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Multimorbidity, also known as multiple long-term conditions ( MLTC), means living with two or more . For example, a person could have diabetes, heart disease and depression at the same time. Multimorbidity can have a significant impact on people's health and wellbeing. It also poses a complex challenge to Health system which are traditionally focused on individual diseases. Multiple long-term conditions can affect people of any age, but they are more common in older age, affecting more than half of people over 65 years old.
Comorbidity means that one 'index' condition is the focus of attention, and others are viewed in relation to this. In contrast, multimorbidity describes someone having two or more long-term (chronic) conditions without any of them holding priority over the others. This distinction is important in how the healthcare system treats people and helps making clear the specific settings in which the use of one or the other term can be preferred. Multimorbidity offers a more general and person-centered concept that allows focusing on all of the patient's symptoms and providing a more holistic care. In other settings, for example in pharmaceutical research, comorbidity might often be the more useful term to use.
Definitions of multimorbidity usually differ in the minimum number of concurrent conditions they require (most often this is two or more) and in the types of conditions they consider. For example the UK's National Institute for Health and Care Excellence (NICE) includes Alcoholism and Substance abuse in their list of conditions considered to constitute multimorbidity.
The UK's National Institute for Health and Care Research (NIHR) uses the term multiple long-term conditions ( MLTC) as it is more accepted and understood by patients and the public.
One risk factor of multimorbidity in young people is being Preterm birth. Lifestyle factors that may increase the risk of multiple long-term conditions include obesity, poor diet, poor sleep, smoking, air pollution, Alcohol abuse; and lifestyles factors that may reduce the risk of MLTC includes eating a healthy diet, physical activity, and strong social networks.
Lower socioeconomic status, measured by a combination of education, occupation and literacy indicators, seems to increase the risk of developing multimorbidity. For instance, based on the Whitehall Study, people in lower employment positions seem to have a 66% higher risk of developing multiple long-term conditions than people in higher positions. However, socioeconomic status does not appear to influence the risk of dying after the onset of multiple long-term conditions. Another study showed an increase of almost 50% in the odds of multimorbidity occurring in those with the least wealth compared to those with the most wealth. Therefore, reducing socioeconomic inequalities by improving working and living conditions and education to everyone is important to reduce the burden of multiple long-term conditions on population health.
In some cases, specific combinations of diseases are associated with higher mortality. For example, people with long-term conditions affecting the heart, lung, and urinary systems have strong effects on mortality.
There are many additional issues associated with living with multiple long term conditions. One study from the US found that having more than 3 conditions significantly increased the chance of reduced quality of life and physical functioning. The researchers called for the holistic treatment of multimorbidities due to the complexities of multiple long-term conditions.
Due to the higher prevalence of multimorbidity (55 - 98%), a new concept of "complex multimorbidity (CMM)" has been proposed CMM differs from the definition of conventional multimorbidity in that CMM is defined by the number of body systems affected by the diseases rather than the number of diseases. CMM is associated is mortality and long-term care needs in older adults.
There is considerable evidence that having multiple long-term physical conditions can lead to the development of both depression and Anxiety disorder. There are many factors which might explain why physical multi-morbidity affects mental health including chronic pain, Frailty syndrome, symptom burden, Disability, reduced quality of life, increased levels of inflammation, and polypharmacy. Evidence from large population studies from the United Kingdom and China suggests that specific combinations of physical conditions increase the risk of developing depression and anxiety more than others, such as co-occurring respiratory disorders and co-occurring painful and gastrointestinal disorders. There has been a scarcity of economic evaluations concerning interventions for managing individuals with mental-physical multimorbidity, including depression. A recent systematic review identified four intervention types (collaborative care, self-management, telephone-based, and antidepressant treatment)) that were assessed for cost-effectiveness in high-income countries. However, such evaluations are currently absent in low-income and middle-income countries as no studies have been identified in these regions.
Strategies to prevent the onset of depression or depressive episodes in people with long-term physical conditions include psychological interventions and pharmacological interventions, however the long-term effectiveness and benefits of these approaches is very uncertain.
There is growing recognition that living with multiple long-term conditions leads to complex and challenging burdens for people living with MLTC themselves but also health care professionals working in the health system looking after those with long-term conditions. Living with multiple-long term conditions can be burdensome in terms of managing the illness, particularly if the diagnoses results in polypharmacy (taking multiple medicines).
Multimorbidity often results in taking 5 or more medicines (polypharmacy) which can represent a burden and might come with potential harm. When the medications are not effective enough or the risks outweigh the benefits, stopping medicines (deprescribing) might be necessary. In people with multiple long-term conditions and polypharmacy this represents a complex challenge as clinical guidelines are usually developed for single conditions. In these cases tools and guidelines like the Beers criteria and STOPP/START could be used safely by clinicians but not all patients might benefit from stopping their medication. Clarity about how much clinicians can do beyond the guidelines and the responsibility they need to take could help them prescribing and deprescribing for complex cases. Further factors that can help clinicians tailor their decisions to the individual are: access to detailed Medical record on the people in their care (including their backgrounds and personal medical goals), discussing plans to stop a medicine already when it is first prescribed, and a good relationship that involves mutual trust and regular discussions on progress. Furthermore, longer appointments for prescribing and deprescribing would allow time explain the process of deprescribing, explore related concerns, and support making the right decisions.
An increased understanding of which conditions most commonly Disease cluster, along with their underlying risk factors, would help prioritise strategies for early diagnosis, screening and prevention.
The prevalence of multimorbidity has been increasing in recent decades. The high prevalence of multimorbidity has led to some describing it as "The most common chronic condition". Multimorbidity is also more common among people from lower socioeconomic statuses. Multimorbidity is a significant issue in low‐ and middle‐income countries, although prevalence is not as high as in high income countries.
There are multiple theories on how socioeconomic inequality leads to multimorbidity but so far there is a lack of scientific evidence about the exact mechanism. Some of the potential links between the two are health-related behaviours (smoking, drinking, diet), lack of access to financial resources and housing, and the psychological response to living in difficult circumstances. Knowing the exact pathway would allow designing effective interventions that prevent or mitigate inequalities in multimorbidity.
Research shows that in Scotland residents of deprived areas are affected by multiple long-term conditions 10 to 15 years earlier than people living in affluent neighborhoods. They also have a higher chance that their long-term conditions include mental health disorders. In England, according to research, people from deprived neighborhoods had complex multimorbidity (3 or more conditions) 7 years earlier than the least deprived. People living in deprived areas also have a higher risk of dying because of multimorbidity.
Belonging to a sexual minority also means being disproportionately affected by multimorbidity, especially mental health conditions.
As rehabilitation usually focuses on a single disease people with multiple long-term conditions are often excluded or not all their conditions are treated during rehabilitation. Researchers are looking for new models of rehabilitation that could be applied to people with multimorbidity. For example the PERFORM (Personalised Exercise-Rehabilitation For people with Multiple long-term conditions) research group in the UK is developing and evaluating an exercise-based rehabilitation intervention that can be personalised for people with multiple long-term conditions. The MOBILIZE group in Denmark are currently undertaking a randomised controlled trial of a rehabilitation intervention for people with multimorbidity co-developed with people with long-term conditions and clinicians.
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