Multimorbidity & Frailty Flashcards
What is meant by a long-term condition (chronic disease)?
How long does it last for?
a condition for which there is currently no cure
they can only be managed with drugs and other treatment
long-term conditions will be with the patient for a very long period of time and potentially for their entire life
What are some examples of long-term conditions?
- COPD
- hypertension
- diabetes
- arthritis
What is meant by multimorbidity?
the presence of 2 or more long-term health conditions
(can include both physical and mental health conditions)
What 5 different categories of conditions can be included as multimorbidities?
- defined physical or mental health conditions
- e.g. diabetes, generalised anxiety disorder, schizophrenia
- ongoing conditions, such as learning disabilities
-
symptom complexes (a group of associated symptoms with no defined organic cause)
- e.g. frailty, chronic pain syndrome, fibromyalgia, IBS
- sensory impairments, such as hearing or sight loss
- alcohol or substance misuse
What are the 5 most common long-term conditions in the UK?
What is significant about how these conditions occur?
- hypertension
- depression / anxiety
- chronic pain
- hearing loss
- irritable bowel syndrome
- groups of conditions tend to occur in clusters
- e.g. HTN associated with chronic pain, diabetes & hearing loss
Approximately what % of English people have 2 or more long-term conditions?
- 2%
* more than 1/4 of the UK population live with multimorbidity
How is the incidence of multimorbidity linked to age?
Are there more younger or older people living with multimorbidity and why is this significant?
the incidence of multimorbidity increases substantially with age
- over 50% of those with multimorbidity are <65
- there are more younger people alive than older people
- nearly 2/3 of those with a physical-mental health comorbidity are <65
- this is significant as it affects people of working age
How is the onset of multimorbidity influenced by socioeconomic status?
- onset of multimorbidity occurs 10-15 years earlier in people in areas of socioeconomic deprivation
- people from this background have a shorter life expectancy and are more likely to become unwell with multiple longterm conditions at a younger age
How is the management of a patient with a longterm condition different?
- often the patient will know more about living with the condition than the doctor
- you are not trying to work out the diagnosis and treatment
- you are there to listen to the problems the patient has and help to look for solutions
What are some of the common problems someone with multiple long-term conditions may struggle with?
- polypharmacy means there is a higher risk of side effects and medications interacting with each other
- can be confusing when there are multiple healthcare professionals involved, especially if there is lack of coordination between them
- attending multiple appointments can be time-consuming and interfere with work
- often unable to work / work reduced hours which can cause financial problems
- mental health conditions are caused / exacerbated by long-term conditions and the impact on functioning / independence
What is the definition of frailty?
the clinically recognisable state of increased vulnerability resulting from age-associated decline in reserve and function across multiple systems
such that the ability to cope with everyday or acute stressors is compromised
What is a major problem with describing a patient as “frail”?
- the dictionary definition of frail is very negative
- easily shattered, morally weak, feeble, decrepit
- this is demeaning / offensive to the patient
How do people with frailty recover from a minor health issue?
- frailty means that even minor events can trigger disproportionate changes in health status
- after these changes, the patient fails to return to their previous level of health
- minor events include conditions such as UTIs and chest infections
How is frailty measured?
- frailty is a spectrum that ranges from mild to severe frailty
- it is measured using the Rockwood scale
Why is it important to define frailty in medicine?
- frailty defines the group of older people who are at highest risk of adverse outcomes
- such as falls, disability, admission to hospital, or the need for long-term care
- it is important to identify these people to try and minimise the risk of adverse outcomes
- not trying to improve their life expectancy, but reduce the burden that healthcare can carry for these people
Is ageing the same thing as frailty?
- they are not the same thing, but are inherently linked
- the older someone becomes, the more likely they are to become frail
- an old person may still be living independently and active - they cannot be described as frail
What % of older people can be described as frail?
- 10% of individuals over 65
- 25-50% of individuals over 85
Do frail people always have multimorbidity?
- often people with frailty will have multiple long-term health conditions
- but people can become frail as they get older and not have any known long-term health conditions
What are the 5 main reasons why the concept of frailty is used?
- active identification and individualised management can reduce the risk of adverse events
-
interventions can be put in place to help
- medication reviews, exercise programmes, proactive case management, nutrition/protein
- to reduce fragmentation of care
- to stop the focus on individual conditions and focus on quality of life
- to improve advanced care planning / end of life care
Why are medication reviews important in people with frailty?
- these individuals are most likely to come to harm from polypharmacy and overmedicalisation
- medication review looks at medications that may be causing more harm than good and reviews interactions
- repeating on a regular basis can reduce risk of falls / hospital admission and improve quality of life
What is meant by proactive case managment in people with frailty?
- this usually involves a community matron overviewing the care of an individual
- it prevents unnecessary overmedicalisation and coordinates healthcare
- these individuals are likely to be under the care of multiple healthcare professionals and be overburdened with appointments
What are the 6 ways in which primary care is involved in diagnosing and managing cancer?
- prevention - e.g. advice for smoking cessation
- screening for cervical, breast and bowel cancer
- recognition of the symptoms and signs
- referral for further investigation if suspicion is made
- support / cancer care reviews and management of other coexisting conditions
- palliative care for those at the end of their life
What are the lifestyle factors that can increase and reduce the risk of breast cancer?
Increased risk:
- smoking
- obesity (BMI >30)
- drinking 2 or more units of alcohol daily
- combined hormone replacement therapy
- combined oral contraceptive pill
Reduced risk:
- oestrogen only HRT
- 2.5 hours of moderate exercise weekly
What are the 5 ways in which cancer may be detected?
- through a screening programme
- presentation with red flag symptoms and 2WW referral
- monitoring of vague symptoms and signs / clinician intuition
- incidental finding on imaging
-
emergency / late presentation
- e.g. haematemesis, increasingly worsening headache
What are “red flag” symptoms associated with cancer?
What is the appropriate next step for these patients?
- red flag symptoms are those that have an increased risk of being associated with cancer
- e.g. rectal bleeding, postmenopausal bleeding, haemoptysis
- these patients are referred to secondary care urgently via the 2 week wait (WW) pathway
- they should be seen within 2 weeks in a clinic that has the facilities to make a diagnosis (or exclusion) of cancer
How would you manage a patient presenting with vague symptoms / signs that could be associated with cancer?
- these patients are NOT eligible for referral via the 2WW pathway
- often the patient is monitored to see if symptoms resolve / get worse
- may consider some imaging
- try to treat other causes of the symptom to see if it clears up or remains
What guidelines are in place to assist GPs in knowing when to refer someone with suspected cancer?
What is the difference between early diagnosis and screening programmes?
Early diagnosis:
- aims to detect symptomatic patients at an early (treatable) stage
- e.g. PSA testing in men with urinary tract symptoms
Screening:
- the use of simple tests across a healthy population to identify the individuals who have a disease but do not yet have symptoms
- e.g. cervical screening in all asymptomatic women aged >25
What are the 3 different delays in cancer diagnosis and treatment?
- access delay
- diagnosis delay
- treatment delay
What is meant by access delay?
In which group is this more prevalent and why?
- people who have cancer symptoms but are not aware that they need to see a healthcare professional
- they may be unaware that their symptoms are associated with cancer
- or they may be unable to access healthcare services
- more common in socioeconomically deprived areas as there is less education, lower availability of services and financial issues (cannot afford transport to hospital etc.)
What is meant by diagnosis delay and why might this occur?
- the delay between an individual presenting to a healthcare professional and being diagnosed with cancer
- there may be difficulties with referral
- it may be due to poor performance of the healthcare worker
- or sometimes cancer can present with subtle symptoms / signs and it is difficult to make a diagnosis
What is meant by treatment delay?
Why might this occur?
- the delay between a patient being diagnosed with cancer and their first treatment
- may be due to waiting lists or limited resources
- less likely to occur in a developed country with a national health service
What are the principles of a good screening programme?
- important health problem where the prevalence is high enough to justify effort + costs of screening
- there must be acceptable, readily available and effective treatments available
- resources must be sufficient to cover nearly all of the target group
- facilities exist for confirming the diagnosis and for treatment in those with abnormal results
- there must be a suitable latent and symptomatic stage
- the screening test must be demonstratibly effective
Why does referral for colonoscopy after bowel screening differ between countries?
- bowel screening looks at the levels of haemoglobin in stool samples
- if Hb is above a certain threshold, the patient is offered diagnostic colonoscopy
- the threshold level of Hb to warrant referral is different across the world due to the availability of resources (colonoscopy) in that country
What are the potential harms of a screening programme?
False positives:
- describes people who do NOT have cancer but test positive through screening
- result in additional testing, invasive diagnostic procedures and patient anxiety
False negatives:
- describes people WITH cancer that is not detected through screening
- false reassurance can result in delayed presentation / diagnosis when symptoms appear
Over diagnosis / treatment of preclinical cancers:
- these are cancers that would have never caused symptoms or had a serious threat to the health of the patient
- there is unnecessary treatment that injures the patient
What are the screening programmes available in the UK?
- breast
- cervical
- bowel - FIT testing
- bowel - colonoscopy
- lung - whole population
- lung - targeted low dose CT screening
- PSA testing
- breast, cervical and FIT testing are offered across the UK to the relevant populations
When may a PSA test be offered?
Why could the threshold for black men potentially become lower?
the rate of prostate cancer is 2x higher in black men compared to white men
- in general, everyone is advised against having a PSA test if they do not have symptoms
- this is due to the high rate of false negatives / positives
How does coming from an area of socioeconomic deprivation affect life expectancy and disability?
- people living in the poorest neighbourhoods die on average 7 years earlier than those in the wealthiest areas
- the average difference in disability free life expectancy is 17 years
How does the incidence of long-term conditions link to level of socioeconomic deprivation?
- most individual long-term conditions are more common in people from lower socioeconomic groups
- the conditions are often more severe
How does socioeconomic deprivation affect cancer?
- highest rates of cancer in low socioeconomic groups
- higher rates of mortality after diagnosis in deprived areas
Who is eligible for cervical screening?
- all women and people with a cervix aged between 25 to 64
What does cervical screening check for?
- a speculum is inserted into the vagina and a small brush inserted to collect a sample of cells from the cervix
- the sample is checked for certain types of human papillomavirus (HPV) that can cause changes to the cells of the cervix
- if the “high risk” HPV is found, the sample is checked for any changes in the cells of the cervix
- this allows for treatment before the abnormal cells turn into cervical cancer
How does the breast screening programme work?
- it involves a mammogram (X-rays) to look for cancers that are too small to see or feel
- the breast is compressed between 2 pieces of plastic whilst the X-rays are taken
- the X-ray machine is then tilted to one side and the process will be repeated on the side of the breast
Who is eligible for breast screening?
- anyone registered with a GP as a female will be invited every 3 years between the ages of 50 and 71
Who is eligible for bowel screening?
- anyone aged 60 to 74 years
- it is expanding to become available to everyone aged 50 - 59 years
How does the bowel screening programme work?
- a faecal immunochemical test (FIT) is performed at home
- a small sample of faeces is collected and sent to a lab to look for blood within it
- blood can be a sign of cancer, or polyps, which can turn into cancer over time
- if the test comes back positive, a colonoscopy may be required
Why is there not a PSA prostate cancer screening programme?
- there is a high risk of men being overdiagnosed and undergoing unnecessary treatment for cancers that would not have caused harm
- this treatment may result in anxiety, complications, infections, sexual dysfunction and bowel control problems
- the screening programme would not save any lives
