Bondesson A, Hoglund P, et al. Impact of the Lund Integrated Medicines Management (LIMM) model on medication appropriateness and drug-related hospital revisits. Eur J Clin Pharmacol 2011; 67: 741-752.
101. Lund BC, Carnahan RM, Egge JA, et al. Inappropriate prescribing predicts adverse drug events in older adults. Ann Pharmacother 2010; 44: 957-963.
102. Schmader KE, Hanlon JT, Landsman PB, et al. Inappropriate prescribing and health outcomes in elderly veteran outpatients. Ann Pharmacother 1997; 31: 529-533.
103. Garfinkel D, Zur-Gil S, Ben-Israel J,. The war against polypharmacy: A new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J 2007; 9: 430-434.