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Comorbidity in Older Adults: Nosology of Impairment, Diseases, and Conditions

¹ Division of Geriatrics, David Geffen School of Medicine at the University of California at Los Angeles.
² Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
³ Epidemiology, Demography & Biometry; National Institute on Aging, Bethesda, Maryland.
⁴ Department of Medicine, University of Pittsburgh, Pennsylvania.
⁵ Department of Community Health, Brown University, Providence, Rhode Island.

Address correspondence to Arun S. Karlamangla, MD, PhD, UCLA Division of Geriatrics, 10945 Le Conte #2339, Los Angeles, CA 90095. E-mail: akarlamangla{at}mednet.ucla.edu

Older adults generally have multiple medical problems as well as subclinical changes in several physiologic systems. This special article presents a framework (based on the World Health Organization International Classification of Functioning, Disability, and Health) for organizing comorbid processes and diseases to facilitate research and assist clinicians caring for older adults. The nosology begins with physiologic systems (e.g., cardiovascular, endocrine) and assesses each system in several domains (e.g., coronary blood flow, systemic blood pressure, and cardiac function in the cardiovascular system). Functioning in each domain can range from high-functioning, even protective, zones (e.g., high levels of high-density-lipoprotein cholesterol) to severe dysfunction (as in end-stage disease). The approach has four advantages. First, it explicitly recognizes that decrements in health begin before onset of symptomatic disease. Second, it accommodates the full range of possible performance for each system instead of measuring only negative aspects. Third, it avoids arbitrary diagnostic thresholds. Fourth, it sets up an exhaustive and mutually exclusive classification system that can stimulate development of summary indices of total comorbidity burden for both research and clinical settings. As the knowledge base grows, the nosology can be updated to add new domains and refine extant ones.

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