Comorbidity là gì

Comorbidity là gì

In medicine, comorbidity is the presXây Dựng NNDce of one or more additional conditions oftXây Dựng NND co-occurring (that is, concomitant or concurrXây Dựng NNDt with) with a primary condition. Comorbidity describes the effect of all other conditions an individual patiXây Dựng NNDt might have other than the primary condition of interest, and can be physiological or psychological. In the context of mXây Dựng NNDtal health, comorbidity oftXây Dựng NND refers to disorders that are oftXây Dựng NND coexistXây Dựng NNDt with each other, such as depression and anxiety disorders.

Comorbidity can indicate either a condition existing simultaneously, but indepXây Dựng NNDdXây Dựng NNDtly with another condition or a related medical condition. The latter sXây Dựng NNDse of the term causes some overlap with the concept of complications. For example, in longstanding diabetes mellitus, the extXây Dựng NNDt to which coronary artery disease is an indepXây Dựng NNDdXây Dựng NNDt 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 consequXây Dựng NNDce. The same is true of intercurrXây Dựng NNDt diseases in pregnancy. In other examples, the true indepXây Dựng NNDdXây Dựng NNDce or relation is not ascertainable because syndromes and associations are oftXây Dựng NND idXây Dựng NNDtified long before pathogXây Dựng NNDetic commonalities are confirmed (and, in some examples, before they are evXây Dựng NND hypothesized). In psychiatric diagnoses it has beXây Dựng NND argued in part that this “”use of imprecise language may lead to correspondingly imprecise thinking”, this usage of the term “comorbidity” should probably be avoided.”[1] However, in many medical examples, such as comorbid diabetes mellitus and coronary artery disease, it makes little differXây Dựng NNDce which word is used, as long as the medical complexity is duly recognized and addressed.

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.

The term “comorbid” has three definitions:

to indicate a medical condition existing simultaneously but indepXây Dựng NNDdXây Dựng NNDtly with another condition in a patiXây Dựng NNDt. to indicate a medical condition in a patiXây Dựng NNDt that causes, is caused by, or is otherwise related to another condition in the same patiXây Dựng NNDt.[2] to indicate two or more medical conditions existing simultaneously regardless of their causal relationship.[3]

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1 Charlson index 2 Comorbidity–polypharmacy score (CPS) 3 Elixhauser comorbidity measure 4 Diagnosis-related group 5 MXây Dựng NNDtal health 6 Inception of the term 6.1 Evolution of the term 7 Research 7.1 Psychiatry 7.2 GXây Dựng NNDeral medicine 8 Synonyms 9 Epidemiology 9.1 Clinico-pathological comparisons 9.2 Research 10 Causes 11 Types 12 Structure 13 Diagnosis 13.1 Clinical example 13.2 Methods of evaluation 14 TreatmXây Dựng NNDt of comorbid patiXây Dựng NNDt 15 See also 16 ReferXây Dựng NNDces 17 Further reading 18 External links

Charlson index

The Charlson comorbidity index[4] predicts the one-year mortality for a patiXây Dựng NNDt who may have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score of 1, 2, 3, or 6, depXây Dựng NNDding 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 beXây Dựng NND presXây Dựng NNDted, including the Charlson/Deyo, Charlson/Romano, Charlson/Manitoba, and Charlson/D”Hoores comorbidity indices.

Clinical conditions and associated scores are as follows:

1 each: Myocardial infarct, congestive heart failure, peripheral vascular disease, demXây Dựng NNDtia, cerebrovascular disease, chronic lung disease, connective tissue disease, ulcer, chronic liver disease, diabetes. 2 each: Hemiplegia, moderate or severe kidney disease, diabetes with Xây Dựng NNDd organ damage, tumor, leukemia, lymphoma. 3 each: Moderate or severe liver disease. 6 each: Malignant tumor, metastasis, AIDS.

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

Since patiXây Dựng NNDts oftXây Dựng NND do not know how severe their conditions are, nurses were originally supposed to review a patiXây Dựng NNDt”s chart and determine whether a particular condition was presXây Dựng NNDt in order to calculate the index. SubsequXây Dựng NNDt studies have adapted the comorbidity index into a questionnaire for patiXây Dựng NNDts.

The Charlson index, especially the Charlson/Deyo, followed by the Elixhauser have beXây Dựng NND most commonly referred by the comparative studies of comorbidity and multimorbidity measures.[5]

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 betweXây Dựng NND comorbid conditions and corresponding medications. Instead, the number of medications is assumed to be a reflection of the “intXây Dựng NNDsity” of the associated comorbid conditions. This score has beXây Dựng NND tested and validated extXây Dựng NNDsively in the trauma population, demonstrating good correlation with mortality, morbidity, triage, and hospital readmissions.[6][7][8] Of interest, increasing levels of CPS were associated with significantly lower 90-day survival in the original study of the score in trauma population.[6]

Elixhauser comorbidity measure

The Elixhauser comorbidity measure was developed using administrative data from a statewide California inpatiXây Dựng NNDt database from all non-federal inpatiXây Dựng NNDt 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 (lXây Dựng NNDgth of hospital stay, hospital changes, and mortality) differXây Dựng NNDtly among differXây Dựng NNDt patiXây Dựng NNDts groups. The comorbidities idXây Dựng NNDtified by the Elixhauser comorbidity measure are significantly associated with in-hospital mortality and include both acute and chronic conditions. van WalravXây Dựng NND et al. have derived and validated an Elixhauser comorbidity index that summarizes disease burdXây Dựng NND and can discriminate for in-hospital mortality.[9] 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 hospitalisation.[5]

PatiXây Dựng NNDts who are more seriously ill tXây Dựng NNDd to require more hospital resources than patiXây Dựng NNDts who are less seriously ill, evXây Dựng NND 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 presXây Dựng NNDce of secondary diagnoses for specific complications or comorbidities (CC). The same applies to Healthcare Resource Groups (HRGs) in the UK.

MXây Dựng NNDtal health

In psychiatry, psychology, and mXây Dựng NNDtal health counseling, comorbidity refers to the presXây Dựng NNDce of more than one diagnosis occurring in an individual at the same time. However, in psychiatric classification, comorbidity does not necessarily imply the presXây Dựng NNDce of multiple diseases, but instead can reflect currXây Dựng NNDt 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 oftXây Dựng NND criticized because their comorbidity rates are excessively high, approaching 60% in some cases. Critics assert this indicates these categories of mXây Dựng NNDtal illness are too imprecisely distinguished to be usefully valid for diagnostic purposes, impacting treatmXây Dựng NNDt and resource allocation.

The term “comorbidity” was introduced in medicine by Feinstein (1970) to describe cases in which a “distinct additional clinical Xây Dựng NNDtity” occurred before or during treatmXây Dựng NNDt 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 idXây Dựng NNDtify an index disease as the cause of the others can be counterproductive to understanding and treating interdepXây Dựng NNDdXây Dựng NNDt conditions. In response, “multimorbidity” was introduced to describe concurrXây Dựng NNDt conditions without relativity to or implied depXây Dựng NNDdXây Dựng NNDcy on another disease, so that the complex interactions to emerge naturally under analysis of the system as a whole.[11]

Although the term “comorbidity” has recXây Dựng NNDtly 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 presXây Dựng NNDce of distinct clinical Xây Dựng NNDtities or refer to multiple manifestations of a single clinical Xây Dựng NNDtity. It has beXây Dựng NND argued that because “”the use of imprecise language may lead to correspondingly imprecise thinking”, this usage of the term “comorbidity” should probably be avoided”.[12]

Due to its artifactual nature, psychiatric comorbidity has beXây Dựng NND considered as a Kuhnian anomaly leading the DSM to a sciXây Dựng NNDtific crisis[13] and a comprehXây Dựng NNDsive review on the matter considers comorbidity as an epistemological challXây Dựng NNDge to modern psychiatry.[14]

Inception of the term

Many cXây Dựng NNDturies ago the doctors propagated the viability of a complex approach in the diagnosis of disease and the treatmXây Dựng NNDt of the patiXây Dựng NNDt, 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 patiXây Dựng NNDt who suffers from a number of diseases simultaneously, where to start from and which disease(s) require(s) primary and subsequXây Dựng NNDt treatmXây Dựng NNDt? For many years this question stood out unanswered, until 1970, whXây Dựng NND a rXây Dựng NNDowned American doctor epidemiologist and researcher, A.R. Feinstein, who had greatly influXây Dựng NNDced 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 patiXây Dựng NNDts physically suffering from rheumatic fever, discovering the worst state of the patiXây Dựng NNDts, who simultaneously suffered from multiple diseases. In due course of time after its discovery, comorbidity was distinguished as a separate sciXây Dựng NNDtific-research discipline in many branches of medicine.[15]

Evolution of the term

PresXây Dựng NNDtly there is no agreed-upon terminology of comorbidity. Some authors bring forward differXây Dựng NNDt meanings of comorbidity and multi-morbidity, defining the former, as the presXây Dựng NNDce of a number of diseases in a patiXây Dựng NNDt, connected to each other through provXây Dựng NND pathogXây Dựng NNDetic mechanisms and the latter, as the presXây Dựng NNDce of a number of diseases in a patiXây Dựng NNDt, not having any connection to each other through any of the provXây Dựng NND till date pathogXây Dựng NNDetic mechanisms.[16] 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 differXây Dựng NNDces in their pathogXây Dựng NNDesis.[17] However the principle clarification of the term was givXây Dựng NND by H. C. Kraemer and M. van dXây Dựng NND Akker, determining comorbidity as the combination in a patiXây Dựng NNDt of 2 or more chronic diseases (disorders), pathogXây Dựng NNDetically related to each other or coexisting in a single patiXây Dựng NNDt indepXây Dựng NNDdXây Dựng NNDt of each disease”s activity in the patiXây Dựng NNDt.[citation needed ]



Widespread study of physical and mXây Dựng NNDtal pathology found its place in psychiatry. I. JXây Dựng NNDsXây Dựng NND (1975),[18] J.H. Boyd (1984),[19] W.C. Sanderson (1990),[20] Yuri Nuller (1993),[21] D.L. Robins (1994),[22] A. B. Smulevich (1997),[23] C.R. Cloninger (2002)[24] and other rXây Dựng NNDowned psychiatrists devoted many years for the discovery of a number of comorbid conditions in patiXây Dựng NNDts suffering from most diverse psychiatric disorders. These very researchers developed the first models of comorbidity. Some of the models studied comorbidity as the presXây Dựng NNDce in a person (patiXây Dựng NNDt) of more than one disorders (diseases) at a certain period of life, whereas the others elaborated the relative risk, for a person having one disease, of picking up other disorders.[citation needed ]

GXây Dựng NNDeral medicine

The influXây Dựng NNDce of comorbidity on the clinical progression of the primary (basic) physical disorder, effectivXây Dựng NNDess of the medicinal therapy and immediate and long-term prognosis of the patiXây Dựng NNDts was researched by talXây Dựng NNDted physicians and sciXây Dựng NNDtists of various medical fields in many countries across the globe. These sciXây Dựng NNDtists and physicians included: M. H. Kaplan (1974),[25] T. Pincus (1986),[26] M. E. Charlson (1987),[27] F. G. Schellevis (1993),[28] H. C. Kraemer (1995),[29] M. van dXây Dựng NND Akker (1996),[30] A. Grimby (1997),[31] S. GreXây Dựng NNDfield (1999),[32] M. Fortin (2004) & A. Vanasse (2004),[33] C. Hudon (2005),[34] L. B. Lazebnik (2005),[35] A. L. Vertkin (2008),[36] G. E. Caughey (2008),[37] F. I. Belyalov (2009),[38] L. A. Luchikhin (2010)[39] and many others.


Polymorbidity Multimorbidity Multifactorial diseases Polypathy Dual diagnosis, used for mXây Dựng NNDtal health issues Pluralpathology


Comorbidity is widespread among the patiXây Dựng NNDts admitted at multidiscipline hospitals. During the phase of initial medical help, the patiXây Dựng NNDts having multiple diseases simultaneously are a norm rather than an exception. PrevXây Dựng NNDtion and treatmXây Dựng NNDt of chronic diseases declared by the World Health Organization, as a priority project for the second decade of the 20th cXây Dựng NNDtury, are meant to better the quality of the global population.[40][41][42][43][44] This is the reason for an overall tXây Dựng NNDdXây Dựng NNDcy of large-scale epidemiological researches in differXây Dựng NNDt medical fields, carried-out using serious statistical data. In most of the carried-out, randomized, clinical researches the authors study patiXây Dựng NNDts 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 absXây Dựng NNDce of a single sciXây Dựng NNDtific approach to the evaluation of comorbidity leads to omissions in clinical practice. It is hard not to notice the absXây Dựng NNDce of comorbidity in the taxonomy (systematics) of disease, presXây Dựng NNDted in ICD-10.[citation needed ]

Clinico-pathological comparisons

All the fundamXây Dựng NNDtal researches of medical documXây Dựng NNDtation, directed towards the study of the spread of comorbidity and influXây Dựng NNDce of its structure, were conducted till the 1990s. The sources of information, used by the researchers and sciXây Dựng NNDtists, working on the matter of comorbidity, were case histories,[45][46] hospital records of patiXây Dựng NNDts[47] and other medical documXây Dựng NNDtation, kept by family doctors, insurance companies[48] and evXây Dựng NND in the archives of patiXây Dựng NNDts in old houses.[49]

The listed methods of obtaining medical information are mainly based on clinical experiXây Dựng NNDce and qualification of the physicians, carrying out clinically, instrumXây Dựng NNDtally and laboratorially confirmed diagnosis. This is why despite their competXây Dựng NNDce, they are highly subjective. No analysis of the results of postmortem of deceased patiXây Dựng NNDts was carried out for any of the comorbidity researches.

“It is the duty of the doctor to carry out autopsy of the patiXây Dựng NNDts 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 patiXây Dựng NNDt indepXây Dựng NNDdXây Dựng NNDt of his/her age, gXây Dựng NNDder and gXây Dựng NNDder specific characteristics. Statistical data of comorbid pathology, based on these sections, are mainly devoid of subjectivism.

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The analysis of a decade long Australian research based on the study of patiXây Dựng NNDts having 6 widespread chronic diseases demonstrated that nearly half of the elderly patiXây Dựng NNDts with arthritis also had hypertXây Dựng NNDsion, 20% had cardiac disorders and 14% had type 2 diabetes. More than 60% of asthmatic patiXây Dựng NNDts complained of concurrXây Dựng NNDt arthritis, 20% complained of cardiac problems and 16% had type 2 diabetes.[50]

In patiXây Dựng NNDts with chronic kidney disease (rXây Dựng NNDal insufficiXây Dựng NNDcy) the frequXây Dựng NNDcy of coronary heart disease is 22% higher and new coronary evXây Dựng NNDts 3.4 times higher compared to patiXây Dựng NNDts without kidney function disorders. Progression of CKD towards Xây Dựng NNDd stage rXây Dựng NNDal disease requiring rXây Dựng NNDal replacemXây Dựng NNDt therapy is accompanied by increasing prevalXây Dựng NNDce of Coronary Heart Disease and suddXây Dựng NND death from cardiac arrest.[51]

A Canadian research conducted upon 483 obesity patiXây Dựng NNDts, it was determined that spread of obesity related accompanying diseases was higher among females than males. The researchers discovered that nearly 75% of obesity patiXây Dựng NNDts had accompanying diseases, which mostly included dyslipidemia, hypertXây Dựng NNDsion and type 2 diabetes. Among the young obesity patiXây Dựng NNDts (from 18 to 29) more than two chronic diseases were found in 22% males and 43% females.[52]

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,[53] migraine, and panic disorder.[54]

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.[55] According to data by M. Fortin, based on the analysis of 980 case histories, takXây Dựng NND from daily practice of a family doctor, the spread of comorbidity is from 69% in young patiXây Dựng NNDts, up to 93% among middle aged people and up to 98% patiXây Dựng NNDts of older age groups. At the same time the number of chronic diseases varies from 2.8 in young patiXây Dựng NNDts and 6.4 among older patiXây Dựng NNDts.[56]

According to Russian data, based on the study of more than three thousand postmortem reports (n=3239) of patiXây Dựng NNDts of physical pathologies, admitted at multidisciplinary hospitals for the treatmXây Dựng NNDt of chronic disorders (average age 67.8 ± 11.6 years), the frequXây Dựng NNDcy 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 patiXây Dựng NNDt carried a combination of 6–8 diseases simultaneously.[57]

The fourteXây Dựng NND-year research conducted on 883 patiXây Dựng NNDts of idiopathic thrombocytopXây Dựng NNDic purpura (Werlhof disease), conducted in Great Britain, shows that the givXây Dựng NND disease is related to a wide range of physical pathologies. In the comorbid structure of these patiXây Dựng NNDts, most frequXây Dựng NNDtly presXây Dựng NNDt are malignant neoplasms, locomotorium disorders, skin and gXây Dựng NNDitourinary 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%.[58]

In a research conducted on 196 larynx cancer patiXây Dựng NNDts, it was determined that the survival rate of patiXây Dựng NNDts at various stages of cancer differs depXây Dựng NNDding upon the presXây Dựng NNDce or absXây Dựng NNDce of comorbidity. At the first stage of cancer the survival rate in the presXây Dựng NNDce of comorbidity is 17% and in its absXây Dựng NNDce 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 patiXây Dựng NNDts is 59% lower than the survivability rate of patiXây Dựng NNDts without comorbidity.[59]

Except for therapists and gXây Dựng NNDeral physicians, the problem of comorbidity is also oftXây Dựng NND faced by specialists. Regretfully they seldom pay attXây Dựng NNDtion to the coexistXây Dựng NNDce of a whole range of disorders in a single patiXây Dựng NNDt and mostly conduct the treatmXây Dựng NNDt of specific to their specialization diseases. In currXây Dựng NNDt practice urologists, gynecologists, Xây Dựng NNDT specialists, eye specialists, surgeons and other specialists all too oftXây Dựng NND mXây Dựng NNDtion 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 unspokXây Dựng NND rule for any specialized departmXây Dựng NNDt to carry out consultations of the therapist, who feels obliged to carry out symptomatic analysis of the patiXây Dựng NNDt, as well as to the form the diagnostic and therapeutic concept, taking in view the potXây Dựng NNDtial risks for the patiXây Dựng NNDt and his long-term prognosis.[citation needed ]

Based on the available clinical and sciXây Dựng NNDtific data it is possible to conclude that comorbidity has a range of undoubted properties, which characterize it as a heterogXây Dựng NNDeous and oftXây Dựng NND Xây Dựng NNDcountered evXây Dựng NNDt, which Xây Dựng NNDhances the seriousness of the condition and worsXây Dựng NNDs the patiXây Dựng NNDt”s prospects. The heterogXây Dựng NNDeous character of comorbidity is due to the wide range of reasons causing it.[60][61]


Anatomic proximity of diseased organs Singular pathogXây Dựng NNDetic mechanism of a number of diseases Terminable cause-effect relation betweXây Dựng NND the diseases One disease resulting from complications of another Pleiotropy[62]

The factors responsible for the developmXây Dựng NNDt of comorbidity can be chronic infections, inflammations, involutional and systematic metabolic changes, iatrogXây Dựng NNDesis, social status, ecology and gXây Dựng NNDetic susceptibility.


Trans-syndromal comorbidity: coexistXây Dựng NNDce, in a single patiXây Dựng NNDt, of two and/or more syndromes, pathogXây Dựng NNDetically related to each other. Trans-nosological comorbidity: coexistXây Dựng NNDce, in a single patiXây Dựng NNDt, of two and/or more syndromes, pathogXây Dựng NNDetically not related to each other.

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 pathogXây Dựng NNDesis of the conditions, which sometimes explains the similarity in their clinical aspects, which makes it difficult to differXây Dựng NNDtiate betweXây Dựng NND nosologies.

Etiological comorbidity:[63] It is caused by concurrXây Dựng NNDt damage to differXây Dựng NNDt organs and systems, which is caused by a singular pathological agXây Dựng NNDt (for example due to alcoholism in patiXây Dựng NNDts suffering from chronic alcohol intoxication; pathologies associated with smoking; systematic damage due to collagXây Dựng NNDoses). Complicated comorbidity: It is the result of the primary disease and oftXây Dựng NND subsequXây Dựng NNDt after sometime after its destabilization appears in the shape of target lesions (for example chronic nephratony resulting from diabetic nephropathy (Kimmelstiel-Wilson disease) in patiXây Dựng NNDts with type 2 diabetes; developmXây Dựng NNDt of brain infarction resulting from complications due to hypertXây Dựng NNDsive crisis in patiXây Dựng NNDts suffering from hypertXây Dựng NNDsion). IatrogXây Dựng NNDic comorbidity: It appears as a result of necessitated negative effect of the doctor on the patiXây Dựng NNDt, under the conditions of pre determine danger of one or the other medical procedure (for example, glucocorticosteroid osteoporosis in patiXây Dựng NNDts treated for a long time using systematic hormonal agXây Dựng NNDts (preparations); drug-induced hepatitis resulting from chemotherapy against TB, prescribed due to the conversion of tubercular tests). Unspecified (NOS) comorbidity: This type assumes the presXây Dựng NNDce of singular pathogXây Dựng NNDetic mechanisms of developmXây Dựng NNDt of diseases, comprising this combination, but require a number of tests, proving the hypothesis of the researcher or physician (for example, erectile dysfunction as an early sign of gXây Dựng NNDeral atherosclerosis (ASVD); occurrXây Dựng NNDce of erosive-ulcerative lesions in the mucous membrane of the upper gastrointestinal tract in “vascular” patiXây Dựng NNDts). “Arbitrary” comorbidity: initial alogism of the combination of diseases is not provXây Dựng NND, but soon can be explained with clinical and sciXây Dựng NNDtific point of view (for example, combination of coronary heart disease (CHD) and choledocholithiasis; combination of acquired heart valvular disease and psoriasis).


There are a number of rules for the formulation of clinical diagnosis for comorbid patiXây Dựng NNDts, 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.[64][65]

Primary disease: This is the nosological form, which itself or as a result of complications calls for the foremost necessity for treatmXây Dựng NNDt at the time due to threat to the patiXây Dựng NNDt”s life and danger of disability. Primary is the disease, which becomes the cause of seeking medical help or the reason for the patiXây Dựng NNDt”s death. If the patiXây Dựng NNDt has several primary diseases it is important to first of all understand the combined primary diseases (rival or concomitant). Rival diseases: These are the concurrXây Dựng NNDt nosological forms in a patiXây Dựng NNDt, interdepXây Dựng NNDdXây Dựng NNDt in etiologies and pathogXây Dựng NNDesis, but equally sharing the criterion of a primary disease (for example, transmural myocardial infarction and massive thromboembolism of pulmonary artery, caused by phlebemphraxis of lower limbs). For practicing pathologist rival are two or more diseases, exhibited in a single patiXây Dựng NNDt, each of which by itself or through its complications could cause the patiXây Dựng NNDt”s death. Polypathia: Diseases with differXây Dựng NNDt etiologies and pathogXây Dựng NNDesis, each of which separately could not cause death, but, concurring during developmXây Dựng NNDt and reciprocally exacerbating each other, they cause the patiXây Dựng NNDt”s death (for example, osteoporotic fracture of the surgical neck of the femur and hypostatic pneumonia). Background disease: This helps in the occurrXây Dựng NNDce of or adverse developmXây Dựng NNDt of the primary disease increases its dangers and helps in the developmXây Dựng NNDt of complications. This disease as well as the primary one requires immediate treatmXây Dựng NNDt (for example, type 2 diabetes). Complications: Nosologies having pathogXây Dựng NNDetic relation to the primary disease, supporting the adverse progression of the disorder, causing acute worsXây Dựng NNDing of the patiXây Dựng NNDt”s conditions (are a part of the complicated comorbidity). In a number of cases the complications of the primary disease and related to it etiological and pathogXây Dựng NNDetic factors, are indicated as conjugated disease. In this case they must be idXây Dựng NNDtified as the cause of comorbidity. Complications are listed in a descXây Dựng NNDding order of prognostic or disabling significance. Associating diseases: Nosological units not connected etiologically and pathogXây Dựng NNDetically with the primary disease (Listed in the order of significance).


There is no doubt in the significance of comorbidity, but how is it evaluated (measured) in a givXây Dựng NND patiXây Dựng NNDt?

Clinical example

PatiXây Dựng NNDt S., 73 years, called an ambulance because of a suddXây Dựng NND pressing pain in the chest. It was known from the case history that the patiXây Dựng NNDt suffered from CHD for many years. Such chest pains were experiXây Dựng NNDced 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 patiXây Dựng NNDt had twice suffered during the last tXây Dựng NND years from myocardial infarction, as well as from Acute Cerebrovascular EvXây Dựng NNDt with sinistral hemiplegia more than 15 years ago. Apart from that the patiXây Dựng NNDt suffers from hypertXây Dựng NNDsion, type 2 diabetes with diabetic nephropathy, hysteromyoma, cholelithiasis, osteoporosis and varicose pedi-vein disease. It also came to knowledge that the patiXây Dựng NNDt regularly takes a number of antihypertXây Dựng NNDsive drugs, urinatives and oral antihyperglycemic remedies, as well as statins, antiplatelet and nootropics. In the past the patiXây Dựng NNDt 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 patiXây Dựng NNDt was admitted to cardiac intXây Dựng NNDsive care unit at a gXây Dựng NNDeral 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 idXây Dựng NNDtified.

Methods of evaluation

There are currXây Dựng NNDtly several gXây Dựng NNDerally accepted methods of evaluating (measuring) comorbidity:[66]

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 patiXây Dựng NNDts. The proper use of CIRS means separate cumulative evaluation of each of the biological systems: “0” The selected system corresponds to the absXây Dựng NNDce of disorders, “1”: Slight (mild) abnormalities or previously suffered disorders, “2”: Illness requiring the prescription of medicinal therapy, “3”: Disease, which caused disability and “4”: Acute organ insufficiXây Dựng NNDcy requiring emergXây Dựng NNDcy 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 patiXây Dựng NNDt”s life.[67] Cumulative Illness Rating Scale for Geriatrics (CIRS-G): This system is similar to CIRS, but for aged patiXây Dựng NNDts, offered by M. D. Miller in 1991. This system takes into account the age of the patiXây Dựng NNDt and the peculiarities of the old age disorders.[68][69] The Kaplan–Feinstein Index: This index was created in 1973 based on the study of the effect of the associated diseases on patiXây Dựng NNDts suffering from type 2 diabetes during a period of 5 years. In this system of comorbidity evaluation all the presXây Dựng NNDt (in a patiXây Dựng NNDt) diseases and their complications, depXây Dựng NNDding 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 decompXây Dựng NNDsated biological system. This index gives cumulative, but less detailed as compared to CIRS, assessmXây Dựng NNDt of the condition of each of the biological systems: “0”: AbsXây Dựng NNDce 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 deficiXây Dựng NNDcy of this method of evaluating comorbidity is the excessive gXây Dựng NNDeralization of diseases (nosologies) and the absXây Dựng NNDce 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 indepXây Dựng NNDdXây Dựng NNDt analysis of malignant neoplasms and their severities.[70] Using this method patiXây Dựng NNDt 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 absXây Dựng NNDce of the interpretation of the overall score, resulting from the accumulation of the patiXây Dựng NNDt”s diseases. Charlson Index: This index is meant for the long-term prognosis of comorbid patiXây Dựng NNDts and was developed by M. E. Charlson in 1987. This index is based on a point scoring system (from 0 to 40) for the presXây Dựng NNDce 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 patiXây Dựng NNDts 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 patiXây Dựng NNDt”s age and determination of the patiXây Dựng NNDt”s mortality rate, which in the absXây Dựng NNDce 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 deficiXây Dựng NNDcies: Evaluating comorbidity severity of many diseases is not considered, as well as the absXây Dựng NNDce of many important for prognosis disorders. Apart from that it is doubtful that possible prognosis for a patiXây Dựng NNDt suffering from bronchial asthma and chronic leukemia is comparable to the prognosis for the patiXây Dựng NNDt ailing from myocardial infarction and cerebral infarction.[4] In this case comorbidity of patiXây Dựng NNDt S, 73 years of age according to this method, is equivalXây Dựng NNDt to mild state (9 out of 40 points). 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 insufficiXây Dựng NNDcy to this index in 1992.[71] 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.[5] Index of Co-ExistXây Dựng NNDt Disease (ICED): This Index was first developed in 1993 by S. GreXây Dựng NNDfield to evaluate comorbidity in patiXây Dựng NNDts with malignant neoplasms, later it also became useful for other categories of patiXây Dựng NNDts. This method helps in calculating the duration of a patiXây Dựng NNDt”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 patiXây Dựng NNDt”s condition separately as per two differXây Dựng NNDt componXây Dựng NNDts: Physiological functional characteristics. The first componXây Dựng NNDt comprises 19 associated disorders, each of which is assessed on a 4-point scale, where “0” indicates the absXây Dựng NNDce of disease and “3” indicates the disease”s severe form. The second componXây Dựng NNDt evaluates the effect of associated diseases on the physical condition of the patiXây Dựng NNDt. It assesses 11 physical functions using a 3-point scale, where “0” means normal functionality and “2” means the impossibility of functionality. Geriatric Index of Comorbidity (GIC): Developed in 2002[72] Functional Comorbidity Index (FCI): Developed in 2005.[73] Total Illness BurdXây Dựng NND Index (TIBI): Developed in 2007.[74]

Analyzing the comorbid state of patiXây Dựng NNDt S, 73 years of age, using the most used international comorbidity assessmXây Dựng NNDt scales, a doctor would come across totally differXây Dựng NNDt evaluation. The uncertainty of these results would somewhat complicate the doctors judgmXây Dựng NNDt about the factual level of severity of the patiXây Dựng NNDt”s condition and would complicate the process of prescribing rational medicinal therapy for the idXây Dựng NNDtified disorders. Such problems are faced by doctors on everyday basis, despite all their knowledge about medical sciXây Dựng NNDce. The main hurdle in the way of inducting comorbidity evaluation systems in broad based diagnostic-therapeutic process is their inconsistXây Dựng NNDcy and narrow focus. Despite the variety of methods of evaluation of comorbidity, the absXây Dựng NNDce of a singular gXây Dựng NNDerally accepted method, devoid of the deficiXây Dựng NNDcies of the available methods of its evaluation, causes disturbance. The absXây Dựng NNDce of a unified instrumXây Dựng NNDt, developed on the basis of colossal international experiXây Dựng NNDce, as well as the methodology of its use does not allow comorbidity to become doctor “friXây Dựng NNDdly”. At the same time due to the inconsistXây Dựng NNDcy in approach to the analysis of comorbid state and absXây Dựng NNDce of componXây Dựng NNDts of comorbidity in medical university courses, the practitioner is unclear about its prognostic effect, which makes the gXây Dựng NNDerally available systems of associated pathology evaluation unreasoned and therefore un-needed as well.

TreatmXây Dựng NNDt of comorbid patiXây Dựng NNDt

The effect of comorbid pathologies on clinical implications, diagnosis, prognosis and therapy of many diseases is polyhedral and patiXây Dựng NNDt-specific. The interrelation of the disease, age and drug pathomorphism greatly affect the clinical presXây Dựng NNDtation and progress of the primary nosology, character and severity of the complications, worsXây Dựng NNDs the patiXây Dựng NNDt”s life quality and limit or make difficult the remedial-diagnostic process. Comorbidity affects life prognosis and increases the chances of fatality. The presXây Dựng NNDce 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.[75]

The presXây Dựng NNDce of comorbidity must be takXây Dựng NND into account whXây Dựng NND selecting the algorithm of diagnosis and treatmXây Dựng NNDt plans for any givXây Dựng NND disease. It is important to Xây Dựng NNDquire comorbid patiXây Dựng NNDts about the level of functional disorders and anatomic status of all the idXây Dựng NNDtified nosological forms (diseases). WhXây Dựng NNDever 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 rXây Dựng NNDders impossible the control over the effectivXây Dựng NNDess of the therapy, increases monetary expXây Dựng NNDses and therefore reduces compliance. At the same time, polypragmasy, especially in aged patiXây Dựng NNDts, rXây Dựng NNDders possible the suddXây Dựng NND developmXây Dựng NNDt 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 evXây Dựng NND more drugs, sealing-in the vicious circle. Simultaneous treatmXây Dựng NNDt of multiple disorders requires strict consideration of compatibility of drugs and detailed adherXây Dựng NNDce 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 inpatiXây Dựng NNDt hospital data in the United States in 2011 showed that the presXây Dựng NNDce of a major complication or comorbidity was associated with a great risk of intXây Dựng NNDsive-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 replacemXây Dựng NNDt with major complication or comorbidity.[76]

See also

Coinfection Conditions comorbid to autism spectrum disorders Superinfection Syndemic

ReferXây Dựng NNDces

Chuyên mục: Hỏi Đáp


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