Multi-morbidity and Complex Care — Viva

Long Case Viva Defence

Candidate's opening statement (model answer)

"Mrs Margaret O'Brien is an 82-year-old woman who is admitted to the ward after a mechanical fall at home, in whom the unifying diagnosis is complex multi-morbidity — she has heart failure with reduced ejection fraction (ejection fraction 30 percent), persistent atrial fibrillation, type 2 diabetes, stage 3b chronic kidney disease (baseline eGFR 35), hypertension, osteoporosis with a previous left 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. [1]

Her main problems are:

1. The mechanical fall, with multifactorial risk factors including her benzodiazepine (temazepam), her anticholinergic (oxybutynin), orthostatic hypotension from her ACE inhibitor and diuretic, her cognitive impairment, and likely environmental hazards at home.
2. Heart failure with reduced ejection fraction, well treated with the foundational four — a beta-blocker, an ACE inhibitor, an MRA, and an SGLT2 inhibitor — plus a diuretic for symptom control, but at the cost of a rising creatinine and a borderline potassium.
3. Atrial fibrillation, anticoagulated with apixaban at the correct dose for her renal function, with a rate controlled on the bisoprolol.
4. Type 2 diabetes in chronic kidney disease, on metformin and an SGLT2 inhibitor, with a recent HbA1c of 58 mmol per mol, which is appropriate for her age and frailty.
5. Polypharmacy, with two high-priority deprescribing targets — oxybutynin and temazepam — both of which are contributing to her falls risk and her cognitive impairment.
6. Mild cognitive impairment, which affects her capacity for complex self-management and makes the simplification of her regimen a priority.
7. Goals of care not yet documented, and advance care planning overdue. [1]

My management is anchored to her stated priority — to remain independent at home — and follows the five principles of multi-morbidity care: patient-centred, holistic, prioritised, coordinated, and evidence-informed. The key interventions are a structured medication review with STOPP/START and Beers, the supervised deprescribing of oxybutynin and temazepam, the continuation of the integrated cardio-renal-metabolic therapy (the SGLT2 inhibitor benefits her heart, her kidney and her diabetes), the documentation of her goals of care and advance care plan, and a coordinated discharge with her GP as the single coordinating clinician, a Home Medicines Review, and a case conference." [1]

Examiner probing questions and model answers

Q1: "You mentioned the five principles of multi-morbidity care. Where do these come from, and how do they apply to Mrs O'Brien?" [1]

"The five principles come from the NICE guideline NG56 on Multimorbidity and from the American Geriatrics Society Guidance on the Care of Older Adults with Multimorbidity, and they are reinforced by the Australian ACSQHC Comprehensive Care Framework. They reflect the shift from the single-disease paradigm that Boyd demonstrated to be unworkable for the multi-morbid patient [2]. For Mrs O'Brien: patient-centred means anchoring every decision to her goal of remaining independent at home; holistic means treating her as a whole person, not as seven separate diseases; prioritised means addressing the fall and the high-risk medications first, not trying to fix everything at once; coordinated means her GP owns the integrated plan with the specialists advising; and evidence-informed means adapting the guideline evidence — for example, the SPRINT evidence on intensive blood pressure control that excluded frail older people — to her individual context and priorities [4]."

Q2: "Walk me through your medication review. Which tool did you use and why?" [1]

"I used the STOPP/START version 3 criteria (2023) and the 2023 AGS Beers Criteria. STOPP/START is the European and Australasian standard, validated in many settings; it identifies potentially inappropriate medications (STOPP) and prescribing omissions (START) in older adults. Beers is the American standard, organised into five categories — PIMs, PIMs in specific diseases, drugs to use with caution, drug-drug interactions, and drugs requiring renal dose adjustment [8] [9].

The high-priority deprescribing targets in Mrs O'Brien are:

1. Oxybutynin — a potent anticholinergic on the Beers list and on the STOPP list for cognitive impairment. It worsens her cognition, causes blurred vision (a falls risk), and constipation. I will taper it to avoid anticholinergic withdrawal and switch to mirabegron or conservative measures if urinary symptoms recur.
2. Temazepam — a benzodiazepine on both Beers and STOPP, associated with falls, fractures 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 [10].
3. Atorvastatin — she is on a statin, and I will review the indication with her. If it is for primary prevention in a mildly frail 82-year-old with limited life expectancy, the time-to-benefit may exceed her life expectancy, and we may jointly decide to stop it. If she has established cardiovascular disease, it stays.

On the START side, I confirmed her HFrEF therapy is complete (beta-blocker, ACEi, MRA, SGLT2i, diuretic) and that her bone protection is in place after her previous hip fracture. I also confirmed her apixaban dose is correct for her renal function — 5 mg twice daily unless she meets two of the three dose-reduction criteria." [1]

Q3: "Why do you say the SGLT2 inhibitor is the prototype multi-morbidity drug?" [1]

"Because it benefits three of her conditions simultaneously, with a single once-daily oral dose and a consistent safety profile. EMPEROR-Reduced showed empagliflozin reduced the composite of cardiovascular death and heart failure hospitalisation by 25 percent in HFrEF, with a slowing of eGFR decline, regardless of diabetes status [6]. DAPA-CKD showed the class reduces the composite of sustained eGFR decline, kidney failure and renal or cardiovascular death in CKD with or without diabetes [5]. EMPA-REG OUTCOME showed cardiovascular mortality benefit in type 2 diabetes. For Mrs O'Brien — who has HFrEF, CKD and diabetes — the SGLT2 inhibitor is treating all three with a single drug that simplifies rather than complicates her regimen. The alternative of three separate drugs, each with its own adverse effect profile and dosing schedule, would be a step backwards in multi-morbidity care.

The one caveat is the sick-day rules: during an acute illness with dehydration, sepsis or reduced oral intake, the SGLT2 inhibitor should be held because of the risk of euglycaemic diabetic ketoacidosis. This is part of the patient education and the shared care plan." [1]

Q4: "How would you conduct the goals-of-care conversation with Mrs O'Brien, given her mild cognitive impairment?" [1]

"I would introduce it early, in a quiet setting, with her and with a family member or surrogate she chooses. I would ask open questions: 'What do you understand about your illnesses and how they affect you? What matters most to you in the time ahead? What are the outcomes you would find unacceptable — for example, being in a nursing home, or being kept alive on machines? Who would you want to make decisions for you if you could not?' I would listen, summarise what I heard, and check my understanding. [1]

Given her mild cognitive impairment, I would assess her capacity to participate in the decision using the four legal criteria: she can understand the information, retain it, weigh it up, and communicate her decision. If she has capacity, the decisions are hers. If she lacks capacity for a particular decision, I would involve her surrogate (a family member or a formal guardian) and make the decision in her best interests, guided by her known values and any prior advance care directive. [1]

I would document the priorities — likely 'remain independent at home' — the ceiling of treatment (likely ward-based care, not for ICU or CPR), the resuscitation status, and the surrogate. I would communicate this to her GP and family, put it in the shared record, and review it as her circumstances change. This is good practice for every adult with multi-morbidity, not only those near the end of life." [1]

Q5: "Mrs O'Brien's family are concerned that she is on too many medications and they want you to stop 'everything that isn't essential'. How do you respond?" [1]

"I would listen to their concern, acknowledge it — they are right that polypharmacy is a problem — and explain that 'stopping everything that isn't essential' would be unsafe because several of her drugs are disease-modifying and stopping them abruptly would cause harm. The beta-blocker cannot be stopped abruptly (rebound tachycardia, ischaemia, destabilisation of the heart failure); the ACE inhibitor, the MRA, the SGLT2 inhibitor and the apixaban are preventing death, hospitalisation and stroke; and even the statin needs a careful risk-benefit conversation rather than an abrupt stop. [1]

Instead, I would explain the structured medication review approach: I will apply STOPP/START and Beers to identify the high-priority deprescribing targets, I will taper the ones that need a taper (oxybutynin, temazepam), I will discuss the ones that need a shared decision (the statin for primary prevention), and I will keep the ones that are protecting her life. I would frame deprescribing as optimisation — the medications were right when they were started, and stopping some of them now is also right, because her circumstances have changed. I would give the family a written deprescribing plan and a review date, and I would involve the community pharmacist in a Home Medicines Review. The conversation is part of building trust — a family that understands the reasoning is more likely to support the plan." [1]

Short Case Discussion

Bedside medication review and the goals-of-care conversation

Examiner instruction: "You are called to the ward to review a 78-year-old man, Mr Frank Webb, who is day 2 of an admission for cellulitis of the right leg, treated with intravenous antibiotics. He has a background of ischaemic heart disease, heart failure with reduced ejection fraction, type 2 diabetes, atrial fibrillation, and osteoarthritis. His family have raised concern that he is on a 'long list of medications' and they want a review. Describe your systematic approach to the bedside medication review, the goals-of-care conversation, and the communication plan." [1]

Candidate's model answer: [1]

"My approach to Mr Webb's bedside medication review follows six structured steps. [1]

Step 1 — Obtain and verify the best possible medication history: I take the history from Mr Webb, his wife, and (with their permission) I contact the GP and the community pharmacist. I check the previous discharge summary, the electronic record, and the patient's own medication list. I explicitly ask about over-the-counter medications (he is on an over-the-counter ibuprofen for the osteoarthritis — a major concern given his heart failure and his CKD), complementary medicines, 'as needed' medications, topical medications, and inhalers. I document the reconciled list, flagging discrepancies (he was on an NSAID that was not on the GP list). [1]

Step 2 — Apply STOPP/START version 3 and the AGS Beers Criteria: The over-the-counter ibuprofen is a STOPP criterion — an NSAID in a patient with heart failure and CKD; this is the triple whammy in waiting and must be stopped. I check for other PIMs (anticholinergics, benzodiazepines, long-acting sulfonylureas) and for START omissions (is he on the foundational four for HFrEF? is he on an anticoagulant for the AF? is he on a statin for the ischaemic heart disease?). [1]

Step 3 — Check the renal function and dose-adjust: I check the eGFR using the 2021 CKD-EPI equation and I dose-adjust the DOAC, the metformin, and any other renally-cleared drugs. [1]

Step 4 — Assess the falls risk and the anticholinergic burden: I ask about falls in the past year, I check the anticholinergic burden score, and I assess the gait and balance. These are the highest-yield modifiable risks in the multi-morbid older patient. [1]

Step 5 — Conduct the goals-of-care conversation: I ask Mr Webb what matters most to him, what outcomes he would find unacceptable, and who he would want to make decisions for him if he could not. I document his priorities — likely to remain at home, independent, and symptom-free — and I use these to anchor the medication review (for example, if his priority is to avoid hospital admissions, the disease-modifying cardiovascular drugs are essential; if his priority is symptom control and he has limited life expectancy, we may deprescribe differently). [1]

Step 6 — Present the integrated plan and the communication: I present the prioritised list of changes — stop the NSAID, start or continue the foundational HFrEF therapy, confirm the DOAC dose, address the osteoarthritis pain with paracetamol and topical NSAIDs, deprescribe any high-burden PIMs — and I communicate the plan to Mr Webb, his family, his GP, and the community pharmacist. I arrange a Home Medicines Review and a follow-up clinic appointment to review the changes."* [1]

Examiner follow-up: "His wife says he has been on diazepam 5 mg at night for years and she is worried he will not sleep if you stop it. How do you handle this?" [1]

"I would explain that diazepam is a long-acting benzodiazepine that accumulates in older adults (it has active metabolites with half-lives of up to 100 hours), it increases the risk of falls, fractures, confusion and delirium, and it is on both the Beers and the STOPP criteria for older adults. I would explain that stopping it is an active, positive intervention, not a withdrawal of care, and that a supervised taper will avoid withdrawal symptoms and rebound insomnia. I would plan a taper of 10 to 25 per cent every 1 to 2 weeks (often with diazepam substitution for shorter-acting agents, but here we are already on diazepam), combined with sleep hygiene measures and, if available, cognitive behavioural therapy for insomnia. I would explain that the first few weeks may be difficult but that the longer-term benefit — better cognition, fewer falls, a lower fracture risk — is substantial. I would arrange close follow-up, perhaps weekly, during the taper, and I would document the plan and the shared decision. The wife's concern is real and the taper must be collaborative — but the long-term gain is clear and I would not avoid the conversation." [1]

Examiner follow-up: "How do you decide whether to continue his statin, given he is 78 with ischaemic heart disease?" [1]

"The decision turns on whether the statin is for secondary prevention (after a documented event — MI, stroke, revascularisation) or primary prevention (risk factor reduction without an event). For secondary prevention, the statin should be continued regardless of age — the evidence of benefit is strong and the time-to-benefit is short (within 1 to 2 years). For primary prevention in a 78-year-old, the decision is more nuanced: the relative benefit is similar but the absolute benefit is smaller and the time-to-benefit is longer, and in a frail patient with limited life expectancy the harm (myopathy, drug interactions, pill burden) may exceed the benefit. I would have a shared decision-making conversation with Mr Webb — present the evidence, elicit his preferences, and decide together. I would not stop a statin unilaterally, and I would not continue one unthinkingly; the decision is patient-specific and is part of the integrated plan." [1]