Comorbidity

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In medicine, comorbidity refers to the simultaneous presence of two or more medical conditions in a patient; often co-occurring (that is, concomitant or concurrent) with a primary condition. It originates from the Latin term morbus (meaning "sickness") prefixed with co- ("together") and suffixed with -ity (to indicate a state or condition). [1] [2] Comorbidity includes all additional ailments a patient may experience alongside their primary diagnosis, which can be either physiological or psychological in nature. In the context of mental health, comorbidity frequently refers to the concurrent existence of mental disorders, for example, the co-occurrence of depressive and anxiety disorders. The concept of multimorbidity is related to comorbidity but is different in its definition and approach, focusing on the presence of multiple diseases or conditions in a patient without the need to specify one as primary.

Contents

Definition

The term "comorbid" has three definitions:

  1. to indicate a medical condition existing simultaneously but independently with another condition in a patient.
  2. to indicate a medical condition in a patient that causes, is caused by, or is otherwise related to another condition in the same patient. [3]
  3. to indicate two or more medical conditions existing simultaneously regardless of their causal relationship. [4]

Comorbidity can indicate either a condition existing simultaneously, but independently with another condition or a related derivative medical condition. The latter sense of the term causes some overlap with the concept of complications. For example, in longstanding diabetes mellitus, the extent to which coronary artery disease is an independent comorbidity versus a diabetic complication is not easy to measure, because both diseases are quite multivariate and there are likely aspects of both simultaneity and consequence. The same is true of intercurrent diseases in pregnancy. In other examples, the true independence or relation is not ascertainable because syndromes and associations are often identified long before pathogenetic commonalities are confirmed (and, in some examples, before they are even hypothesized). In psychiatric diagnoses it has been argued in part that this "'use of imprecise language may lead to correspondingly imprecise thinking', [and] this usage of the term 'comorbidity' should probably be avoided." [5] However, in many medical examples, such as comorbid diabetes mellitus and coronary artery disease, it makes little difference which word is used, as long as the medical complexity is duly recognized and addressed.

Difference from multimorbidity

Comorbidity is often referred to as multimorbidity even though the two are considered distinct clinical scenarios. [6] [7] [8]

Comorbidity means that one 'index' condition is the focus of attention, and others are viewed in relation to this. In contrast, multimorbidity describes someone having two or more long-term (chronic) conditions without any of them holding priority over the others. This distinction is important in how the healthcare system treats people and helps making clear the specific settings in which the use of one or the other term can be preferred. Multimorbidity offers a more general and person-centered concept that allows focusing on all of the patient's symptoms and providing a more holistic care. In other settings, for example in pharmaceutical research, comorbidity might often be the more useful term to use. [9] [8]

Mental health

In psychiatry, psychology, and mental health counseling, comorbidity refers to the presence of more than one diagnosis occurring in an individual at the same time. However, in psychiatric classification, comorbidity does not necessarily imply the presence of multiple diseases, but instead can reflect current inability to supply a single diagnosis accounting for all symptoms. [10] On the DSM Axis I, major depressive disorder is a very common comorbid disorder. The Axis II personality disorders are often criticized because their comorbidity rates are excessively high, approaching 60% in some cases. Critics[ who? ] assert this indicates these categories of mental illness are too imprecisely distinguished to be usefully valid for diagnostic purposes, impacting treatment and resource allocation.[ citation needed ] Symptom overlap is a key component against DSM classification and serves as a note towards redefining criteria in disorders that the root cause may not be understood thoroughly. Regardless of criticisms, it stands that, annually[ where? ], up to 45% of mental health patients fit the criteria for a comorbid diagnosis. A comorbid diagnosis is associated with more severe symptomatic expression and greater chance of dismal prognosis. [11] Certain diagnoses such as ADHD, autism, OCD, and mood disorders have higher rates of co-occurring or being prevalent in separate diagnoses. "Comorbidity in OCD is the rule rather than the exception" with OCD diagnoses facing a lifetime rate of 90%. [12] With overlapping symptoms comes overlap in treatment as well, CBT for example is common for both ADHD and OCD with pediatric onset and can be effective for both in a comorbid diagnosis. [13] OCD and eating disorders have a high rate of occurrence, it is estimated that 20-60% of patients with an eating disorder have OCD. [14] More often, comorbidity complicates and can prevent treatment efficacy on a varying scale depending on the circumstances.

The term 'comorbidity' was introduced in medicine by Feinstein (1970) to describe cases in which a 'distinct additional clinical entity' occurred before or during treatment for the 'index disease', the original or primary diagnosis. Since the terms were coined, meta studies have shown that criteria used to determine the index disease were flawed and subjective, and moreover, trying to identify an index disease as the cause of the others can be counterproductive to understanding and treating interdependent conditions. In response, 'multimorbidity' was introduced to describe concurrent conditions without relativity to or implied dependency on another disease, so that the complex interactions to emerge naturally under analysis of the system as a whole. [15]

Although the term 'comorbidity' has recently become very fashionable in psychiatry, its use to indicate the concomitance of two or more psychiatric diagnoses is said to be incorrect because in most cases it is unclear whether the concomitant diagnoses actually reflect the presence of distinct clinical entities or refer to multiple manifestations of a single clinical entity. It has been argued that because "'the use of imprecise language may lead to correspondingly imprecise thinking', this usage of the term 'comorbidity' should probably be avoided". [16]

Due to its artifactual nature, psychiatric comorbidity has been considered as a Kuhnian anomaly leading the DSM to a scientific crisis [17] and a comprehensive review on the matter considers comorbidity as an epistemological challenge to modern psychiatry. [18] The Hierarchical Taxonomy of Psychopathology is a leading alternative classification system that addresses these concerns about comorbidity.

History

Widespread study of physical and mental pathology found its place in psychiatry. I. Jensen (1975), [19] J.H. Boyd (1984), [20] W.C. Sanderson (1990), [21] Yuri Nuller (1993), [22] D.L. Robins (1994), [23] A. B. Smulevich (1997), [24] C.R. Cloninger (2002) [25] and other psychiatrists discovered a number of comorbid conditions in those with psychiatric disorders.

The influence of comorbidity on the clinical progression of the primary (basic) physical disorder, effectiveness of the medicinal therapy and immediate and long-term prognosis of the patients was researched by physicians and scientists of various medical fields in many countries across the globe. These scientists and physicians included: M. H. Kaplan (1974), [26] T. Pincus (1986), [27] M. E. Charlson (1987), [28] F. G. Schellevis (1993), [29] H. C. Kraemer (1995), [30] M. van den Akker (1996), [31] A. Grimby (1997), [32] S. Greenfield (1999), [33] M. Fortin (2004) & A. Vanasse (2004), [34] C. Hudon (2005), [35] L. B. Lazebnik (2005), [36] A. L. Vertkin (2008), [37] G. E. Caughey (2008), [38] F. I. Belyalov (2009), [39] L. A. Luchikhin (2010) [40] and many others.

Inception of the term

Many centuries ago the doctors propagated the viability of a complex approach in the diagnosis of disease and the treatment of the patient, however, modern medicine, which boasts a wide range of diagnostic methods and a variety of therapeutic procedures, stresses specification. This brought up a question: How to wholly evaluate the state of a patient who has a number of diseases simultaneously, where to start from and which disease(s) require(s) primary and subsequent treatment? For many years this question stood out unanswered, until 1970, when a renowned American doctor epidemiologist and researcher, A.R. Feinstein, who had greatly influenced the methods of clinical diagnosis and particularly methods used in the field of clinical epidemiology, came out with the term of "comorbidity". The appearance of comorbidity was demonstrated by Feinstein using the example of patients physically affected by rheumatic fever, discovering the worst state of the patients, who simultaneously had multiple diseases. In due course of time after its discovery, comorbidity was distinguished as a separate scientific-research discipline in many branches of medicine. [41]

Evolution of the term

Presently there is no agreed-upon terminology of comorbidity. Some authors bring forward different meanings of comorbidity and multi-morbidity, defining the former, as the presence of a number of diseases in a patient, connected to each other through proven pathogenetic mechanisms and the latter, as the presence of a number of diseases in a patient, not having any connection to each other through any of the proven to date pathogenetic mechanisms. [42] Others affirm that multi-morbidity is the combination of a number of chronic or acute diseases and clinical symptoms in a person and do not stress the similarities or differences in their pathogenesis. [43] However the principle clarification of the term was given by H. C. Kraemer and M. van den Akker, determining comorbidity as the combination in a patient of 2 or more chronic diseases (disorders), pathogenetically related to each other or coexisting in a single patient independent of each disease's activity in the patient.[ citation needed ]

Synonyms

Epidemiology

Comorbidity is widespread among the patients admitted at multidiscipline hospitals. During the phase of initial medical help, the patients having multiple diseases simultaneously are a norm rather than an exception. Prevention and treatment of chronic diseases declared by the World Health Organization, as a priority project for the second decade of the 20th century, are meant to better the quality of the global population. [44] [45] [46] [47] [48] This is the reason for an overall tendency of large-scale epidemiological researches in different medical fields, carried-out using serious statistical data. In most of the carried-out, randomized, clinical researches the authors study patients with single refined pathology, making comorbidity an exclusive criterion. This is why it is hard to relate researches, directed towards the evaluation of the combination of ones or the other separate disorders, to works regarding the sole research of comorbidity. The absence of a single scientific approach to the evaluation of comorbidity leads to omissions in clinical practice. It is hard not to notice the absence of comorbidity in the taxonomy (systematics) of disease, presented in ICD-10.[ citation needed ]

Clinico-pathological comparisons

All the fundamental researches of medical documentation, directed towards the study of the spread of comorbidity and influence of its structure, were conducted until the 1990s. The sources of information, used by the researchers and scientists, working on the matter of comorbidity, were case histories, [49] [50] hospital records of patients [51] and other medical documentation, kept by family doctors, insurance companies [52] and even in the archives of patients in old houses. [53]

The listed methods of obtaining medical information are mainly based on clinical experience and qualification of the physicians, carrying out clinically, instrumentally and laboratorially confirmed diagnosis. This is why despite their competence, they are highly subjective. No analysis of the results of postmortem of deceased patients was carried out for any of the comorbidity researches.[ citation needed ]

"It is the duty of the doctor to carry out autopsy of the patients they treat", said once professor M. Y. Mudrov. Autopsy allows you to exactly determine the structure of comorbidity and the direct cause of death of each patient independent of his/her age, gender and gender specific characteristics. Statistical data of comorbid pathology, based on these sections, are mainly devoid of subjectivism.

Research

The analysis of a decade long Australian research based on the study of patients having 6 widespread chronic diseases demonstrated that nearly half of the elderly patients with arthritis also had hypertension, 20% had cardiac disorders and 14% had type 2 diabetes. More than 60% of asthmatic patients complained of concurrent arthritis, 20% complained of cardiac problems and 16% had type 2 diabetes. [54]

In patients with chronic kidney disease (renal insufficiency) the frequency of coronary heart disease is 22% higher and new coronary events 3.4 times higher compared to patients without kidney function disorders. Progression of CKD towards end stage renal disease requiring renal replacement therapy is accompanied by increasing prevalence of Coronary Heart Disease and sudden death from cardiac arrest. [55]

A Canadian research conducted upon 483 obesity patients, it was determined that spread of obesity related accompanying diseases was higher among females than males. The researchers discovered that nearly 75% of obesity patients had accompanying diseases, which mostly included dyslipidemia, hypertension and type 2 diabetes. Among the young obesity patients (from 18 to 29) more than two chronic diseases were found in 22% males and 43% females. [56]

Fibromyalgia is a condition which is comorbid with several others, including but not limited to; depression, anxiety, headache, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, rheumatoid arthritis, [57] migraine, and panic disorder. [58]

The number of comorbid diseases increases with age. Comorbidity increases by 10% in ages up to 19 years, up to 80% in people of ages 80 and older. [59] According to data by M. Fortin, based on the analysis of 980 case histories, taken from daily practice of a family doctor, the spread of comorbidity is from 69% in young patients, up to 93% among middle aged people and up to 98% patients of older age groups. At the same time the number of chronic diseases varies from 2.8 in young patients and 6.4 among older patients. [60]

According to Russian data, based on the study of more than three thousand postmortem reports (n=3239) of patients of physical pathologies, admitted at multidisciplinary hospitals for the treatment of chronic disorders (average age 67.8 ± 11.6 years), the frequency of comorbidity is 94.2%. Doctors mostly come across a combination of two to three disorders, but in rare cases (up to 2.7%) a single patient carried a combination of 6–8 diseases simultaneously. [61]

The fourteen-year research conducted on 883 patients of idiopathic thrombocytopenic purpura (Werlhof disease), conducted in Great Britain, shows that the given disease is related to a wide range of physical pathologies. In the comorbid structure of these patients, most frequently present are malignant neoplasms, locomotorium disorders, skin and genitourinary system disorders, as well as haemorrhagic complications and other autoimmune diseases, the risk of whose progression during the first five years of the primary disease exceeds the limit of 5%. [62]

In a research conducted on 196 larynx cancer patients, it was determined that the survival rate of patients at various stages of cancer differs depending upon the presence or absence of comorbidity. At the first stage of cancer the survival rate in the presence of comorbidity is 17% and in its absence it is 83%, in the second stage of cancer the rate of survivability is 14% and 76%, in the third stage it is 28% and 66% and in the fourth stage of cancer it is 0% and 50% respectively. Overall the survivability rate of comorbid larynx cancer patients is 59% lower than the survivability rate of patients without comorbidity. [63]

Except for therapists and general physicians, the problem of comorbidity is also often faced by specialists. Regretfully they seldom pay attention to the coexistence of a whole range of disorders in a single patient and mostly conduct the treatment of specific to their specialization diseases. In current practice urologists, gynecologists, ENT specialists, eye specialists, surgeons and other specialists all too often mention only the diseases related to "own" field of specialization, passing on the discovery of other accompanying pathologies "under the control" of other specialists. It has become an unspoken rule for any specialized department to carry out consultations of the therapist, who feels obliged to carry out symptomatic analysis of the patient, as well as to the form the diagnostic and therapeutic concept, taking in view the potential risks for the patient and his long-term prognosis.[ citation needed ]

Based on the available clinical and scientific data it is possible to conclude that comorbidity has a range of undoubted properties, which characterize it as a heterogeneous and often encountered event, which enhances the seriousness of the condition and worsens the patient's prospects. The heterogeneous character of comorbidity is due to the wide range of reasons causing it. [64] [65]

Causes

The factors responsible for the development of comorbidity can be chronic infections, inflammations, involutional and systematic metabolic changes, iatrogenesis, social status, ecology and genetic susceptibility.

Types

The division of comorbidity as per syndromal and nosological principles is mainly preliminary and inaccurate, however it allows us to understand that comorbidity can be connected to a singular cause or common mechanisms of pathogenesis of the conditions, which sometimes explains the similarity in their clinical aspects, which makes it difficult to differentiate between nosologies.

Structure

There are a number of rules for the formulation of clinical diagnosis for comorbid patients, which must be followed by a practitioner. The main principle is to distinguish in diagnosis the primary and background diseases, as well as their complications and accompanying pathologies. [68] [69]

Diagnosis

Many tests attempt to standardize the "weight" or value of comorbid conditions, whether they are secondary or tertiary illnesses. Each test attempts to consolidate each individual comorbid condition into a single, predictive variable that measures mortality or other outcomes. Researchers have validated such tests because of their predictive value, but no one test is as yet recognized as a standard.

Charlson Comorbidity Index (CCI)

The Charlson Comorbidity Index [70] predicts the mortality for a patient who may have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 17 conditions). Each condition is assigned a score of 1, 2, 3, or 6, depending on the risk of dying associated with each one. Scores are summed to provide a total score to predict mortality. Many variations of the Charlson comorbidity index have been presented, including the Charlson/Deyo, Charlson/Romano, Charlson/Manitoba, and Charlson/D'Hoores comorbidity indices.

For a physician, this score is helpful in deciding how aggressively to treat a condition. For example, a patient may have cancer with comorbid heart disease and diabetes. These comorbidities may be so severe that the costs and risks of cancer treatment would outweigh its short-term benefit.

Since patients often do not know how severe their conditions are, nurses were originally supposed to review a patient's chart and determine whether a particular condition was present in order to calculate the index. Subsequent studies have adapted the comorbidity index into a questionnaire for patients.

The Charlson index, especially the Charlson/Deyo, followed by the Elixhauser have been most commonly referred by the comparative studies of comorbidity and multimorbidity measures. [71]

Comorbidity–Polypharmacy Score (CPS)

The comorbidity–polypharmacy score (CPS) is a simple measure that consists of the sum of all known comorbid conditions and all associated medications. There is no specific matching between comorbid conditions and corresponding medications. Instead, the number of medications is assumed to be a reflection of the "intensity" of the associated comorbid conditions. This score has been tested and validated extensively in the trauma population, demonstrating good correlation with mortality, morbidity, triage, and hospital readmissions. [72] [73] [74] Of interest, increasing levels of CPS were associated with significantly lower 90-day survival in the original study of the score in trauma population. [72]

Elixhauser Comorbidity Index

The Elixhauser comorbidity measure was developed using administrative data from a statewide California inpatient database from all non-federal inpatient community hospital stays in California (n = 1,779,167). The Elixhauser comorbidity measure developed a list of 30 comorbidities relying on the ICD-9-CM coding manual. The comorbidities were not simplified as an index because each comorbidity affected outcomes (length of hospital stay, hospital changes, and mortality) differently among different patients groups. The comorbidities identified by the Elixhauser comorbidity measure are significantly associated with in-hospital mortality and include both acute and chronic conditions. van Walraven et al. have derived and validated an Elixhauser comorbidity index that summarizes disease burden and can discriminate for in-hospital mortality. [75] In addition, a systematic review and comparative analysis shows that among various comorbidities indices, Elixhauser index is a better predictor of the risk especially beyond 30 days of hospitalization. [71]

Patients who are more seriously ill tend to require more hospital resources than patients who are less seriously ill, even though they are admitted to the hospital for the same reason. Recognizing this, the diagnosis-related group (DRG) manually splits certain DRGs based on the presence of secondary diagnoses for specific complications or comorbidities (CC). The same applies to Healthcare Resource Groups (HRGs) in the UK.

Clinical example of evaluation

Patient S., 73 years, called an ambulance because of a sudden pressing pain in the chest. It was known from the case history that the patient had CHD for many years. Such chest pains were experienced by her earlier as well, but they always disappeared after a few minutes of sublingual administration of organic nitrates. This time taking three tablets of nitroglycerine did not kill the pain. It was also known from the case history that the patient had twice had myocardial infarctions during the last ten years, as well as had an Acute Cerebrovascular Event with sinistral hemiplegia more than 15 years ago. Apart from that the patient had hypertension, type 2 diabetes with diabetic nephropathy, hysteromyoma, cholelithiasis, osteoporosis and varicose pedi-vein disease. It was also learned that the patient regularly takes a number of antihypertensive drugs, urinatives and oral antihyperglycemic remedies, as well as statins, antiplatelet and nootropics. In the past the patient had undergone cholecystectomy due to cholelithiasis more than 20 years ago, as well as the extraction of a cataract of the right eye 4 years ago. The patient was admitted to cardiac intensive care unit at a general hospital diagnosed for acute transmural myocardial infarction. During the check-up moderate azotemia, mild erythronormoblastic anemia, proteinuria and lowering of left vascular ejection fraction were also identified.

Methods of evaluation

There are currently several generally accepted methods of evaluating (measuring) comorbidity: [76]

  1. Cumulative Illness Rating Scale (CIRS): Developed in 1968 by B. S. Linn, it became a revolutionary discovery, because it gave the practicing doctors a chance to calculate the number and severity of chronic illnesses in the structure of the comorbid state of their patients. The proper use of CIRS means separate cumulative evaluation of each of the biological systems: "0" The selected system corresponds to the absence of disorders, "1": Slight (mild) abnormalities or previously had disorders, "2": Illness requiring the prescription of medicinal therapy, "3": Disease, which caused disability and "4": Acute organ insufficiency requiring emergency therapy. The CIRS system evaluates comorbidity in cumulative score, which can be from 0 to 56. As per its developers, the maximum score is not compatible with the patient's life. [77]
  2. Cumulative Illness Rating Scale for Geriatrics (CIRS-G): This system is similar to CIRS, but for aged patients, offered by M. D. Miller in 1991. This system takes into account the age of the patient and the peculiarities of the old age disorders. [78] [79]
  3. The Kaplan–Feinstein Index: This index was created in 1973 based on the study of the effect of the associated diseases on patients with type 2 diabetes during a period of 5 years. In this system of comorbidity evaluation all the present (in a patient) diseases and their complications, depending on the level of their damaging effect on body organs, are classified as mild, moderate and severe. In this case the conclusion about cumulative comorbidity is drawn on the basis of the most decompensated biological system. This index gives cumulative, but less detailed as compared to CIRS, assessment of the condition of each of the biological systems: "0": Absence of disease, "1": Mild course of the disease, "2": Moderate disease, "3": Severe disease. The Kaplan–Feinstein Index evaluates comorbidity by cumulative score, which can vary from 0 to 36. Apart from that the notable deficiency of this method of evaluating comorbidity is the excessive generalization of diseases (nosologies) and the absence of a large number of illnesses in the scale, which, probably, should be noted in the "miscellaneous" column, which undermines (decreases) this method's objectivity and productivity of this method. However the indisputable advantage of the Kaplan–Feinstein Index as compared to CIRS is in the capability of independent analysis of malignant neoplasms and their severities. [80] Using this method patient S's, age 73, comorbidity can be evaluated as of moderate severity (16 out of 36 points), however its prognostic value is unclear, because of the absence of the interpretation of the overall score, resulting from the accumulation of the patient's diseases.
  4. Charlson Index: This index is meant for the long-term prognosis of comorbid patients and was developed by M. E. Charlson in 1987. This index is based on a point scoring system (from 0 to 40) for the presence of specific associated diseases and is used for prognosis of lethality. For its calculation the points are accumulated, according to associated diseases, as well as the addition of a single point for each 10 years of age for patients of ages above forty years (in 50 years 1 point, 60 years 2 points etc.). The distinguishing feature and undisputed advantage of the Charlson Index is the capability of evaluating the patient's age and determination of the patient's mortality rate, which in the absence of comorbidity is 12%, at 1–2 points it is 26%; at 3–4 points it is 52% and with the accumulation of more than 5 points it is 85%. Regretfully this method has some deficiencies: Evaluating comorbidity severity of many diseases is not considered, as well as the absence of many important for prognosis disorders. Apart from that it is doubtful that possible prognosis for a patient with bronchial asthma and chronic leukemia is comparable to the prognosis for the patient ailing from myocardial infarction and cerebral infarction. [70] In this case comorbidity of patient S, 73 years of age according to this method, is equivalent to mild state (9 out of 40 points).
  5. Modified Charlson Index: R. A. Deyo, D. C. Cherkin, and Marcia Ciol added chronic forms of ischemic cardiac disorder and the stages of chronic cardiac insufficiency to this index in 1992. [81]
  6. Elixhauser Index: The Elixhauser comorbidity measure include 30 comorbidities, which are not simplified as an index. Elixhauser shows a better predictive performance for mortality risk especially beyond 30 days of hospitalization. [71]
  7. Index of Co-Existent Disease (ICED): This Index was first developed in 1993 by S. Greenfield to evaluate comorbidity in patients with malignant neoplasms, later it also became useful for other categories of patients. This method helps in calculating the duration of a patient's stay at a hospital and the risks of repeated admittance of the same at a hospital after going through surgical procedures. For the evaluation of comorbidity the ICED index suggests to evaluate the patient's condition separately as per two different components: Physiological functional characteristics. The first component comprises 19 associated disorders, each of which is assessed on a 4-point scale, where "0" indicates the absence of disease and "3" indicates the disease's severe form. The second component evaluates the effect of associated diseases on the physical condition of the patient. It assesses 11 physical functions using a 3-point scale, where "0" means normal functionality and "2" means the impossibility of functionality.
  8. Geriatric Index of Comorbidity (GIC): Developed in 2002 [82]
  9. Functional Comorbidity Index (FCI): Developed in 2005. [83]
  10. Total Illness Burden Index (TIBI): Developed in 2007. [84]

Analyzing the comorbid state of patient S, 73 years of age, using the most used international comorbidity assessment scales, a doctor would come across totally different evaluation. The uncertainty of these results would somewhat complicate the doctors judgment about the factual level of severity of the patient's condition and would complicate the process of prescribing rational medicinal therapy for the identified disorders. Such problems are faced by doctors on everyday basis, despite all their knowledge about medical science. The main hurdle in the way of inducting comorbidity evaluation systems in broad based diagnostic-therapeutic process is their inconsistency and narrow focus. Despite the variety of methods of evaluation of comorbidity, the absence of a singular generally accepted method, devoid of the deficiencies of the available methods of its evaluation, causes disturbance. The absence of a unified instrument, developed on the basis of colossal international experience, as well as the methodology of its use does not allow comorbidity to become doctor "friendly". At the same time due to the inconsistency in approach to the analysis of comorbid state and absence of components of comorbidity in medical university courses, the practitioner is unclear about its prognostic effect, which makes the generally available systems of associated pathology evaluation unreasoned and therefore un-needed as well.

Treatment of comorbid patient

The effect of comorbid pathologies on clinical implications, diagnosis, prognosis and therapy of many diseases is polyhedral and patient-specific. The interrelation of the disease, age and drug pathomorphism greatly affect the clinical presentation and progress of the primary nosology, character and severity of the complications, worsens the patient's life quality and limit or make difficult the remedial-diagnostic process. Comorbidity affects life prognosis and increases the chances of fatality. The presence of comorbid disorders increases bed days, disability, hinders rehabilitation, increases the number of complications after surgical procedures, and increases the chances of decline in aged people. [85]

The presence of comorbidity must be taken into account when selecting the algorithm of diagnosis and treatment plans for any given disease. It is important to enquire comorbid patients about the level of functional disorders and anatomic status of all the identified nosological forms (diseases). Whenever a new, as well as mildly notable symptom appears, it is necessary to conduct a deep examination to uncover its causes. It is also necessary to be remembered that comorbidity leads to polypragmasy (polypharmacy), i.e. simultaneous prescription of a large number of medicines, which renders impossible the control over the effectiveness of the therapy, increases monetary expenses and therefore reduces compliance. At the same time, polypragmasy, especially in aged patients, renders possible the sudden development of local and systematic, unwanted medicinal side-effects. These side-effects are not always considered by the doctors, because they are considered as the appearance of comorbidity and as a result become the reason for the prescription of even more drugs, sealing-in the vicious circle. Simultaneous treatment of multiple disorders requires strict consideration of compatibility of drugs and detailed adherence of rules of rational drug therapy, based on E. M. Tareev's principles, which state: "Each non-indicated drug is contraindicated"[ This quote needs a citation ] and B. E. Votchal said: "If the drug does not have any side-effects, one must think if there is any effect at all".[ This quote needs a citation ]

A study of inpatient hospital data in the United States in 2011 showed that the presence of a major complication or comorbidity was associated with a great risk of intensive-care unit utilization, ranging from a negligible change for acute myocardial infarction with major complication or comorbidity to nearly nine times more likely for a major joint replacement with major complication or comorbidity. [86]

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Multimorbidity, also known as multiple long-term conditions (MLTC), means living with two or more chronic illnesses. For example, a person could have diabetes, heart disease and depression at the same time. Multimorbidity can have a significant impact on people's health and wellbeing. It also poses a complex challenge to healthcare systems which are traditionally focused on individual diseases. Multiple long-term conditions can affect people of any age, but they are more common in older age, affecting more than half of people over 65 years old.

<span class="mw-page-title-main">Bipolar disorder in children</span>

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents. The diagnosis of bipolar disorder in children has been heavily debated for many reasons including the potential harmful effects of adult bipolar medication use for children. PBD is similar to bipolar disorder (BD) in adults, and has been proposed as an explanation for periods of extreme shifts in mood called mood episodes. These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes. Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously. Mood episodes of children and adolescents with PBD are different from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time and cause severe disruptions to an individual's life. There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). The average age of onset of PBD remains unclear, but reported age of onset ranges from 5 years of age to 19 years of age. PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

<span class="mw-page-title-main">Cirrhosis</span> Chronic disease of the liver, characterized by fibrosis

Cirrhosis, also known as liver cirrhosis or hepatic cirrhosis, and end-stage liver disease, is the impaired liver function caused by the formation of scar tissue known as fibrosis due to damage caused by liver disease. Damage to the liver leads to repair of liver tissue and subsequent formation of scar tissue. Over time, scar tissue can replace normal functioning tissue, leading to the impaired liver function of cirrhosis. The disease typically develops slowly over months or years. Early symptoms may include tiredness, weakness, loss of appetite, unexplained weight loss, nausea and vomiting, and discomfort in the right upper quadrant of the abdomen. As the disease worsens, symptoms may include itchiness, swelling in the lower legs, fluid build-up in the abdomen, jaundice, bruising easily, and the development of spider-like blood vessels in the skin. The fluid build-up in the abdomen may develop into spontaneous infections. More serious complications include hepatic encephalopathy, bleeding from dilated veins in the esophagus, stomach, or intestines, and liver cancer.

Functional disorder is an umbrella term for a group of recognisable medical conditions which are due to changes to the functioning of the systems of the body rather than due to a disease affecting the structure of the body.

The differential diagnoses of anorexia nervosa (AN) includes various types of medical and psychological conditions, which may be misdiagnosed as AN. In some cases, these conditions may be comorbid with AN because the misdiagnosis of AN is not uncommon. For example, a case of achalasia was misdiagnosed as AN and the patient spent two months confined to a psychiatric hospital. A reason for the differential diagnoses that surround AN arise mainly because, like other disorders, it is primarily, albeit defensively and adaptive for, the individual concerned. Anorexia Nervosa is a psychological disorder characterized by extremely reduced intake of food. People with anorexia nervosa tend to have a low self-image and an inaccurate perception of their body.

Clinical nutrition centers on the prevention, diagnosis, and management of nutritional changes in patients linked to chronic diseases and conditions primarily in health care. Clinical in this sense refers to the management of patients, including not only outpatients at clinics and in private practice, but also inpatients in hospitals. It incorporates primarily the scientific fields of nutrition and dietetics. Furthermore, clinical nutrition aims to maintain a healthy energy balance, while also providing sufficient amounts of nutrients such as protein, vitamins, and minerals to patients.

Somatic symptom disorder, also known as somatoform disorder, is defined by one or more chronic physical symptoms that coincide with excessive and maladaptive thoughts, emotions, and behaviors connected to those symptoms. The symptoms are not deliberately produced or feigned, and they may or may not coexist with a known medical ailment.

<span class="mw-page-title-main">Disruptive mood dysregulation disorder</span> Medical condition

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of same-aged peers. DMDD was added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as a type of depressive disorder diagnosis for youths. The symptoms of DMDD resemble many other disorders, thus a differential includes attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder, intermittent explosive disorder (IED), major depressive disorder (MDD), and conduct disorder.

Hypertensive disease of pregnancy, also known as maternal hypertensive disorder, is a group of high blood pressure disorders that include preeclampsia, preeclampsia superimposed on chronic hypertension, gestational hypertension, and chronic hypertension.

In medicine, the Charlson Comorbidity Index (CCI) predicts the mortality for a patient who may have a range of concurrent conditions (comorbidities), such as heart disease, AIDS, or cancer. A score of zero means that no comorbidities were found; the higher the score, the higher the predicted mortality rate is. For a physician, this score is helpful in deciding how aggressively to treat a condition.

In medicine, the Comorbidity–polypharmacy score (CPS) is a measure of overall severity of comorbidities. It is defined as the simple sum of the number of known comorbidities and pre-admission medications taken by the patient (polypharmacy), as a surrogate for the “intensity” of the comorbidities.

In medicine, the Elixhauser Comorbidity Index is a measure of overall severity of comorbidities, predicting hospital length of stay, hospital charges, and in-hospital mortality. The higher the score, the higher the predicted hospital resource use and mortality rate are. For a physician, this score is helpful in deciding how aggressively to treat a condition.

<span class="mw-page-title-main">Autoimmune urticaria</span> Autoimmune disease causing hives and itching

Autoimmune urticaria, also known as chronic autoimmune urticaria, is a type of chronic urticaria characterized by the presence of autoantibodies in the patient's immune system that target the body's own mast cells, leading to episodes of hives (urticaria). This immunologically distinct type of urticaria is considered autoimmune because the immune system, which normally protects the body from foreign organisms, mistakenly attacks the body's own cells, causing inflammation and other symptoms.

References

  1. ↑ "comorbidity", Wiktionary, 2022-02-07, retrieved 2022-08-18
  2. ↑ "comorbidity | Etymology of comorbidity by etymonline". www.etymonline.com. Retrieved 2024-03-22.
  3. ↑ Valderas, Jose M.; Starfield, Barbara; Sibbald, Bonnie; Salisbury, Chris; Roland, Martin (2009). "Defining Comorbidity: Implications for Understanding Health and Health Services". Annals of Family Medicine. 7 (4): 357–63. doi:10.1370/afm.983. PMC   2713155 . PMID   19597174.
  4. ↑ Jakovljević M, Ostojić L (June 2013). "Comorbidity and multimorbidity in medicine today: challenges and opportunities for bringing separated branches of medicine closer to each other". Psychiatr Danub. 25 Suppl 1 (25 Suppl 1): 18–28. PMID   23806971.
  5. ↑ Maj, M (2005), "'Psychiatric comorbidity': an artefact of current diagnostic systems?", Br J Psychiatry, 186 (3): 182–84, doi: 10.1192/bjp.186.3.182 , PMID   15738496.
  6. ↑ Multimorbidity: a priority for global health research. Academy of Medical Sciences. 2018.
  7. ↑ Nicholson, Kathryn; Makovski, Tatjana T.; Griffith, Lauren E.; Raina, Parminder; Stranges, Saverio; van den Akker, Marjan (22 September 2018). "Multimorbidity and comorbidity revisited: refining the concepts for international health research". Journal of Clinical Epidemiology. 105: 142–146. doi:10.1016/j.jclinepi.2018.09.008. PMID   30253215. S2CID   52825086.
  8. 1 2 Harrison, Christopher; Fortin, Martin; van den Akker, Marjan; Mair, Frances; Calderon-Larranaga, Amaia; Boland, Fiona; Wallace, Emma; Jani, Bhautesh; Smith, Susan (2021-01-01). "Comorbidity versus multimorbidity: Why it matters". Journal of Multimorbidity and Comorbidity. 11: 263355652199399. doi:10.1177/2633556521993993. ISSN   2633-5565. PMC   7930649 . PMID   33718251.
  9. ↑ Marengoni, Alessandra; Angleman, Sara; Melis, René; Mangialasche, Francesca; Karp, Anita; Garmen, Annika; Meinow, Bettina; Fratiglioni, Laura (12 March 2011). "Aging with multimorbidity: A systematic review of the literature". Ageing Research Reviews. 10 (4): 430–439. doi:10.1016/j.arr.2011.03.003. PMID   21402176. S2CID   40912813.
  10. ↑ First, Michael B. (2005). "Mutually Exclusive versus Co-Occurring Diagnostic Categories: The Challenge of Diagnostic Comorbidity". Psychopathology. 38 (4): 206–10. doi:10.1159/000086093. PMID   16145276. S2CID   24215247.
  11. ↑ van Loo, Hanna M.; Romeijn, Jan-Willem (February 2015). "Psychiatric comorbidity: fact or artifact?". Theoretical Medicine and Bioethics. 36 (1): 41–60. doi:10.1007/s11017-015-9321-0. ISSN   1386-7415. PMC   4320768 . PMID   25636962.
  12. ↑ Klein Hofmeijer-Sevink, Mieke; van Oppen, Patricia; van Megen, Harold J.; Batelaan, Neeltje M.; Cath, Danielle C.; van der Wee, Nic J. A.; van den Hout, Marcel A.; van Balkom, Anton J. (2013-09-25). "Clinical relevance of comorbidity in obsessive compulsive disorder: The Netherlands OCD Association study". Journal of Affective Disorders. 150 (3): 847–854. doi:10.1016/j.jad.2013.03.014. ISSN   0165-0327. PMID   23597943.
  13. ↑ Reale, Laura; Bartoli, Beatrice; Cartabia, Massimo; Zanetti, Michele; Costantino, Maria Antonella; Canevini, Maria Paola; Termine, Cristiano; Bonati, Maurizio; Conte, Stefano; Renzetti, Valeria; Salvoni, Laura (2017-12-01). "Comorbidity prevalence and treatment outcome in children and adolescents with ADHD". European Child & Adolescent Psychiatry. 26 (12): 1443–1457. doi:10.1007/s00787-017-1005-z. ISSN   1435-165X. PMID   28527021. S2CID   3076193.
  14. ↑ Bang, Lasse; Kristensen, Unn Beate; Wisting, Line; Stedal, Kristin; Garte, Marianne; Minde, Åse; Rø, Øyvind (2020-01-30). "Presence of eating disorder symptoms in patients with obsessive-compulsive disorder". BMC Psychiatry. 20 (1): 36. doi: 10.1186/s12888-020-2457-0 . ISSN   1471-244X. PMC   6993325 . PMID   32000754.
  15. ↑ Rhee, Soo Hyun; Hewitt, John K.; Lessem, Jeffrey M.; Stallings, Michael C.; Corley, Robin P.; Neale, Michael C. (May 2004). "The Validity of the Neale and Kendler Model-Fitting Approach in Examining the Etiology of Comorbidity". Behavior Genetics. 34 (3): 251–65. doi:10.1023/B:BEGE.0000017871.87431.2a. PMID   14990866. S2CID   23065315.
  16. ↑ Maj, Mario (2005). "'Psychiatric comorbidity': An artifact of current diagnostic systems?". The British Journal of Psychiatry. 186 (3): 182–84. doi: 10.1192/bjp.186.3.182 . PMID   15738496.
  17. ↑ Massimiliano Aragona (2009). "The Role of Comorbidity in the Crisis of the Current Psychiatric Classification System". Philosophy, Psychiatry, & Psychology. 16: 1–11. doi:10.1353/ppp.0.0211. S2CID   143888431.
  18. ↑ Jakovljević, Miro; Crnčević, Željka (June 2012). "Comorbidity as an epistemological challenge to modern psychiatry". Dialogues in Philosophy, Mental and Neuro Sciences. 5 (1): 1–13.
  19. ↑ Kristiansen, K.; Nesbakken, R. (1975). "Proceedings of the 26th annual meeting of the Nordisk Neurokirurgisk Förening (Scandinavian Neurosurgical Society) Sept. 5–7, 1974, Oslo, Norway". Acta Neurochirurgica. 31 (3–4): 257–74. doi:10.1007/BF01406298. S2CID   13220380.
  20. ↑ Boyd, Jeffrey H.; Burke, Jack D.; Gruenberg, Ernest; Holzer, Charles E.; Rae, Donald S.; George, Linda K.; Karno, Marvin; Stoltzman, Roger; et al. (1984). "Exclusion Criteria of DSM-III: A Study of Co-occurrence of Hierarchy-Free Syndromes". Archives of General Psychiatry. 41 (10): 983–89. doi:10.1001/archpsyc.1984.01790210065008. PMID   6477056.
  21. ↑ Sanderson, William C.; Beck, Aaron T.; Beck, Judith (1990). "Syndrome comorbidity in patients with major depression or dysthymia: Prevalence and temporal relationships". The American Journal of Psychiatry. 147 (8): 1025–28. doi:10.1176/ajp.147.8.1025. PMID   2375436.
  22. ↑ Нуллер, Ю. Л. "Депрессия и деперсонализация: проблема коморбидности" [Depression and depersonalization: the problem of comorbidity]. Депрессии и коморбидные расстройства[Depression and comorbid disorders] (in Russian).
  23. ↑ Robins, Lee N. (1994). "How Recognizing 'Comorbidities' in Psychopathology May Lead to an Improved Research Nosology". Clinical Psychology: Science and Practice. 1: 93–95. doi:10.1111/j.1468-2850.1994.tb00010.x.
  24. ↑ Смулевич, А. Б.; Дубницкая, Э. Б.; Тхостов, А. Ш.; Зеленина, Е. В.; Андрющенко, A. В.; Иванов, C. В. "Психопатология депрессий (к построению типологической модели)" [Psychopathology of depression (the construction of a typological model)]. Депрессии и коморбидные расстройства[Depression and comorbid disorders] (in Russian).
  25. ↑ Cloninger, C. Robert (2002). "Implications of Comorbidity for the Classification of Mental Disorders: The Need for a Psychobiology of Coherence". In Maj, Mario; Gaebel, Wolfgang; López-Ibor, Juan José; et al. (eds.). Psychiatric Diagnosis and Classification . pp.  79–106. doi:10.1002/047084647X.ch4. ISBN   978-0-471-49681-6.
  26. ↑ Kaplan, Moreson H.; Feinstein, Alvan R. (1974). "The importance of classifying initial co-morbidity in evaluating the outcome of diabetes mellitus". Journal of Chronic Diseases. 27 (7–8): 387–404. doi:10.1016/0021-9681(74)90017-4. PMID   4436428.
  27. ↑ Pincus, T; Callahan, LF (1986). "Taking mortality in rheumatoid arthritis seriously--predictive markers, socioeconomic status and comorbidity". The Journal of Rheumatology. 13 (5): 841–45. PMID   3820193.
  28. ↑ Charlson, Mary E.; Sax, Frederic L. (1987). "The therapeutic efficacy of critical care units from two perspectives: A traditional cohort approach vs a new case-control methodology". Journal of Chronic Diseases. 40 (1): 31–39. doi:10.1016/0021-9681(87)90094-4. PMID   3805232.
  29. ↑ Schellevis, F.G.; Van De Lisdonk, E.; Van Der Velden, J.; Van Eijk, J.Th.M.; Van Weel, C. (1993). "Validity of diagnoses of chronic diseases in general practice". Journal of Clinical Epidemiology. 46 (5): 461–68. doi:10.1016/0895-4356(93)90023-T. PMID   8501472.
  30. ↑ Kraemer, Helena Chmura (1995). "Statistical issues in assessing comorbidity". Statistics in Medicine. 14 (8): 721–33. doi:10.1002/sim.4780140803. PMID   7644854.
  31. ↑ Van Den Akker, Marjan; Buntinx, Frank; Knottnerus, J André (1996). "Comorbidity or multimorbidity". European Journal of General Practice. 2 (2): 65–70. doi:10.3109/13814789609162146.
  32. ↑ Grimby, A; Svanborg, A (1997). "Morbidity and health-related quality of life among ambulant elderly citizens". Aging. 9 (5): 356–64. doi:10.1007/bf03339614. PMID   9458996. S2CID   28534072.
  33. ↑ Stier, David M; Greenfield, Sheldon; Lubeck, Deborah P; Dukes, Kimberly A; Flanders, Scott C; Henning, James M; Weir, Julie; Kaplan, Sherrie H (1999). "Quantifying comorbidity in a disease-specific cohort: Adaptation of the total illness burden index to prostate cancer". Urology. 54 (3): 424–29. doi:10.1016/S0090-4295(99)00203-4. PMID   10475347.
  34. ↑ Fortin, Martin; Lapointe, Lise; Hudon, Catherine; Vanasse, Alain; Ntetu, Antoine L; Maltais, Danielle (2004). "Multimorbidity and quality of life in primary care: A systematic review". Health and Quality of Life Outcomes. 2: 51. doi: 10.1186/1477-7525-2-51 . PMC   526383 . PMID   15380021.
  35. ↑ Fortin, Martin; Lapointe, Lise; Hudon, Catherine; Vanasse, Alain (2005). "Multimorbidity is common to family practice: Is it commonly researched?". Canadian Family Physician. 51 (2): 244–45. PMC   1472978 . PMID   16926936.
  36. ↑ Лазебник, Л. Б. (2007). Старение и полиморбидность [Aging and polymorbidity]. Новости медицины и фармации (in Russian). 1 (205).[ page needed ]
  37. ↑ Вёрткин, А. Л.; Зайратьянц, О. В.; Вовк, Е. И. (2009). Окончательный диагноз [The final diagnosis] (in Russian). Moscow: GEOTAR-Media. ISBN   978-5-9704-0920-6. Archived from the original on 2013-06-08. Retrieved 2011-12-15.[ page needed ]
  38. ↑ Caughey, Gillian E; Vitry, Agnes I; Gilbert, Andrew L; Roughead, Elizabeth E (2008). "Prevalence of comorbidity of chronic diseases in Australia". BMC Public Health. 8: 221. doi: 10.1186/1471-2458-8-221 . PMC   2474682 . PMID   18582390.
  39. ↑ Белялов, Ф. И. (2012). Лечение внутренних болезней в условиях коморбидности: монографияЛечение внутренних болезней в условиях коморбидности [Internal Medicine in comorbidity](PDF) (in Russian). Irkutsk: РИО ИГМАПО. ISBN   978-5-89786-091-3. Archived from the original (PDF) on August 19, 2019.[ page needed ]
  40. ↑ Лучихин, Л. А. (2010). "Co-morbidity in ENT practice" Коморбидность в ЛОР-практике [Co-morbidity in ENT practice](PDF). Вестник оториноларингологии (in Russian) (2): 79–82. PMID   20527094. Archived from the original (PDF) on 2012-01-18.
  41. ↑ Feinstein, Alvan R. (1970). "The pre-therapeutic classification of co-morbidity in chronic disease". Journal of Chronic Diseases. 23 (7): 455–68. doi:10.1016/0021-9681(70)90054-8. PMID   26309916.
  42. ↑ Лазебник Л. Б. Старение и полиморбидность // Консилиум Медикум, 2005, № 12 Archived 2016-03-04 at the Wayback Machine
  43. ↑ Greenfield, Sheldon; Apolone, Giovanni; McNeil, Barbara J.; Cleary, Paul D. (1993). "The Importance of Co-Existent Disease in the Occurrence of Postoperative Complications and One-Year Recovery in Patients Undergoing Total Hip Replacement: Comorbidity and Outcomes after Hip Replacement". Medical Care. 31 (2): 141–54. doi:10.1097/00005650-199302000-00005. JSTOR   3765891. PMID   8433577. S2CID   13474819.
  44. ↑ Starfield, B.; Lemke, KW; Bernhardt, T; Foldes, SS; Forrest, CB; Weiner, JP (2003). "Comorbidity: Implications for the Importance of Primary Care in 'Case' Management". Annals of Family Medicine. 1 (1): 8–14. doi:10.1370/afm.1. PMC   1466556 . PMID   15043174.
  45. ↑ Van Weel, Chris; Schellevis, François G (2006). "Comorbidity and guidelines: Conflicting interests". The Lancet. 367 (9510): 550–51. doi:10.1016/S0140-6736(06)68198-1. PMID   16488782. S2CID   10491258.
  46. ↑ Gill, Thomas M.; Feinstein, AR (1994). "A Critical Appraisal of the Quality of Quality-of-Life Measurements". JAMA. 272 (8): 619–26. doi:10.1001/jama.1994.03520080061045. PMID   7726894.
  47. ↑ "Reliability and validity of a diabetes quality-of-life measure for the diabetes control and complications trial (DCCT). The DCCT Research Group". Diabetes Care. 11 (9): 725–32. 1988. doi:10.2337/diacare.11.9.725. PMID   3066604. S2CID   219229163.
  48. ↑ Michelson, Helena; Bolund, Christina; Brandberg, Yvonne (2000). "Multiple chronic health problems are negatively associated with health related quality of life (HRQoL) irrespective of age". Quality of Life Research. 9 (10): 1093–104. doi:10.1023/A:1016654621784. PMID   11401042. S2CID   23029997.
  49. ↑ Hoffman, Catherine; Rice, D; Sung, HY (1996). "Persons with Chronic Conditions: Their Prevalence and Costs". JAMA. 276 (18): 1473–79. doi:10.1001/jama.1996.03540180029029. PMID   8903258.
  50. ↑ Fuchs, Z.; Blumstein, T.; Novikov, I.; Walter-Ginzburg, A.; Lyanders, M.; Gindin, J.; Habot, B.; Modan, B. (1998). "Morbidity, Comorbidity, and Their Association with Disability Among Community-Dwelling Oldest-Old in Israel". The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 53A (6): M447–55. doi: 10.1093/gerona/53A.6.M447 . PMID   9823749.
  51. ↑ Daveluy, C.; Pica, L.; Audet, N. (2001). Enquête Sociale et de Santé 1998 (2nd ed.). Québec: Institut de la statistique du Québec. Archived from the original on 2013-01-26. Retrieved 2013-02-12.[ page needed ]
  52. ↑ Wolff, J. L.; Starfield, B; Anderson, G (2002). "Prevalence, Expenditures, and Complications of Multiple Chronic Conditions in the Elderly". Archives of Internal Medicine. 162 (20): 2269–76. doi: 10.1001/archinte.162.20.2269 . PMID   12418941.
  53. ↑ Cuijpers, Pim; Van Lammeren, Paula; Duzijn, Bernadette (1999). "Relation Between Quality of Life and Chronic Illnesses in Elderly Living in Residential Homes: A Prospective Study". International Psychogeriatrics. 11 (4): 445–54. doi:10.1017/S1041610299006067. PMID   10631590. S2CID   28550953.
  54. ↑ Caughey, G. E.; Ramsay, E. N.; Vitry, A. I.; Gilbert, A. L.; Luszcz, M. A.; Ryan, P.; Roughead, E. E. (2009). "Comorbid chronic diseases, discordant impact on mortality in older people: A 14-year longitudinal population study" (PDF). Journal of Epidemiology & Community Health. 64 (12): 1036–42. doi:10.1136/jech.2009.088260. hdl: 2440/62696 . PMID   19854745. S2CID   206990104.
  55. ↑ Aronow, Wilbert S; Ahn, Chul; Mercando, Anthony D; Epstein, Stanley (2000). "Prevalence of coronary artery disease, complex ventricular arrhythmias, and silent myocardial ischemia and incidence of new coronary events in older persons with chronic renal insufficiency and with normal renal function". The American Journal of Cardiology. 86 (10): 1142–43, A9. doi:10.1016/S0002-9149(00)01176-0. PMID   11074216.
  56. ↑ Bruce, Sharon G.; Riediger, Natalie D.; Zacharias, James M.; Young, T. Kue (2010). "Obesity and Obesity-Related Comorbidities in a Canadian First Nation Population". Preventing Chronic Disease. 31 (1): 27–32. PMID   21213616.
  57. ↑ Weir, Peter T.; Harlan, Gregory A.; Nkoy, Flo L.; Jones, Spencer S.; Hegmann, Kurt T.; Gren, Lisa H.; Lyon, Joseph L. (2006). "The Incidence of Fibromyalgia and Its Associated Comorbidities". Journal of Clinical Rheumatology. 12 (3): 124–28. doi:10.1097/01.rhu.0000221817.46231.18. PMID   16755239. S2CID   24272513.
  58. ↑ Hudson, James I.; Goldenberg, Don L.; Pope, Harrison G.; Keck, Paul E.; Schlesinger, Lynn (1992). "Comorbidity of fibromyalgia with medical and psychiatric disorders". The American Journal of Medicine. 92 (4): 363–67. doi:10.1016/0002-9343(92)90265-D. PMID   1558082.
  59. ↑ Van Den Akker, Marjan; Buntinx, Frank; Metsemakers, Job F.M.; Roos, Sjef; Knottnerus, J. André (1998). "Multimorbidity in General Practice: Prevalence, Incidence, and Determinants of Co-Occurring Chronic and Recurrent Diseases". Journal of Clinical Epidemiology. 51 (5): 367–75. doi:10.1016/S0895-4356(97)00306-5. PMID   9619963.
  60. ↑ Fortin, Martin; Bravo, Gina; Hudon, Catherine; Vanasse, Alain; Lapointe, Lise (2005). "Prevalence of Multimorbidity Among Adults Seen in Family Practice". Annals of Family Medicine. 3 (3): 223–8. doi:10.1370/afm.272. PMC   1466875 . PMID   15928225.
  61. ↑ Вёрткин, А. Л.; Скотников, А. С. Роль хронического аллергического воспаления в патогенезе бронхиальной астмы и его рациональная фармакотерапия у пациентов с полипатией [Role of chronic allergic inflammation in bronchial asthma pathogenesis and its rational pharmacological therapy for patients with polypathia](PDF). Врач скорой помощи (in Russian) (4): 6–14.[ permanent dead link ]
  62. ↑ Feudjo-Tepie, M. A.; Le Roux, G.; Beach, K. J.; Bennett, D.; Robinson, N. J. (2009). "Comorbidities of Idiopathic Thrombocytopenic Purpura: A Population-Based Study". Advances in Hematology. 2009: 1–12. doi: 10.1155/2009/963506 . PMC   2778146 . PMID   19960044.
  63. ↑ Taylor, VM; Anderson, GM; McNeney, B; Diehr, P; Lavis, JN; Deyo, RA; Bombardier, C; Malter, A; Axcell, T (1998). "Hospitalizations for back and neck problems: A comparison between the Province of Ontario and Washington State". Health Services Research. 33 (4 Pt 1): 929–45. PMC   1070294 . PMID   9776943.
  64. ↑ Zhang, M.; Holman, C D. J; Price, S. D; Sanfilippo, F. M; Preen, D. B; Bulsara, M. K (2009). "Comorbidity and repeat admission to hospital for adverse drug reactions in older adults: Retrospective cohort study". BMJ. 338: a2752. doi:10.1136/bmj.a2752. PMC   2615549 . PMID   19129307.
  65. ↑ Wang, P. S.; Avorn, J; Brookhart, MA; Mogun, H; Schneeweiss, S; Fischer, MA; Glynn, RJ (2005). "Effects of Noncardiovascular Comorbidities on Antihypertensive Use in Elderly Hypertensives". Hypertension. 46 (2): 273–79. CiteSeerX   10.1.1.580.8951 . doi:10.1161/01.HYP.0000172753.96583.e1. PMID   15983239. S2CID   13218664.
  66. ↑ Tomblin, J. Bruce; Mueller, Kathyrn L. (2012). "How Can Comorbidity with Attention-Deficit/Hyperactivity Disorder Aid Understanding of Language and Speech Disorders?". Topics in Language Disorders. 32 (3): 198–206. doi:10.1097/TLD.0b013e318261c264. PMC   4013272 . PMID   24817779.
  67. ↑ Gijsen, Ronald; Hoeymans, Nancy; Schellevis, François G.; Ruwaard, Dirk; Satariano, William A.; Van Den Bos, Geertrudis A.M. (2001). "Causes and consequences of comorbidity". Journal of Clinical Epidemiology. 54 (7): 661–74. doi:10.1016/S0895-4356(00)00363-2. PMID   11438406.
  68. ↑ Пальцев, М.А.; Автандилов, Г.Г.; Зайратьянц, О.В.; Кактурский, Л.В. (2006). Никонов Е.Л. Правила формулировки диагноза. Часть 1. Общие положения [Rules language diagnosis. Part 1. General provisions] (in Russian). Moscow: Scientific Research Institute of Human Morphology.[ page needed ]
  69. ↑ Зайратьянц, О. В.; Кактурский, Л. В. (2011). Формулировка и сопоставление клинического и патологоанатомического диагнозов: справочникФормулировка и сопоставление клинического и патологоанатомического диагнозов: Справочник [Formulation and comparison of clinical and postmortem diagnoses: A Handbook] (in Russian) (2nd ed.). Moscow: Meditsinskoe informatsionnoe agentstvo. ISBN   978-5-89481-881-8.[ page needed ]
  70. 1 2 Charlson, Mary E.; Pompei, Peter; Ales, Kathy L.; MacKenzie, C. Ronald (1987). "A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation". Journal of Chronic Diseases. 40 (5): 373–83. doi:10.1016/0021-9681(87)90171-8. PMID   3558716.
  71. 1 2 3 Sharabiani, Mansour; Aylin, Paul; Bottle, Alex (December 2012). "Systematic review of comorbidity indices for administrative data". Medical Care. 50 (12): 1109–18. doi:10.1097/MLR.0b013e31825f64d0. PMID   22929993. S2CID   25852524.
  72. 1 2 Evans, DC; Cook, CH; Christy, JM (August 2012). "Comorbidity–polypharmacy scoring facilitates outcome prediction in older trauma patients". J Am Geriatr Soc. 60 (8): 1465–70. doi:10.1111/j.1532-5415.2012.04075.x. PMID   22788674. S2CID   40542659.
  73. ↑ Justiniano, CF; Coffey, RA; Evans, DC (Jan 2015). "Comorbidity–polypharmacy score predicts in-hospital complications and the need for discharge to extended care facility in older burn patients". J Burn Care Res. 36 (1): 193–96. doi:10.1097/bcr.0000000000000094. PMID   25559732. S2CID   3677354.
  74. ↑ Justiniano, CF; Evans, DC; Cook, CH (May 2013). "Comorbidity–polypharmacy score: a novel adjunct in post-emergency department trauma triage". J Surg Res. 181 (1): 16–19. doi:10.1016/j.jss.2012.05.042. PMC   3717608 . PMID   22683074.
  75. ↑ Van Walraven, Carl; Austin, Peter C.; Jennings, Alison; Quan, Hude; Forster, Alan J. (2009). "A Modification of the Elixhauser Comorbidity Measures into a Point System for Hospital Death Using Administrative Data". Medical Care. 47 (6): 626–33. doi:10.1097/MLR.0b013e31819432e5. PMID   19433995. S2CID   35832401.
  76. ↑ Degroot, V; Beckerman, H; Lankhorst, G; Bouter, L (2003). "How to measure comorbiditya critical review of available methods" (PDF). Journal of Clinical Epidemiology. 56 (3): 221–29. doi:10.1016/S0895-4356(02)00585-1. PMID   12725876.
  77. ↑ Linn, Bernard S.; Linn, Margaret W.; Gurel, Lee (1968). "Cumulative illness rating scale". Journal of the American Geriatrics Society. 16 (5): 622–26. doi:10.1111/j.1532-5415.1968.tb02103.x. PMID   5646906. S2CID   46332750.
  78. ↑ Miller M.D., Towers A. Manual of Guidelines for Scoring the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) // Pittsburgh, Pa: University of Pittsburgh; 1991 Archived 2012-01-25 at the Wayback Machine
  79. ↑ Miller, Mark D.; Paradis, Cynthia F.; Houck, Patricia R.; Mazumdar, Sati; Stack, Jacqueline A.; Rifai, A. Hind; Mulsant, Benoit; Reynolds, Charles F. (1992). "Rating chronic medical illness burden in geropsychiatric practice and research: Application of the Cumulative Illness Rating Scale". Psychiatry Research. 41 (3): 237–48. doi:10.1016/0165-1781(92)90005-N. PMID   1594710. S2CID   21806654.
  80. ↑ Kaplan, M. H.; Feinstein, A. R. (1973). "A critique of methods in reported studies of long-term vascular complications in patients with diabetes mellitus". Diabetes. 22 (3): 160–74. doi:10.2337/diab.22.3.160. PMID   4689292. S2CID   39418912.
  81. ↑ Deyo, R; Cherkin, DC; Ciol, MA (1992). "Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases". Journal of Clinical Epidemiology. 45 (6): 613–19. doi:10.1016/0895-4356(92)90133-8. PMID   1607900.
  82. ↑ Rozzini, R.; Frisoni, GB; Ferrucci, L; Barbisoni, P; Sabatini, T; Ranieri, P; Guralnik, JM; Trabucchi, M (2002). "Geriatric Index of Comorbidity: Validation and comparison with other measures of comorbidity". Age and Ageing. 31 (4): 277–85. doi: 10.1093/ageing/31.4.277 . PMID   12147566.
  83. ↑ Groll, D; To, T; Bombardier, C; Wright, J (2005). "The development of a comorbidity index with physical function as the outcome". Journal of Clinical Epidemiology. 58 (6): 595–602. doi:10.1016/j.jclinepi.2004.10.018. PMID   15878473.
  84. ↑ Litwin, Mark S.; Greenfield, Sheldon; Elkin, Eric P.; Lubeck, Deborah P.; Broering, Jeanette M.; Kaplan, Sherrie H. (2007). "Assessment of prognosis with the total illness burden index for prostate cancer". Cancer. 109 (9): 1777–83. doi: 10.1002/cncr.22615 . PMID   17354226. S2CID   36052321.
  85. ↑ Muñoz, Eric; Rosner, Fred; Friedman, Richard; Sterman, Harris; Goldstein, Jonathan; Wise, Leslie (1988). "Financial risk, hospital cost, and complications and comorbidities in medical non-complications and comorbidity-stratified diagnosis-related groups". The American Journal of Medicine. 84 (5): 933–39. doi:10.1016/0002-9343(88)90074-5. PMID   3129939.
  86. ↑ Barrett ML, Smith MW, Elizhauser A, Honigman LS, Pines JM (December 2014). "Utilization of Intensive Care Services, 2011". HCUP Statistical Brief #185. Rockville, MD: Agency for Healthcare Research and Quality. PMID   25654157.

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