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Managing long-term conditions: A multimorbidity resource

This resource supports student nurses, student nursing associates and early career nurses in understanding and identifying multimorbidity— the coexistence of two or more long-term health conditions in a patient.

Multimorbidity is becoming increasingly common. Now more than ever, those working in nursing settings must be equipped to recognise the complex ways in which long-term conditions interact and impact patient care. 

Understanding the range of conditions

Managing multimorbidity requires recognising the interplay between conditions, adapting care plans accordingly and making holistic, person-centred decisions in practice.

These conditions may include:

  • defined physical or mental health diagnoses (such as diabetes, schizophrenia or infectious diseases)
  • ongoing conditions (such as learning disabilities), symptom complexes (like frailty or chronic pain)
  • sensory impairments (such as sight or hearing loss)
  • alcohol or substance misuse.

Learning objectives

  • Define multimorbidity and identify common long-term conditions involved.
  • Recognise how these conditions interact and influence patient care.
  • Discuss key considerations with practice supervisors/assessors.
  • Use additional resources to support learning in university and placement settings.

How to use this resource

  1. Start by reviewing the condition summaries.
  2. Use the condition interaction list to identify condition pairs of interest.
  3. Explore the corresponding interaction sections for focused learning. 

Condition summaries

This is a long-term condition where the body cannot effectively regulate blood glucose. Diabetes UK data shows that 4.4 million people in the UK live with diabetes.

Type 2 diabetes is the most common type of diabetes. Approximately 90% of people with diabetes have type 2 diabetes (T2DM), 8% have type 1 diabetes (T1DM), 2% have rarer types and 1.2 million people could be living with it, but are yet to be diagnosed.

Type 1: Autoimmune, insulin dependent.

Type 2: Insulin resistance or insufficient production.

Symptoms: Frequent urination, thirst, fatigue, blurred vision.

Key Test: The main test used for diabetes includes a glycated haemoglobin blood test (HbA1c); however, other tests such as c-peptide and autoimmune antibodies can be used to determine different types of diabetes, such as type 1. Find out more: Diabetes test: How to test for diabetes | Diabetes UK.

This is persistently elevated blood pressure (BP), which increases the risk of heart failure, stroke and kidney disease.

There are two numbers used to describe BP. It’s measured in millimetres of mercury (mmHg) and is written like this: 130/80mmHg.

  1. The first number is the systolic pressure. This is the maximum amount of pressure your heart uses when beating to push the blood around your body.
  2. The second number is the diastolic pressure. This is the least amount of pressure your heart uses when it is relaxed between beats.

Target clinic BPs are*:

Under the age of 80 — clinic BP below 140/90 mmHg; ABPM/HBPM below 135/85 mmHg.

Over the age of 80 — clinic BP below 150/90 mmHg; ABPM/HBPM below 145/85 mmHg.

Postural hypertension (a condition where BP rises suddenly when a person stands up)— BP target should be based on standing BP.

Frailty or multimorbidity — clinical judgement should be used.

*These are dependent on other conditions and patient clinical assessment.  

COPD is a collective term for progressive lung diseases, including chronic bronchitis and emphysema. These conditions cause long-term breathing difficulties due to airflow obstruction that is not fully reversible.

Chronic bronchitis: Defined clinically as a productive cough (with sputum) lasting for at least three months in each of two consecutive years.

Emphysema: A pathological diagnosis referring to damage and destruction of the alveoli — the tiny air sacs in the lungs responsible for gas exchange. Healthy lung parenchyma appears spongy and pink grey in colour, with thin-walled alveoli providing a large surface area for oxygen and carbon dioxide exchange.

Symptoms: Persistent breathlessness, chronic cough and sputum production.

Causes: Primarily caused by smoking but can also result from long-term exposure to environmental pollutants (for example, fumes, dust, chemicals) and, in rarer cases, genetic factors such as alpha-1 antitrypsin deficiency.

IBD is a chronic, relapsing-remitting, non-infectious inflammatory disease of the GI tract. It describes two conditions:

Crohn's disease: A lifelong condition where parts of the digestive system become inflamed.

Ulcerative colitis: A long-term condition where the colon and rectum become inflamed with ulceration.

Signs and symptoms of IBD include:

  • diarrhoea
  • stomach aches and cramps
  • blood in stool
  • tiredness
  • weight loss.

IBD often coexists with other long-term conditions, including diabetes, making joined-up care essential for safe and effective treatment.  

Heart failure typically results from myocardial dysfunction—systolic, diastolic, or both. The most common underlying cause is coronary artery disease.

It is caused by structural and/or functional abnormalities of the heart that lead to elevated intracardiac pressures and/or insufficient cardiac output, either at rest or during exertion.

Typical symptoms include:

  • Breathlessness — on exertion, at rest, on lying flat (orthopnoea), nocturnal cough or waking from sleep (paroxysmal nocturnal dyspnoea).
  • Fluid retention (ankle swelling, bloated feeling, abdominal swelling or weight gain).
  • Fatigue, decreased exercise tolerance, or increased recovery time after exercise.
  • Light-headedness or history of syncope (fainting).

Symptoms can be classified by using tools such as the New York classification.

The main test used to help diagnose heart failure is the N-terminal pro-B-type natriuretic peptide level (NT-pro-BNP). This is a substance released when the heart walls are stretched, indicating the heart is working harder. It is important to remember that NT-pro-BNP can be affected by age, diabetes and chronic kidney disease. An echocardiogram (ultrasound of the heart) may then be ordered to further identify any changes. Find out more: How to assess | Diagnosis | Heart failure - chronic | CKS | NICE.

A chronic, progressive neurodegenerative condition resulting from the loss of the dopamine-containing cells, which affect movement.

Symptoms: There are more than 40 symptoms of Parkinson’s Disease. The three main symptoms are tremor (shaking), slowness of movement and rigidity (muscle stiffness).

Symptoms start to appear when the brain can’t make enough dopamine to control movement properly. Other symptoms include postural instability and bradykinesia.

Causes: Parkinsonism is a broad term describing a clinical syndrome seen in various neurodegenerative diseases. There are three main forms of Parkinsonism:

  1. Idiopathic Parkinsonism: The most common form, also known as Parkinsonism. Idiopathic means the cause is unknown.
  2. Vascular Parkinsonism: Affects people whose blood supply to their brain is limited - if you have had a mild stroke, for example.
  3. Drug-induced Parkinsonism: Neuroleptic drugs (used to treat schizophrenia and other severe mental health conditions) are the biggest cause of drug-induced parkinsonism. They block the action of the chemical dopamine in the brain.

Overview of condition and interaction pairings 

To help you explore how different long-term conditions interact with one another, here is a list of all relevant condition pairings included in this resource.

Each pair offers clinical information, key discussion questions and useful resources to support your learning.

Diabetes

Diabetes and hypertension

Summary: Combined increase in risk for stroke, heart attack and retinopathy.

Clinical context: Increased sugar levels can cause damage to blood vessels in the heart, impacting cardiac output. This impact on cardiac output increases fluid retention and impacts how the heart functions. Additionally, having high sugar levels can increase risk of other problems associated with heart failure, such as hypertension, high cholesterol and insulin resistance.

It is also important to remember that thiazide diuretics, also referred to as ‘water tablets’, may be taken to reduce high blood pressure or to remove excess water from the body.

Side effects of taking thiazide diuretics include increased blood sugar levels and having low levels of salts, such as potassium, magnesium and sodium, in the body. Blood glucose levels may, but not always, return to normal if treatment with thiazide diuretics is stopped.

Key questions:

  • What treatment is the patient on and is it appropriate for the patient's current condition(s)?
  • Outside of pharmacological treatment, what other lifestyle factors need to be considered?
  • What is the patient’s current BP readings and what is their individualised target?
  • What are their symptoms of high BP?
  • How do these conditions affect cardiovascular risk and does the patient need additional holistic support or lifestyle interventions?

Practice tips: Joint BP-glucose control; holistic education.

Resources:

Diabetes and COPD

Summary: Steroid use can worsen glucose control; chronic inflammation increases systemic risks.

Clinical context: Often in periods of respiratory exacerbation (where acute treatment is required to support symptoms such as purulent sputum, increased cough, wheezing, shortness of breath, and so on), steroid therapy is needed to help reduce inflammation in the airways.

This can be either oral and/or intravenous steroids; however, steroids can cause insulin resistance, often resulting in deranged blood sugars and hyperglycaemia. This, therefore, can increase the risk of developing diabetes and, in those living with diabetes, negatively impact glycaemic control.

A common effect of diabetes is inflammation. People with COPD who are also diagnosed with diabetes are more likely to have impaired lung function, increased length of stay in hospitals and in-hospital mortality.

Key questions:

  • That treatment is the patient on for diabetes? Will this need to be reviewed if starting steroid therapy?
  • How does weight impact on breathing and blood sugars?
  • What are the main ways to prevent exacerbations?
  • How well is the patient educated on the signs and symptoms of exacerbation and the link between steroid use and diabetes?

Practice tips: Adjust diabetes medicines during flare-ups; encourage smoking cessation.

Resources:

Diabetes and IBD

Summary: Steroid use for IBD can worsen diabetes; inflammation increases cardiovascular risk.

Clinical context: Studies have shown a link between type 2 diabetes and IBD, in that having genetic susceptibility to type 2 diabetes increases the risk of IBD. It is important to remember that often steroid therapy is used in flare-ups for IBD.

Steroids can cause insulin resistance, resulting in deranged blood sugars and hyperglycaemia in those who already are living with diabetes. Additionally, frequent use of steroids due to the insulin resistance can increase the risk of developing diabetes.

Key questions:

  • What treatment is the patient on for diabetes?
  • Will this need to be reviewed if starting steroid therapy?
  • If the patient is symptomatic with loose stools, do we need to think about how their medications are absorbed?
  • Other than steroid therapy, how else can IBD flare-ups be treated?
  • What are the mental health implications for someone living with both IBD and diabetes?
  • How do these conditions affect cardiovascular risk, and does the patient need additional holistic support or lifestyle interventions?

Practice tips: Monitor sugars closely; reduce steroid reliance if possible.

Resources:

Diabetes and heart failure

Summary: Hyperglycaemia impacts heart function; some diuretics affect glucose levels.

Clinical context: Increased sugar levels can cause damage to blood vessels in the heart, impacting on cardiac output. This impact on cardiac output increases fluid retention and impacts on how the heart functions.

Additionally having high sugar levels can increase the risk of other problems associated with heart failure such as hypertension, high cholesterol and insulin resistance. It is also important to remember that thiazide diuretics, also referred to as ‘water tablets’, may be taken to reduce high blood pressure or to remove excess water from the body.

Side effects of taking thiazide diuretics include increased blood sugar levels and having low levels of salts, such as potassium, magnesium and sodium, in the body. Blood glucose levels may, but not always, return to normal if treatment with thiazide diuretics is stopped.

Key questions:

  • What treatments would be useful for both diabetes and heart failure (SGLT-2is)?
  • How does weight impact symptoms for both conditions?
  • What other factors can be optimised to improve quality of life?
  • What future care needs should be considered?

Practice tips: Weight and fluid balance monitoring; optimise diabetes medicines.

Resources:

Diabetes and Parkinson’s Disease

Summary: Symptoms of hypo may be masked; high sugars may increase Parkinson’s Disease risk.

Clinical context: Studies have indicated that having higher-than-normal sugar levels, can increase the risk of developing Parkinson’s Disease.

It is important to remember that, due to the effects on movement and posture from Parkinson’s, patients who experience low blood sugar symptoms (hypoglycaemia) can sometimes be misinterpreted as being related to their Parkinson’s condition.

Therefore, it is important that in those living with both diabetes and Parkinson’s, any change in symptoms is monitored against their sugar levels accordingly.

Key questions:

  • Are there any treatments in diabetes that could be useful for those living with Parkinson’s?
  • How do you recognise signs of a low blood sugar in those living with Parkinson’s?
  • Is the patient at risk of hypoxia and how can we determine if any change in symptoms is related to either of their conditions?
  • Why are time critical medications so important in both conditions?

Practice tips: Monitor symptoms against glucose levels; strict medicine adherence.

Resources: 

Hypertension

Hypertension and COPD

Summary: Chronic inflammation and steroid use raise BP; atherosclerosis risk increased.

Clinical context: Due to inflammatory processes that cause COPD through tobacco smoking, it can increase the risk of hypertension. This is because atherosclerosis (build-up of fatty material in the arteries) can happen, narrowing blood vessels and increasing pressure.

It is also important to remember that often in COPD, oral and/or intravenous steroids are used to manage exacerbations (where acute treatment is required to support symptoms such as purulent sputum, increased cough, wheezing, shortness of breath and so on), which can develop insulin resistance, therefore increasing the risk of hypertension happening.

Key questions:

  • What treatment is the patient on and is it optimised?
  • What about the use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) for blood pressure (BP) management—are these beneficial in COPD?
  • Are there any other cardiac concerns or other causes for the hypertension?
  • Outside of pharmacological treatment, what other lifestyle factors need to be considered?
  • What are the current patient’s BP readings and what is their individualised target?
  • What are their symptoms of high BP?

Practice tips: Consider ACE inhibitors; address lifestyle.

Resources: 

Hypertension and IBD

Summary: IBD inflammation may contribute to high BP; steroids exacerbate it.

Clinical context: Patients living with IBD are at increased risk of hypertension due to the systemic inflammation that is involved. This can increase the risk of developing atherosclerosis (build-up of fatty material in arteries), narrowing blood vessels and increasing pressure.

Additionally, systemic inflammation increases the risk of inflammatory events, which can be alleviated by anti-inflammatory treatment. Hypertension is an early and common manifestation of atherosclerosis and various cardiovascular events and therefore increases the risk for patients with IBD.

Key questions:

  • What treatment is the patient on and is it optimised?
  • What is the patient’s cardiovascular risk and do they have any cardiac history?
  • Outside of pharmacological treatment, what other lifestyle factors need to be considered?
  • What is the patient’s current BP readings and what is their individualised target?
  • What are the symptoms of high blood pressure?

Practice tips: Monitor BP in flares; consider CV risk profile.

Resources:

Hypertension and heart failure

Summary: High BP leads to heart strain; managing BP prevents worsening heart failure.

Clinical context: It is important to remember that having hypertension itself is a risk factor for developing heart failure. This is because prolonged high pressure can damage the heart vessels and valves, cause increased workload on the heart and an enlarged heart.

It can also increase the risk of developing atherosclerosis (build-up of fatty material in arteries), narrowing blood vessels and increasing pressure. These complications increase the risk of cardiovascular events, such as a heart attack and stroke.

Key questions:

  • What treatments would be beneficial for both hypertension and heart failure?
  • Outside of pharmacological treatment, what other lifestyle factors need to be considered?
  • What is the patient’s current BP readings and what is their individualised target?
  • What are the risks of not treating hypertension and heart failure?

Practice tips: Educate on compliance; regular monitoring.

Resources:

Hypertension and Parkinson's Disease

Summary: Parkinson’s Disease can cause low BP; BP control is a balance.

Clinical context: It is often common in patients with Parkinson’s that they may experience low blood pressure (hypotension), this is because Parkinson’s affects the autonomic nervous system, which controls blood pressure.

However, this can also increase the risk of having hypertension, which can also increase the risk of developing motor stages of the disease more quickly, therefore causing stiffness, tremors and rigidity.

Key questions:

  • What treatment is the patient on and is this the best treatment for their symptoms?
  • Outside of pharmacological treatment, what other lifestyle factors need to be considered?
  • What are the current patient’s BP readings and what is their individualised target?
  • What are the symptoms of high BP?

Practice tips: Monitor lying/standing BP; individualise targets.

Resources:

COPD

COPD and IBD

Summary: Shared inflammatory pathways; smoking worsens both.

Clinical context: Due to shared inflammatory pathways, individuals with COPD may have an increased risk of developing IBD. Systemic inflammation associated with COPD can extend to the gastrointestinal tract, potentially triggering bowel inflammation and symptoms characteristic of IBD.

Additionally, tobacco smoking (a primary cause of COPD) can disrupt the gut microbiome, further contributing to gastrointestinal symptoms such as diarrhoea and abdominal pain, which are commonly associated with IBD.

Key questions:

  • Has the patient been referred to smoking cessation services (if applicable)?
  • Why does inflammatory processes increase the risk of developing IBD?
  • What pharmacological and non-pharmacological treatments can support both conditions and reduce inflammatory processes?

Practice tips: Target inflammation holistically; MDT input.

Resources:

COPD and heart failure

Summary: Hypoxia strains heart; salbutamol affects BP and rhythm.

Clinical context: COPD can lead to low blood oxygen levels (hypoxia), which puts extra strain on the heart. This can then cause high blood pressure in the pulmonary arteries, the pressure then backflows into the right side of the heart, which can result in heart failure. This, combined with inflammation, can lead to damaged blood vessels, therefore increasing the risk of developing heart failure.

Key questions:

  • What treatment is the patient on for both COPD and heart failure?
  • What is their current BP measurement and is this within target range?
  • How does smoking, weight and lifestyle impact on both conditions?
  • How does salbutamol help both conditions?

Practice tips: Smoking cessation; consider pulmonary rehab.

Resources: 

COPD and Parkinson's Disease

Summary: Both affect breathing; shared inflammation risk.

Clinical context: Parkinson’s itself can increase shortness of breath symptoms of irregular and rapid breathing (respiratory dyskinesia). However, when this happens in someone living with both Parkinson’s and COPD, this can produce often heightened shortness of breath symptoms.

It is also important to remember that studies indicate that living with COPD can additionally increase the risk of developing Parkinson’s. This is due to chronic low oxygen levels and systemic inflammation impacting dopamine production.

Key questions:

  • What treatment is the patient on for both COPD and Parkinson’s Disease?
  • What breathing techniques have been explored?
  • Does the patient require smoking cessation therapy (if applicable)?
  • How does having both conditions impact on the patient’s activities of daily living?

Practice tips: Assess respiratory patterns; inhaler technique.

Resources:

IBD

IBD and heart failure

Summary: Chronic inflammation increases heart failure risk; steroid use may complicate fluid balance.

Clinical context: Due to inflammatory pathways associated with both conditions, having IBD can increase the likelihood of developing heart failure. This can happen due to the chronic inflammation damaging heart valves and vessels.

IBD also increases the risk of developing atherosclerosis (build-up of fatty material in arteries), narrowing blood vessels and increasing pressure, therefore resulting in heart failure.

Key questions:

  1. How does inflammatory processes impact on different parts of the body?
  2. What medication is the patient taking to reduce inflammation?
  3. What pharmacological and non-pharmacological treatments can support both conditions and reduce inflammatory processes?
  4. Is the patient's treatment for IBD optimised to reduce risk of developing heart failure?

Practice tips: Monitor for weight gain/fluid overload; balance therapy.

Resources:

IBD and Parkinson's Disease

Summary: Gut-brain axis suggests inflammatory links.

Clinical context: Due to ‘gut-brain-axis’ which identifies that the gut and brain communicate via microbiomes, having chronic intestinal inflammation can contribute to neurodegeneration and IBD. There is a possible genetic overlap between the conditions, therefore increasing the risk of development with chronic inflammatory processes.

Key questions:

  • How does inflammatory processes impact on different parts of the body?
  • What medication is the patient taking to reduce inflammation?
  • What pharmacological and non-pharmacological treatments can support both conditions and reduce inflammatory processes?
  • Is the patient's treatment for IBD optimised to reduce risk of developing Parkinson’s?

Practice tips: Encourage good gut health; MDT approach.

Resources: 

Heart failure 

Heart failure and Parkinson's Disease

Summary: Parkinson’s Disease autonomic dysfunction affects cardiac output; some medicines worsen heart failure.

Clinical context: Parkinson’s can impact the autonomic nervous system, specifically nerves that impact on the cardiovascular system (cardiac dysautonomia).

This in turn can increase the risk of heart failure as cardiac output is affected and therefore fluid accumulates. Additionally, Parkinson’s medications (dopamine agonists) can increase the risk of heart failure directly.

Key questions:

  • What medication for Parkinson’s disease is the patient taking that may increase the risk of heart failure?
  • How can patients living with Parkinson’s disease prevent heart failure?
  • How do we support the patient with both pharmacological and non-pharmacological treatments for their conditions?

Practice tips: Interdisciplinary care; symptom tracking.

Resources:

 

 

 

 

 

 

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