Comorbidities and Secondary Conditions
Waldman, H. Barry, Rader, Rick, Wong, Allen, Perlman, Steven P., Chaudhry, Ramiz A., The Exceptional Parent
Comorbidity and secondary conditions in adults with intellectual and other disabilities can affect significantly the health provider's decisions for clinical management of a patient. While comorbidity conditions may frequently be considered by practitioners and family members, secondary conditions (e.g. social, emotional, family, and community factors) require additional consideration. Government reports are used to describe the wide variations in the prevalence rates of some of these conditions at the state level in an effort to promote health provider attention to this relevant information.
The evidence of comorbidity; i.e. establishing the relationships between the various conditions in one person and understanding the implications for total health services, can affect significantly the clinical management and referrals for individuals with disabilities. (1) But so too can secondary conditions. A secondary condition is "any condition to which a person is more susceptible by virtue of having a primary disabling condition." (2) Comorbidity refers to the existence of additional diseases after diagnosis of the primary disabling condition. Secondary conditions add three dimensions not fully captured by the term comorbidity. They include: 1) non-medical events, e.g. isolation; 2) conditions that affect the general population, but to a greater extent affect people with a disabling condition; e.g. obesity; and 3) problems that arise any time during the lifespan, e.g. inaccessibly to medical facilities. (3) Comorbidities and secondary conditions may best be visualized using Venn diagrams (i.e. the use of overlapping circles to show relationships between varying factors).
An understanding by family members, daily care providers, and supervising health practitioners of the consequences of concurrent conditions can enhance early recognition of systemic developments and the potential consequences of comorbidities and secondary conditions. For example, the Charlson comorbidity index is used to predict the one-year mortality of patients who may have a range of comorbid conditions such as heart disease, AIDS or cancer (a total of 22 conditions). Each condition is assigned with a scored of 1,2,3 or 6 depending on the risk of dying associated with the condition. The scores are summed up and given a total score which predicts mortality. Decisions based on severity vs. costs, risks of treatment and short-term benefits can be determined. (4)
SPECIFICALLY, INTELLECTUAL DISABILITIES
A growing awareness of comorbidity and secondary factors affecting individuals with intellectual disabilities (ID) is emphasized in an extensive literature which focuses on 1) the increased life expectancy of individuals with ID and integration in their communities with resultant needed services from local practitioners, 2) emphasis on often overlooked health concerns (e.g. sexually transmitted diseases and end of life decisions), 3) frequent reports of associated psychiatric syndromes, and 4) the need to establish comprehensive treatment protocols (including routine periodic health screenings to review medical and behavior disorders) common to the population of individuals with ID. (5-16)
The recognition of comorbidities and secondary conditions is not limited to individuals with ID. It extends into all aspects of care for individuals with a wide array of disabilities and the general population. For example, epilepsy is prevalent among those with other disabilities, including autism (25.5%), cerebral palsy (13%), Down syndrome (13.6%), and intellectual disabilities (25.5%). Forty percent of people who have both cerebral palsy and intellectual disabilities also have epilepsy. (17)
There are increasing reports of comorbidities and secondary conditions among individuals with various psychological diagnoses and involving the growing geriatric population. (18-20) Adults with ID "... have more medical problems than do age-matched persons (in the general population), approximately five medical conditions per person. …