Co-morbidities in dementia: time to focus more on assessing and managing co-morbidities

Abstract

Dementia is commonly associated with co-morbidities. Co-morbidities in dementia may be mistaken for the symptoms of dementia. Co-morbidities in dementia associated with poor outcomes and impaired quality of life. Dementia overshadows recognition of co-morbidities. Interactions between co-morbidities in dementia further worsens outcome. Older people living with dementia have on an average four co-morbidities compared with older people without dementia who have two on average [1]. Nearly 9 in 10 people living with dementia have at-least one other health condition; just under 1 in 6 have one health condition and just over 1 in 6 have 6 health conditions or more [2]. Co-morbidities affecting outcomes in dementia are well known and the impact of such co-morbidities in dementia are well described [3]. Co-morbidities lead to a worse prognosis with increased morbidity and mortality [4, 5]. While it is recognised that co-morbidities affect the course of the illness and its outcome, there are few studies that determine what the co-morbidity profile is in such people suffering with dementia. It is, therefore, assumed that co-morbidities people with dementia present with, are similar to that of age-matched population but this may not necessarily be so. It is also unclear if the co-morbidity profiles differ with the severity of the dementia or if the profiles of co-morbidities are similar between those living in the community compared with those living in supervised settings such as in nursing homes. Ageing in people with dementia also leads to a new effect of multi-morbidity—the interaction of the different co-morbidities. The recognition and effect of this is not that well known. While individual conditions and their impact on the dementing illnesses have been recognised [6] as is also that healthcare expenditure is greater with increased level of co-morbidities [7]; the cumulative impacts of having multiple morbidities and how their interactions affect the progression in dementia are less well recognised. In a timely and pertinent accompanying article (the IDEAL study) in this issue, Nelis and colleagues [8] aim to identify the co-morbidity profile of community dwelling older people with dementia and examine the associations between severity of co-morbidity, quality of life- and health-related quality of life and the common combinations of co-morbid conditions. They demonstrate that those with the greatest levels of co-morbidity also show the greatest impact on well-being. In clinical practice, dementia is often the main theme in consultations and co-morbidities are paid less attention [9]. People with dementias face a real risk of serious delay in recognising new symptoms or exacerbation of old symptoms. Nearly 1 in 2 of nursing home residents with dementia with acute infections receives no physical assessment [10]. Unplanned emergency medical admissions occur in about 1 in 5 of people with dementia with a higher risk of mortality at 6 months [11, 12]. Co-morbidity and poor control of existing conditions result in increased care giver burden [13, 14, 15] and increase health and social care costs [16]. People with dementia and co-morbidities are likely to be hospitalised more often and spend longer in hospitals [17, 18, 19], but more importantly many of these admissions are preventable [20]. Management of such people is also complicated with polypharmacy and over and under treatment of conditions [21]. As a result their physical and psychological well-being may be compromised with impaired quality of life and ensuing disability [22]. Timely identification of physical symptoms lead to decreased hospitalisation [13] reduced healthcare costs [23] and maintaining physical comfort and quality of life [24, 25]. It is time that we put a greater emphasis and start focussing more on attempts to assess and manage the nature and impact of different co-morbidities in people with dementia and be vigilant to the interacting effects between the co-morbidities. Care service provision and organisation of care should have the ability to deal with multiple conditions in an integrated way targeting the interventions to deal with co-morbidities at the groups most at risk. Declarations of Conflicts of Interest: None. Declarations of Sources of Funding: None.