Multimorbidity and atypical presentations

Question 1

Define multimorbidity

Answer 1

2 or more long-term health conditions (check GP definition which may be different)

Question 2

Which conditions are included as ‘long-term health conditions’ in the definition of multimorbidity?

Answer 2

• Physical health conditions
• Mental health conditions
• Ongoing conditions eg learning disability
• Symptom complexes eg frailty
• Sensory impairment eg sight or visual loss
• Alcohol and substance misuse

Question 3

What are the signs that someone has multimorbidity?

Answer 3

• presenting to A+E frequently
• requiring support from OT, physio
• polypharmacy

Question 4

Why do we get atypical presentations in older people?

Answer 4

1. Age related physiological changes
   a. these blunt the patient’s response to illness
   b. Do not have the same acute physiological response that young people have
2. Loss of physiological and functional reserve – so instead present as loss of function eg geriatric giants (incontinence, instability, immobility)
3. Comorbidities
   a. Interact and affect presentation picture
4. Older people often underreport symptoms
   a. Often have to rely on caregivers for history

Question 5

What are the geriatric giants?

Answer 5

• Instability (frailty)
• Immobility
• Intellectual impairment
• Incontinence
• Iatrogenesis

Question 6

How might a PE present in an older person?

Answer 6

Fall

Question 7

How might sepsis present?

Answer 7

intellectual impairment - ie confusion, delirium
decreased mobility
fall
(may be no fever or rise in WBC)

Question 8

How might pneumonia present?

Answer 8

difficulties in doing activities of daily living
delirium 
falls
Increased resp rate is common 
poor oral intake
decreased mobility 
carer stress
Cough, fever and pleuritic chest pain may be absent

Question 9

What are the three ways that comorbidities interact to cause atypical presentation?

Answer 9

SYNERGYSTIC
- comorbidities can combine together and contribute to a SINGLE presentation

CAUSAL
- one cmorbidity can lead to a presentation in ANOTHER SYSTMEM

HIDDEN
- A previously hidden comorbidity can be unmasked after the occurrence of an external stressful event

Question 10

Give an example of a synergistic presentation

Answer 10

heart failure treated with diuretics gives incontinence

Question 11

Give an example of a causal presentation

Answer 11

pneumonia causes sepsis, which causes AF and then heart failure

Treating the AF alone will not treat the heart failure

Question 12

Give an example of a hidden presentation

Answer 12

worsening heart failure following death of wife