L22 Chronic Disease and Co-Morbidities

• Co-morbidities/multi-morbidities


  The presence of two or more chronic diseases or conditions in the same individual
• Chronic diseases covered in this course and lecture
• Chronic diseases covered


  • Dementia
  • Diabetes
  • Obesity
  • Immunodeficiency
  • Anaemia
  • Amyloidosis
  • Chronic rheumatic fever
  • Rheumatoid arthritis/joint disease
  • COPD
  • Gastrointestinal Diseases
• Not covered in this course but of relevance to overall patient care
• Over 80% of the older population have at least one chronic disease and numbers increase still
• Chronic diseases common in the older population

  • Diabetes
  • Obesity
  • Mental health
  • Dementia
  • Frailty / Sarcopenia
• Need to consider overall co-morbidity and multi-morbidity

  
• Sarcopenia


  Loss of muscle and strength
• Sarcopenia


  • 8% loss of skeletal muscle per decade >40 years
  • 15% loss of skeletal muscle per decade >70 years
• Dementia (aka Major Neurocognitive Disorder)


  Decline from a patient's prior level of cognitive ability, that is persistent and progressive over time, and is not associated exclusively with an episode of delirium. Also be a decline in the patient's ability to function
• Dementia


  • >65 years 10%, >85 years 30% of people. More in women
  • Different types- Alzheimer's, Vascular, Lewy body, alcohol
• Complications of dementia


  • Brain failure
  • Inadequate nutrition
  • Fractures due to falls
  • Infections (pneumonia)
• Obesity


  Increases with age and growing in numbers
• 7% total health burden due to obesity or overweight
• Obesity definition


  Varies->100kg – 120kg, BMI, abdo circumference
• Complications of obesity


  • Osteoarthritis
  • Gallstones
  • Obstructive sleep apnoea (leading to right sided heart failure- cor pulmonale)
• Metabolic syndrome


  Associated with obesity, includes insulin resistance, type 2 diabetes, and hormonal changes
• Chronic inflammation may contribute to insulin resistance, metabolic abnormalities, thrombosis, cardiovascular disease, and cancer in obesity
• Cancers associated with obesity

  • Oesophageal
  • Thyroid
  • Colon
  • Kidney
  • Endometrium
  • Gallbladder
• Case 1 - Ms A

  42-year-old woman, completely bed bound, abdominal hernia, gallstones, hypothyroidism, sleep apnoea, and type 2 diabetes requiring insulin
• Ms A's weight: 186.5kg, height: 161cm, BMI 71kg/m2
• Ms A was found "pale and with purple lips" at home, then became unresponsive and could not be resuscitated
• Ms A's heart


  • Four chambers 1014g (normal 560g +/- 1SD 659g, upper 95% 731g)
  • "Obesity cardiomyopathy," can develop independent of hypertension, coronary heart disease, and other heart diseases

  
• About 10% of all deaths are due to diabetes
• Pre-diabetes maybe 20%- 1/3 go on to develop type 2 diabetes
• Case 2 - Mrs P

  68-year-old, unexpected death at home, unwitnessed, multiple morbidities including diabetes
• Mrs P's weight: 92kg, height: 172cm, BMI 31.1
• Mrs P's kidneys


  • Nodular glomerulosclerosis with Kimmelstiel-Wilson nodules
  • Diffuse glomerulosclerosis
  • Hyaline arteriolosclerosis- glassy pink homogenous thickening of the vessel walls
  • Intimal and medial thickening resulting in luminal narrowing and ischaemia

  
• Mrs P had pneumonia, type 2 diabetes, cardiomegaly consistent with essential hypertension, widespread atherosclerosis, obesity, and previous surgical interventions
• Case 3 - Mr H

  74 year old man, bachelor, living alone, 40 pack year smoking history, 4 gins and a beer /week, retired truck driver, long history of respiratory disease with increasing shortness of breath
• Mr H was able to walk 100m to the dairy, had no home support, and was referred to hospital for probable infective exacerbation of COPD
• Mr H was taking salbutamol, ipratropium inhalers, and prednisone 10mg/day for 20 years
• Mr H failed to improve, had ongoing poor appetite, chronic back pain, persistent shortness of breath, low blood pressure, persistent neutrophil leucocytosis, high CRP and ESR
• Mr H developed oral ulcers, herpes simplex infection, ischaemic right leg, wasting and weakness of proximal leg muscles
• Mr H had a large abdominal aortic aneurysm that ruptured, and he declined surgery due to his severe COPD
• Mr H's autopsy findings

  • Large amount of mucopurulent sputum and white froth in trachea and main bronchi, grew Strep. agalactiae and Acinetobacter
  • Emphysematous change
  • Multiple small thromboemboli
  • Aged myocardial infarct
  • Moderate coronary artery atherosclerosis
  • Ruptured abdominal aortic aneurysm
  • Moderate steatosis of liver