Many of us are living our lives with one or more long-term conditions. The older we get the more likely it becomes that we will have at least one long-term condition, and many older people have several. This is called Multimorbidity.
Long-term conditions can involve a person’s physical health and / or mental health. They include conditions such as diabetes, cardiovascular disease, stroke, arthritis, dementia, asthma and chronic obstructive pulmonary disease. Once a person acquires a new long-term condition, they will usually be living with it for the rest of their lives.
In the context of frailty, it can also be helpful to take a broader view of ‘long-term conditions’ to include not just the classical medical type of condition, but also to consider things such as poor hearing, poor vision, incontinence and functional impairment. Managing and improving these types of conditions as far as possible will also help to increase resilience and reduce vulnerability in this domain.
The greater the numbers of long-term conditions that any individual has the more vulnerable they are likely to be in this domain. This is partly because the direct effects of all the separate conditions accumulate and have an additive effect upon the individual concerned. There can also be indirect effects in that there can be complex interactions between different long-term conditions, which can make their combined impact even greater than the sum of the individual effects. For example, the medication used to treat one condition might exacerbate another condition, as in treatments for heart failure and hypertension that can exacerbate chronic kidney disease. Furthermore, the presence of one condition might make the treatment of another more difficult, such as compliance with medication for any other long-term condition being adversely affected if the person also has dementia.
These types of interactions between the effects of different long-term conditions and their treatments are more likely to occur in older people. This is because firstly they are more likely to have multiple long-term conditions, and therefore multiple associated medications, and secondly because their bodies react differently to some medications compared to those of younger people, making them more at risk of adverse side effects and interactions.
NICE (National Institute of Clinical Excellence) has released guidance on the clinical assessment and management of people with multimorbidity who need an approach to care that takes account of their multimorbidity because the combination of their conditions (disease burden) and/or the complexity of their treatments and healthcare appointments (treatment burden) significantly affect their life. This guidance recommends assessing for frailty as those individuals with frailty are likely to find the recommended approach particularly beneficial. The approach to assessment and management of care is closely aligned with the principles of person-centred supported self-care included in this toolkit.
Regardless of an older person’s total number of long-term conditions, their vulnerability and resilience in this domain can be influenced and improved by controlling each one of their conditions as well as possible. Control of long-term conditions is achieved not just by taking medication, but also, and in many cases, more importantly, by a person being proactive about their own care, including making healthy lifestyle choices appropriate to their condition. There may also be situations where reducing or changing medication is the most appropriate course of action, as outlined in the NICE guidance on multimorbidity.
The Multimorbidity (long-term conditions) domain of frailty has close interactions and interrelationships with the other domains of frailty, for example:
- Psychological issues such as cognitive impairment can have an adverse effect upon compliance with treatment for long-term conditions;
- The presence of long-term conditions can have an adverse impact upon a person’s psychological wellbeing and their social interactions;
- Factors in the environment, such as damp, cold or severe weather, can have an adverse effect upon long-term conditions.
- The degree of co-ordination and integration of systems of care will affect the overall treatment burden for an individual with multimorbidity.