Multimorbidity: will it stand the test of time?

The concept of multimorbidity has risen in popularity over the past few years. Its use has led to, or coincided with, an increased recognition that patients often have more than one health problem which should not be treated in isolation. The motivation for more holistic, person-centred care that lies behind multimorbidity is to be welcomed. The 2016 National Institute for Health and Care Excellence multimorbidity management guideline helpfully makes recommendations in key areas that are important in the care of patients with complicated medical problems.However, we question the sustainability of the term for the following four reasons: (i) it is doctor and researcher centred rather than patient centred, focusing upon the number of diagnoses rather than the patient's lived experience, (ii) it is not a positive term for patients and is at odds with the move towards promoting active and healthy ageing, (iii) its non-specific nature means it holds little value in daily clinical practice and (iv) most definitions apply to a large segment of the population making it of limited use for health care planners. We argue that the complementary concepts of complexity and frailty would fit better with the delivery of patient centred care for people with multiple co-existing health problems and would be more useful to clinicians, commissioners and researchers.

How should we investigate CUO (C-Reactive Protein elevation of unknown origin)? A case-based discussion of infective endocarditis in an octogenarian.

Infective endocarditis and other chronic infections may cause diagnostic difficulties, regardless of age. The likelihood of an atypical presentation of chronic infection probably increases with age. Serum CRP may be a useful guide to the presence of underlying infection and its resolution in older people. The term CUO (CRP elevation of unknown origin) may have a place in triggering further investigation for the presence of infection or other pathology.

Inappropriate prescribing of proton pump inhibitors in older patients: effects of an educational strategy.

BACKGROUND: An increasing number of older patients are prescribed proton pump inhibitors (PPIs). However, the extent of inappropriate PPI prescribing in this group is largely unknown. OBJECTIVE: We sought to identify clinical and demographic factors associated with inappropriate PPI prescribing in older patients and to assess the effects of a targeted educational strategy in a controlled hospital environment. METHODS: Clinical and demographic characteristics and full medication exposure on admission were recorded in 440 consecutive older patients (mean ± SD age 84 ± 7 years) admitted to a teaching hospital between 1 February 2011 and 30 June 2011. A 4-week educational strategy to reduce inappropriate PPI prescribing during hospital stay, either by stopping or reducing PPI doses, was conducted within the study period. The main outcome measures of the study were the incidence of inappropriate PPI prescribing and the effects of interventions to reduce it. RESULTS: On admission, PPIs were established therapy in 164 patients (37%). This was considered inappropriate in 100 patients (61%). Lower Charlson Comorbidity Index score (odds ratio [OR] 0.76; 95% CI 0.57, 0.94; p = 0.006) and history of dementia (OR 1.65; 95% CI 1.28, 1.83; p = 0.005) were independently associated with inappropriate PPI prescribing. Interventions to reduce inappropriate PPI prescribing occurred more frequently during and after the education phase (frequency of interventions in patients with inappropriate PPI prescribing: pre-education phase 9%, during education phase 43%, and post-education phase 46%, p = 0.006). Prescribing interventions were not associated with acid rebound symptoms. CONCLUSIONS: Inappropriate PPI prescribing in older patients is frequent and independently associated with co-morbidities and dementia. A targeted in-hospital educational strategy can significantly and safely reduce inappropriate PPI prescribing in the short term.