GPAtlas🧭 When to suspect (who to identify)
Multimorbidity is the presence of two or more long-term health conditions. NICE deliberately defines this broadly to include not only defined physical and mental health conditions (such as diabetes or schizophrenia), but also frailty, chronic pain, sensory impairment, learning disability, and alcohol or substance misuse. Roughly two-thirds of people over 65 are affected, and rates rise with age and deprivation.
The clinical problem is structural: almost every single-condition guideline is built from trials that excluded people with multimorbidity. Stacking those guidelines onto one person generates polypharmacy, conflicting advice, and a heavy treatment burden – with higher rates of adverse drug events, falls, gastrointestinal bleeding and acute kidney injury (AKI). The skill in primary care is to identify the right people – opportunistically during routine care and proactively from the electronic record – and to shift from disease-centred to person-centred care.
| Offer a multimorbidity approach when… | Practical marker in primary care |
|---|---|
| The person requests it | Asks to make sense of fragmented or duplicated care |
| Difficulty managing treatments or daily activities | Struggling with adherence, monitoring or self-care |
| Care from multiple services | Several specialties and frequent appointments |
| Both physical and mental health conditions | e.g. COPD with depression; diabetes with anxiety |
| Frailty or falls | Identified frailty (see Examination) or recurrent falls |
| Frequent unplanned / emergency care | Repeated admissions or out-of-hours contacts |
| Multiple regular medicines | ≥ 15 → use this approach · 10–14 → consider · < 10 if at particular risk |
Source: NICE NG56
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