News

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Three disease clusters shape health of older Australians: Study

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A new national study has revealed that multimorbidity affects more than three quarters of older Australians, with chronic conditions tending to occur in one of three key ‘clusters’.
 
The University of Sydney study, published in the Medical Journal of Australia, reveals that 76% of Australians aged 65 and over have two or more chronic conditions, and about one third have five or more. 
 
Analysing the health records of more than 4.4 million Australians aged 65 and over, researchers found chronic conditions occur within three key ‘clusters’ rather than at random, with certain conditions commonly occurring in the same cluster:
 

• Cardiovascular-metabolic (hypertension, heart failure, diabetes) 
• Neuropsychiatric-functional decline (depression, pain, anxiety) 
• Inflammatory-musculoskeletal-cancer (chronic airway disease, osteoporosis, cancer)

 
Researchers say the analysis is ‘the first up‑to‑date national study’ to show how cluster patterns differ by age and socioeconomic status, highlighting ‘major health inequalities and the need for more coordinated care for an ageing population’.
 
One study author, Associate Professor Edwin Tan, said living with multiple chronic conditions is ‘the norm, not the exception’ for most older Australians.
 
‘Understanding how chronic conditions cluster together is critical for planning healthcare services for an ageing population,’ he said. 
 
An RACGP expert agrees, saying planning and coordinating those services should begin with general practice.
 
Dr Anthony Marinucci, the Chair of RACGP Specific Interests Aged Care, told newsGP that GPs and primary care practices are best placed to plan and coordinate care for older patients living with multimorbidity.
 
‘GPs and primary care practices are natural coordinators,’ he said.
 
‘In most cases, [a GP is] the only clinician who sees the whole person rather than a single organ system.’
 
However, he said such care coordination cannot be an ‘unfunded expectation’ of general practice.
 
‘This study is really an argument for strengthening that role, but … the current MBS structure rewards episodic, single-problem care, which is precisely the fragmented model this study warns against,’ he said.
 
Dr Marinucci said he was not surprised by the ‘very significant number’ of older Australians shown by the study to be living with multiple morbidities.
 
‘Especially for us working in aged care, multimorbidity really is the norm … and the study does quantify that well, and at a national scale,’ he said.
 
However, he also suspects the number of people living with chronic conditions would likely be higher than indicated, as only people with at least one Pharmaceutical Benefits Scheme and/or Medicare Benefits Schedule claim were counted.
 
‘It probably likely undercounts conditions, because we’re assuming that every single condition has been identified, diagnosed and being treated,’ he said.
 
‘But there would be people with further conditions that wouldn’t be being treated for such.
 
‘So really, the figures here represent a floor rather than the ceiling.’
 
The figures also clearly reveal the equity disparity, with all three clusters being most prevalent in the most disadvantaged areas of Australia.
 
‘Multimorbidity is not evenly distributed, and neither should our response be,’ said Dr Marinucci.
 
Conversely, he believes the finding of lower cluster prevalence in remote areas is underservice ‘masquerading as a good result’.
 
‘It almost certainly reflects reduced access to medicines and services, not better health,’ he said.
 
Researchers found high blood pressure, high cholesterol, and gastroesophageal reflux disease were the most common individual conditions. 
 
However, Dr Marinucci said the neuropsychiatric-functional decline cluster identified in the study is of greatest concern, as it often fed into physical declines.
 
‘It combines depression, pain, dementia, incontinence and antipsychotic use, and these are the conditions that drive loss of independence, carer burden and entry into residential care,’ he said.
 
He said it is also the cluster where care is ‘most fragmented’.
 
‘If you look at the cardiometabolic cluster, it does have clearer pathways and targets,’ he said.
 
‘We have very specific cardiovascular disease targets in this country, and the framework around treatment is quite well structured, whereas mood, dementia, things like that within an older person and early cognitive decline, they’re not as well-structured yet in this country.
 
‘This is where of course we are trying to do things like the Dementia Action Plan to try to address those gaps, so I think that’s probably why that cluster would be more of a concern for me.’
 
Dr Marinucci said GPs can be better supported to address multimorbidity in older patients with a complementary approach of funding for longer consultations as well as for practice-embedded nursing and care coordination.
 
‘Managing five or more chronic conditions cannot be done well in short appointments, and current chronic disease item structures don’t reflect the cognitive work involved,’ he said.
 
‘The GP doesn’t need to personally make every allied health referral and follow-up call, but someone in the team does, and that role needs sustainable funding.’
 
For older people in residential aged care, Dr Marinucci wants to see dedicated, adequately remunerated models of GP-led outreach.
 
‘This is the population with the heaviest multimorbidity burden and the poorest access to coordinated primary care,’ he said.
 
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aged care cardiovascular chronic disease comorbidity comorbidity cluster dementia

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