Mastering Multimorbidity Consultations in MRCP PACES Geriatrics

Why Multimorbidity Is a PACES favourite

If you have revised for MRCP PACES Station 5 long enough, you already know that examiners love complexity. A patient with a single, clean diagnosis is rare in real NHS practice — and even rarer in a PACES consultation designed to stretch your clinical reasoning. Multimorbidity, defined by NICE as the presence of two or more long-term health conditions in a single individual, is the perfect vehicle for testing whether you can think like a registrar rather than a textbook-reciting machine.

In the geriatric population, multimorbidity is the norm rather than the exception. A typical Station 5 patient might have type 2 diabetes, chronic kidney disease stage 3b, heart failure with reduced ejection fraction, atrial fibrillation on warfarin, and osteoarthritis — all interacting, all requiring medication, and all competing for priority in a 10-minute consultation. Your job is not to solve every problem. Your job is to demonstrate that you can prioritise, communicate, and plan safely within the constraints of the encounter.

The NICE Multimorbidity Framework: Your Consultation Backbone

The NICE guideline NG56 (Multimorbidity and clinical assessment) is the single most important document you should internalise for these scenarios. It provides a structured approach that examiners explicitly look for when scoring your consultation domain. Here is how to apply it in a PACES context:

1. Identify the patient's main concerns and priorities

This is not a box-ticking exercise. In PACES, the examiner is listening for whether you genuinely elicit what matters to the patient — not just what is medically urgent. An elderly patient with five chronic conditions may be far more troubled by their knee pain stopping them from walking to the shops than by their asymptomatic AF.

Exam tip: Open with a broad question such as, 'I can see from your records that you have several long-term conditions. Today, what matters most to you? What would you like us to focus on?' This immediately signals a patient-centred, guideline-concordant approach.

2. Review medications and interactions

Polypharmacy is the natural consequence of multimorbidity, and the NICE guideline specifically recommends performing a structured medication review for patients on multiple regular medications. In PACES, you will not have time to review every drug, but you should demonstrate awareness of:

• High-risk drug combinations (e.g., NSAIDs in a patient with CKD and heart failure)

• Anticholinergic burden — particularly relevant in patients with dementia or delirium risk

• Falls-risk medications (sedatives, antihypertensives, diuretics)

• Drugs that may no longer provide net benefit in the context of reduced life expectancy

The Anticholinergic Burden Scale and the STOPP/START criteria are tools you should be able to reference conversationally. You do not need to recite them — but mentioning that you would use them signals senior-level thinking.

3. Assess frailty

Frailty transforms the way multimorbidity is managed. A patient with a Clinical Frailty Scale (CFS) score of 7 (severely frail) will have different treatment goals and risk-benefit thresholds than someone with CFS 2 (mildly frail). In PACES, you should:

• State that you would assess frailty using the CFS or PRISMA-7

• Explain how frailty influences your management decisions (e.g., intensive glycaemic control may cause more harm than benefit in a frail elderly patient)

• Consider whether a Comprehensive Geriatric Assessment (CGA) is indicated

4. Consider interactions between conditions and treatments

This is where candidates often falter. The examiner wants to see that you understand how one condition's treatment affects another. Classic examples include:

Structuring Your PACES Multimorbidity Consultation

A successful consultation in Station 5 follows a clear architecture. Here is a framework that consistently scores well across all four PACES marking domains:

Opening (30 seconds)

• Introduce yourself and your role

• Confirm the patient's identity

• Set the agenda collaboratively: 'I understand you have several health conditions. I would like to understand what is troubling you most, review your medications, and make a plan together. Does that sound okay?'

Information gathering (3–4 minutes)

• Explore the primary complaint in detail (SOCRATES or relevant framework)

• Briefly assess each chronic condition: 'How has your diabetes been? Any issues with your breathing?'

• Screen for red flags that may need urgent attention (e.g., weight loss, falls, confusion)

• Assess functional status: Activities of Daily Living (ADLs), mobility, continence

• Take a brief social history: who lives at home, what support is in place, what is the patient's living arrangement?

Shared decision-making (3–4 minutes)

• Summarise your understanding back to the patient

• Identify 2–3 priorities for today's consultation (you cannot solve everything)

• Discuss the risk-benefit balance of any changes you propose

• Use teach-back to confirm understanding: 'Just so I know I have explained this clearly, could you tell me what you understand about the plan?'

Closing (1–2 minutes)

• Agree on a clear, written plan with the patient

• Arrange appropriate follow-up (GP review, specialist referral, MDT discussion)

• Safety-net: 'If you develop chest pain, worsening breathlessness, or confusion, please seek urgent medical attention.'

High-Yield Multimorbidity Scenarios for PACES

Based on examiner patterns and recent PACES cases reported by candidates, here are five scenarios you should rehearse thoroughly:

Scenario 1: The Falls-Prone Diabetic

Patient profile: 78-year-old woman with T2DM (HbA1c 58), hypertension, osteoarthritis, and two falls in the past month. Medications: metformin, gliclazide, ramipril, amlodipine, paracetamol.

Key discussion points:

• Tight glycaemic control is inappropriate — relax HbA1c target to 58–64 mmol/mol (NICE NG28 for older adults with frailty)

• Gliclazide is a sulfonylurea causing hypoglycaemia — a key falls risk factor. Consider stopping or reducing

• Review antihypertensives — is the patient hypotensive or orthostatic? Check lying and standing BP

• Falls assessment: refer to falls clinic, assess for postural hypotension, vision, foot care

• Consider vitamin D supplementation for falls prevention

Scenario 2: Heart Failure with CKD and AF

Patient profile: 82-year-old man with HFrEF (EF 35%), CKD stage 3b (eGFR 38), persistent AF, and gout. Currently on bisoprolol, furosemide, ramipril, apixaban, allopurinol.

Key discussion points:

• SGLT2 inhibitor initiation — dapagliflozin or empagliflozin benefit both HF and CKD (NICE NG106, NG203). Discuss benefits and risks (euglycaemic DKA, genital infections)

• RAAS blockade — is the ACE inhibitor still beneficial with declining eGFR? Monitor creatinine and potassium

• Anticoagulation — apixaban is appropriate; confirm dose is correct for renal function

• Diuretic titration — balance between euvolaemia and over-diuresis causing AKI

• Gout management — continue allopurinol; avoid NSAIDs entirely

Scenario 3: Dementia with Behavioural Issues and Polypharmacy

Patient profile: 79-year-old woman with moderate Alzheimer's dementia, hypertension, depression, previous TIA. Carer reports increasing agitation. Medications: donepezil, citalopram, aspirin, lercanidipine.

Key discussion points:

• Anticholinergic burden assessment — citalopram has low anticholinergic activity, but review any over-the-counter medications

• Agitation may indicate pain, infection, constipation, or delirium — rule out reversible causes first (PINCH ME: Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment)

• Avoid antipsychotics unless absolutely necessary and for the shortest possible duration (NICE NG97)

• Discuss advance care planning and lasting power of attorney if not already in place

• Consider non-pharmacological strategies: structured activities, music therapy, environmental modifications

Scenario 4: COPD with Cardiac Comorbidity

Patient profile: 75-year-old former smoker with severe COPD (FEV1 42%), ischaemic heart disease (post-NSTEMI 2 years ago), and peripheral vascular disease. Medications: salmeterol/fluticasone, tiotropium, aspirin, atorvastatin, bisoprolol.

Key discussion points:

• Beta-blocker safety in COPD — cardioselective agents (bisoprolol, nebivolol) are safe and beneficial in cardiac disease even in COPD (NICE NG115 confirms this)

• Pulmonary rehabilitation referral — benefits both exercise capacity and quality of life

• Assess for cor pulmonale — check for peripheral oedema, elevated JVP

• Oxygen therapy — only if hypoxaemic (PaO₂ < 7.3 kPa) and with caution due to hypercapnia risk

• Smoking cessation remains the single most beneficial intervention

Scenario 5: The Frail Elderly Patient with Acute Confusion

Patient profile: 85-year-old care home resident, brought to the acute medical unit with 3-day history of confusion. Background: vascular dementia, HFpEF, CKD stage 3, chronic back pain. Medications: furosemide, spironolactone, paracetamol, codeine, donepezil, sertraline.

Key discussion points:

• 4AT assessment to screen for delirium — score ≥4 suggests delirium

• Identify and treat the underlying cause — urine dip, blood cultures, CXR, electrolytes, calcium

• Codeine may be contributing to confusion (opioid-induced neurotoxicity) — review and consider alternative analgesia

• Spironolactone + furosemide + CKD = high risk of hyperkalaemia and dehydration — check U&Es urgently

• Consider whether donepezil should be continued during acute illness (may worsen bradycardia if concurrent infection)

• Involve the frailty team and consider CGA

• Discuss with family and care home about baseline function and goals of care

Scoring Across the Four PACES Domains

Understanding how your multimorbidity consultation is scored helps you focus your preparation:

Domain A: Clinical Communication Skills

• What examers want: Clear, structured, patient-centred communication with appropriate use of plain language and teach-back

• Common pitfall: Using medical jargon without explanation (e.g., 'We need to optimise your RAAS blockade')

• Fix: Always translate: 'We need to review your blood pressure tablets to make sure they are helping your heart without putting too much strain on your kidneys'

Domain B: Physical Examination

While this is less relevant in a pure consultation station, if the scenario involves examination findings, ensure you can interpret them in the context of multimorbidity (e.g., bilateral crackures in a patient with both heart failure and COPD — which is the primary contributor?).

Domain C: Clinical Judgement

• What examiners want: Evidence of prioritisation, risk-benefit analysis, and guideline-concordant decision-making

• Common pitfall: Trying to address every single condition exhaustively within 10 minutes

• Fix: Explicitly state your priorities: 'There are several things we could discuss today, but I think the most important issues are your falls risk and your diabetes control. Shall we focus on those, and arrange a separate review for your other conditions?'

Domain D: Managing Patient Concerns

• What examiners want: Evidence that you have explored the patient's ideas, concerns, and expectations (ICE)

• Common pitfall: Jumping straight to management without acknowledging the patient's emotional state or personal priorities

• Fix: Always ask: 'What are you most worried about?' and address that concern directly before moving to your clinical priorities

Evidence-Based Tools to Reference in PACES

You do not need to memorise every guideline, but being able to reference the following tools conversationally demonstrates senior-level competence:

1. NICE NG56 — Multimorbidity: clinical assessment and management

2. NICE NG97 — Dementia: assessment, management and support for people living with dementia and their carers

3. STOPP/START criteria — Screening Tool of Older Persons' Prescriptions / Screening Tool to Alert to Right Treatment

4. Anticholinergic Burden Scale — ACB score ≥3 associated with increased mortality and cognitive decline

5. Clinical Frailty Scale (CFS) — validated 9-point scale (1 = very fit, 9 = terminally ill)

6. eFI (Electronic Frailty Index) — population-level frailty identification using GP records

7. 4AT — rapid delirium screening tool (Attention, AMT4, Acute change)

8. PRISMA-7 — 7-item questionnaire to screen for disability and frailty

Practical Rehearsal Strategies

1. practise With a Timer

Your PACES consultation is 10 minutes for interaction and 5 minutes for discussion. Set a timer and practise with a study partner playing the role of an elderly patient with multimorbidity. The pressure of time will reveal your weaknesses — most candidates either run out of time or rush the shared decision-making phase.

2. Use AI Patient Simulation

AI-based patient simulators can generate realistic multimorbidity scenarios and provide instant feedback on your consultation structure. Use them to:

• practise opening questions that elicit patient priorities

• Rehearse summarising complex information concisely

• Test your ability to pivot when the patient raises an unexpected concern

However, remember that AI cannot replicate the nuanced examiner questioning in the discussion phase. Use AI for the interaction portion and a human partner for the discussion.

3. Build a Scenario Bank

Create a personal bank of 10–15 multimorbidity scenarios with varying complexity. For each, write:

• The patient profile (age, conditions, medications)

• 3 key clinical priorities

• 2 communication challenges

• The likely examiner questions in the discussion phase

This active preparation will help you recognise patterns during the actual exam.

4. practise the Discussion Phase

The 5-minute discussion is where many candidates lose marks. Examiners may ask:

• 'How would you decide whether to stop this medication?'

• 'What is the evidence for SGLT2 inhibitors in this patient?'

• 'How would you involve the family in this decision?'

• 'What is your understanding of the anticholinergic burden in this patient?'

Practise answering these questions succinctly — 30–60 seconds per answer, structured, and evidence-based.

Common Pitfalls and How to Avoid Them

Final Thoughts

Multimorbidity consultations in MRCP PACES are not about knowing every detail of every guideline. They are about demonstrating that you can navigate complexity safely, prioritise effectively, and communicate clearly with patients who often have overlapping, competing, and sometimes contradictory clinical needs.

The candidates who pass are not the ones who recite the most facts. They are the ones who can sit with an elderly patient who has six chronic conditions, ten medications, and three concerns — and emerge from 10 minutes with a safe, sensible, patient-centred plan that addresses what matters most.

Internalise the NICE NG56 framework. practise with timers. Build your scenario bank. And remember: in PACES, structured simplicity beats exhaustive complexity every time.

Good luck with your preparation. The exam is not testing whether you know everything — it is testing whether you can be trusted to manage everything safely.