Patient-Centered Decision-Making in Multimorbid Older Adults: Challenges for Contemporary Internal Medicine
DOI:
https://doi.org/10.64784/206Palabras clave:
Multimorbidity, Clinical complexity, Internal medicine, Geriatrics, Polypharmacy, Frailty, Chronic diseases, Patient-centered care, Shared decision-making, Public health, Healthcare systems, Latin America, Aging population, Functional decline, Healthcare fragmentationResumen
Multimorbidity and clinical complexity have become increasingly important challenges in contemporary internal medicine due to demographic aging, epidemiological transition, and the growing prevalence of chronic non-communicable diseases. The coexistence of multiple chronic conditions frequently leads to polypharmacy, frailty, cognitive impairment, functional decline, increased healthcare utilization, and difficulties in therapeutic decision-making. The present review aimed to analyze the relationship between multimorbidity and clinical complexity within modern internal medicine, emphasizing the impact of chronic disease accumulation, patient-centered care, healthcare fragmentation, and public health determinants, particularly in Latin American contexts such as Mexico, Colombia, and Ecuador. A narrative review methodology based on the Scientific Method was employed using scientific literature indexed in PubMed, Scopus, Google Scholar, BMJ Journals, and related academic databases. The analyzed evidence demonstrated that multimorbidity significantly increases healthcare utilization, medication-related risks, hospitalization, and therapeutic complexity, particularly among geriatric populations. The findings additionally highlighted the importance of interdisciplinary management, shared decision-making, comprehensive geriatric assessment, and individualized therapeutic planning focused on functionality and quality of life rather than isolated disease-centered targets. The review concludes that modern internal medicine requires integrative and humanistic healthcare models capable of balancing scientific evidence with patient priorities, social determinants, and long-term healthcare sustainability.
Referencias
• Aggarwal, P., Woolford, S. J., & Patel, H. P. (2020). Multi-morbidity and polypharmacy in older people: Challenges and opportunities for clinical practice. Geriatrics, 5(4), 85. doi:10.3390/geriatrics5040085.
• American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. (2012). Guiding principles for the care of older adults with multimorbidity: An approach for clinicians. Journal of the American Geriatrics Society, 60(10), E1–E25. doi:10.1111/j.1532-5415.2012.04188.x.
• Boyd, C. M., Darer, J., Boult, C., Fried, L. P., Boult, L., & Wu, A. W. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA, 294(6), 716–724. doi:10.1001/jama.294.6.716.
• Boyd, C. M., Smith, C. D., Masoudi, F. A., Blaum, C. S., Dodson, J. A., Green, A. R., … & Tinetti, M. E. (2019). Decision making for older adults with multiple chronic conditions: Executive summary for the American Geriatrics Society guiding principles. Journal of the American Geriatrics Society, 67(4), 665–673. doi:10.1111/jgs.15809.
• Brown, E. L., Macdonald, W., Fong, S., et al. (2022). Shared decision making between older people with multimorbidity and general practitioners: A qualitative study. British Journal of General Practice, 72(721), e609–e618. doi:10.3399/BJGP.2021.0529.
• Calderón-Larrañaga, A., Vetrano, D. L., Onder, G., Gimeno-Feliu, L. A., Coscollar-Santaliestra, C., Carfí, A., … & Fratiglioni, L. (2019). Assessing and measuring chronic multimorbidity in the older population: A proposal for its operationalization. Journals of Gerontology: Series A, 72(10), 1417–1423.
• Farmer, C., Fenu, E., O’Flynn, N., & Guthrie, B. (2016). Clinical assessment and management of multimorbidity: Summary of NICE guidance. BMJ, 354, i4843. doi:10.1136/bmj.i4843.
• Hoffmann, T., Jansen, J., & Glasziou, P. (2018). The importance and challenges of shared decision making in older people with multimorbidity. PLoS Medicine, 15(3), e1002530. doi:10.1371/journal.pmed.1002530.
• Ho, I. S. S., Azcoaga-Lorenzo, A., Akbari, A., Davies, J., Hodgins, P., Khunti, K., … & Mercer, S. W. (2022). Variation in the estimated prevalence of multimorbidity: Systematic review and meta-analysis of 193 international studies. BMJ Open, 12(4), e057017. doi:10.1136/bmjopen-2021-057017.
• Huaquía-Díaz, A. M., Chalán-Dávila, T. S., Carrillo-Larco, R. M., & Bernabé-Ortiz, A. (2021). Multimorbidity in Latin America and the Caribbean: A systematic review and meta-analysis. BMJ Open, 11(7), e050409. doi:10.1136/bmjopen-2021-050409.
• Macinko, J., Andrade, F. C. D., Nunes, B. P., & Guanais, F. C. (2019). Primary care and multimorbidity in six Latin American and Caribbean countries. Revista Panamericana de Salud Pública, 43, e8. doi:10.26633/RPSP.2019.8.
• Marengoni, A., Angleman, S., Melis, R., Mangialasche, F., Karp, A., Garmen, A., … & Fratiglioni, L. (2011). Aging with multimorbidity: A systematic review of the literature. Ageing Research Reviews, 10(4), 430–439. doi:10.1016/j.arr.2011.03.003.
• Mercer, S. W., Salisbury, C., & Fortin, M. (2014). ABC of multimorbidity. Wiley Blackwell.
• Muth, C., Blom, J. W., Smith, S. M., Johnell, K., Gonzalez-Gonzalez, A. I., Nguyen, T. S., … & Glasziou, P. P. (2019). Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: A systematic guideline review and expert consensus. Journal of Internal Medicine, 285(3), 272–288. doi:10.1111/joim.12842.
• National Institute for Health and Care Excellence. (2016). Multimorbidity: Clinical assessment and management (NICE Guideline NG56). NICE.
• Nicholson, K., Liu, W., Fitzpatrick, D., Hardacre, K. A., Roberts, S., Salerno, J., Stranges, S., Fortin, M., & Mangin, D. (2024). Prevalence of multimorbidity and polypharmacy among adults and older adults: A systematic review. The Lancet Healthy Longevity, 5(4), e287–e296. doi:10.1016/S2666-7568(24)00007-2.
• Pazan, F., & Wehling, M. (2021). Polypharmacy in older adults: A narrative review of definitions, epidemiology and consequences. European Geriatric Medicine, 12, 443–452. doi:10.1007/s41999-021-00479-3.
• Reeve, J., Maden, M., Hill, R., Turk, A., Mahtani, K., Wong, G., … & Gabbay, M. (2022). Deprescribing medicines in older people living with multimorbidity and polypharmacy: The TAILOR evidence synthesis. Health Technology Assessment, 26(32), 1–148. doi:10.3310/AAFO2475.
• Rozsnyai, Z., Jungo, K. T., Reeve, E., Poortvliet, R. K. E., Rodondi, N., Gussekloo, J., … & Streit, S. (2020). What do older adults with multimorbidity and polypharmacy think about deprescribing? BMC Geriatrics, 20, 471. doi:10.1186/s12877-020-01843-x.
• Tinetti, M. E., Fried, T. R., & Boyd, C. M. (2012). Designing health care for the most common chronic condition—multimorbidity. JAMA, 307(23), 2493–2494. doi:10.1001/jama.2012.5265.
