He who has fleas … can also have lice

I have always adored old sayings. They are a poetic expression of generations and generations of “living” experiences and they are usually right and very wise.

The title for this “Prescription” is a very old Portuguese saying that my father, who was a good old fashioned, dedicated family doctor, used to say many times.

The meaning is that no one suffering from one disease should immediately relate every complaint that he/she starts feeling to the basic main disease. Even more important is that doctors should never do it! Before deciding that it is all connected and resulting from the same basic ailment, it is mandatory to be sure that nothing else is being missed.

Sometimes these different diseases are not even related but many other times they are. Even when they are related, they are different entities that have to be recognised as such, as the patient’s treatment will have to be considered in a different perspective.

In medicine, the term comorbidity describes the effect of all other diseases an individual patient might have other than the primary disease of interest, like two or more coexisting medical conditions that are additional to an initial diagnosis and also the extent to which two pathological conditions occur together in a given population.

What is comorbidity
A comorbidity is a disease or condition that coexists with a primary disease but also stands on its own as a specific disease. For example, someone can have hypertension (high blood pressure) and not have diabetes. But, on the other hand, someone with diabetes very often has hypertension, too. Thus, hypertension is a common comorbidity of diabetes. Other common comorbidities of diabetes are hyperlipidemia (high cholesterol), cardiovascular disease, kidney disease, nonalcoholic fatty liver disease, and obesity.

The term “comorbid” has two definitions:
1. It indicates a medical condition existing simultaneously but independently with another condition in a patient
2. It indicates a medical condition in a patient that causes, is caused by, or is otherwise related to, another condition in the same patient

The many challenges of multimorbidity
Many years ago, I wrote about this problem, but I decided it was about time to pick up this subject once more, as the recognition of this reality is becoming more and more important when the dramatic rise in long-term conditions represents a major challenge for individuals, families, and healthcare systems worldwide. Due to the scale of this rise, the management of these patients largely falls within the domain of primary care.

In the UK, these patients account for 80% of general practice consultations thus being a top priority in correct patient management. Adding to this, the pattern of patients admitted to internal medicine wards has also dramatically changed in the last 20-30 years as elderly people are now the most rapidly growing proportion of the patient population in the majority western countries.

Ageing seldom comes alone, often being accompanied by chronic diseases, comorbidity, disability, frailty, and social isolation. Multiple diseases and multimorbidity inevitably leads to the use of multiple drugs, a condition known as polypharmacy.

This is often a major challenge for family doctors as many times these patients are seen by several specialists in several different areas – for the heart, for the kidneys, the stomach, the bones… and when they come back, they have a frightening list of medicines that needs to be managed in an integrated way.

Unfortunately, patients have very frequently the tendency to enter this model of care, which is very typical of delivery systems that are constructed around specialised care, where areas of expertise are defined around specific conditions and bodily systems. Not surprisingly, clinical practice guidelines, arising from that model of care, lack pertinence for patients with multiple health conditions.

Patients are certainly unique, but they can certainly have multiple diseases.

In fact, not everything a person feels has to do with the one and only disease that he/she is aware of.

I remember a patient in my practice that was feeling more and more tired and, for quite some time, thought this was a result of his asthma getting worse. He finally went to see his family doctor who diagnosed a problem with one of the heart valves. Treatment was totally different.

Even if it is true that physicians should always try to integrate patient’s symptoms into only one disease, nobody should ever forget that if one has “fleas”, he can also have … another health problem! Or even more than one.

Best healthy wishes,
Dr. Maria Alice

By Dr Maria Alice
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Dr Maria Alice is a consultant in General and Family Medicine. General Manager/Medical Director – Luzdoc International Medical Service / Medilagos. Medical Director – Grupo Hospital Particular do Algarve