The 5M Framework for Improved Health Care in Older Adults With IBD, Cirrhosis

To meet the challenges of providing gastroenterology care to an increasingly aging population in the United States, researchers have proposed a strategy for integrating the principles of geriatrics, according to guidelines published in Clinical and Translational Gastroenterology.

The outlined plan, called the “5M framework,” focuses on medications, mind, mobility, multicomplexity, and what matters most for managing age friendly care in older adults with inflammatory bowel diseases (IBD) and cirrhosis.

Regarding medications, the framework highlights the importance of recognizing the high prevalence of polypharmacy in older adults. Mind refers to the relationship between mood and memory. Mobility involves the ability to perform activities of daily living and beyond. Multicomplexity involves recognizing the burden of multiple comorbidities, and what matters most is a reminder for clinicians to provide patient-centered care to prioritize older adults’ outcome goals and care preferences.

IBD

Although available treatment options for IBD have increased during the past 2 decades, less than 1% of adults included in clinical trials for IBD medications that have been approved since 2000 have been aged 65 years and older. “There is an urgent need to generate safety and efficacy data for agents used to treat IBD, especially for older adults,” the researchers noted.

Drug interactions for newer immunosuppressive medications are not well-researched, and many of the agents used for management of IBD symptoms have significant anticholinergic properties, which may interact with other medications to cause significant anticholinergic side effects in older adults, according to the study authors. This anticholinergic burden can also lead to falls and cognitive decline in older adults. “A detailed review of medications and their indications at each visit is warranted,” the researchers stated.

Patients with IBD have high rates of depression and other mood disorders, and screening for mood disorders using tools validated in younger adults may not detect these disorders in older adults. “With an increasing number of older adults in our clinical practice, we should study whether using a Geriatric Depression Scale will better identify older adults at risk for depression and potentially linked, worsening IBD-related outcomes,” the study authors noted. Detecting depression is also important for older adults because it is associated with cognitive decline.

Older adults with IBD also have an increased risk for falls and fractures owing to factors such as chronic steroid use that can lead to osteoporosis and anticholinergic drug burden. “Given age-related declines in mobility, assessing the influence of disease and drugs on mobility and determining reversible causes is especially important in caring for older adults with IBD,” the investigators wrote.

Older adults with IBD have an increased risk for serious infections and malignancies, and they are more likely than younger adults to have serious comorbid conditions that may limit treatment strategies and increase the risk of medication side effects. “Recognizing the increasing medical and social complexities that accompany advancing age, while balancing the implementation of appropriate therapeutic strategies, is critical to caring for the older adult with IBD,” the researchers commented.

An increased understanding is needed regarding what matters most to older adults about their IBD, treatments, and their expectations and goals. “Talking to patients and learning from their experiences will teach us to focus on what matters most to the rapidly aging population of older adults with IBD,” the study authors noted.

Cirrhosis

In patients with cirrhosis, polypharmacy is common and is associated with poor health-related quality of life, including unplanned hospital readmissions. The use of beta-blockers, ciprofloxacin, diuretics, and lactulose for managing complications of cirrhosis may lead to an increased risk for falls, cognitive impairment, urinary incontinence, and fecal incontinence, respectively, in older adults. “Clinicians should perform medication reconciliation at every clinical visit and consider collaboration with pharmacists if available,” the investigators advised.

More than 40% of patients with cirrhosis will have at least 1 episode of hepatic encephalopathy, and older adults with cirrhosis also have an increased risk for aging-related cognitive impairment due to cerebrovascular disease, neurodegenerative disorders, dementia, medication side effects, delirium, and depression. “These conditions may synergize with hepatic encephalopathy to negatively affect quality of life among older adults with cirrhosis and can additionally impair medication adherence and self-care activities,” the researchers stated.

Patients with cirrhosis are at high risk for functional impairment, falls, and frailty. Falls are independently associated with mortality. “Future work could assess the use of frailty testing to quantify risks of poor outcomes after transplant and nontransplant surgeries and procedures for older adults with cirrhosis,” the investigators noted.

Older adults with cirrhosis have a high risk for poor health outcomes. In clinical care, routine assessment for multimorbidity is critical for older adults with cirrhosis owing to the risk of drug-disease interactions, according to the study authors. “Clinicians should incorporate outcomes beyond mortality that are important to older adults, such as functional independence, financial burden, and quality of life in shared decision-making,” the researchers advised.

Liver transplantation is increasingly common in older adults with cirrhosis, although they have a higher waitlist and post-transplant mortality. In addition, many older adults with cirrhosis will not be transplant candidates owing to multimorbidity. Older patients with cirrhosis often receive high-intensity end-of-life care. “These data highlight the increased need for early advance care planning for older adults with cirrhosis and their families to guide shared medical decision that is centered on their values, goals, and what matters most to them in life in the face of limited life expectancy,” the researchers commented.

Integrating Geriatrics Into Gastroenterology

Although a number of geriatric tools and interventions are used in other specialty practices, none has been studied and integrated into routine gastroenterology practice, the study authors explained.

“Clinicians should be aware of the prevalence of geriatric syndromes such as frailty, cognitive and functional impairment, falls, and depression among older adults with IBD and cirrhosis and screen for these conditions where appropriate,” the researchers recommended. “As telemedicine and telehealth expand, clinicians should be aware of the potential effects of cognitive, visual, and auditory impairments on the ability of older adults to engage in care.”

Some patients may require comanagement through multidisciplinary and collaborative care with primary care providers and other subspecialty clinicians.

“Gastroenterology clinicians should recognize the burden of caregiving for older adults with IBD and cirrhosis and work collaboratively with both patients and their caregivers to develop personalized approaches to care that incorporate a patient’s goals, values, and preferences,” the study authors advised.

Evidence-based and systematic methods are also needed to guide treatment decision-making in older adults with chronic gastroenterology conditions, according to the researchers.

“Gastroenterology societies fund a substantial amount of research in the field; we recommend that they issue a request for proposals from bench to bedside focusing on aging as it pertains to gastroenterology conditions with study topics ranging from microbiome changes to shared decision making,” the investigators commented. “In addition, the gastroenterology societies should create aging interest groups to advance clinical care, advocacy, and research of our older patients.”

Disclosure: One of the study authors declared an affiliation with a pharmaceutical company. Please see the original reference for a full list of authors’ disclosures.

Reference

Kochar B, Ufere NN, Ritchie CS, Lai JC. The 5Ms of geriatrics in gastroenterology: The path to creating age-friendly care for older adults with inflammatory bowel diseases and cirrhosis. Clin Transl Gastroenterol. 2022;13(1):e00445. doi:10.14309/ctg.0000000000000445