Multi-morbidity and Complex Care — Clinical Case

DCE Long Case

Patient brief (provided to trainee)

Patient: Mrs Margaret O'Brien, 82 years old, retired schoolteacher. [1]

Presenting complaint (current): Admitted to the ward after a mechanical fall at home. She tripped on the corner of a rug in her hallway while walking to the bathroom at 3 am, fell onto her right side, and was unable to get up for two hours until her neighbour found her. She has bruising on her right hip and right elbow but no fracture on imaging. She did not lose consciousness, had no preceding chest pain, palpitation, or dizziness, and had no postural symptoms suggestive of syncope. [1]

Past medical history:

• Heart failure with reduced ejection fraction (ejection fraction 30 percent on echocardiography six months ago), NYHA class II
• Persistent atrial fibrillation, rate-controlled
• Type 2 diabetes mellitus (diagnosed 15 years ago)
• Stage 3b chronic kidney disease (baseline eGFR 35 mL per minute per 1.73 m2)
• Hypertension
• Osteoporosis (T-score minus 2.8 at the femoral neck), with a previous left intertrochanteric hip fracture 3 years ago, fully recovered after open reduction and internal fixation
• Mild cognitive impairment (MoCA 22 six months ago) [1]

Current medications (14 medications):

• Frusemide 40 mg daily
• Bisoprolol 5 mg daily
• Ramipril 5 mg daily
• Spironolactone 25 mg daily
• Apixaban 5 mg twice daily
• Metformin 1000 mg twice daily
• Empagliflozin 10 mg daily
• Atorvastatin 40 mg at night
• Alendronate 70 mg weekly
• Calcium-vitamin D (600 mg/1000 IU) daily
• Temazepam 10 mg at night
• Oxybutynin 5 mg three times daily
• Glyceryl trinitrate spray as needed (not used in six months)
• Salbutamol inhaler as needed (not used in years) [1]

Current vital signs: Blood pressure 135/75 (no postural drop), heart rate 68 in atrial fibrillation, respiratory rate 16, oxygen saturation 96 percent on room air, temperature 36.8 degrees Celsius. [1]

Investigations on the current admission:

• Haemoglobin 122 g per litre, white cell count 7.2, platelets 220, sodium 138, potassium 4.8, creatinine 138 micromol per litre (baseline 130), eGFR 35, ALT normal.
• HbA1c 58 mmol per mol.
• NT-proBNP 1850 ng per litre.
• Echocardiography (six months ago): left ventricular ejection fraction 30 percent, dilated left atrium, no significant valvular disease.
• 12-lead ECG on admission: atrial fibrillation, rate 68, left ventricular strain pattern, no acute ischaemia.
• CT brain on admission: no intracranial haemorrhage, mild small vessel disease, no mass.
• X-ray right hip and right elbow: no fracture, soft tissue swelling only. [1]

Social history: Widowed five years ago. Lives alone in her own single-storey home. Her daughter visits weekly. She has twice-weekly community nursing support for medication supervision and daily Meals on Wheels. She mobilises with a four-wheeled frame. She was independent in basic ADLs (bathing, dressing, feeding) before this admission, but required assistance with IADLs (shopping, housework, transport). She has a fall alarm pendant but was not wearing it at the time of the fall. [1]

Clinical Frailty Scale score: 5 (mildly frail — she has evident slowing and needs help with high-order IADLs). [1]

Candidate's structured presentation (model)

SASPOP opening statement: [1]

"Mrs Margaret O'Brien is an 82-year-old retired schoolteacher who is admitted after a mechanical fall at home, in whom the unifying diagnosis is complex multi-morbidity — she has heart failure with reduced ejection fraction, atrial fibrillation, type 2 diabetes, stage 3b chronic kidney disease, hypertension, osteoporosis with a previous hip fracture, and mild cognitive impairment, and she is on 14 medications. She lives alone at home with community support, and her Clinical Frailty Scale score is 5, mildly frail. She did not lose consciousness with the fall and imaging has excluded fracture and intracranial haemorrhage." [1]

Structured problem list (prioritised): [1]

1. The mechanical fall — multifactorial, with modifiable risk factors including the benzodiazepine (temazepam), the anticholinergic (oxybutynin), orthostatic and volume effects from her cardio-renal medications, her cognitive impairment, and environmental hazards at home. Highest priority — address the falls risk to keep her at home.
2. Polypharmacy — 14 medications, with two high-priority deprescribing targets (oxybutynin, temazepam) on Beers and STOPP criteria, and one requiring a shared decision (atorvastatin). The treatment burden is a harm in itself.
3. Heart failure with reduced ejection fraction — well treated with the foundational four plus a diuretic, but the rising creatinine and borderline potassium need monitoring.
4. Atrial fibrillation — appropriately anticoagulated with apixaban at the correct dose for her renal function, rate controlled on the bisoprolol.
5. Type 2 diabetes in chronic kidney disease — on metformin and an SGLT2 inhibitor, with a reasonable HbA1c for her age and frailty; the target should be individualised, not intensified.
6. Osteoporosis with previous hip fracture — on appropriate bone protection; the fall is a high-risk event for a further fracture.
7. Mild cognitive impairment — affects her capacity for complex self-management; simplification of the regimen is a priority.
8. Goals of care and advance care plan — not yet documented; this is a priority for this admission. [1]

Integrated management plan

1. The fall and the modifiable risk factors: [1]

The fall is multifactorial and the management is to address every modifiable risk factor. The highest-yield interventions are the deprescribing of the benzodiazepine (temazepam) and the anticholinergic (oxybutynin) — both are major contributors to falls, confusion and fracture risk in older adults, and both are on the 2023 AGS Beers Criteria and the STOPP/START version 3 list [7] [8]. I will also arrange an occupational therapy home hazard assessment (loose rugs, poor lighting, no grab rails in the bathroom), a physiotherapy assessment for strength and balance training, a vision and hearing check, and a foot and footwear review. The fall alarm pendant was not worn on this occasion — I will reinforce its use with her and her daughter. I will not intensify her cardiovascular medication in response to the fall (her blood pressure is well controlled at 135/75, and intensive lowering would increase the falls risk).

2. Structured medication review — STOPP/START and Beers: [1]

I will reconcile the medication list first — the best possible medication history from the patient, her daughter, the GP, the community pharmacist, and the previous discharge summary — and then apply STOPP/START version 3 and the 2023 AGS Beers Criteria. [1]

Deprescribe (STOPP targets):

1. Oxybutynin 5 mg three times daily — a potent anticholinergic on the Beers and STOPP lists. It worsens her cognition, causes blurred vision (falls risk), constipation, and urinary retention. I will taper it (twice daily for 1 to 2 weeks, then once daily for 1 to 2 weeks, then alternate day for 1 week, then stop) to avoid anticholinergic withdrawal. If overactive bladder symptoms recur, I will switch to mirabegron or conservative measures.
2. Temazepam 10 mg at night — a benzodiazepine on Beers and STOPP, associated with falls, fractures, cognitive impairment and delirium in older adults. I will taper it at 10 to 25 per cent every 1 to 2 weeks, combined with cognitive behavioural therapy for insomnia and sleep hygiene measures [9].
3. Glyceryl trinitrate spray — not used in six months; no current angina. Stop.
4. Salbutamol inhaler — not used in years; no current respiratory indication. Stop after confirming there is no reversible airways disease on spirometry.
5. Atorvastatin — I will review the indication with her. If she has established cardiovascular disease, continue. If it is for primary prevention, I will discuss the time-to-benefit in her context and decide together; in a mildly frail 82-year-old, the harm (myopathy, interactions, pill burden) may exceed the long-term benefit.

Confirm or add (START targets):

1. Her HFrEF therapy is complete (beta-blocker, ACEi, MRA, SGLT2i, diuretic) — I will confirm the doses are at guideline-recommended targets.
2. Her bone protection is appropriate (alendronate weekly, calcium-vitamin D) after her previous hip fracture — continue.
3. Her AF is appropriately anticoagulated — apixaban at the correct dose. I will confirm her weight: apixaban 5 mg twice daily is the standard dose; the dose reduces to 2.5 mg twice daily only if she meets two of the three criteria (age 80 or more, weight 60 kg or less, creatinine 133 micromol per litre or more). At 82 and creatinine 138, she meets one criterion; her weight determines the dose. [1]

Renal dose adjustment: I check the eGFR (35) and dose-adjust accordingly. Metformin 1000 mg twice daily is at the upper safe limit at eGFR 35; I will reduce it if her renal function declines further (reduce at eGFR below 30, stop at eGFR below 15). [1]

3. Heart failure with reduced ejection fraction: [1]

Continue the foundational four — bisoprolol (beta-blocker), ramipril (ACE inhibitor), spironolactone (MRA), and empagliflozin (SGLT2 inhibitor) — plus frusemide for symptom control. The SGLT2 inhibitor is the prototype multi-morbidity drug here: EMPEROR-Reduced showed it reduces cardiovascular death and heart failure hospitalisation in HFrEF [5], DAPA-CKD showed the class reduces renal and cardiovascular events in CKD [4], and it also benefits her diabetes. I will monitor the renal function and potassium (an acceptable creatinine rise is up to 30 per cent from baseline, and an acceptable potassium is up to 5.5); if hyperkalaemia is persistent, I will consider a potassium binder (patiromer, sodium zirconium cyclosilicate) to enable continuation of the disease-modifying drugs rather than stopping them.

4. Atrial fibrillation: [1]

Continue the apixaban at the dose-adjusted level (see above) — her CHA2DS2-VASc is high (age, sex, hypertension, diabetes, heart failure, vascular disease), and the annual stroke risk without anticoagulation would be 9 per cent or higher. The rate is well controlled on the bisoprolol (resting heart rate 68 in AF). [1]

5. Type 2 diabetes: [1]

Individualise the HbA1c target to 58 to 70 mmol per mol (7.5 to 8.5 per cent) for her age and frailty — her current HbA1c of 58 is appropriate and I will not intensify. The priority is cardiovascular and renal risk reduction (which the SGLT2 inhibitor is providing), not tight glycaemic control. I will avoid sulfonylureas (hypoglycaemia, particularly in renal impairment) and sliding-scale insulin. The metformin is at the upper safe limit and I will review it if her renal function declines. [1]

6. Osteoporosis: [1]

Continue the alendronate and calcium-vitamin D. The fall is a high-risk event for a further fracture in a patient with a T-score of minus 2.8 and a previous hip fracture; I will consider a dual-energy X-ray absorptiometry after this admission and a review of the bone protection regimen, possibly switching to denosumab or an anabolic agent if she sustains a further fragility fracture. [1]

7. Mild cognitive impairment: [1]

Reassess cognition with a MoCA during the admission, screen for depression (PHQ-9), and assess her capacity for complex self-management. Simplification of the medication regimen (through deprescribing) is itself a cognitive intervention — fewer drugs, fewer cognitive adverse effects, and a regimen she can manage with her community support. I will refer her to a memory clinic if there is concern about progression to dementia. [1]

8. Goals of care and advance care plan: [1]

I will introduce the goals-of-care conversation early in the admission, in a quiet setting with Mrs O'Brien and her daughter. I will ask what matters most to her, what outcomes she would find unacceptable (for example, nursing home placement, prolonged unconsciousness, dependence on machines), and who she would want to make decisions for her if she could not. I will document her priorities (likely to remain independent at home), the ceiling of treatment (likely ward-based care, not for ICU or CPR), the resuscitation status, and the surrogate decision-maker (likely her daughter, or a formal guardian if the daughter is unavailable). I will communicate this to her GP, her daughter, and the hospital team, and put it in the shared record. [1]

Examiner discussion questions

Q1: "Boyd and colleagues showed that applying single-disease guidelines uncritically to a multi-morbid patient produces an intolerable regimen. How does the principle of 'evidence-informed' rather than 'evidence-based' care apply to Mrs O'Brien?" [1]

"The principle of evidence-informed care takes the disease-specific evidence and adapts it to the individual multi-morbid patient by asking three questions. First, does the benefit seen in the trial population apply to this patient, who was probably excluded from the trial on the basis of age, frailty, comorbidity or polypharmacy? For Mrs O'Brien, the SPRINT evidence on intensive blood pressure control excluded patients like her — frail, multi-morbid, in residential-type care — so the relative benefit may be smaller and the absolute harm (falls, syncope, AKI) may be larger [3]. Second, what is the time to benefit — will the patient live long enough to benefit? A statin for primary prevention takes 2 to 3 years to show benefit; in a mildly frail 82-year-old, that may exceed her life expectancy. Third, what is the harm — drug interactions, treatment burden, frailty? For Mrs O'Brien, every additional drug adds to the anticholinergic burden, the risk of falls, and the complexity she cannot manage. The answer is to apply the evidence selectively, to stop the treatments whose harm now exceeds benefit, and to anchor every decision to her priorities. This is the essence of evidence-informed, patient-centred multi-morbidity care [2]."

Q2: "How would you explain to Mrs O'Brien and her daughter that you are stopping the oxybutynin and the temazepam, given she has been on them for years?" [1]

"I would frame it as optimisation rather than withdrawal of care. I would explain that the oxybutynin and the temazepam were the right medications when they were started, but that her circumstances have changed — she is now more sensitive to their effects because of her age and her other conditions, and they are contributing to her falls and her confusion. Stopping them is an active, positive intervention to keep her safe and independent at home, which is her stated priority. I would explain that the oxybutynin will be tapered over about four weeks to avoid a return of bladder symptoms, and that the temazepam will be tapered over six to eight weeks with close support, because the first few weeks may be difficult as her sleep pattern adjusts. I would explain that the longer-term benefit — clearer thinking, fewer falls, a lower fracture risk — is substantial and aligns with what she has told me she wants. I would give her and her daughter a written taper plan and a review date, and I would involve the community pharmacist in a Home Medicines Review to support the taper at home." [1]

Q3: "You mentioned the SPRINT trial in the context of blood pressure targets. What does SPRINT actually tell us, and how does it apply to Mrs O'Brien?" [1]

"SPRINT — the Systolic Blood Pressure Intervention Trial — randomised patients with cardiovascular risk (but excluded diabetes, stroke, heart failure, and institutionalised patients) to a target systolic blood pressure of less than 120 mmHg versus less than 140 mmHg, and showed a 25 percent relative reduction in the composite of cardiovascular events and a 27 percent reduction in all-cause mortality in the intensive group [3]. The trial has been highly influential and has lowered treatment targets in many guidelines.

For Mrs O'Brien, the SPRINT evidence does not directly apply — she was excluded from the trial (she has heart failure, diabetes, atrial fibrillation, and she is frail). The SPRINT-Senior and SPRINT-MIND subanalyses suggested that older and pre-frail patients derived similar relative benefit, but with more serious adverse events (hypotension, syncope, AKI, falls). For Mrs O'Brien specifically — mildly frail, with an eGFR of 35 and on five cardio-renal medications — intensive blood pressure lowering would carry a real risk of falls, syncope and AKI, with an uncertain benefit. Her current blood pressure of 135/75 is well controlled and I would not intensify it. This is the essence of evidence-informed care: take the trial evidence, ask whether it applies to this patient, weigh the benefit against the harm in her context, and anchor the decision to her priorities." [1]

Q4: "How do you coordinate her discharge to prevent the chaos of fragmented care?" [1]

"I nominate her GP as the single coordinating clinician and I build a shared care plan with the reconciled medication list, the prioritised problem list, the goals of care, and the advance care plan. I communicate the plan by a detailed discharge summary and a direct phone call to the GP, flagging the medication changes (the oxybutynin and temazepam tapers, the NSAID avoidance, the renal function monitoring). I arrange a Home Medicines Review by the community pharmacist within two weeks of discharge — the pharmacist visits her at home, reconciles all the medications (including any in the bathroom cabinet), and reports back to the GP. I book a case conference within two to four weeks, including the GP, the community nurse, the pharmacist, the occupational therapist, the physiotherapist, and her daughter, to review the falls risk, the medication changes, the functional trajectory, and the goals of care. I book a clinic review at four to six weeks to assess her renal function and potassium, her HbA1c, her functional trajectory, and the success of the deprescribing tapers. I provide her and her daughter with a written medication list, a sick-day rules card (hold the ACEi, MRA, diuretic, metformin and SGLT2i during any acute illness with dehydration, sepsis or AKI), and a falls prevention plan. The aim is a single, shared, coordinated plan that the GP owns and that every clinician and the patient can see and follow." [1]

Q5: "Mrs O'Brien's daughter asks whether her mother should go into residential aged care after this fall. How do you respond?" [1]

"I would not make that decision unilaterally or in haste. I would explore the daughter's concerns — is it the risk of another fall and another long lie, the difficulty of supervising medications, the burden of caring, the social isolation, or something else? I would explain that with the modifiable falls risk factors addressed (deprescribing the benzodiazepine and the anticholinergic, the home hazard reduction, the strength and balance training, the vision and hearing correction), and with the increased community support (more frequent community nursing, a personal alarm that she will wear, a falls alarm on the floor, a daily check-in call), the risk of a further fall and a long lie is substantially reduced. I would explain that remaining at home is aligned with her mother's stated priority, and that moving to residential care would carry its own harms (loss of autonomy, increased falls in unfamiliar surroundings, depression, increased mortality in the first year after placement). I would suggest a trial period at home with the enhanced supports, a reassessment at four to six weeks, and an open conversation about residential care if the trial fails. The decision is ultimately Mrs O'Brien's, with her daughter's support, and I would document the conversation, the plan, and the review date. If at any point her cognition declines, her capacity to live safely at home is lost, or she has a further serious fall, the residential care conversation is reopened — but it is not the default after a single, modifiable fall." [1]

Q6: "What are the high-yield exam traps in multi-morbidity that you want the candidate to avoid?" [1]

"The most common error in a multi-morbidity stem is adding a new drug to treat a symptom that is actually an adverse effect of an existing drug — the prescribing cascade. The correct answer is to review and stop the causative drug. The second is the myth that beta-blockers are contraindicated in COPD — cardioselective beta-1 blockers are safe and beneficial in the majority of patients with COPD. The third is missing the SGLT2 inhibitor as the integrated answer in a patient with two or more of heart failure, CKD and diabetes — the SGLT2 inhibitor benefits all three and is very likely the single-best-answer in a multi-morbidity stem. The fourth is the long-case error of presenting a list of diseases each with its own plan, without integration or prioritisation — the examiner wants an integrated plan anchored to what matters to the patient. And the fifth is the advance care planning error of deferring the goals-of-care conversation until the patient is too unwell to participate — introduce it early, document the priorities, and anchor every treatment decision to them [9] [2] [6]."