Wednesday, November 26, 2014

How to manage multiple medical problems (also known as "do I really need all these medications?")

(PS this post ended up being longer than I thought.  Skip to the end for the punch line)

Too many times, older adults have a lot of medical problems that get treated by a lot of doctors with a lot of medications.  (I'm tempted to say too many but that would simply reflect my bias).  For example, I once had a patient with 3, THREE, neurologists!!  I asked him, "What for?" and he said, "1 for my stroke, 1 for my seizures and 1 for my memory issues."  Just between those three neurologists, he was put on 7 medications!  (2 seizure drugs, 2 memory drugs and 3 for preventing strokes).  That type of craziness I expect out of cardiologists.  The more docs you see the more meds you get.  (that's a true statement by the way, I didn't make that up).

Some doctors haven't the faintest idea what to do either.  The organologists (cardiologist, pulmonologist, endocrinologist) often just buckle down and do what they do, just harder.  This is simply avoiding complexity instead of managing it.  (and it often makes the problem worse or kills the patient)

The American Geriatric Society, as experts in managing complicated older adults, put out a paper on the topic.  From my humble perspective, it adds to complexity instead of reducing it.  Here are the steps suggested in the paper....
1.  Elicit the chief complaint of the patient (or family).  
Sounds good.  I'm on board with this one.
2.  Either review the whole multimorbidity picture or focus on just a part
Yes, these are the obvious choices of agenda for a visit.  The difficult part is how to figure out which one to do.
3.  Ask:  What are the current medical problems and interventions combined with is there adherence/comfort with the treatment plan?
So this is taking option #1 from the previous question.  I like it.  But why are we doing this, what will we do w/the info?
4.  Consider patient preferences.
While important, there are medical issues that are obvious priorities that are not subjected to preference.  Managing multimorbidity is not just an art or emotional or value based.  There are concrete priorities.  See below.
5.  Is there evidence available related to important outcomes?
While this makes sense to ask, there are two problems.  You can't ask a practicing clinician to stop and review evidence in the middle of making a clinical decision.  The process would grind to a halt and no decision would ever be made.  Second, when reading the article they talk about how poor the evidence is in the setting of multimorbidity so the proper answer to this question may be simply "There isn't any."  (per authors)
6.  Consider prognosis
7.  Consider interactions within and among treatments and conditions.
Agree but if you have someone with afib who has GI bleeds there are principles that guide priorities that this article doesn't discuss.  Asking a question without good guidance leads to random outcomes.
8.  Weight benefits and harms of components of treatment plans.
Agree.  Harms are like a another problem on a patients problem list.
9.  Communicate and decide for or against implementation or continuation of intervention/treatment
Fish or cut bait.
10.  Reassess at selected intervals
Everything is a time limited trial to quote an esteemed geriatric expert.  Or to quote Mike Tyson, "Everyone has a plan until they are punched in the face."  That's a better quote.

10 steps.  TEN.  For crying out loud.  How does managing multimorbidity with questions that simply bring up complexity (2, 7, 8, 9) or are unanswerable (5) or are exceedingly difficult to apply (4, 9) help simplify multimorbidity?  My head spins looking at this and I do this every day.

So here is my cheat sheet. It is simple.

1. Active symptoms
         Pain, nausea, constipation, dyspnea, delirium
2. Multiorgan frailty syndromes: 
         Falls, weight loss, cognitive decline, functional decline
3. Secondary prevention/chronic diseases: in this order
         Congestive heart failure>Hypertension>Osteoporosis>>>High cholesterol>>>>>Diabetes
4. Primary prevention
          Vaccines>>aspirin for preventing heart attacks, colon cancer screening>>Prostate cancer screening

Repeat after me: "Active symptoms are more important than preventing symptoms."  No point in worrying about what can happen years into the future if you're going to ignore a problem hitting you in the face.  (see Mike Tyson quote-I quoted him because he is right, if you are getting hit in the face you should change your plan.  In my case run and scream).

Example of application....
So if a patient is having active symptoms (ie Pain) then treat it.  Until you get those symptoms under control, what difference does it make if their blood pressure is 160 instead of 140?  Or if pain meds put them at risk of constipation or delirium even?  Active symptoms=active suffering.  Treat it!

Why this medically makes sense.
Generally speaking, if you are trying to get a higher priority issue under control, then don't worry about the lower priority issue.  Especially if worrying about the lower priority issue got you into having the higher priority issue in the first place.  What do I mean?  If tight control of diabetes is leading to hypoglycemia and falls, then by all means, BACK OFF THE INSULIN.  Multiorgan frailty syndromes pose a much greater threat to quality of life, health, safety than anything in 3 or 4.  As patients have higher priority issues, the efficacy of lower priority issues starts to disappear and harms of lower priority issue start to appear.  These are medical principles.

Why this makes patient sense as well.
By prioritizing active symptoms, you are prioritizing what bothers them most.  #1 takes precedence.  Second, this list automatically prioritizes what is the biggest danger to a persons life and health and function.  3rd, a patient can decide how far down the priority list they want to go.  It gives them a (logical/clear/structured) sense of how to be aggressive if that's what they want.

So there you go.  This is how you manage multimorbidity simply.

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