Clinical issues - functional decline, frailty, and multimorbidity, and their implication for management

Overview

Functional decline, frailty, and multimorbidity frequently coexist in older patients and together require a fundamentally different management approach from single-disease-focused care - management is organised around function and goals, not disease-by-disease
The majority of adults over 85 have multimorbidity (two or more chronic conditions), and disease-specific single-condition guidelines often do not account for this combined burden or for competing treatment priorities

Multiple chronic conditions interact - treatment for one condition can worsen another (e.g. beta-blockers for cardiac disease worsening COPD symptoms), and cumulative treatment burden (medication load, appointment burden) itself contributes to functional decline

Comprehensive geriatric assessment identifies the functional, cognitive, and social impact of the combined disease burden, which single-organ-system review misses
Functional trajectory (not just current disease severity) guides prognosis and treatment intensity decisions - a patient in steady functional decline despite treatment may need a shift in goals rather than escalation of disease-specific therapy

Prioritise by patient goals and functional impact, not by disease severity in isolation - treating the condition causing the most functional/quality-of-life impact first, even if it is not the most "dangerous" condition by conventional risk metrics
Deprescribing and simplification of complex regimens is often as valuable an intervention as adding new disease-specific treatment in this population

Functional decline in the setting of multimorbidity is often the earliest and most clinically meaningful marker of deterioration - preceding, and sometimes more informative than, any single disease-specific biomarker

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