General Principles of Management of Patients with Multimorbidity and Frailty

The progressive ageing of the population has led to a new health scenario, where frailty and multimorbidity are extremely common. Multimorbidity, usually described as the coexistence of two or more chronic diseases in the same individual, is a heterogeneous and complex entity characterized by the intricate relationship between chronic conditions and clinical, social, behavioural and functional factors and is associated with worse health outcomes and a challenging clinical management. Frailty, an increased vulnerability to physiological stressors, also confers increased risk of adverse health outcomes including mortality, hospitalization and disability. The presence of chronic diseases and multimorbidity has a central role in initiating or worsening frailty, and most frail individuals are also multimorbid. However, there is a lack of guidance to optimize the management of complexity, and guidelines for chronic diseases are usually single-disease oriented. A new clinical approach to deal with complexity has been underlined by the National Institute for Health and Care Excellence on multimorbidity guidelines and the recently published Italian Guidelines on Multimorbidity and Polypharmacy that strongly suggest a multidisciplinary approach to patients with multimorbidity to avoid fragmentation of care between different specialists, stratification strategies to detect individuals with more demanding needs and complex-to-treat groups, standard assessment of frailty to identify a target multimorbid population that is more susceptible to negative outcome and that can benefit from an integrated, patient-centred and holistic management. This approach outlines the importance to incorporate patients’ preferences and expectations, to empower self-management of one’s health, to discuss and accommodate individualized care plans with patients and caregivers, and to support a more flexible use of existing guidelines on single diseases to optimize benefits of treatment (such as symptomatic treatment of pain), minimize potential harms and reduce polytherapy. In this context, precision medicine could be a key to integrate the care of multimorbidity and frailty and to create effective interventions to comprehensively target multimorbidity.