Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium

The pattern of patients admitted to internal medicine wards has dramatically changed in the last 20–30 years. Elderly people are now the most rapidly growing proportion of the patient population in the majority of Western countries, and aging seldom comes alone, often being accompanied by chronic diseases, comorbidity, disability, frailty, and social isolation. Multiple diseases and multimorbidity inevitably lead to the use of multiple drugs, a condition known as polypharmacy. Over the last 20–30 years, problems related to aging, multimorbidity, and polypharmacy have become a prominent issue in global healthcare.

This review discusses how internists might tackle these new challenges of the aging population. They are called to play a primary role in promoting a new, integrated, and comprehensive approach to the care of elderly people, which should incorporate age-related issues into routine clinical practice and decisions. The development of new approaches in the frame of undergraduate and postgraduate training and of clinical research is essential to improve and implement suitable strategies meant to evaluate and manage frail elderly patients with chronic diseases, comorbidity, and polypharmacy.

Journal of Comorbidity 2011;1(1):28–44.



Internal and geriatric medicine: an alliance for the challenges of the elderly.

It is now time for the renaissance of an internal medicine able to deal optimally with the changing demography, tackle the challenges of the complexity of patients admitted to internal medicine hospital wards, and ensure the integration and continuity of care between the network of health and social services. This new era of internal medicine provides the opportunity for a renaissance of our practice, to overcome the risk of feeling overwhelmed and avoid the nihilism of the routine daily clinical activity. Current health care structures where the internists practice medicine do not facilitate the multidimensional approach to the elderly with multimorbidity, and encourage to measure outcomes related to single diseases, whereas the challenge is to delivery patient-centered care to complex chronic patients with multimorbidities. With their basic training designed to acquire a holistic approach to clinical problems, internists are fortunately in an optimal position to acquire this new knowledge and expertise, even though this acquisition requires some degree of humility joined with awareness of the ongoing change of their mission.

Eur J Intern Med. 2012 Sep;23(6):479-82. doi: 10.1016/j.ejim.2012.06.008. Epub 2012 Jul 4.



Multimorbidity and polypharmacy in the elderly: lessons from REPOSI.

The dramatic demographic changes that are occurring in the third millennium are modifying the mission of generalist professionals such as primary care physicians and internists.
Multiple chronic diseases and the related prescription of multiple medications are becoming typical problems and present many challenges. Unfortunately, the available evidence regarding the efficacy of medications has been generated by clinical trials involving patients completely different from those currently admitted to internal medicine: much younger, affected by a single disease and managed in a highly controlled research environment. Because only registries can provide information on drug effectiveness in real-life conditions, REPOSI started in 2008 with the goal of acquiring data on elderly people acutely admitted to medical or geriatric hospital wards in Italy. The main goals of the registry were to evaluate drug prescription appropriateness, the relationship between multimorbidity/polypharmacy and such cogent outcomes as hospital mortality and re-hospitalization, and the identification of disease clusters that most often concomitantly occur in the elderly. The findings of 3-yearly REPOSI runs (2008, 2010, 2012) suggest the following pertinent tasks for the internist in order to optimally handle their elderly patients: the management of multiple medications, the need to become acquainted with geriatric multidimensional tools, the promotion and implementation of a multidisciplinary team approach to patient health and care and the corresponding involvement of patients and their relatives and caregivers. There is also a need for more research, tailored to the peculiar features of the multimorbid elderly patient.

Intern Emerg Med. 2014 Oct;9(7):723-34. doi: 10.1007/s11739-014-1124-1. Epub 2014 Aug 28.