Multimorbidity and COVID 19: A catastrophic combination

Jeemon Panniyammakal

Multimorbidity is the existence of multiple long-term mental, physical, and cognitive disorders in one patient. These could include diabetes, hypertension, lung diseases, heart attacks, stroke, kidney failure, mental health conditions, and liver problems or other chronic conditions. Multimorbid conditions often share common disease causes and consequences. The disease pattern, progression and trajectories in multimorbidity are path-dependent in nature and often determined by age, sex and socio-demographic characteristics. However, addition of COVID 19 dramatically changes the disease progression pathways and cut-short the trajectories to immediate clinical end-points in individual with multimorbidity.

Richardson et al, presented the characteristics and early outcomes of sequentially hospitalized patients with confirmed COVID-19 in the New York City area. (doi:10.1001/jama.2020.6775). Hypertension (57%), obesity (42%) and diabetes (34%) were the most common comorbid conditions in this group of patients with median age of 63 years. Nearly, 9 of 10 COVID 19 patients had more than one comorbidities. The median number of comorbid conditions were 4. Similarly, the median score on the Charlson Comorbidity Index was 4 points (Inter Quartile Range, 2-6). In short, the comorbidity burden was substantial in the affected COVID 19 cases in the New York City area. For example, the cumulative comorbidity burden corresponds to a 53% estimated 10-year survival.

Richardson and colleagues reported mortality rates only for patients with definite outcomes (discharge or death). Of the total 2634 patients with one of the definite outcomes, 553 died (21%). Nearly three of four deaths were reported in individuals with >65 years of age. There were no deaths in the age group of <18 years. Nearly, 70% of patients died in the hospital had hypertension as a comorbidity. However, only 47% of discharged patients had hypertension as a comorbidity. Diabetes was present in 40% of patients died in the hospital, while it was 26% in those who were discharged from the hospital. It is reasonably clear that individuals with comorbid conditions have poor prognosis when affected by COVID 19. Although the data are not presented separately by multmorbidity pattern, it is probably appropriate to assume that multimorbidity is associated with poor survival outcomes in COVID 19 patients.

In comparison to people with single health problems and no other comorbid conditions, people with multimorbidity are more likely to have worse general health and an increased risk of premature death. Available data indicate that COVID 19 further increases the risk of mortality in individuals with multimorbidity. We may have to devise effective public health strategies to protect individuals with multimorbidity from COVID 19. Further, such individuals may require prioritised testing and management for COVID 19. They also need to get access to their regular medications and health services essential to manage their comorbid conditions. Ignoring their immediate medical needs may lead to catastrophic consequences even if they escape from COVID 19. 

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