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Amy C. Justice, MD, PhD Section Chief, General Internal Medicine VA Connecticut Healthcare System

Optimizing Health Care in the Context of Multimorbidity, Polypharmacy, and Decreasing Physiologic Reserve. Amy C. Justice, MD, PhD Section Chief, General Internal Medicine VA Connecticut Healthcare System Professor of Medicine and Public Health Yale University. Multimorbidity.

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Amy C. Justice, MD, PhD Section Chief, General Internal Medicine VA Connecticut Healthcare System

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  1. Optimizing Health Care in the Context of Multimorbidity, Polypharmacy, and Decreasing Physiologic Reserve Amy C. Justice, MD, PhD Section Chief, General Internal Medicine VA Connecticut Healthcare System Professor of Medicine and Public Health Yale University

  2. Multimorbidity

  3. HIV Has Never Occurred in a Vacuum • Irrespective of aging, HIV care complicated by: • Multi drug regimens susceptible to non adherence, resistance, and toxicity • Co infections (HCV, TB, MDR-TB) • Socio economic issues: stigma, substance addiction, incarceration, homelessness, under nutrition • Aging adds multiple chronic diseases (multimorbidity) to mix

  4. Multimorbidity and Age in HIV+ South Africans % Prevalence WHO Survey “Study of global AGEing and adult health (SAGE), South African subjects”Data are restricted to those with HIV infection. Negin J. et al. AIDS 2012 26(S1):S55-63

  5. Incident Chronic Disease: Swiss Cohort 2008-10 Of 1,189 events in 8,444 patients, only 16% were HIV events, 84% were Non HIV: Hasse B. et al. Morbidity and Aging in HIV-Infected Persons: The Swiss HIV Cohort Study CID 2011 53:1130-1139

  6. Limit of Silos: Coordination and Communication

  7. Accelerated or Accentuated? A. Accelerated and Accentuated: cancer occurs earlier among those with HIV than uninfected comparators and there are more cancer events. B. Accentuated risk: cancer occurs at the same ages but more often than among comparators. Shiels MS. Ann Intern Med 2010:153:452-460.

  8. Age at Onset of Cancer AIDS Patients and Age Matched Uninfected Individuals Looked at 26 different diagnoses, no difference (p>0.05) for 18 cancer. Differences for remaining cancers were <5 years. Shiels MS. Ann Intern Med 2010:153:452-460.

  9. Age at Diagnosis in VACS See also: IAC 2012 TUPE160 Shiels M. Age at Cancer Diagnosis in HIV+ in North America Compared to General US Population

  10. Polypharmacy

  11. Polypharmacy • Typically defined as >5 drugs • Associated with diminished marginal benefit from additional medication due to: • Nonadherence • Adverse drug events (confusion, falls, renal failure, etc.) • Risk of adverse events increases approximately 10% with each additional medication Salazar JA. Expert Opin Drug Saf (2007) 6(6):695-704 Gandhi TK. N Engl J Med 2003;348:1556-64

  12. Decreasing Physiologic Reserve

  13. Disability, Frailty, and Functional Status • 3 geriatric concepts increasingly applicable to those aging with HIV • Each is a consequence of total physiologic injury rather than of any particular diagnosis • Of note, these concepts also relate to cognitive dysfunction, especially delirium and dementia

  14. VACS Index Thresholds and Weights Age HIV Specific Biomarkers Biomarkers of General Organ System Injury VACS.MED.YALE.EDU

  15. VACS Index • Predicts mortality: • All Cause, HIV, and non HIV (European Data) • Risk of mortality over 5 years (North American Data) • Predicts morbidity: hospitalization, MICU admission, and fragility fractures • Correlated with functional performance and symptom burden • Responsive to changes in risk after ART initiation, intensification, and interruption For more information and full documentation go to: www.vacohort.org To use/comment on the VACS Index Calculator go to: HTTP://vacs.med.yale.edu

  16. We Need a “Map” to Optimize Care • A comprehensive outcome to compare effectiveness of interventions and identify those with the best benefit/harm ratio • A means of combining interventions into a strategy for medical patients with multimorbidity • A means of motivating and guiding patients and providers to pay attention to that which matters most for patient outcomes

  17. Health Risk Assessment: A Means of Navigating Complexity • Identify and prioritize modifiable risks among a lengthening list of possibilities • Motivate and map progress • Quantify harm and benefit from interventions • Level of susceptibility to adverse drug events • Short term risk of hospitalization • Risk of disability, assisted living requirements • Identify end of life to signal change in priorities

  18. We Have a Sense for 50-64 yrs,But 65+ Remains Uncharacterized

  19. Relative Risk of Incident Disease at 50-64 and 65+ Compared with <50 Yrs Relative Risk (HR) Hasse B. et al. Morbidity and Aging in HIV-Infected Persons: The Swiss HIV Cohort Study CID 2011 53:1130-9

  20. End of Life • With aging inevitably comes end of life • Aging patients want to know when they are within 5 years of death to:1 • Prepare • Make the most of remaining life • Make medical/health-related decisions 1. Ahatt C. et al. “Knowing is Better”: Preferences of Diverse Older Adults for Discussing Prognosis. J Gen Intern Med 2011, 27(5):568-75

  21. Conclusions • Multimorbidity is common for those aging with HIV and requires a new approach to care and research • Individual diagnoses less important than cumulative injury • We need tools to assess injury and its impact • In the context of polypharmacy and physiologic injury, additional medication may cause more harm than good • Need to consider what medications are most essential • Ongoing risk assessment, evidence based prioritization, and coordination of care must become the new bywords

  22. Research Priorities • Study mechanisms in multimorbidity: • “Multi-hit” (cancer) and “cumulative frailty” (geriatrics) • Develop a standard approach to measuring physiologic injury • Compare HIV+/- to determine whether HIV has distinct mechanisms of injury • Compare harms and benefits of additional treatment and of decreased treatment • Consider alternative ways of organizing and delivering care in the context of multimorbidity • Test whether care prioritized based upon risk, benefit, and preferences is more effective than UC

  23. Two Studies in General Population Illustrate the Tension in Studying Aging and HIV STOPP Polycap

  24. METHODS • Randomized 400 hospitalized patients aged 65+ yrs. to receive either usual care or screening with STOPP/START criteria with follow up recommendations to providers. • RESULTS • Unnecessary drugs decreased 36% • Underutilization of indicated drugs decreased by 21% • Improvements sustained for 6 mos. • No significant differences in deaths, falls, readmission, LOS, or f/u outpt visits—all but readmissions less in intervention arm (but not significant)

  25. 2007-2008 • 2,053 subjects; 50 centers in India • 45-80 yrs; 1 risk factor • Not on medication • Aspirin, thiazide, ramipril, atenolol, and simvastatin • Outcome: BP, LDL, heart rate, urine biomarker for plt. act. • ADE: discontinuation Yusuf S. Lancet 2009; 373:1341-51.

  26. Agrayingpandemic.tumblr.com

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