Personalized Management of Multimorbidity

Multi-morbidity is a technical word used to explain the conditions of an individual who has been suffering from myriads of chronic illnesses at a time. In most cases, the individual suffers from two or more chronic illnesses at a time, one of which or sometimes both may hasten fatal consequences. Multimorbidity has been emerging as one of the most significant challenges that the world is facing in the current and coming decades in regards to health service. The global health system is unable to provide necessary care for the people who are having multimorbidity issues as complex care service is more critical and require interdisciplinary teamwork. There are myriads of unmet needs, proper outpatient and inpatient utilisation, the duration of the sickness, available health status and at the same time, the EQ-5D index scores as the parameter of the obvious consequences associated with multimorbidity have been used to identify the level of seriousness of this issue (Kim, Keshavjee and Atun 2020).

Complexities, impact and strategies of multimorbidity in aging populations

The assignment discusses the adverse effects of the multiple conditions on the lives of people and healthcare services, as well as the dynamic interplay between various mental and physical conditions with consecutive risk factors that include behaviour and socio-economic status. Moreover, in the first part, the assignment would try to evaluate the approaches to the assessment of the patient who require complex care. As the assignment moves to the second part, the pivotal complexities of care related issues of the mentioned patient in the case study, would be identified and discussed critically. In order to make a vivid study of the complex care needs of a patient with multimorbidity, discussion would include the critical issues like pain management, pharmacology and medication compliance or medication concordance. However, there is additional issues too that involve, the huge emotional, physical and financial burden of treatment that comorbidity demands. Patient awareness regarding their own condition, acceptance of their health condition and educating them to comply with their new lifestyle that should be adopted to fight against such critical illnesses to extend longevity with a quality life is of utmost importance.  The entire treatment procedure should be a collaborated teamwork as multiple diseases means multiple medical expertise and special care nurses or associated healthcare professionals like physiotherapists who would together support the patient to get a better life. Self medication management of the patient is important to keep them stable in cases of emergency as well as to relieve the primary caregivers from 24 hours stress and at the same time the harmful effects of substance abuse must be well understood by the patient themselves so that they does not continue with the toxic addictions while the treatment is in progress. Multimorbity is a critical issue that demands active involvement of a collaborated multidisciplinary team as well as family members which again adds the ethical and legal considerations related to the patient and the treatment in order to treat the patient walk and ensure a comfortable living and a decent end of life care. This assignment would discuss all these aspects with clarity. The third and the final portion would enumerate the empirical study of the primary complexity which is hypertension, in this particular case study, and the steps taken to provide support, comfort and autonomy to the patient at the highest level possible. Thorough research and interaction would lead to proper understanding the clusters of medical conditions and deep insight and perception may bring forth improved treatments and health care services.

Multiple conditions have been identified among cohorts of adult population in England while the geriatric population has been ailing with numerous complex health issues (NIHR 2021). Multimorbity is a current phenomenon that the entire world has been encountering and it may impact at any age yet the geriatric population happens to be suffering in an enormous proportion. The global population have been ageing and a vital part of this demographic shift stands as a reason of the increase of critical illnesses. Chronic respiratory and cardiovascular diseases are directly proportional to ageing and at the same time such chronic diseases cluster together giving birth to further complications and fatality which indicates that comorbidity must be dealt seriously to offer a scope to the geriatric population to age in a healthy manner (Divo, Martinez and Mannino 2014). The government must take initiatives to address the health complexities and support the delicate service requirements of the constantly increasing multimorbid population (Afshar et al., 2015).

Complexities of managing comorbid chronic conditions in aging populations

The surge witnessed in co-morbid chronic ailments among the ageing population worldwide, over the last twenty years, have been a subject of concern of the government with restricted financial resources in both developed and developing nations. Most of the countries have identified the growing need for developing an integrated healthcare system to improve patterns of care, standard and safety of care, accessibility and cost efficacy of care. Since the program deals with the geriatric population, the pivotal responsibility for primary healthcare should encompass seamless and comprehensive care around the patient having a core dimension of integration. Fragmentation within the realms of health and social care services results in the patients, with need for complex care, are compelled to arrange for their own service providers which may turn out to be enormous and confusing. Most of the nations identify the need to care coordination yet there is a dearth of a solo conceptual model for the concerned issue and the whole system generates much ambiguity and confusion. Case management has been adopted as the most significant intervention among the plethora of approaches to care coordination has been formulated as an earmarked, community oriented and the most proactive approaches which encircle case finding, assessment with care planning and coordination. Patient navigation is a vital part of primary care that aims at linking the patient and their family to the service providers, specialist care and also community oriented health and social services that may provide patient specific care. The care coordinator may belong to plethora of backgrounds of professionals that involves the nurses, social workers, physiotherapists, occupational therapists but each of them must possess the necessary skill sets to provide relevant care. For example, patients with severe pathological disorders need clinical nurses while the social care experts may provide care to patients in rehabilitation phases and with functional decline (Karam et al. 2021). The primary healthcare practices have deployed a team based model in which the social workers and the registered nurses work in collaboration and this model has proved its efficacy in enhancing the communication between the care providers and patients with multiple complexities. It has been noticed that care coordination led by the nurses proved to bring better clinical results in imparting better treatment at reduced cost with improved patient condition (Karam et al. 2021).

The pivotal challenges that come forward while dealing with multiple morbidity issues, the plurality of conditions determine the estimation of seriousness. Mr. XY has been suffering from long term conditions like diabetes with chronic pain in groin from hidradenitis suppurativa along with critical conditions like hypertension along with symptoms of frailty. Hypertension is a particular health condition in which the pressure that the blood exerts on the arterial walls is too high, consequently exerting excess pressure on the heart and can bring about heart diseases or stroke if left untreated over time. It is commonly known as high blood pressure which can be considered as one of the chronic heart diseases. The conditions are critical and need seamless care service and constant medical intervention (Stafford et al. 2018). Patients suffering from hypertension most often suffer from additional chronic illnesses which also degrade the quality of life in the preliminary stages bringing fatality in the later stages. Although, the last few decades have witnessed improvement in blood pressure control rates over the globe due to increased awareness and diet management which would reduce the chances of cardiovascular risks. Additionally, well-tolerated medications that can treat hypertension are available at a nominal cost in the global market that would reduce the fatality rates. In case of hypertensive patients above the age of 65 years, new guidelines as well as the newly found evidences and recommendations have seen a sea change that needs to be adopted by the modern health care professions to enhance efficacy of the treatment. Hypertension has been defined as a systolic blood pressure above 130mmHg or the diastolic pressure beyond 80mm Hg and this condition is vastly common in the older adults in most parts of the world. The research studies conducted about 30 years ago, had supported the hypertensive therapy among the older adults in order to reduce cardiovascular risks, and those researches include SHEP trial (Systolic Hypertension in the Elderly Program),  MRC trial ( Medical Research Council) in older adults, Syst-Eur trial, and Hypertension  in the Very Elderly trial and most of the patients were recorded to have a baseline mean systolic BP of about 160mm Hg in place of 140mm Hg setting a much higher treatment target for the older adults (Clark, Hall and Jones 2020).

Diabetes and hypertension often seem to coexist bringing about additive enhancement in the risk of cardiovascular diseases. Hypertension is a prevalent comorbid condition among the patients with Type 1 and Type 2 Diabetes in comparison with the general population and happens with about 75% of patients with Diabetes mellitus. Arterial blood pressure often causes renal damage and also enhances the course of the microvascular and macrovascular complications of Diabetes. Hypertension has been found to precede Diabetes and again, patients with type 2 Diabetes and nephropathy have been recorded with circadian changes in the blood pressure that could be correlated to increased risk of nephropathy. However, early detection of nocturnal hypertension with an early intervention by dint of angiotensin blockade may defer the progression Diabetic nephropathy (Schutta 2007).

The clinical characteristics of the prevalence of frailty in patients are still unknown whether the functional capacity for screening frailty is much useful. The clinical portrait of physical frailty is generally determined by the application of Fried criteria that includes the level of exhaustion, the amount of body mass lost, lower physical activity, tolerance towards exercise, capacity to perform other functions or any other associated anxiety or depressive symptoms and the fatigue score of the patient. A substantial proportion of hypertensive patients is affected by physical frailty who need a home-based intervention. More vivid studies are required for frailty management; however the gait speed functions as a simple tool for screening physical frailty among the aged population (Gephine et al. 2021). Hidradenitis suppuritiva (HS) happens to be a chronic inflammatory condition of the skin that impacts the follicular part of the body resulting in pain in the nodules, abscesses and also the draining sinus tracts in various regions of the human body. HS is more prevalent among the women yet it may happen to men too. The current empirical study has shown that this cutaneous disease itself may cause severe morbidity; nevertheless, it is associated with a multitude of comorbidities among with cardiovascular diseases are the most customary. HS brings about a substantial comorbidity issue not only in association with the skin but also endocrine, cardiovascular, metabolic, gastrointestinal, rheumatic and also psychiatric disorders that degrade the quality of life of the patient. Thus, signs of HS must be identified and addressed with immediate navigation to the dermatologists to perform necessary screening and referral for proper management of this issue (Carton and Driscoll 2019).

Pharmacological treatment of Hypertension

The present pharmacological treatment of Hypertension is much based on changing lifestyle that would help to manage the blood pressure levels. The healthcare provider usually suggest lifestyle changes like eating heart healthy diet with less sodium content, maintaining ideal body weight, optimum exercise and resting time and no addiction of alcohol or tobacco. Above the age of 65, medication becomes mandatory in most of the cases because at that age, only lifestyle modification cannot keep the increasing blood pressure in control. Apart from taking low sodium diet, diuretics, also known as water pills, may be prescribed in order to remove excess water and sodium from the body. There are different varieties of diuretics that include thiszide, loop and potassium sparing. The most commonly used diuretics are chlorthalidone, hydrochlorothiazide and some others. Maintaining the potassium level is absolutely essential in hypertensive patients but frequent urination due to Diabetes mellitus and the application of diuretics can reduce the potassium levels which should be prevented by using potassium sparing diuretics that contain triamterene. Other medications can be the Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin II receptor blockers ARB and the most effective calcium chain blockers that help the muscles of the blood vessels to relax. These medicines include amlodipine, diltiazem and others (Mayo Clinic 2021).

Medication compliance in Hypertension

Medical treatment of Hypertension has made substantial progress but non compliance on the part of the patient and then primary care provider as well as non adherence to the treatment regimen functions as a marked barrier to achieve the desired result. Improper use of drugs and often overuse or underuse results in degraded adherence to therapy and at the same time Hypertension management becomes suboptimal in cases where the health care providers are unable to provide relevant therapies due to poor diagnosis or less alignment to evidence based guidelines. Moreover, it has been observed that in most of the cases, medication adherence becomes a critical success factor in the context of successful controlling of the concerned chronic condition (CDC 2020). It has also been observed that higher adherence to antihypertensive medication has correlation with higher odds of blood pressure control; however, non-adherence to cardio-protective medications often increases the risk of death in a good number of patients (CDC 2020).

Patient awareness and education in Hypertension

While trying to assess the degree of awareness about Hypertension, it has been identified that although there is a sharp hike in the number of hypertensive patients all over the world, awareness is remarkably poor regarding the management of hypertension among the patients, their family and also among the physicians. Although, patients can live a long life with hypertension yet lack of awareness and irregularity of medication may lead to cardiovascular complications, stroke or even destroy some nerves in the kidney. High blood pressure may turn out immensely fatal in pregnant patients and obese patients.  Patient knowledge and compliance play a pivotal role while controlling blood pressure because maintaining low sodium diet, drinking adequate amount of water, exercising regularly and taking optimum amount of sleep along with proper dose of medication can help in recovery but non-compliance on the part of the patient may hinder progress and elevate blood pressure level (Alexander et al., 2003).

Diabetes

Diabetes can be effectively managed with pharmacological treatment and lifestyle modification to attain smooth control over metabolism and gaining a significant level of almost normal glycated haemoglobin. The current diabetes medications are of two types: oral and injectable and the algorithms that have been patterned for the treatment hinder the progress of the complications maintaining a strong glycaemia control. Metfermin is still the most preferred choice along with second-line treatment options too.  The dietary modifications aids in attaining the desired blood sugar level, blood pressure, lipid profile and body weight, simultaneously improving sleep patterns, psychological health and overall quality of life. Dietary changes along with physical exercise and adequate rest may improve the condition (Marín-Peñalver et al. 2016). Compliance to diabetes related drugs as prescribes by the primary health care provider assists to accomplish control over the blood glucose level and prevent mortality and morbidity. Oral hypoglycaemic agents or OHAs have proved their efficacy in treating type II diabetes if taken aptly although adherence OHAs ranges between 36% and 93% within multiple populations (Aloudah et al. 2018). In diabetes mellitus, the body fails to respond to the produced insulin consequently producing less insulin and this is a life threatening comorbidity that can become fatal in absence of medication and intervention. A cohort of population in United Kingdom is living with diabetes in spite of having myriads of diabetic education campaign and programs. It is mandatory for the diabetic patients to be conscious of the nature and literature of the disease, treatment options and procedures, risk factors and added complications that are associated with the disease. A study reveals that the interconnection between health awareness, complication awareness and diabetic control among the patients worldwide score in a negative which is pretty alarming. More steps should be taken to spread awareness and health literacy among the population, exclusively programmes should be arranged for the geriatric population (Nazar et al. 2015).

Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic inflammatory disease that may lead to impairment if not identified and treated appropriately. It is a recurrent condition that often occurs genetically and is also influenced by habitual factors like smoking and also obesity. It creates huge impact on the physical, psychological, social and emotional aspect of the patient and often comes as a comorbid condition (Magalhães et al. 2019). HS may require a combined treatment of both medication and surgery to reduce the complication. The medications used are generally antibiotics to be applied on skin, steroid injections like Triamcinolone, and hormonal therapy with estrogens containing contraceptive pills in advanced cases of women. The physician might prescribe oral medications such as clindamycin, doxycycline, rifampin. The injections manipulate the immune system of the body dismantling the disease cycle and bringing in development and improvement in health. Pain medications are added to provide support to trauma management (Mayo Clinic Staff 2022). Although HS possesses a weird structure, most patients overlook the condition in nascent stages which bring forth late diagnosis with enhanced complications. Improved awareness and promptness of action may help in recovery and early self diagnosis may reduce chances of complications (Ribero et al. 2019).

Relevant ethical and legal considerations

Patient identifiable data is an absolute requirement for the purpose of research and study of the various developmental stages of the disease register but gathering such data proves to be exorbitantly expensive there are security protocols for patient data. The legal obligations and justifications for the collection of patient identifiable data devoid of consent generates ethical and legal issues addressed at the time of the development of the population based disease register. The Data Protection Act of 1998 and Caldicott principles of good practice on the utilisation of personal data have been discussed in multiple commentaries and case studies but ambiguity still prevails on the ground of using personal data for research purposes (Strobl 2000). There exists massive misconception and misinterpretation of the common law duty of confidentiality along with section 60 of Health and Social Care Act of 2001. The former mandates that sharing personal data with third parties is strictly prohibited even if it adheres to the conditions of DPA 1998. Adherence to section 60 ascertains that collection of patient identifiable data is lawful for research purposes yet collecting data on implementation of this act is expensive and risky. This results in poor research scope that enhances the chances of ambiguity to prevail even in future reducing further scope of improved treatment and therapies (Haynes, Cook and Jones 2007). 

Latest advancements in personalized hypertension management for the elderly.

The following paper would reveal the prevailing advancements in personalised and individualised medication and management of Hypertension. The strategies and goals of the treatment procedures of the elderly population is quite segregated than treating the younger adults. Many hypertensive medications like the beta-blockers and alpha blockers cannot be recommended for the geriatric population and most of the Hypertensive patients at the elderly age require more than one medication to reach the BP goal. Moreover, the elderly patients are prone to developing orthostatic hypotension, which is actually a potentially fatal drop of the blood pressure during change of positions from supine to standing position with an enhanced risk of syncope, fall or injury. They are more at risk to stroke, myocardial infarction or any other cardiovascular mortality issues. At this age, they become immensely sensitive to salt intake compared to the younger adults and hence, the difference between systolic and diastolic pressure is disrupted with intake of more salt. These characteristics must be considered while selecting an appropriate treatment mandate for the ageing population (Nguyen et al. 2012).

Conclusion

The paper in its conclusion provided the insight that individualised or personalised treatment can radically modify the condition of hypertension patients, even in older adults, providing them autonomy and functionality to adopt self care along with the confidence to face the physical, emotional, psychological and social challenges that are associated with the concerned disease. Hypertension in itself, is a cluster of troubles and it attracts numerous comorbidities that the patient is compelled to deal with, while already encountering the impacts of Hypertension itself. Every patient is unique and they need personalised perception of their condition and this would help the healthcare provider to gain the accountability of the patient who in return would allow maximised cooperation and compliance while attempting comorbidity management. Comorbidity is a global issue that has become one of the leading causes of death across the world in the last two decades and the comorbid population is increasing day by day. Hence, to fight the cause, the area that still needs to be addressed is enhancement of personalised care to pertain self management training, skill and emotional support to the patient for improvement of their condition. In spite of the limitation of research due to the various acts that hinder sharing of patient identifiable data, the medical world has been striving to emerge with novel and improved methods of treatment with futuristic, evidence-based approach that would not only improve the condition of the patient but also enhance cordial and interdependent relationship between the healthcare provider and the patient.