Managing Multimorbidity

Introduction

Multimorbidity is the coexistence of two or more long-term health conditions in a single person. It is now the typical presentation in general practice rather than the exception: by age 65, most people in the UK have at least two long-term conditions, and by age 75 the majority have three or more.¹

It matters clinically because single-disease guidelines are developed and trialled in relatively 'clean' populations with one index condition, and rarely account for how their recommendations interact when applied simultaneously to a patient with, say, type 2 diabetes, heart failure, COPD and osteoarthritis. Mechanically stacking four guidelines produces a regimen that is often unsafe, unaffordable in time and effort, and sometimes internally contradictory.

Multimorbidity is also socially patterned: it develops 10-15 years earlier in people living in the most deprived areas compared with the least deprived, and combinations involving mental health conditions are especially common in deprived populations.²

Patterns of clustering

Long-term conditions do not combine randomly - certain clusters recur often enough to be clinically useful to recognise, because they share risk factors, mechanisms, or simply the burden of overlapping management.

Recognising a cluster is useful because it often points towards a shared intervention with benefit across several conditions at once - for example, structured weight management and physical activity support addressing the cardiometabolic-musculoskeletal cluster together, rather than being managed as unrelated referrals to different services.

Why single-disease management fails

• Guideline stacking: following every relevant NICE guideline in full can generate ten or more regular medicines, a phenomenon informally called the 'guideline-induced polypharmacy' problem
• Conflicting advice: a beta-blocker helps heart failure but can worsen COPD symptoms; NSAIDs help osteoarthritis pain but harm heart failure and renal function
• Trial populations don't match real patients: most randomised trials exclude older, multimorbid, frail participants, so the evidence base for treating them exactly as per single-disease guidance is weaker than it looks
• Treatment burden is itself a harm: appointment attendance, monitoring blood tests, multiple daily dosing times and side effects all consume a patient's finite time and capacity, which is rarely counted as a cost in single-disease guidelines
• Competing risk: treating one condition aggressively may not extend life if a different condition dominates prognosis - tight glycaemic control has little value if life expectancy is dominated by advanced heart failure

The NICE multimorbidity approach

NICE NG56 recommends considering an explicit multimorbidity approach - rather than a series of separate single-disease reviews - for patients who:³

• Find it hard to manage their treatments or day-to-day activities
• Receive care and support from multiple services and need enhanced coordination
• Have both a mental health condition and a physical long-term condition
• Have frailty or falls
• Are prescribed multiple regular medicines (polypharmacy)
• Request an approach that takes account of their multimorbidity

The core technique is a structured review that starts from the patient's priorities rather than from a disease register, covering:

1. What matters most to the patient - function, independence, symptom control, avoiding hospital, or life extension
2. Review of current problems, treatment burden and how well the current regimen is working
3. Identifying which treatments provide the most benefit relative to burden and risk, and which could be stopped or reduced
4. Agreeing an individualised management plan, including realistic targets
5. Agreeing how and when to review

Assessing treatment burden

Treatment burden is the workload a patient's healthcare generates, plus its impact on their wellbeing and functioning. It is often invisible on a medication list but visible if you ask about a typical week.

• Number of daily medication doses and how they fit around meals and routine
• Number of different prescribers and services involved
• Frequency of blood tests, monitoring and appointments
• Practical burden - collecting prescriptions, managing a dosette box, attending clinics - especially where mobility or carer support is limited
• Financial cost, including prescription charges and travel to appointments
• Psychological burden - feeling defined by illness, or overwhelmed by the volume of instructions

High treatment burden relative to a patient's capacity to cope with it - sometimes framed as a mismatch between 'workload' and 'capacity' - predicts poor adherence, and poor adherence is frequently mislabelled as poor 'compliance' when it is really a rational response to an unmanageable regimen.

Capacity itself varies - a patient with strong family support, good health literacy and financial stability can absorb a higher treatment burden than one who is isolated, has low literacy, or is also managing significant social or financial stress. Two patients with an identical medication list and identical disease severity can therefore have very different real-world treatment burden, which is why this needs to be asked about directly rather than inferred from the medication list alone.

Structured medication review and deprescribing

Deprescribing is the planned, supervised process of stopping or reducing a medicine when the harms or burden now outweigh the benefit, or when the original indication no longer applies. It is a proactive clinical decision, not a passive drift, and it should be as deliberate a process as prescribing.⁴

See ⁵ for a fuller treatment of practical deprescribing techniques and prioritisation, which is covered in depth as its own topic in geriatric medicine.

Continuity of care

Relational continuity - seeing the same GP or a small, consistent team over time - has a disproportionately large effect in multimorbidity. A clinician who already knows the patient's history, values and social context can make judgement calls that a series of one-off consultations cannot, and avoids the duplicated tests and conflicting advice that come from fragmented care.

Observational evidence links higher continuity with lower all-cause mortality, fewer emergency admissions and higher patient satisfaction, with the effect size larger in patients with more conditions.⁶ Structuring appointments (longer slots, named GP, care coordination) to preserve continuity is now an explicit aim of the NHS Long Term Plan for people with complex needs.

Practical consultation approach

1. Start by asking what matters most to the patient right now, not with a disease-by-disease review
2. Bring the full medication list into view and ask the patient to describe how they actually take it
3. Identify the one or two problems causing the most day-to-day impact and focus the consultation there rather than attempting to address everything
4. Explicitly discuss trade-offs - for example, tighter blood pressure control against the risk of postural hypotension and falls
5. Agree a small number of concrete next steps rather than a long list
6. Arrange a specific, realistic review rather than an open-ended 'come back if problems'

Mental and physical health together

The combination of a long-term physical condition with depression or anxiety is one of the most common and most consequential multimorbidity patterns, and NICE specifically identifies it as a trigger for an explicit multimorbidity approach. The relationship runs in both directions: chronic physical illness roughly doubles the risk of depression, while depression worsens self-management, adherence and outcomes of the physical condition, and is independently associated with higher mortality after myocardial infarction and in diabetes.

Despite this, mental health is frequently the domain least addressed in a physical-disease review, partly because disease-specific templates rarely prompt for it. Screening directly - even with two brief questions about low mood and loss of interest - and treating what is found, often improves the physical condition's control as well, which is a more persuasive argument to a reluctant patient than framing it purely as a separate psychiatric problem.

Complications of poorly managed multimorbidity

• Adverse drug events and drug-drug or drug-disease interactions, which rise steeply with each additional medicine
• Non-adherence driven by burden rather than by disagreement with treatment
• Fragmented, contradictory care across multiple specialists with no one taking an overview
• Avoidable hospital admission, often medication-related
• Erosion of patient autonomy and a sense of being 'managed' rather than cared for

Red flags

Prognosis and goals of care

Multimorbidity itself is not a diagnosis with a single prognosis; outcomes depend on which conditions are present, their severity, and the degree of frailty. What is consistent is that patient-defined goals - independence, symptom control, staying at home, avoiding hospital - are a more useful organising principle for care than an aggregate disease count.

Revisiting goals over time matters, since priorities shift as conditions progress: a patient focused on tight risk-factor control in their sixties may reasonably prioritise comfort and simplicity two decades later. Good multimorbidity management is an ongoing conversation, not a single review.

This shift - from managing diseases in parallel towards managing a whole person's priorities - is sometimes described under the banner of realistic medicine: doing what actually benefits this individual, given their own goals, prognosis and preferences, rather than doing everything that guidelines make technically possible. It is not a lowering of standards, but a recognition that the right standard in multimorbidity is individualised, not a mechanical sum of single-disease targets.