[Managing multimorbidity is more than counting the number of conditions]. / Zorg voor multimorbiditeit is meer dan het tellen van ziektes.

The prevalence of patients with multimorbidity, defined by two chronic conditions is rapidly increasing. Defining multimorbidity remains challenging, with varying criteria in research. A recent study by MacRae et al. examined the impact of the number and selection of conditions on estimated multimorbidity prevalence, revealing significant variations from 4.6% to 40.5%. To standardize the definition for research, MacRae et al. recommend using three measurement instruments (Ho always + usually, Barnett, or Fortin condition-lists) to consistently measure prevalence over time. Multimorbidity's complexity is not adequately captured by dichotomous definitions, as this depends on context and purpose. Chronic diseases profoundly affect daily life, leading to reduced physical function and adverse psychosocial outcomes. Patients often experience increased stress, anxiety, and depression, which can further exacerbate somatic conditions. To assess multimorbidity from a patient perspective, considering experienced health and quality of life indicators like ADL functioning, mobility, mood, memory, and social factors is crucial. Effectively managing multimorbidity requires a holistic, tailored approach, including identifying and prioritizing key health issues, promoting self-management, proactive care planning, and coordinating treatments. Understanding the potential for differential treatment effects and considering individual life expectancy is vital. Multimorbidity also places a significant burden on healthcare systems, leading to fragmented care, communication gaps, and increased costs. Identifying complex disease clusters with high mortality and resource utilization can guide integrated care efforts. In less complex cases, primary care physicians can collaborate to provide comprehensive care. Multimorbidity remains a priority in healthcare, necessitating appropriate measurement and tailored interventions for diverse populations.

[Guidelines for customised integrated care in multimorbidity]. / Richtlijnen voor passende zorg bij multimorbiditeit.

In patients with multimorbidity, healthcare providers follow various disease-specific guidelines. Besides the fact that simultaneous treatment of several chronic diseases can be intensive for the patient, there is also the risk of contradictory advice or interactions when all recommendations are applied simultaneously. There are a number of developments to make guidelines more applicable to the growing target group of multimorbid patients. The 'Methodology for senior-proof guidelines' describes how to pay attention to patients with multimorbidity in all phases of guideline development. In addition, integrated guideline use for multimorbidity is being developed through a new modular structure with the use of interconnections. The future doctor will have to acquire knowledge and skills in translating treatment goals of patients with multimorbidity into an integral and coordinated tailor-made plan in cooperation with other professionals. A guideline for the treatment of multimorbidity can provide support in working across domains without directly applicable evidence.

Plasma melatonin levels in hip fracture patients with and without delirium: A confirmation study.

BACKGROUND: Melatonin plays a major role in maintaining circadian rhythm. Changes in melatonin metabolism might lead to circadian rhythm disturbances which are often observed in delirious patients. AIM: To assess if high morning plasma melatonin concentrations were associated with delirium. METHODS: Consecutive hip fracture patients aged ≥65 years were included. Delirium was assessed daily with the Confusion Assessment METHOD: Blood samples were collected at 11.00am on weekdays during first week of hospitalization. Melatonin was analyzed by liquid chromatography-tandem mass spectrometry. RESULTS: We analyzed 389 samples of 144 participants [mean age 84.0, 70 experienced delirium]. A Generalized Estimating Equations (GEE) model with outcome melatonin level in highest tertile ( >3.36 pg/ml) and covariates delirium group (i.e. never, before, during, post delirium), cognitive impairment, age, sex and anesthesia type, was constructed. Highest melatonin levels were associated with postoperative samples (Odds Ratio(OR) 2.11 compared to preoperative samples; 95% Confidence Interval(CI) 1.17-3.82, p=0.01) and higher age (OR 1.05 per year; CI 1.01-1.11, p=0.03), but not with delirium group(p=0.35). CONCLUSION: Undergoing surgery and aging in general may induce changes in melatonin metabolism. Future research should focus on daily multiple melatonin measurements to determine whether melatonin supplementation might be beneficial for delirium treatment or prevention.

Physiological melatonin levels in healthy older people: A systematic review.

OBJECTIVE: Melatonin plays a major role in maintaining circadian rhythm. Previous studies showed that its secretion pattern and levels could be disturbed in persons with dementia, psychiatric disorders, sleep disorders or with cancer. Also ageing is a factor that could alter melatonin levels, although previous research provides contradicting results. As melatonin supplementation is increasingly applied in older persons as sleep medication, it is important to know if melatonin levels decrease in healthy ageing and/or secretion patterns change. The objective of this study is to determine physiological levels and secretion patterns of melatonin in healthy older people. METHODS: We performed a systematic review and searched PubMed and Embase for studies published between January 1st 1980 and October 5th 2015 that measured melatonin in healthy persons aged ≥65years. RESULTS: Nineteen studies were retrieved. The number of participants ranged from 5 to 60 per study. Melatonin was mostly measured by radioimmunoassay (RIA) and the number of measurements per 24hours varied from 1 to 96. Sixteen studies showed a secretion pattern with a clear peak concentration, mostly at 0200h or 0300h. Maximum concentrations varied greatly from 11.2 to 91.3pgml(-1). Maximum melatonin level in studies with participants mean aged 65-70years was 49.3pgml(-1) and in studies with participants mean aged ≥75years 27.8pgml(-1), p-value <0.001. CONCLUSION: Total melatonin production in 24hours seems not to change in healthy ageing, but the maximal nocturnal peak concentration of melatonin might decline. It is important to take this into account when prescribing melatonin supplementation to older people.

Optimal dosages for melatonin supplementation therapy in older adults: a systematic review of current literature.

BACKGROUND: Melatonin is a hormone that regulates circadian rhythm, and its levels decline with age. As melatonin levels decrease, older adults are prone to develop disorders related to an altered circadian rhythm. The effective dose of melatonin supplementation in these disorders remains unclear. OBJECTIVES: Our objective was to define the optimal dosage of exogenous melatonin administration in disorders related to altered melatonin levels in older adults aged 55 years and above by determining the dose-response effect of exogenous administered melatonin on endogenous levels. METHODS: We conducted a systematic review through PubMed/MEDLINE and Embase, both from 1980 until November 2013. Included articles studied the effect of exogenous melatonin administration on endogenous melatonin levels in either serum, urine, or saliva in humans aged 55 years and above. RESULTS: We included 16 articles, nine of which were randomized controlled trials (RCTs). The mean age varied from 55.3 to 77.6 years. Melatonin dosage varied from 0.1 mg to 50 mg/kg and was administered orally in all studies. Pre- and post-intervention levels revealed a significant elevation of the post-intervention melatonin levels in a dose-dependent fashion. The maximum concentrations measured in serum and urine were all elevated compared with placebo, and a higher elevation in older adults than in younger adults was demonstrated. Even though there were no differences between times to reach maximum concentration in serum and urine, melatonin levels with higher doses were maintained longer above a certain threshold than were lower doses. CONCLUSION: In older adults, we advise the use of the lowest possible dose of immediate-release formulation melatonin to best mimic the normal physiological circadian rhythm of melatonin and to avoid prolonged, supra-physiological blood levels.