Anda di halaman 1dari 64

Comorbidities

Pub-Med search with comorbidity 115.826 records

morbidities, complications, disease burden, patient complexities,

Michael Davidson MD

Content
Definition(s) and general comments
Dementia and medical comorbidities
Depression, apathy and medical
comorbidities
Psychosis and medical comorbidities
More comments

Questions to you

First physician that psychiatrist ?


The reverse ?
Who is the case manager of your patient?
What do you know about the relationship
between your elderly patient and her offspring?
Silly questions ?
Is the benefit/risk ratio of psychotropics in
young and elderly the same?
Do you treat with psychotropics a depressed,
agitated, slightly cognitively impaired elderly
who is already on 8 medications?

The Definition of comorbidity


is:
1. Any distinct additional clinical entity that has
existed or may occur during the course of a
patient who has the INDEX disease under
study
2. A medical condition existing simultaneously
but independently with another condition in a
patient
3. A medical condition in a patient that causes, is
caused by, or is otherwise related to another
condition in the same patient
4. All of the above

What statement regarding


comorbidity among mental
illnesses is not true?
1. The large number of psychiatric comorbidities
is due to splitting into distinct categories which
do not exist in nature
2. The term comorbidities apply rather to
medical-psychiatric or medical-medical
condition than to psychiatric-psychiatric
conditions
3. Narrow distinction into discrete diseases severs
daily clinical practice
4. Patients can easily meet criteria for 2-3
mental disorders

Which of the following is more


likely to determine what is the
index illness and what is the
comorbidity?
1. The relative importance of the cooccurring condition(s)
2. The chronology of presentation of the
conditions
3. The research question
4. The disease that prompted a particular
episode of care(hospitalization)
5. The specialty of the attending physician

Types of comorbidities
Chance
CHF (dyspnea) and osteoarthritis
leading to poor mobility

Selection bias
People who seek care have more
comorbidities than the general population

Causal association
CHF and venous peripheral edema
leading to poor mobility

Which of the following is not a


contributor to comorbidities
1.
2.
3.
4.

Socio-economical status
Education
Age
Type of health care system (private,
public or mixed)

Percentage with more than one


condition by age and sex
> 50% of the elderly have >3 medical comorbidities
50
45
40
MALE

35

FEMALE

30
%

25
20
15
10
5
0
18-24

25-34

35-44

45-54
Age-group

55-64

65-74

75-84

85+

Epidemiology of multimorbidity
Among the 65 years old 2/3 have >2 chronic
conditions, and 1/3 have >4
The age of multimorbidity onset is lower by 10
among the low income populations
Arthritis and heart disease coexist in 20% of older
adults
The odds of developing disability from arthritis or
heart disease is x4 by each condition separately
but the risk for disability increases 14-fold if both
are present

Content
Definition(s)
Dementia with medical comorbidities
Depression, apathy and medical
comorbidities
Psychotic illnesses and medical
comorbidities

Comorbidities in elderly demented are mostly


related to dementia or to aging?
Dementia

Falls

Epilepsy

Weight loss and/or


malnutrition

Poor reporting of alarm


sensations pain, nausea

Incontinence
Disruption of sleep/wake cycle

Depression/Apathy

Aging
Frailty
Hypertension
Ischemic cardiovascular
disease
Metabolic and endocrine
(diabetes, thyroid)
Malignancies
Bone, Muscular
Skin
Sensory

What is not true about falls in the


elderly demented?
1. The most likely reasons for falls in
demented elderly are abnormal gait and
muscle weakness
2. Only 5% of the falls result in fractures
3. Rehabilitations is made difficult by the
cognitive impairment
4. Fractures affect survival

Etiology of falls

Accidents / environment 37%


Weakness, balance, gait
12%
Dizziness or vertigo
8%
Orthostatic hypotension
5%
Acute illness, medications, vision
18%
Unknown
8%
Rubenstein et al JAGS 1988

Changes in Bone Mass Density


with age

Peak bone density


Menopause
Osteopenia
Puberty

Osteoporosis

Age

Incidence of all-limb
fractures
500
400
Rate per 100,000 population
300
200
100
0
0-4 5-14 15-2425-3435-4445-5455-6465-7475-84 85+

Fr 5%
Falls

Survival probability with and without


fracture
A Women

B Men

1.0

1.0

0.9

0.9

Non-fracture
0.7
0.6
0.5
0.4
0.3

Any fracture

0.2
0.1

0.8

Cummulative survival proportion

Cummulative survival proportion

0.8

0.7

Non-fracture

0.6
0.5
0.4
0.3
0.2
0.1

0.0
0

9 10 11 12 13 14 15

Time to follow-up (year)

Any fracture

0.0
0

9 10 11 12 13 14 15

Time to follow-up (year)

Where are elderly likely to fall?


Nursing Home 10%**

Public Places 30%

Home 60%*

*Most falls happen to women in their homes in the afternoon


**Falls in nursing homes occur during the first week after
admission and tends to result in injury. Higher use of psychotropic
drugs have been associated with risk of falling.

Which statement is not true regarding

epilepsy in dementia
1. 5% to 10% of demented individuals have
seizure which is X 6 normal population
2. Epilepsy is more prevalent in early rather than
late onset dementia
3. Incidence is higher in patients with vascular
compared to AD
4. Treatment of seizure in elderly demented is as
effective as it is in non-demented individuals

Which statement is not true regarding


dementia, malnutrition and weight
loss?
1. Demented patients are likely to lose 10-15 % of
their weight during the course of the disease
2. Serum albumin is a good marker of malnutrition
3. A large number of medications might impair
appetite
4. Gastrostomy is the accepted solution in end stage
dementia to prevent malnutrition and aspiration

Drugs that can cause anorexia

digoxin
phenytoin
SSRIs / lithium
Ca++ channel blockers
H2 receptor
antagonists / PPIs
Any chemotherapy
metronidazole

narcotic analgesics
K+ supplements
furosemide
ipratropium bromide
theophylline
spironolactone
levodopa
fluoxetine

More than 250 medications reportedly disturb gustatory


sensation
More than 40 drugs reportedly disturb the sense of olfaction

What is not true regarding urinary


incontinence in dementia
1. Loss of cognitive ability to interpret the
sensation of a full bladder
2. Inability to plan how to self-toilet.
3. Occurs earlier in vascular dementia, dementia
with Lewy bodies and FTD than in Alzheimers
disease
4. The majority of the patients with a MMSE <18
are incontinent

Hints to assess pain in dementia


Facial expression
Bracing (clutching or holding onto furniture,
equipment)
Rubbing (massaging affected area)
Restlessness and agitation
Verbal vocal complaints such as ouch or stop
Sympathetic arousal

Which statement is true about demented


patients ?

1. RCT found antidepressant effective in


treating depressed mood
2. RCT found antipsychotics effective in
treating psychosis
3. RCT found amphetamine-like drugs
effective in treating apathy
4. All of the above

Why do we prescribe
drugs with poor
benefit/risk ration?

Content
Definition(s)
Dementia with medical comorbidities
Depression, apathy and medical
comorbidities
Psychotic illnesses and medical
comorbidities

Prevalence of Depressive

Disorders in Various Patient


General population 5.8%
Populations*
Chronically ill

9.4%

Hospitalized

33.0%

Geriatric inpatients

36.0%

Cancer outpatients

33.0%

Cancer inpatients

42.0%

Stroke

47.0%

MI

45.0%

Parkinsons disease
0%

39.0%
10%

* There is a range of percentages


depending on the study.

20%

30%

Prevalence

Adapted from WPA/PTD Educational Program on Depressive Disorders

40%

50%

Which of the following


statement has not been
proven
1. Depression can be the presenting symptoms of
several somatic diseases
2. Depression is associated with decreased selfcare and adherence to medical regimens
3. Direction of causality (presence of depression
increases mortality due to medical condition)
4. Of all patients with Cardiovascular Diseases
(CVD) 40 % have depressive symptoms and
20% MDD
Katon. Gen Hosp Psychiatry. 1996;18:215.

What is not true regarding depression


and CVD
1. There is an OR of 1.6 for developing
CVD in those who are depressed
2. Depression increases risk for death
Post-MI OR 2.5
3. Depression increases risk for death postbypass and angioplasty
4. Antidepressant drugs are effective in
depression associated with CVD

SADHEART Trial
369 patients with MDD, mean HAMD=19.6
74% had an MI; 26% had unstable angina
RCT sertraline (50-200mg) vs placebo for
24 weeks
No significant difference in MI, rehospitalization, death or HAM-D
scores

The explanation for the


Depression-CVD association is?
1. Life style choices (e.g. smoking, exercise,
diet) and non-compliance with medication
2. Hyperactivity of HPA axis (cortisol, CRF,
NE)
3. Autonomic nervous system dysregulation
resulting in BP and HR abnormal
variations
4. Non of the above

Pain in the elderly depressed


1/3 elderly in the community and 1/2 in nursing
homes report pain
20% above 65 are taking pain medications
31% of women & 19% of men > 75 years report
pain in 3 or more sites
Pain makes recognition of depression more
difficult and treatment less successful
Depression makes recognition and treatment of
pain more difficult
CDCs National Center for Health Statistics 2006,

What is true regarding pain and ageing

1. Some degree of pain is natural with


aging
2. Pain medication should be limited
since elderly are vulnerable to
addiction to pain medications
3. Pain is under-reported due to
sensory and cognitive impairments
4. All of the above

Depression and apathy in the elderly


Components of apathy:
Decreased goal directed activity
Lack of motivation
Indifference to previously emotionally exciting experiences

Nosology:
Apathy
Abulia
Negative symptoms

Is the phenomenology
the same and are the
underlying mechanism
the same?

Epidemiology

Average point prevalence, cortical 60% Sub-cortical 40%


Variability between studies up to 100%

The reason for the variability in prevalence of


apathy is

1.
2.
3.
4.

Population studied
Threshold for severity
Scale used and rater training
All of the above

How Homogenous an Entity is Apathy ?


What is involved?
Neurotransmitters
Focal lesion (stroke) or
diffuse lesion (AD)?
Cortical or (frontal lobe
dementia) or basal ganglia
(Huntington)?
Abnormal circuits or local
lesion (Fronto-sub-cortical
circuit lesion)?
Personality
Life events

Which neurotransmitter(s)?

Ach: awakening,
motivation and attention
NA: motivation, novelty
seeking and resistance to
distraction

DA: motivation and


reward
GABA: interacts and
modulates Ach, NE, DA

Depression vs Apathy the overlap

Should apathy be treated pharmacologically?


No
Patient does not complain
No direct danger to self or others
It rarely reflects the core disease
AE
Cost

Yes
Patient maybe suffering?
Caregiver burden and frustration
Potential to improve functionality

Amphetamines, DA agonists, ChEI, Memantine, MAOI,


TCA, SSRI, NSRI?

Content
Definition(s)
Dementia and medical
comorbidities
Depression, apathy and
medical comorbidities
Psychotic illnesses and
medical comorbidities

The increased prevalence of CVD in chronic


psychotic patients (schizophrenia, schizoaffective,
bipolar) compared to controls is due to:
1. Long-term administration of antipsychotics and
other psychotropics
2. Over-diagnosis of CVD in this population
3. Inadequate access to treatment
4. Poor life style habits (smoking, exercise,
weight)
5. Inadequate selection of the control group

Final considerations

Complexities
79-year-old woman with hypertension, diabetes , osteoporosis,
osteoarthritis, COPD and depressed mood is caring for her 80
year old husband affected by severe dementia with behavioral
disturbances
The hypothetical woman patient would need to take 13
medications ( $ 600 per month) and follow 14
recommendations)
CDC report, 37 percent of older Americans use five or more
prescription drugs
Patient with five chronic conditions would result in the
prescription of 19 doses of 12 different drugs, taken at five time
points during the day, and carrying the risk of 10 attendant
interactions or adverse events

What is the main knowledge gap in making treatment


decisions on psychotropic treatment in elderly with
comorbidities

Paucity of EBM for older adults with


multimorbidity.
Finding a balance between poor life expectancy,
and QL during the remaining years
Unpredictable variability in pharmacokinetics
The fact that psychotropics have been developed
and proven effective in young and middle age
healthy individuals not in elderly, many of whom
are affected by brain degenerative diseases

Disparate entities (based on profession, jurisdiction and

function)

that communicate but are not integrated


Outpatient

Social
Services

Medical
Buracracy

General
Practicioner

Acute ward
Day hospital

Specialist

Alcohol & Drugs


Income
Optometrist

General
hospital

Rehab
Crisis
AO = Assertive Outreach

The Maze

What to do when the ramp becomes too stiff?

The role of the psychiatrist in the


care of the elderly
psychiatric/demented patient with
medical comorbidities
Specialist/consultant

Primary care physician


Care coordinator

Be nice to your kids.


They choose your nursing home.

Age-dependent success
3 years: not wetting your pants
10
having friends
18
having a drivers license
20
having sex
35
having money
50
having money
60
having sex
70
having a drivers license
75
having friends
80
not wetting your pants
Age is not a particularly interesting subject; anyone can get old.
All you have to do is live long enough. - Groucho Marx
Getting old is not so bad, considering the alternative. Maurice Chevalier

Thank you for your attention


For a copy of the slides please E-MAIL to:

mdavidson6@gmail.com