home Drugs Comorbidity - what is it? Nesterovich I.I., Kotov M.E. Comorbid conditions in rheumatic diseases Treatment of patients with comorbid conditions

Comorbidity - what is it? Nesterovich I.I., Kotov M.E. Comorbid conditions in rheumatic diseases Treatment of patients with comorbid conditions

COMORBIDITY(Latin co - prefix co-, together, morbus - disease) - the coexistence of two and/or more syndromes (transsyndromic comorbidity) or diseases (transnosological comorbidity) in one patient, pathogenetically interrelated or coinciding in time (chronological comorbidity).

Comorbidity- a combination of two or more independent diseases or syndromes, none of which is a complication of the other, if the frequency of this combination exceeds the probability of a random coincidence.

Comorbidity may be associated with a single cause or common mechanisms of pathogenesis of these conditions, but is sometimes explained by the similarity of their clinical manifestations, which does not allow them to be clearly differentiated from each other. An example of comorbidity is atherosclerosis and hypertension.

The concept of comorbidity was first proposed by A.R. Feinstein (1970). He put into this term the idea of the presence of an additional clinical picture that already exists or may appear independently, in addition to the current disease, and differs from it. Comorbidity is especially widely discussed in connection with the differences between depressive and anxiety disorders due to the constant combination of symptoms of both groups, which often makes it difficult to classify them into one or another group of disorders. To date, large-scale epidemiological studies in many countries and at different levels of organization of differentiated populations using serious statistical calculations have shown that a third of all current diseases of the population meet more than one disorder diagnostic criteria. Data from many studies have shown that it is especially important to consider the morbidity of two or more independent diseases that occur during life (life time). Along with this, comorbidity is distinguished as the presence of more than one disorder in a person at a certain period of life - a model focused on descriptive diagnostic classes (Burke J.D. et al., 1990), and a comorbidity model that considers the relative risk of a person with one disease (disorder) to acquire another disorder (Boyd J.H. et al., 1984).

So, comorbidity is not an artifact, an atypical phenomenon or a certain myth and fashion. It does not fall into the taxonomy of diseases presented in ICD-10, but, on the contrary, provides the basis for the further development of a general classification of diseases. Comorbidity is a clinical reality that affects not only mental disorders, but also has implications for somatic diseases. Currently, with a broad understanding of comorbidity as the coexistence in a certain period of two diseases - somatic and mental, there is a high probability of delving into the problems of causation, overcoming dualistic ideas about the relationship between the soma and the psyche.

1 . Comorbidity is common, especially in the elderly.

2 . Comorbidity is heterogeneous (random, causal, complicated, unspecified).

3 . Comorbidity increases the severity of the condition and worsens the prognosis.

4 . Comorbidity should be taken into account when diagnosing diseases.

5 . For comorbid diseases, treatment should be clarified.

6 . Treatment of several diseases requires taking into account the compatibility of drugs.

7 . Comorbid illnesses increase resource costs.

8 . Comorbidity increases the risk of side effects from medications.

9 . Comorbid diseases reduce adherence to treatment.

10 . Comorbidity research needs to be expanded.

11 . The optimal strategy for managing comorbid diseases (sequential, parallel) is important.

Facts about bipolar disorder

What is a co-occurring mental disorder?

Many people suffering from some kind of bipolar disease experience the so-called. comorbid disorders, i.e. accompanying illnesses. The most common comorbid diseases:

Drug and alcohol abuse: Alcohol (up to 60%) or drug abuse (up to 50%) often accompanies bipolar disorder. This means that 50 to 60 percent of patients will suffer from co-occurring addiction syndrome at least once during their lifetime. Dependency syndrome has a bad effect on the course of the disease, the frequency of episodes increases, and hospitalizations become more frequent.

Anxiety disorders: Anxiety disorders are classified as mental illnesses in which the picture of mental disorders is determined by a huge sense of fear. The risk of developing some form of fear at least once in a lifetime in bipolar patients is from 70 to 90 percent, and from 20 to 40 percent suffer from the so-called. panic disorder, a variant of anxiety disorder with frequent panic attacks. As with any addiction, in this case the important rule is the following: If comorbid diseases are not consistently treated, they worsen the course and prognosis of bipolar disease.

Obsessive phobic disorders: Obsessive phobic disorders are classified as mental illnesses in which the picture of mental disorders is determined by obsessive thinking and behavior. About one in five people with bipolar disease (20%) also suffer from some kind of obsessive-phobic disorder.

Personality disorders: Personality disorders are mental illnesses, the causes of which are different and lie in a violation of the patient’s personal development. As a result, personalities arise that, due to their pronounced nature, become painful; one example is borderline personality disorder. About 50 percent of bipolar patients are borderline.

All of the above concomitant diseases must be treated in any case. This is possible through special psychotherapy, various group programs or with the correct dosage of medications. If you notice any changes in yourself, such as emerging feelings of embarrassment, fear, regardless of the severity of the phase of the disease, you should consult with your doctor. He will be able to correctly assess the situation and prescribe treatment. Taking into account the severity of the consequences of drug abuse or addiction, we will consider this issue in a separate chapter.

What are comorbid mental disorders?

Comorbidity in social phobia is extremely common. Only less than a third of people with social phobia do not suffer from other mental disorders.

In most cases, symptoms of social phobia precede symptoms of comorbid conditions. This suggests that the presence of social phobia contributes to the onset of comorbidity.

It has been established that social phobia is the primary pathology in 70.9% of people with comorbid depression, in 76.7% of people with comorbid drug addiction and in 85% of people with comorbid alcoholism.

Therefore, early identification and treatment of social phobia will help prevent the development of secondary forms of pathology.

Predominant comorbid conditions

The most common comorbid conditions in patients with social phobia are:

simple phobias (59%)

major depression (17%)

drug abuse (17%).

There is also a link between social phobia and the subsequent development of eating disorders.

Lifetime risk of developing comorbid conditions for social phobia (%)

Mental illness

Social phobia (n=1 23)

Without social phobia (n=3678)

Schizophrenia/schizophreniform conditions

Post-traumatic stress disorder

Alcoholism/alcohol addiction

Suicide/Suicide attempt

If simple, uncomplicated social phobia a disease that reduces performance and puts the patient into distress, then the comorbid condition is undoubtedly much worse. Individuals with social phobia and comorbid conditions appear to be in much greater distress and at much higher risk of serious disease complications.

For example, the likelihood of suicide with comorbid social phobia is much higher than with an uncomplicated condition.

The probability of committing a suicide attempt during life in patients with comorbid social phobia is 5.73 times higher than in the general population. Suicidal thoughts in comorbid social phobia are more pronounced than in comorbid panic disorder (34% and 31%, respectively).

Suicide in simple and comorbid social phobia

ESA research data

Suicide attempts

Frequent thoughts about death

Feeling of insignificance leading to suicide attempt

According to Davidson et al., J Clin Psychopharmacol., 1993

According to Schneier et al., Arch Gen Psychiatry, 1992

Although most studies have found that the onset of social phobia precedes the development of any comorbid condition, patients still more often receive drug therapy for the secondary disease. Of the total number of patients with social phobia who receive treatment, it is aimed specifically at the phobia in only 11.5% of patients. Those suffering from social phobia are much more likely to be treated for anxiety (34.6%), depression (42.3%) or panic disorder (19.2%).

Comorbidity is not the exception, but rather the rule for patients with social phobia. A diagnosis of uncomplicated, non-comorbid social phobia almost certainly means the need to look for other mental disorders.

In cases where social phobia is combined with another disease, it is important not to give preference to one of the forms of pathology.

A wide range of comorbid conditions have been described for social phobia. These include:

The fact that in most cases of comorbidity social phobia appears to be primary suggests that it may contribute to the onset of another psychopathological condition. Early identification and treatment of simple social phobia could therefore help prevent comorbidity and thereby spare many sufferers much of the impairment and distress.

Patients suffering from comorbid social phobia are more disabled than patients with uncomplicated disease, and more often make suicide attempts.

www.psychiatry.ru

Comorbidity

Two worms crawled out of the ground.
The first to the second: “Hello worm! Happy Spring!"
Second: “Fool! I’m your own ass!”

Comorbidity is the simultaneous occurrence of different diseases or pathological conditions in a patient.
This is the only common place for the whole variety of interpretations of K., if you try to generalize them.

Synonym (more precisely, in Russian): comorbidity.

Since 2010, the journal “J. Comorbidity” has been published. There are tools to record and measure it. The topic is presented by its adherents as something new and holistic. Is it so?

The term is of foreign origin: all articles on the topic begin with the fact that the term K. was coined by clinical epidemiologist Alvan Feinstein (A.R. Feinstein, 1970).
And then, as often happens at school, when all the boys fall in love with one girl, everyone suddenly fell in love with A. Feinstein! And they rushed to tell each other that he “discovered K.” (!) and then, they copied each other’s definition of K., which, as a result of this procedure, as well as through the efforts of A. Fainstein himself, turned out to be different for everyone... Fainstein himself did not give a clear definition, but scattered its “clarifications” throughout the text. Then his article was subject to interpretation, receiving several more reading options “from the trade union” (just like with the Gospels).

If you believe those who write about the topic on the great and mighty, then, according to some, A. Feinstein allegedly spoke about an “additional clinical picture” in relation to the “current disease”; according to others, about some mysterious “clinical entity.” When checking, we find that, at least in the abstract to his article, he literally wrote this: “In patients who have been given a primary diagnosis (index disease), the term “comorbidity” refers to any additional, coexisting disease.”

It is appropriate to say here that in medical articles translated into Russian there is an imitation of scientific terminology. When the authors do not understand (or “do not want” to understand) what is written, they do not translate it, but write it in Russian letters (Cyrillize the text) or provide an interlinear translation that simulates significant scientific incomprehensibility. “Clinical essence” and “index disease” (as well as “compliance”, etc.) are just such wonderful inventions.

Our authors, apparently in a fit of self-deprecation (“Whoever wants to come to us, please / The door is open for the invited and the uninvited / Especially from foreigners”) attributed the “breadth of ideas” to the obvious negligence of A. Feinstein. By it (contrary to the definition from the abstract of his article), it was meant that the underlying disease can be combined not only with another disease, but also with a pathological syndrome, pregnancy, long-term “strict” diet or complication of therapy.

They thought it was comorbidity, but looked closer and she became pregnant. " I wonder if such a “clinical entity” as comorbid horns in men (for example, along with clap) has a right to exist?

At first it was thought that this stupidity was invented by our people. It turned out to be true - Feinstein himself “stuck out”, and ours only obsequiously designated it as “breadth of ideas” (“What a shiGrota! What a motherfucker!”).

I don’t know how correct it is to classify pregnancy as ailment and take it out of the realm of healthy life. Perhaps, in the North American tradition, pregnancy is classified as an illness, so to speak, for euphemistic reasons ( “The Countess is slightly ill, Sir!...”), but anyway…
This is where it turns out that the mysterious “clinical entities”, which is actually “normally” translated as "nosological form") A. Fainstein names pregnancy and other conditions. With such a “breadth of ideas”, when one definition is given in the abstract, and then in the text ( “to have sufficiently broad opportunities for discussion”, p.457) it is suddenly supplemented, and the confusion that still reigns in this area begins!

Here is a series of common definitions of K., the authorship of which could not be established:

"TO. – coexistence of two and/or more syndromes (transsyndromal K.) or diseases (transnosological) in one patient, pathogenetically interrelated or coinciding in time (chronological).”
- (if they did not coincide in time, the word “coexistence” would be inappropriate. It is remarkable that the author specifies: “in one patient” (!). It is also strange that he did not decorate his definition with the term “pathogenetic K.” in parentheses... The prefix "trans" suggests something more than co-occurrence).
. "TO. - a combination of two or more independent diseases or syndromes, none of which is a complication of the other, if the frequency of this combination exceeds the probability of a random coincidence.”
- (for A. Fainstein, both complications and pregnancy are suitable).
"TO. may be associated with a single cause or common mechanisms of pathogenesis these states but sometimes explained by similarity their clinical manifestations, which does not allow one to clearly differentiate them from each other. An example is atherosclerosis and hypertension.”
- (simply read like this: “may be connected, or maybe not connected - this is unknown to science”!).

In this surprisingly rich variety of answers, the second “definition” simply lacks the word “chronic or long-term.” Is all the cheese coming out due to chronification or duration?

Confusion with K. and MM. trivial mistakes also make matters worse. In the 2014 article, when the authors, as usual, set out “in their own words” what was written by van den Akker and A. Fainstein, the latter, having mixed up the references, attributed the term “MM” and “clarified” (p. 363) what is its basis, in contrast from K., “...it is not the disease that lies, but a specific patient...” (that is, not sour, but round...). A complete bullshit paragraph. In a word, another exegesis of A. Fainstein and other muddy texts.

And here is another storehouse of wisdom, a certain medical reference book by F.I. Belyalov:

Comorbidity is the presence of another disease or medical condition at the same time as the present disease. Multimorbidity is a combination of many chronic or acute diseases and medical conditions in one person (National Library of Medicine).

100 1000 rubles to the one who finds the difference. Does the first definition mean two or three people, not one?

Summarizing what has been written, it is clear that the authors of different definitions of K. and CC, in the process of pounding the waters in the mortar of clarifications of these concepts, focus either on the presence of a “main” disease, or on the chronification of the process, or on the general pathogenesis (risk factors, etc. ) sometimes in the absence/presence of all of the above, sometimes they include “non-diseases”, sometimes not, etc. and so on. Only one Oblomov question remains open - For what?

It’s certainly not K. Feinstein’s fault for this. It’s impossible to get rid of the feeling that he just moved their "followers" rewrite in some places traditional medicine “into the language of K.” The fact itself untranslated term, its use in the Cyrillic version is already a claim to the presence of some other meaning in it. Say: “comorbidity” and the scientific bubble will immediately burst! There's been a change language, to denote previously known by others names.

Some examples of language transformation

In the form of Russian terms of Feinstein's followers.

Comorbid mental disorders as a factor in the effectiveness of treatment and rehabilitation measures in cardiac patients Text of a scientific article on the specialty " Medicine and healthcare»

Abstract of a scientific article on medicine and healthcare, author of the scientific work - Petrova Natalia Nikolaevna

Using the example of 90 patients with chronic heart failure at the stage of stabilization, the effect of concomitant anxiety and depressive disorders on functionality, quality of life and adherence to therapy was studied. An interdisciplinary approach was used to assess the psychosomatic state of patients. A significant frequency of anxiety and depressive disorders has been confirmed, which have different effects on compliance and aggravate the functioning of patients. It has been shown that treatment results are mediated by the presence and severity of mental disorders.

The human body is a single whole, where every organ, every cell is closely interconnected. Only the harmonious and coordinated work of all organs and systems makes it possible to maintain homeostasis (constancy) of the internal environment of the human body, which is necessary for its normal functioning.

A disruption in the functioning of an individual link in a single chain of vital activity of the body ricochets through the functioning of other systems and organs. This is how new diseases appear. They may not develop immediately, but years after the illness that gave rise to their development. During the study of this mechanism, the concept of “comorbidity” appeared.

Definition and history

Comorbidity is understood as the simultaneous occurrence of two or more diseases or syndromes that are pathogenetically (according to the mechanism of occurrence) interrelated. Literally translated from Latin, the word comorbidity has 2 semantic parts: co - together, and morbus - disease. The concept of comorbidity was first proposed in 1970 by the outstanding American epidemiologist Alvan Fenstein. In the open concept of comorbidity, researcher Fenstein included the idea of the existence of an additional clinical picture against the background of the current disease. The first example of comorbidity studied by Professor Fenstein was a somatic (therapeutic) disease - acute rheumatic fever, which worsened the prognosis in patients suffering from a number of other diseases.

Soon after the discovery of the phenomenon of comorbidity, it attracted the attention of researchers from all over the world. The concept of “comorbidity” has been modified over time into “polymorbidity”, “multimorbidity”, “polypathy”, “dual diagnosis”, “soreness”, “pluripathology”, but the essence remained the same.

The great Hippocrates wrote:“Inspection of the human body is a single and complete process that requires the presence of hearing, vision, touch, smell, language and reasoning.” That is, before starting to treat a patient, it is necessary to comprehensively study the general condition of his body: the clinical picture of the underlying disease, complications, and concomitant pathologies. Only after this does it become possible to choose the most rational treatment strategy.

Types of comorbidity

Comorbidity can be divided into the following groups:

1. Causal comorbidity, caused by parallel damage to organs and systems caused by a single pathological factor. An example of such comorbidity is damage to internal organs due to alcoholism.

2. Complicated comorbidity. This type of comorbidity appears as a result of an underlying disease, which to one degree or another destroys the so-called target organs. We are talking, for example, about chronic renal failure resulting from diabetic nephropathy (type 2 diabetes mellitus). Another example of this type of comorbidity is a heart attack (or stroke) that develops against the background of a hypertensive crisis due to arterial hypertension.

3. Iatrogenic comorbidity. The reason for its appearance is the forced negative impact of diagnosis or therapy on the patient, provided that the danger of any medical procedure is established and known in advance. A striking example of this type of comorbidity is osteoporosis (bone fragility), which develops as a result of the use of hormonal drugs (glucocorticosteroids). Such comorbidity can also develop during chemotherapy, which can cause the development of drug-induced hepatitis in the patient.

4. Unspecified comorbidity. This type of comorbidity is spoken of when it is assumed that there are common mechanisms for the development of diseases that make up the overall clinical picture, but certain studies are required to confirm this thesis. For example, a patient suffering from arterial hypertension may develop erectile dysfunction (impotence). Another example of unspecified comorbidity may be the presence of erosions and ulcers on the mucous membrane of the upper digestive tract in patients with vascular diseases.

5. "Random" comorbidity. The combination of chronic coronary heart disease and the presence of gallstones in a patient (cholelithiasis) demonstrates an example of “random” comorbidity.
Some statistics

It has been established that the number of comorbid diseases directly depends on the patient’s age: in young people this combination of diseases is less common, but the older the person, the greater the likelihood of developing comorbid pathologies. Under the age of 19, comorbid diseases occur in only 10% of cases; by the age of 80, this figure reaches 80%.

If we consider the data of pathological studies (autopsies) of those who died from therapeutic pathology in the age category of 67–77 years, then the comorbidity is about 95%. Comorbidity is more common in the form of a combination of two or three diseases, but there are cases when one patient has a combination of up to 6–8 diseases (in 2–3% of cases).

General practitioners and therapists are the most likely to encounter comorbidity. However, narrow specialists are also not immune to encountering this phenomenon. But in this case, doctors often “turn a blind eye” to the phenomenon of comorbidity, preferring to treat only “their own” – the core disease. And other diseases are left to their colleagues - therapists.

Diagnosis for comorbidity

In the presence of comorbidity, in order to make a correct diagnosis, the patient must follow certain rules: the diagnosis identifies the underlying disease, background diseases, complications and concomitant pathologies. That is, among the “bouquet” of diseases, it is necessary, first of all, to determine the disease that requires priority treatment, since it threatens the patient’s life, reduces his ability to work, or can provoke dangerous complications. It happens that the underlying disease is not one, but several. In this case, they talk about competing diseases, i.e. diseases occurring in the patient simultaneously, mutually independent in their mechanism of occurrence.

Background pathologies complicate the course of the underlying disease, aggravate the situation, make it more dangerous for the health and life of the patient, and contribute to the development of various complications. The background disease, like the main one, requires immediate treatment.

Complications of the underlying disease are related to it in pathogenesis (mechanism of occurrence) and can lead to an unfavorable outcome, in some cases even to the death of the patient.

Concomitant diseases are all other pathologies that are not related to the main disease and, as a rule, do not affect its course.

Thus, comorbidity is a negative factor for the prognosis of the disease, which increases the likelihood of death. Comorbid pathologies lead to an increase in the length of treatment for a patient in a hospital, increase the number of complications after operations, the percentage of disability, and slow down the patient’s rehabilitation.

Therefore, the task of every doctor is to see the clinical picture as a whole, as they say, “to treat not the disease, but the patient himself.” With this approach, in particular, the likelihood of severe side effects when choosing pharmaceuticals is reduced: the doctor can and should take into account their compatibility when simultaneously treating several pathologies at once, and simply must always remember the saying of E.M. Tareeva: “Every non-indicated medicine is contraindicated.”

“We should not treat the disease itself, for which we cannot find a part or name, we should not treat the cause of the disease, which is often unknown to us, the patient, or those around him, but we should treat the patient himself, his composition, his organ, his strength "

Professor M. Ya. Mudrov(assembly speech “A speech on the way to teach and learn practical medicine or active medical art at the bedside of the sick,” 1820)

Part 2. read in No. 6, 2013.

As can be seen from recent works, in addition to therapists and general practitioners, narrow specialists also often encounter the problem of comorbidity. Unfortunately, they extremely rarely pay attention to the coexistence of a whole spectrum of diseases in one patient and primarily treat a specialized disease. In current practice, urologists, gynecologists, otorhinolaryngologists, ophthalmologists, surgeons and other specialists often include only “their” disease in the diagnosis, leaving the search for concomitant pathology to other specialists. The unspoken rule of any specialized department has become the advisory work of the therapist, who takes upon himself the syndromic analysis of the patient, as well as the formation of a diagnostic and treatment concept that takes into account the patient’s potential risks and his long-term prognosis.

Thus, the influence of comorbid pathology on clinical manifestations, diagnosis, prognosis and treatment of many diseases is multifaceted and individual. The interaction of diseases, age and drug pathomorphism significantly changes the clinical picture and course of the main nosology, the nature and severity of complications, worsens the patient’s quality of life, and limits or complicates the diagnostic and treatment process.

Comorbidity affects the prognosis for life and increases the likelihood of death. The presence of comorbid diseases contributes to an increase in bed days, disability, interferes with rehabilitation, increases the number of complications after surgical interventions, and increases the likelihood of falls in elderly patients.

However, in the majority of randomized clinical trials conducted, the authors included patients with a separate refined pathology, making comorbidity an exclusion criterion. That is why the listed studies, devoted to assessing the combination of certain individual diseases, are difficult to classify as works studying comorbidity in general. The lack of a unified, comprehensive scientific approach to assessing comorbidity leads to gaps in clinical practice. The absence of comorbidity in the taxonomy of diseases presented in the International Classification of Diseases, X Revision (ICD-10) cannot go unnoticed. This fact alone provides the basis for the further development of a general classification of diseases.

Despite the many unsolved patterns of comorbidity, the lack of its unified terminology and the ongoing search for new combinations of diseases, based on the available clinical and scientific data, we can conclude that comorbidity is characterized by a range of undoubted properties that characterize it as a heterogeneous, frequently occurring phenomenon that increases the severity of the condition and worsens the prognosis of patients. The heterogeneity of comorbidity is due to a wide range of causes that cause it.

There are a number of rules for formulating a clinical diagnosis for a comorbid patient that should be followed by a practicing physician. The basic rule is to distinguish in the structure of the diagnosis the main and background diseases, as well as their complications and concomitant pathologies.

If a patient suffers from many diseases, then one of them is the main one. This is the nosological form that itself or as a result of complications causes a priority need for treatment at a given time due to the greatest threat to life and ability to work. The underlying disease itself or through complications can cause death. The main disease is the reason for seeking medical help. As the examination progresses, the diagnosis of the least prognostically favorable disease becomes the main diagnosis, while other diseases become concomitant.

The underlying cause may be several competing serious diseases. Competing diseases are nosological forms present simultaneously in the patient, mutually independent in etiology and pathogenesis, but equally meeting the criteria of the underlying disease.

The background disease contributes to the occurrence or unfavorable course of the underlying disease, increases its danger, and contributes to the development of complications. This disease, like the main one, requires immediate treatment.

All complications are pathogenetically related to the underlying disease; they contribute to an unfavorable outcome of the disease, causing a sharp deterioration in the patient’s condition. They belong to the category of complicated comorbidity. In some cases, complications of the underlying disease, associated with it by a common etiological and pathogenetic factors, are designated as concomitant diseases. In this case, they must be classified as causal comorbidity. Complications are listed in descending order of prognostic or disabling significance.

The remaining diseases present in the patient are listed in order of importance. The concomitant disease is not etiologically or pathogenetically related to the main disease and is considered to not significantly affect its course.

The presence of comorbidity should be taken into account when choosing a diagnostic algorithm and treatment regimen for a particular disease. For this category of patients, it is necessary to clarify the degree of functional disorders and morphological status of all identified nosological forms. Whenever a new symptom, including a mild one, appears, a comprehensive examination should be carried out to determine its cause. It is also necessary to remember that comorbidity leads to polypharmacy, i.e. the simultaneous prescription of a large number of drugs, which makes it impossible to control the effectiveness of therapy, increases the material costs of patients, and therefore reduces their compliance (adherence to treatment). In addition, polypharmacy, especially in elderly and senile patients, contributes to a sharp increase in the likelihood of developing local and systemic unwanted side effects of drugs. These side effects are not always taken into account by doctors, since they are regarded as a manifestation of one of the comorbidity factors and entail the prescription of even more medications, closing a “vicious circle.”

Simultaneous treatment of several diseases requires strict consideration of the compatibility of drugs and thorough adherence to the rules of rational pharmacotherapy, based on the postulates of E. M. Tareev “Every non-indicated drug is contraindicated” and B. E. Votchal “If a drug has no side effects, you should think about whether it has any effects at all."

Thus, the significance of comorbidity is beyond doubt, but how can it be measured in a specific patient, for example, in patient S., 73 years old, who called an ambulance due to sudden pressing pain in the chest? From the anamnesis it is known that the patient has suffered from coronary artery disease for many years. She had experienced similar pain in the chest before, but always went away within a few minutes after taking sublingual organic nitrates. In this case, taking three nitroglycerin tablets did not produce an analgesic effect. From the anamnesis it is known that the patient suffered myocardial infarction twice over the past ten years, as well as acute cerebrovascular accident with left-sided hemiplegia more than 15 years ago. In addition, the patient suffers from hypertension, type 2 diabetes mellitus with diabetic nephropathy, uterine fibroids, cholelithiasis, osteoporosis and varicose veins of the legs. It was possible to find out that the patient regularly takes a number of antihypertensive drugs, diuretics and oral hypoglycemic agents, as well as statins, antiplatelet agents and nootropics. In the past, the patient underwent cholecystectomy for cholelithiasis more than 20 years ago, as well as lens extraction for cataracts in the right eye 4 years ago. The patient was hospitalized in the cardiac intensive care unit of a multidisciplinary hospital with a diagnosis of acute transmural myocardial infarction. The examination revealed moderate azotemia, mild hypochromic anemia, proteinuria and a decrease in left ventricular ejection fraction.

There are currently 12 generally accepted methods for measuring comorbidity. The first methods for assessing comorbidity were the CIRS (Cumulative Illness Rating Scale) system and the Kaplan-Feinstein index, developed in 1968 and 1974. respectively. The CIRS system, proposed by B. S. Linn, was a revolutionary discovery, as it enabled practitioners to assess the number and severity of chronic diseases in the structure of the comorbid status of their patients. However, it did not take into account the age of patients and the specifics of diseases of old age, and therefore 23 years later it was revised by M. D. Miller. A variation of the CIRS system in elderly patients is called CIRS-G (Cumulative Illness Rating Scale for Geriatrics).

Correct use of the CIRS system implies a separate summary assessment of the condition of each organ system: “0” corresponds to the absence of diseases of the selected system, “1” - mild deviations from the norm or previous diseases, “2” - a disease requiring drug therapy, “ 3" - a disease that has caused disability, and "4" - severe organ failure requiring emergency treatment. The CIRS system evaluates comorbidity by a score that can vary from 0 to 56. According to its developers, maximum results are not compatible with the life of patients. An example of comorbidity assessment is presented in Table. 1.

Thus, the comorbidity of patient S., 73 years old, can be regarded as moderate (23 points out of 56), however, it is not possible to assess the patient’s prognosis due to the lack of interpretation of the results obtained and their connection with a number of prognostic characteristics.

The Kaplan-Feinstein Index was created by examining the impact of comorbidities on 5-year survival in patients with type 2 diabetes. In this comorbidity assessment system, all existing diseases and their complications, depending on the severity of organ damage, are classified into mild, moderate and severe. In this case, the conclusion about total comorbidity is made on the basis of the most decompensated organ system. This index provides a summary, but less detailed than the CIRS system, assessment of the condition of each organ system: “0” - absence of disease, “1” - mild disease, “2” - moderate disease, “3” - severe disease. The Kaplan-Feinstein index evaluates comorbidity using a score that can vary from 0 to 36. An example of comorbidity assessment is presented in Table. 2.

Thus, the comorbidity of patient S., 73 years old, can be regarded as moderate (16 points out of 36), but its prognostic significance is again unclear due to the lack of interpretation of the total score obtained by summing up the diseases the patient has. In addition, the obvious disadvantage of this method of assessing comorbidity is the excessive generalization of nosologies and the absence of a large number of diseases on the scale, which should probably be noted in the “miscellaneous” column, which reduces the objectivity and effectiveness of this method. However, the undeniable advantage of the Kaplan-Feinstein index over the CIRS system is the possibility of independent analysis of malignant neoplasms and their severity.

Among the comorbidity assessment systems existing today, the most common are the ICED scale and the Charlson index, proposed to assess the long-term prognosis of patients in 1987 by Professor Mary Charlson.

This index is a scoring system (from 0 to 40) for the presence of certain concomitant diseases and is used to predict mortality. When calculating it, the points corresponding to concomitant diseases are summed up, and one point is added for every ten years of life when the patient exceeds forty years of age (i.e. 50 years - 1 point, 60 years - 2 points) (Table 3).

Thus, the comorbidity of patient S., 73 years old, according to this method corresponds to a mild degree (9 points out of 40). The main distinctive feature and unconditional advantage of the Charlson index is the ability to assess the patient’s age and determine the mortality of patients, which in the absence of comorbidity is 12%, with 1-2 points - 26%; with 3-4 points - 52%, and with a total of more than 5 points - 85%. Unfortunately, the presented method has some drawbacks: when calculating comorbidity, the severity of many diseases is not taken into account, and a number of prognostically important diseases are also missing. In addition, it is doubtful that the theoretically possible prognosis of a patient suffering from bronchial asthma and chronic leukemia is comparable to the prognosis of a patient with myocardial infarction and cerebral infarction. Some of the indicated shortcomings of the Charlson index were corrected by R. A. Deyo in 1992. Chronic forms of coronary heart disease and stages of chronic heart failure were added to the modified Charlson index.

The ICED (Index of Co-Existent Disease) index was originally developed by S. Greenfield to assess the comorbidity of patients with malignant neoplasms, and subsequently found application in other categories of patients. This method helps in calculating the length of hospital stay and the risk of readmission of a patient after surgery. To calculate comorbidity, the ICED scale proposes to evaluate the patient’s condition separately according to two components: physiological and functional characteristics. The first component includes 19 comorbidities, each of which is rated on a 4-point scale, where “0” is the absence of the disease and “3” is its severe form. The second component assesses the impact of comorbidities on the patient's physical condition. It rates 11 physical functions on a 3-point scale, where “0” is normal function and “2” is impossible to perform.

Having analyzed the comorbid status of patient S., 73 years old, using the most popular international scales for assessing comorbidity, we obtained fundamentally different results. Their ambiguity and inconsistency to a certain extent complicated our judgment about the true severity of the patient’s condition and complicated the prescription of rational pharmacotherapy for her diseases. Every clinician, regardless of clinical experience and knowledge of medical science, faces such challenges every day. Moreover, in addition to the comorbidity assessment systems discussed in this article, there are currently the GIC index (Geriatric Index of Comorbidity, 2002), the FCI index (Functional Comorbidity Index, 2005), the TIBI index (Total Illness Burden Index, 2009), as well as a number scales that allow patients to independently assess their comorbidity. Analysis of the patient's concomitant pathology in the same clinical case using these indices would undoubtedly give new results, but would also confuse the practitioner even more.

It seems to the authors that the main obstacles to the implementation of comorbidity assessment systems in the diverse treatment and diagnostic process are their fragmentation and narrow focus. Despite the variety of methods for assessing comorbidity, the lack of a single generally accepted way of measuring it, devoid of the shortcomings of existing methods, is of concern. The lack of a single tool created on the basis of enormous international experience, as well as the methodology for its use, does not allow comorbidity to “turn its face” to a practicing physician. At the same time, due to disparate approaches to the analysis of comorbid status and the absence of comorbidity components in the curricula of medical universities, its prognostic impact is not obvious to the clinician, which makes publicly available systems for assessing comorbidity unreasonable and therefore unclaimed.

“A specialist is like a gumboil - its completeness is one-sided,” a group of authors once wrote under the pseudonym Kozma Prutkov, and therefore today the question has arisen of conducting a generalizing fundamental study of comorbidity, its properties and patterns, as well as the phenomena and phenomena associated with it - bedside research the patient and at the section table. The result of this work should be the creation of a universal tool that allows a practicing doctor to easily and easily assess the structure, severity and possible consequences of comorbidity, conduct a targeted examination of patients and prescribe them adequate treatment.

Literature

A. L. Vertkin,Doctor of Medical Sciences, Professor
A. S. Skotnikov 1,Candidate of Medical Sciences

But, as is known, stability in the body is disrupted by various pathological agents (bacteria, viruses, etc.), leading to pathological changes and causing the development of diseases. Moreover, if at least one system fails, many protective mechanisms are launched, which, through a series of chemical and physiological processes, try to eliminate the disease or prevent its further development. However, despite this, a “trace” of the disease still remains. A disruption in the functioning of an individual link in a single chain of vital activity of the body ricochets through the functioning of other systems and organs. This is how new diseases appear. They may not develop immediately, but years after the illness that gave rise to their development. During the study of this mechanism, the concept of “comorbidity” appeared.

Definition and history

The great Hippocrates wrote: “Inspection of the human body is a single and complete process that requires hearing, sight, touch, smell, language and reasoning.” That is, before starting to treat a patient, it is necessary to comprehensively study the general condition of his body: the clinical picture of the underlying disease, complications, and concomitant pathologies. Only after this does it become possible to choose the most rational treatment strategy.

Types of comorbidity

Comorbidity can be divided into the following groups:
1. Causal comorbidity, caused by parallel damage to organs and systems caused by a single pathological factor. An example of such comorbidity is damage to internal organs due to alcoholism.
2. Complicated comorbidity. This type of comorbidity appears as a result of an underlying disease, which to one degree or another destroys the so-called target organs. We are talking, for example, about chronic renal failure resulting from diabetic nephropathy (type 2 diabetes mellitus). Another example of this type of comorbidity is a heart attack (or stroke) that develops against the background of a hypertensive crisis due to arterial hypertension.
3. Iatrogenic comorbidity. The reason for its appearance is the forced negative impact of diagnosis or therapy on the patient, provided that the danger of any medical procedure is established and known in advance. A striking example of this type of comorbidity is osteoporosis (bone fragility), which develops as a result of the use of hormonal drugs (glucocorticosteroids). Such comorbidity can also develop during chemotherapy, which can cause the development of drug-induced hepatitis in the patient.
4. Unspecified comorbidity. This type of comorbidity is spoken of when it is assumed that there are common mechanisms for the development of diseases that make up the overall clinical picture, but certain studies are required to confirm this thesis. For example, a patient suffering from arterial hypertension may develop erectile dysfunction (impotence). Another example of unspecified comorbidity may be the presence of erosions and ulcers on the mucous membrane of the upper digestive tract in patients with vascular diseases.

5. “Random” comorbidity. The combination of chronic coronary heart disease and the presence of gallstones in a patient (cholelithiasis) demonstrates an example of “random” comorbidity.

Some statistics

Diagnosis for comorbidity

Complications of the underlying disease are related to it in pathogenesis (mechanism of occurrence) and can lead to an unfavorable outcome, in some cases even to the death of the patient.

Concomitant diseases are all other pathologies that are not related to the main disease and, as a rule, do not affect its course.

Professor M. Ya. Mudrov (actual speech “A word on the way to teach and learn practical medicine”

or active medical art at the bedside of the sick", 1820)

Dear colleagues, in addition to therapists and general practitioners, narrow specialists often encounter the problem of comorbidity. Unfortunately, they extremely rarely pay attention to the coexistence of a whole spectrum of diseases in one patient and primarily treat a specialized disease. In current practice, urologists, gynecologists, otorhinolaryngologists, ophthalmologists, surgeons and other medical specialists often include only “their” disease in the diagnosis, leaving the search for concomitant pathology to other specialists. The unspoken rule of any specialized department has become the advisory work of the therapist, who takes upon himself the syndromic analysis of the patient, as well as the formation of a diagnostic and treatment concept that takes into account the patient’s potential risks and his long-term prognosis.

Everything in the body is connected (thank God, few people deny this fact). Not a single function, not a single organ, not a single system works in isolation. Their continuous joint activity maintains homeostasis, ensures the coherence of ongoing processes, and protects the body. However, in real life, this mechanism, ideal from the point of view of nature, encounters every second a multitude of pathological agents, under the influence of which its individual components fail, leading to the development of the disease. If it happens, hundreds of adaptive and protective mechanisms will launch thousands of chemical reactions and physiological processes aimed at suppressing, limiting and completely eliminating the disease, as well as preventing its complications.

Nothing passes without a trace. The disruption of one seemingly tiny link, despite the timely elimination of the defect, entails changes in many processes, mechanisms and functions. This contributes to the emergence of new diseases, the debut of which may take many years. In addition, such a violent response of the body to the influence of a pathological agent is not always possible. Its protective powers are lost with age, and also fade away against the background of immunodeficiency, due to a wide range of reasons.

There are no specific diseases. However, doctors often prevent, diagnose and treat a patient’s disease in isolation, paying insufficient attention to the illnesses the person has suffered and its concomitant pathology. The practical process drags on as usual from year to year, as if the patient had only one illness, as if only it needed to be treated. Medicine is forced to become commonplace. From the point of view of modern medicine, this state of affairs cannot continue to persist, and therefore it would be more correct to consider the current disease and look for approaches to it in conjunction with an analysis of previous diseases, risk factors and predictors available to the patient, as well as with calculation of the likelihood of potentially possible complications.

An individual approach to the patient dictates the need for a comprehensive study of the clinical picture of the underlying, concomitant and past diseases, as well as their comprehensive diagnosis and rational treatment. This is precisely the essence of the famous principle of Russian doctors, voiced in the epigraph to our article, which has become the property of world medicine and the subject of many years of discussion among domestic and foreign scientists and clinicians. However, long before Mudrov, Zakharyin, Pirogov and Botkin, who proclaimed this principle of managing somatic patients in Russia, traditional medicine arose in Ancient China, using an integrated approach to the treatment of the human body, a complete diagnosis of diseases, coupled with the general improvement of the body and its unity with nature. In Ancient Greece, the great thinker and physician Hippocrates wrote: “Examination of the body is a whole business: it requires knowledge, hearing, smell, touch, language, reasoning.” He, contrary to his opponents, was convinced of the need to search for the deeply hidden cause of the disease, and not to eliminate only its symptoms. The healers of Ancient Egypt, Babylonia and Central Asia were also aware of the relationship between some diseases and others. More than four thousand years ago, they knew how to diagnose diseases using the pulse, the measurement of which today is used only in the diagnosis of heart disease. Many centuries ago, generations of doctors promoted the advisability of an integrated approach in identifying the disease and healing the patient, but modern medicine, characterized by an abundance of diagnostic techniques and a variety of treatment procedures, required specification. In this regard, the question has arisen: how to comprehensively assess a patient suffering from several diseases at the same time, where to begin his examination and where to focus treatment in the first and subsequent stages?

For many years this question remained open, until in 1970 Alvan Feinstein, an outstanding American physician, researcher and epidemiologist who had a significant influence on the technique of clinical research, and especially in the field of clinical epidemiology, proposed the concept of “comorbidity” (lat. co - together, morbus - disease). He put into this term the idea of the presence of an additional clinical picture that already exists or may appear independently, in addition to the current disease, and is always different from it. Professor A. Feinstein demonstrated the phenomenon of comorbidity using the example of somatic patients with acute rheumatic fever, finding a worse prognosis for patients suffering from several diseases simultaneously.

Immediately shortly after the discovery of comorbidity, it was identified as a separate research area. A broad study of the combination of somatic and mental pathology has found a place in psychiatry. I. Jensen (1975), J. H. Boyd and J. D. Burke (1984), W. C. Sanderson (1990), U. L. Nuller (1993), L. Robins (1994), A. B. Smulevich (1997), C. R. Cloninger (2002) and other leading psychiatrists have devoted many years to identifying a number of comorbid conditions in patients with a variety of mental disorders. It was these researchers who developed the first models of comorbidity. Some of the open models viewed comorbidity as the presence of more than one disorder in a person at a given time in life, while others viewed it as the relative risk of a person with one disorder acquiring another disorder. These scientists identified transsyndromal, transnosological and chronological comorbidity. The former represent the coexistence in one patient of two and/or more syndromes or diseases that are pathogenetically interrelated, and the latter type requires their temporary coincidence. This classification was largely inaccurate, but it made it possible to understand that comorbidity can be associated with a single cause or common mechanisms of pathogenesis of these conditions, which is sometimes explained by the similarity of their clinical manifestations, which does not allow accurately differentiating nosologies.

The problem of the influence of comorbidity on the clinical course of the underlying somatic disease, the effectiveness of drug therapy, and the immediate and long-term prognosis of patients has been studied by talented clinicians and scientists from various medical specialties in many countries around the world. Among them were M. H. Kaplan (1974), M. E. Charlson (1987), F. G. Schellevis (1993), H. C. Kraemer (1995), M. van den Akker (1996), T. Pincus ( 1996), A. Grimby (1997), S. Greenfield (1999), M. Fortin (2004), A. Vanasse (2005) and C. Hudon (2005), L. B. Lazebnik (2005), A. L. Vertkin and O. V. Zairatyants (2008), G. E. Caughey (2008), F. I. Belyalov (2009), L. A. Luchikhin (2010) and many others. Under their influence, the term “comorbidity” arose many synonyms, among which the most prominent are “polymorbidity”, “multimorbidity”, “multifactorial diseases”, “polypathy”, “soreness”, “dual diagnosis”, “pluripathology”, etc. Thanks to the work done, the causes of comorbidity have become clear to some extent: anatomical proximity, a single pathogenetic mechanism, cause-and-effect relationship and complication. However, despite the abundance of definitions and synonyms, there is no unified classification and generally accepted terminology of comorbidity today.

Some authors contrast the concepts of comorbidity and multimorbidity with each other, defining the first as the multiple presence of diseases associated with a proven single pathogenetic mechanism, and the second as the presence of multiple diseases not related to each other by currently proven pathogenetic mechanisms. Others argue that multimorbidity is a combination of many chronic or acute diseases and medical conditions in one person, and do not emphasize the unity or difference of their pathogenesis. However, a fundamental clarification of the term “comorbidity” was given by H. C. Kraemer and M. van den Akker, defining it as a combination of several, namely chronic, diseases in one patient. They also proposed the first classification of comorbidity. According to their data, factors influencing the development of comorbidity may include chronic infection, inflammation, involutory and systemic metabolic changes, iatrogeny, social status, environmental conditions and genetic predisposition.

Causal comorbidity caused by parallel damage to various organs and systems, which is caused by a single pathological agent, for example, alcoholic visceropathy in patients with chronic alcohol intoxication, pathology associated with smoking, or systemic damage due to collagenosis.

Complicated comorbidity is the result of the underlying disease and usually consistently manifests itself in the form of target organ damage some time after its destabilization. Examples of this type of comorbidity are chronic renal failure due to diabetic nephropathy in patients with type 2 diabetes mellitus or the development of cerebral infarction as a result of a complicated hypertensive crisis in patients with essential hypertension.

Iatrogenic comorbidity manifests itself when a doctor has a forced negative impact on a patient, subject to the pre-established danger of a particular medical procedure. Glucocorticosteroid osteoporosis is widely known in patients receiving systemic hormone therapy for a long time, as well as drug-induced hepatitis as a result of chemoprophylaxis of pulmonary tuberculosis prescribed due to changes in tuberculin tests.

Unspecified comorbidity assumes the presence of common pathogenetic mechanisms for the development of diseases that make up this combination, but requires a number of studies to confirm the hypothesis of the researcher or clinician. Examples of this type of comorbidity are the development of erectile dysfunction in patients with atherosclerosis and arterial hypertension, as well as the occurrence of erosive and ulcerative lesions of the mucous membrane of the upper gastrointestinal tract in “vascular” patients.

An example of a so-called “random” type of comorbidity is a combination of coronary heart disease (CHD) and cholelithiasis, or a combination of acquired heart disease and psoriasis. However, the “randomness” and apparent illogicality of these combinations can soon be explained from a clinical and scientific point of view.

Comorbidity as the coexistence of two and/or more syndromes or diseases, pathogenetically interrelated or coinciding in time in one patient, regardless of the activity of each of them, is widely represented among patients hospitalized in therapeutic hospitals. In primary care, patients with multiple medical conditions are the rule rather than the exception. According to M. Fortin, based on an analysis of 980 case histories taken from the daily practice of a family doctor, the prevalence of comorbidity ranges from 69% in young patients (18-44 years old) to 93% among middle-aged people (45-64 years old) and up to 98% - in patients of the older age group (over 65 years). Moreover, the number of chronic diseases varies from 2.8 in young patients to 6.4 in old people. In this work, the author points out that fundamental studies of medical documentation aimed at studying the prevalence of comorbidity and identifying its structure were carried out before the 1990s. Noteworthy are the sources of information used by researchers and scientists dealing with the problem of comorbidity. They were medical histories, outpatient records of patients and other medical documentation available from family doctors, insurance companies and even in the archives of nursing homes. The listed methods for obtaining medical information were mostly based on the clinical experience and qualifications of clinicians who made clinically, instrumentally and laboratory confirmed diagnoses for patients. That is why, despite their unconditional competence, they were very subjective. It is surprising that none of the comorbidity studies performed analyzed the results of pathological autopsies of deceased patients, which would be very important. “The duty of doctors is to open the person they treated,” Professor Mudrov once said. Autopsy allows us to reliably establish the structure of comorbidity and the immediate cause of death of each patient, regardless of his age, sex and gender characteristics. Statistical data on comorbid pathology, based on these sections, are largely devoid of subjectivity.

Prevention and treatment of chronic diseases are designated by the World Health Organization as a priority project of the second decade of the 21st century, aimed at improving the quality of life of the world population. This determines the widespread tendency to conduct large-scale epidemiological studies in various fields of medicine, carried out using serious statistical calculations.

An analysis of a ten-year Australian study of patients with six common chronic diseases found that about half of older patients with arthritis had hypertension, 20% had cardiovascular disease, and 14% had type 2 diabetes. More than 60% of patients with bronchial asthma indicated concomitant arthritis, 20% - cardiovascular diseases and 16% - type 2 diabetes mellitus. Elderly patients with chronic renal failure had a 22% higher incidence of coronary artery disease and a 3.4-fold higher incidence of new coronary events compared with patients without renal impairment. With the development of end-stage renal failure requiring replacement therapy, the incidence of chronic forms of ischemic heart disease is 24.8%, and myocardial infarction is 8.7%. The number of comorbid diseases increases significantly with age. Comorbidity increases from 10% in people under 19 years of age to 80% in people 80 years of age and older.

A Canadian study of 483 obese patients found that the prevalence of obesity-related comorbidities was higher among women than men. The researchers found that about 75% of obese patients had comorbidities, which in most cases were dyslipidemia, hypertension and type 2 diabetes. It is noteworthy that among young obese patients (from 18 to 29 years old), 22% of men and 43% of women had more than two chronic diseases.

According to our data, based on materials from more than three thousand pathological sections (n = 3239) of patients with somatic pathology admitted to a multidisciplinary hospital for decompensation of a chronic disease (average age 67.8 ± 11.6 years), the comorbidity rate is 94.2% . Most often in a doctor’s work there are combinations of two and three nosologies, but in isolated cases (up to 2.7%) one patient combines up to 6-8 diseases at the same time.

A fourteen-year study of 883 patients with idiopathic thrombocytopenic purpura conducted in the UK showed that the disease is associated with a wide range of somatic pathologies. In the structure of comorbidity of these patients, the most common are malignant neoplasms, diseases of the musculoskeletal system, skin and genitourinary system, as well as hemorrhagic complications and other autoimmune diseases, the risk of developing which within five years from the onset of the underlying disease exceeds 5%.

The study, conducted in the United States, included 196 patients with laryngeal cancer. This work showed that the survival of patients with different stages of laryngeal cancer varies depending on the presence or absence of comorbidity. At the first stage of cancer, survival is 17% in the presence of comorbidity and 83% in its absence, in the second stage it is 14% and 76%, in the third stage it is 28% and 66%, and in the fourth stage it is 0% and 50%, respectively. In general, the survival rate of comorbid patients with laryngeal cancer is 59% lower than the survival rate of patients without comorbidity.

« A specialist is like gumboil - its completeness is one-sided“- a group of authors once wrote under the pseudonym Kozma Prutkov (yeah, for those who didn’t know - K. Prutkov is not a real person who once lived on our land), and therefore today the question of conducting a generalizing fundamental study of comorbidity, its properties and patterns, as well as phenomena and events associated with it - studies at the patient’s bedside and at the dissecting table. The result of this work should be the creation of a universal tool that allows a practicing doctor to easily and easily assess the structure, severity and possible consequences of comorbidity, conduct a targeted examination of patients and prescribe them adequate treatment.