EFFECT OF COEXISTING DISEASES ON THE TREATMENT OF UNRELATED DISEASE NEEDS MORE STUDIES

To the Editor: Older people often have multiple chronic diseases1 and take many medications.2,3 Multiple coexisting diseases and multiple medications are associated with more adverse effects2 and poor adherence to taking medications.3 Nevertheless, how one disease affects treatment of another unrelated disease has rarely been studied. Using Medical Expenditure Panel Surveys, Dr. Harman et al. have shown that hypertension and diabetes mellitus, but not heart disease or arthritis, were associated with a greater likelihood of receiving adequate depression care in older people.4 The reason could be due to frequent contacts with primary care providers.4 In contrast to their findings, Dr. Redelmeier et al., using the Ontario Drug Benefit program data, have shown that elderly patients with one disease are undertreated for another unrelated disease.5 For example, a patient with pulmonary emphysema received less treatment for lipid-lowering agents than a patient without pulmonary emphysema, and patients with psychotic syndromes were consistently unlikely to receive lipid-lowering or medical arthritis treatments, but patients with breast cancer were just as likely to receive glaucoma treatment as patients without breast cancer.5 The free medications for older people in the drug program indicated that cost was not a factor. Several alternative explanations were explored.5 First, chronic diseases associated with shorter life expectancy make long-term preventive therapy, such as taking lipid-lowing agents, unwanted. Second, adding more medications increases the risk of potential drug interaction and adverse events. Third, time constraints, communication problems, patient's preferences, and priorities of the specialist may limit time to address more than one disease effectively. Fourth, elderly patients with chronic disease may be exhausted and reluctant to accept multiple interventions. Last, it is often sensible to postpone minor treatment until major diseases are resolved. It was recently found that adhering to disease-based clinical practice guidelines in older people with multiple coexisting diseases may have undesirable effects, including adverse drug effects, cost burden, and multiple medications.6 Disease-based clinical practice guidelines might not work well for elderly patients with multiple coexisting diseases.6,7 Some healthcare providers feel that a typical trial patient is not necessarily the typical patient in their practice and question the applicability of the guidelines based on the trials.8 Therefore, healthcare providers might not be willing to follow the guidelines that were based on the trials.8 This could be another factor for undertreatment of one or more diseases. The true answer for almost opposite findings from these two groups4,5 is still unknown. Alternatively, drug-related morbidity and mortality was estimated to cost $76.6 billion in the ambulatory setting alone in the United States.9 Undertreatment of one disease because of one unrelated or multiple coexisting diseases might not be a bad thing. We have to ask ourselves how many medications are enough for older people with multiple coexisting diseases.10 Studying the influence of one chronic condition on the treatment of another chronic condition in older people4,5 is important and complex. More research is warranted. I have no conflicts of interest and no sponsors and am the sole author of this letter.

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