OPIC Flashcards
(131 cards)
1
Q
what is the definition of dementia?
A
cognitive impairment: decline in both memory and thinking sufficient to impair ADLs, process in interpreting incoming information and maintaining info
present to =>6 months
2
Q
definition of delirium?
A
impairment of cognition, distubrances of attnetion and consious level, abnormal psychomotor behaviour, disturbed sleep-wake cycle
acute onset (hours/days)
typically symptoms worse at night
3
Q
what are the three types of delirium?
A
- hyperactive
- hypoactive
- mixed
4
Q
what examinations should be done when a patient comes in having had a fall?
A
- functional assessment of their mobility (how do they mobilise, gait)
- CVS examination e.g. ECG, lying and standing BP
- neuro examination
- MSK examination (joints)
- medication review
5
Q
list 3 fall risk assessment tools
A
- timed up and go (TUG)
- 30 second chair stand test
- 4 stage Balance test
6
Q
list some risk factos for osteoporosis?
A
- menopause
- age
- smoking
- alcohol (3units or more a day)
- oral corticosteroids
- previous fragility fracture
- immobility
- BMI <18.5
7
Q
risk factors for delirium?
A
- vision impairment
- infection
- > 65yo
- illness severity
- cognitive impairment
- fracture on admission
- post op (recovery from anaesthesia)
- opioids, steroids, diuretics, psychotropic drugs
8
Q
what T score is osteopenia and osteoporosis?
A
osteopenia -1 to -2.5
osteoporosis -2.5 to -4
9
Q
managment of delirium?
A
- treat underlying cause
- reassure and reorientate: talk to relative, put in low stimulant room, invovled dementia/delirium team, maintain adequate distance, de-escalation techniques
- manage distress
10
Q
medication for osteoporosis?
A
- bisphosphonate (alendronate 10md OD)
- Vit D (10mg)
(3. calcium - if inadequate levels: 1000mg) - consider HRT to younger postmenopausal women
11
Q
risks with bisphosphonates?
A
- GI disorders (acid reflux)
- joint swelling
- vertigo
- heamorrhage
- femoral stress fracture
- oesophagitis/oesophageal ulcer
12
Q
what is polypharmacy?
A
older pts have more conditions required diff meds
polypharmacy occurs which is when 6 or more drugs prescribed at any one time
13
Q
what are the different types of falls?
A
- syncopal (neurogenics, cardiogenic)
- non syncopal (MSK, visual etc)
- multifactoral
- simple
14
Q
what are the two risk assessment tools fro fracture risk?
A
Q- FRACTURE (better) and FRAX
15
Q
what are teh 4 P’s of fall prevention
A
pain
position
placement
personal needs
16
Q
what are the four different types of incontinence?
A
- stress
- urge
- overflow
- functional
17
Q
symptoms of stress incontinence?
A
leakage when increased intrabdo pressure (e.g. coughing or laughing)
- urgency
- frequency
18
Q
symptoms or urge incontinence?
A
related to OAB (detrusor overactivity)
- frequency
- urgency
- nocturia
19
Q
symptoms of overflow incontinence?
A
unable to completely empty bladder secondary to bladder outlet obstruction (BOO) or detrusor inactivity
- constant dribbling
- frequent urination with only small amounts
20
Q
symptoms of functional incontinence?
A
disability means they cannot reach toielt in time e.g. walking with aid
- urgency
- frequency
- nocturia
21
Q
managament of stress incontinence (conservative and pharm)
A
conservative:
- reduce caffeine
- stop XS fluid intake
- stop smoking
- lose weight
- pelvis floor msucle training (3 months)
pharm: duloxetine
surgical:
- colposuspension
- autologous rectus fascial sling
- retropubic mid-urethral mesh sling
- intramural urethral bulking agents
22
Q
management for urge incontinence?
A
conservative: (for women)
- reduce caffeine
- stop XS fluid intake
- stop smoking
- lose weight
- offer bladder training (for at least 6 wks)
pharm:
- anticholinergic e.g. oxybutynin (not great in older people!)
- second line: mirabegnon
23
Q
what is teh memory loss pattern like for dementia
A
in early stage of dementia pts start to lose their short term memory -> then long term as the disease progresses
24
Q
managment of overflow incontinence?
A
treat underlying cause of bladder outflow obstruction e.g. surgery to remove blockage, meds to shrink prostate, self catherisation (for detrusor inactivity)
25
managment of fucntional incontinence?
using behavioural methods that teach you to urinate on a timed voiding schedule and by modifying your environment so you can get to and use the toilet more quickly. This may involve moving furniture, making clothes easier to remove, or making other changes
26
what is importatn as part of a continence examination? (examinations and invesitgations)
- review of bladder and bowel diary
- abdo examination
- urine dipstick and MSU
- PR exam (will commonly have an impacted rectum if have a full bladder) + prostate in male
- external genitalia review particularly lookign fro atrophic vaginitis in female
- post micturition bladder scan
27
finasteride: class, indications, SE
5-alpha reductase inhibitor
BPH
sexual dysfunction, testicular pain, breast abnormalities
28
oxybutynin: class, indications, SE
anticholinergic
reduce detrusor overactivity
Constipation, dizziness, dry mouth, headache, n+v, palpitations, tachycardia
29
doxazosin and tamsulosin: class, indications, SE
both alpha blockers
both used for BPH but doxazosin can also be used to lower BP
arrythmias, chest pain, cough, dizzines, dry mouth, hypotensions, n+v, headahce
30
mirabegron: class, indications, SE
beta blocker
used for OAB
arrythmias, constipation, diarrhoea, dizziness, headache, icnreased risk fo infection, nausea
31
name 3 other medications used to treat OAB (bar oxybutynin and mirabegron)
- solifenacin
- trospium
- tolteradine
32
if faecal incontinence is suspected what exmiantions need to be done?
- PR examination-> assess rectum, prostate, anal tone and sensation as well as visual inspection of the rectum
- assess stool type as well
- abdo examination
33
what is the reassoning behind older persons getting faecal incontinence?
as body ages, rectum can become mroevacous and the anal sphincter cna gape due to a number fo factors e.g. haemorrhoids, chronci constipation
cannot exert the same amount of intrabdo pressure so and muscle tension to force out a stool
34
managment for constipation?
- enemas
- stool softeners (NEEDED if stool is hard as otherwise wont come out with just stimulants)
- stimulants
- manual evacuation if difficult cases
- in older pts any drug that cuases constipation is prescribed alongside laxative always
35
before chronic diarrohea can be managed what investigations need to be done to exclude underyling cuases?
- bowel imaging
- stool culture
- causative medications removed
- faecal impact needed to be excluded
36
managment of chronic diarrhoea?
regualr toileting and dietary review
then
low dose loperamide trialled then constipating and enema regimes used if this doesn't work
37
which two assessments are important to be done for elderly people to plan future healthcare?
1. clinical frailty score
2. comprehensive geriatric assessment
38
name some common stroke complications?
- recurrent stroke and extension of stroke
- raised ICP
- infections (chest due to aspiration or UTI due to incomplete bladder emptying or constipation)
- complications of immobility (VTE, constipation, bed sores)
- mood and cognitive dysfunction
- post stroke pain and fatigue
- spasticity, contractures and secondary epilepsy
39
how long are drivers licences taken off patient after strokes?
minimum 4 weeks for car
minimum 1 year for HGV licences
40
what are the stages of stroke management?
- admission to stroke unit
- revascularisation therapy
- optimising physiology and nutritional support
- secondary prevention
- rehabilition and reablement
41
what is the immediate management done for patients who have had an ischaemic stroke?
THROMBOLYSIS:
- IV alteplase (presents within 4.5hrs)
- mechanical thrombectomy (endovascular) - if large vessel occlusion and complete within 6 hrs of symptom onset
42
when is a decompressive hemicraniectomy (DHC) indicated?
- management of malignant oedema in pts <60yo (can be considered over cut off if pt biologically fit)
- referrals to neurosurgical units shld be made within 24 hrs and surgery completed within 48hrs
43
what is the management for intracerebral heamorrhages?
non surgical: blood pressure control and correction of clotting abnormalities
surgical options: evacuation of heamotoma (DHC) and ventricular drains
44
what ongoign antibthrombotic therapy is needed 24 hrs after thrombolysis?
two weeks of aspirin 300 mg followed by clopidogrel 75 mg daily
plus a DOAC
45
what is the management for carotid disease post TIA or stroke?
carotid endartectomy if lumen is >50% occluded
46
what conservative managament is given to pt to reduce risk of reccurent stroke?
- stop smoking
- maintain good BP control
- maintain glyceaemic control
- weight loss
- exercise
47
what surgical option in AF can be doen to prevent stroke if pts whom anticoagulation is contraindicated?
left atrial appendage closure
48
what ongoing management is given to pt post stroke/TIA?
- BP control
- Blood glucose control (control diabetes)
- Anti-lipid therapy: statin 48 hrs post start of stroke. Avoided in cerebral haemorrhage.
- Anti-platelet/anti-coagulation: 2 wks aspirin 300 mg then clopidogrel 75 mg daily. DOAC maybe (e.g. in AF)
- Carotid artery assessment: carotid dopplers or CT angiography. Consider carotid endarterectomy if anterior stroke and significant stenosis (>50%)
- Swallow and nutrition assessment
- Rehabilitation: referral to local stroke unit
- Palliative care
49
what swallow and nutrition therapy is needed to help pts who have had a stroke?
assess via bedside, video fluoroscopy or/& flexible endoscopic evaluation of swallowng (FEES)
if unsafe swallow function: tube assisted enteral feeding needed
(avoid parenteral feeding in end of life as reduces QoL)
50
what type of rehab is needed in pts post stroke?
assessment of & help with:
- mobility
- ADL
- speech
- cognitive
- spasticity
51
what two scores are important to know to help diagnose and manage strokes?
oxford community stroke project (OCSP) classification: classifies different strokes based on vessel involvement
&
National institutes of health stroke scale (NIHSS): quantitive measure of stroke-related neurologic deficit
high score is >22 and means a significant part of the brain is ischaemia (score is out of 42)
52
which two tools are used to guise anticoagulation therapy in patients with AF?
CHA2DS2-VASc and HAS-BLED
53
what investigations are ordered when pt has a suspected stroke?
- Bedside: observations, blood glucose, ECG (AF)
- Bloods: FBC, U&Es, Bone profile, LFT, ESR, coagulation, lipid profile, HbA1c
- non contrast CT ( can be normal in first few hours)
+/- CT angiography +/- MRI head
54
causes of malnutrition in the elderly?
- reduced dietary intake (dementia, reduced appetite)
- malabsorption
- increased losses or altered requirements
- energy expenditure (reduced physical activity)
55
name some consequences to poor malnutrition
Fatigue and lethargy
Falls
Difficulty coughing (risk of chest infection)
Heart failure
Anxiety and depression
Reduced ability to fight infection
56
what is a tool used to screen for malnutrition?
MUST tool (malnutrition universal screening tool)
5 step screening tool to identify adults who are malnourished, at risk of malnutrition or obese
57
name the four stages of wound healing.
- haemostasis
- inflammation
- proliferation
- remodelling
58
what factors influence wound healing?
- age
- gender
- stress
- ischaemia
- diseases (diabetes, fibrosis, jaundice, uraemia)
- obesity
- meds (steroids, NSAIDs, chemo)
- immunocompromised
- nutrition
59
5 signs of wounds infection?
- dollor
- callor
- rubor
- pus
- pain
60
what causes pressure ulcers?
icnreased pressure or friction to the skin = reduced/no blood supply to that area of skin = no oxygen and nutrients to starts to degrade
61
what are the common sites of pressure ulcers
- heels
- elbows
- hips/buttocks
- base of spine
- back of head
62
name 3 tools used to assess pressure ulcers?
1. braden scale
2. norton scale
3. waterlow scale
63
how can you measure a patients height from their ulna?
measure from olecranon process to styloid process on wrist -> convert in online chart
64
how do you measure someones BMI from arm circumferance
find upper arm midpoint - measure circumfernace
if MUAC <23.5cm, BMI likely to be <20
if MUAC >32cm then BMI likely to be >30
65
definiton of an unpaid carer?
a person of any age who provides unpaid support to a relative, partner, friend who needs support for ADLs
66
what is the difference between expressed and implied consent?
expressed consent i consent given with words, paper or verbally
implied consent si udnerstood through actions
67
what is meant by the mental capacity beign time and decision specific?
his means that the principles of the Act must be applied each time that a decision needs to be made.
68
what are teh 5 principles of the mental health act?
1. a presumption of capacity
2. individuals supported to make own decisions
3. unwise decisions
4. best interests
5. least restrictive option
69
what is the two stage capacity test?
stage 1: does the person have an impairment of mind/brain as a result of illness or external factors?
stage 2: does this impairment mean the person is unable to make a decision?
70
what are the four steps a person shoudl able to do with information that allows them to have capacity?
if cannot do one or mroe of following the dont have capacity:
- understand info given
- retain info long enough to make decision
- weigh up info to be able to make decision
- communicate decision
71
what is a lasting power of attorney?
a person can appoint one or more people to help them make a decision on their behalf
72
what is advance decisions to refuse treatment?
written statement of your wishes to refuse treatment in a particualr situation
73
what are Independent mental capacity advocate (IMCA) and independent mental health advocate (IMHA)?
IMCA: advocate appointed on your behalf if you lack capacity to make decisions
IMHA: independent advocate who is trained under the MHA 1983 + suports people to understand their rights under their acts + participate in decisions about their care and treatment
74
define a mental disorder?
clinically significant distubrnace in an individuals cognitive, emotional regulation or behaviour
75
what is a DNACPR decision?
decision of a patient or healthcare professional to refuse CPR should a patient suffer a cardiac arrest or die suddenly
76
what is a ReSPECT form?
creates a summary of personalised recommendations for a person's clinical care in a future emergency in which they do not have capacity to make or express choices
77
how quickly post fall does a CT head need to be done (with trauma and without)
trauma to head after fall - imaging need to be within 4 hours
fall - ct head without 12 hours
78
name some risk factors for falls
- previous fall
- age
- unsteady balance
- imapired gait
- impaired congition
- muscle weakness
- visual disturbnaces
- postural hypotension
- reduced sensation in feet/ legs - can be due to diabetes
- polypharmacy (>4 drugs)
- depression
79
name some causes of falls
syncopal:
- postural hypotensiosn (MOST COMMON)
- cardiogenic (angina, extertional)
- neurogenic (stroke/TIA, seizure)
non syncopal:
- MSK (weak muscles, poor balance)
- visual disturbances
- medications induced
80
how does the WHO analgeisa ladder go? (3 steps)
1. non opioid and adjuvant therapy
2. weak opioid + non opioid + adjuvant therapy
3. strong opioid + non opioid + adjuvant therapy
81
list of commonly used opioids from weakest to strongesT?
codeine
tramadol
morphine
buprenorphine
fentanyl
82
what is included in a confusion screen (Ix)??
Bloods:
- FBC (e.g. infection, anaemia, malignancy)
- U&Es (e.g. hyponatraemia, hypernatraemia)
- LFTs (e.g. liver failure with secondary encephalopathy)
- Coagulation/INR (e.g. intracranial bleeding)
- TFTs (e.g. hypothyroidism)
- Calcium (e.g. hypercalcaemia)
- B12 + folate/haematinics (deficiency)
- Glucose (e.g. hypoglycaemia/hyperglycaemia)
- Blood cultures (e.g. sepsis)
Urinalysis:
UTI is a very common cause of delirium in the elderly.
A positive urine dipstick + clinical signs: WCC↑/supra-pubic tenderness/dysuria/offensive urine/positive urine culture
Imaging:
- CT head: bleeding, ischaemic stroke, abscess
- Chest X-ray: pneumonia, pulmonary oedema
83
give examples of 10 questions you would ask in a AMT (abbreviated mental test) ?
1. What is your age?
2. What is the time to the nearest hour?
3. Give the patient an address, and ask him or her to repeat it at the end of the test
e.g. 42 West Street
4. What is the year?
5. What is the name of the hospital or number of the residence where the patient is
situated?
6. Can the patient recognize two persons (the doctor, nurse, home help, etc.)?
7. What is your date of birth? (day and month sufficient)
8. In what year did World War 1 begin?
9. Name the present monarch/prime minister/president.
10. Count backwards from 20 down to 1.
84
what AMT score suggest delirium or dementia and you would need to complete an MMSE?
<7
85
what questions would you ask a patietn to assess their independent living?
- ADLs
- toileting/washing abilities
- driving
- finances (are they able to handle them themselves?)
- medications (can they order them/are they taking them properly)
86
what is teh clock drawing test?
a person is asked to draw a clock showing the time as “10 past 11.” Someone with dementia will draw the clock incorrectly
-- good test for dementia (used alongside MMSE if MMSE shows possible dementia signs)
87
causes of delirium (PINCH ME)
Pain
Infection
Nutrition
Constipation
Hydration
Medication
Enivironment
88
what are the core differences between delirium and dementia?
- sleep wake cycle severely affected in delirium (sleep in day and awake during night)
- attention highly affected in delirium (slightly affected in dementia)
- delirium lasts a few days - to weeks whereas dementia is rest of life
- dementia onset is months/years and delirium is one/two days
- delirium fluctuates whereas dementia is consistent
- hallucinations common in delirium, not so common in dementia
- fluctuating levels of consiousness in delirium
89
describe the features fo hypoactive, hyperactive and mixed delirium?
hypoactive: lethargy, withdrawal, drowsiness and staring into space
hyperactive: restlessness, agitation, aggression, wandering, hyper alertness, hallucinations and delusions, and inappropriate behaviour
mixeD: mixture of hypo and hyperactive
90
what is teh most common type of deliriumm?
hypoactive
91
what routien investigations do you perform on a pt with delirium
confusion screen !
92
what are teh risks of using sedation in delirium?
lorazepam -> worsen delirium, can cause resp distress, increase risk of falls
haloperidol -> can worsen parkinsons
93
list some preventabel causes fo dementia ?
diabetes
high BP
smoking
obesity
high alcohol intake
lack of exercise
94
what cognitive tests can used on wards to assess patient s?
AMT
MMSE (longer and mroe comprehensive than AMT)
Mini COG (used in GPs?)
CAM (for delirium)
95
what CT head changes can be seen in delirium?
- cerebral atrophy
- enlargement of cerebral sulci
96
non pharm managment of dementia?
- programmes to imporve cognitive functioe
- exercise
- aromatherapy
- therapeutic use of music/dancing
- massages
97
pharm managemnt fo dementia?
Acetylcholinesterase inhibitors (donepezil, rivastigmine)
NMDA receptor antagonists (ketamine, methadone)
+ antipsychotics
+ CVD drugs (aspirin, clopidogrel)
98
what are teh differences between a residential home and a nursing home?
residential homes provide accom and personal care such as help with washing, dressing, taking meds + going to toilet (some offer activities within and outside of care home)
nursing homes also provide personal care but there wil always be 1 or more qualified nurse on duty to provide nursing care - some offer more care for pts with learnign diasbilites, dementia, mental health diagnosis or complex medical condition that has a certain need e.g. NG tube
99
how much do care homes cost?
600£ a week for residential homes
800£ a week for nursing homes
- pay for it themselves
- get help from family
- help from local authority via Adult Social Care
100
how do you treat pressure sores?
relieve the pressure from the are every 2 hrs (or more)
use special mattresses to reduce or relieve pressure
clean and dress the area
antiseptic / antibiotic creams if needed (oral abx if serious)
healthy balanced diet and hydration
may need debridement and surgery
101
define: learning disability
a reduced intellectual ability and difficulty with everyday activities due to a state of arrested or incomplete development period and skills that contribute the overall level of intelligence
102
what are some psychiatric comorbidities in patients with learnign difficulties
- ADHD
- OCD
- depression
- anxiety
- dyslexia
103
why do people with learning disabilties have worse health than peple without learning disabilites
due to reduced access to healthcare:
- a lack of accessible transport links
- patients not being identified as having a learning disability
- anxiety or a lack of confidence for people with a learning disability
- lack of joint working from different care providers
- not enough involvement allowed from carers
- inadequate aftercare or follow-up care.
also reduced cancer screenign if you have a learnign disability (not as many pts attend their cancer screenign appts)
high rate of co morbities e.g. mental health problems, dementia, being under or overweigth
104
what IQ is defined by mild moderate and severe learnign diability?
mild (50– 69)
moderate (35–49)
severe (20–34)
profound (20 or less)
105
which medications do you have to be careful of prescribing to the elderly?
- NSAIDs
- oral hypoglyceamics e.g. glicazide
- antidepressants (=postural hypotension) e.g. citalopram
- benzodiazepines (increase risk of falls and congitive impairment)
- anticoagulants
- opioids (= constipation, resp depression, falls)
106
what investigations woudl you liek to do if someone had a fall?
bedside:
- A-E (obs and blood glucosE)
- lying and standing BP
- urine MC+S/colour
- ECG
- AMT
bloods:
- FBC
- U+Es
- bone profile
- LFTs
imaging:
- CT head (head trauma?)
- Xray (any broken bones?)
- CXR
- Echo (valvular heart disease?)
107
what is the definition of postural hypotension?
>=20mmHg drop in systolic or >=10mmHg drop in diastolic
108
causes for postural hypotension?
- severe D+V, dehydration, hypovolemia
- antihypertensives, duiretics
- old age = reduced sensitivity of baroreceptors
109
If a pts osteoporosis T score in >=2.5, what is the treatment?
modify risk factors
treat conditions
repeat at 2 years
110
what SE of tramadol and dangerous in elderly?
drowiness, constipation, hallucinations
111
WHY IS zopiclone not prescribed in elderly
increased risk of falls !!!
112
name the frailty assessment tools
gait speed <0.8m/s
TUGT <12s
grip strength
PRISMA 7 questionnaire
clinical frailty sclae
edmonton frail scale
eFI (estimated frailty index)
113
name the resp changes in old age
- decreased levels of IgA secretions in nose - more liekly to have viruses
- decreased number of nerve endings in larynx
- the number of cilia + their level of activity is reduced
- mucociliary clearance slower and less effective
- hypertophy of mucous glands
- cough reflex in blunted thus decreasing teh effectiveness of cough
- decreased elasticity of lung and decreased elastic recoil - due to reduced collagen cross linking
- the number of alveoli does not change but hte number of functioning alveoli decreased as alveolar wall becomes thin
- resp muscles lose strength and endurance
114
name some features fo parieto-temporal dementia
aphasia
apathy
agnosia
apraxia
115
name soem features of frontal dementia
irritibility
disinhibition (sexual, financial etc)
116
name some features of dementia with Lewy Body
- parkinsonism
- fluctuating cognition
- visual hallucinations
117
non pharm interventions for a pt with hyperactive delirium
- move to quiet side room
- re orientation
- hydration and sleep
- early and frequent mobilisation
118
pharm treatment for delirium? (hyperactive)
haloperidol (+lorazepam)
start low, go slow
119
what are the 3 criteria for diagnosis of learnign disability?
- IQ less than 70
- onset in childhood
- significant impairment in social or adaptive functioning
120
name some importatn genetic syndromes that causing learning difficulties
- downs syndrome
- fragile X syndrome
- prader-willi syndrome
- angelman syndrome
- cornellia de lange syndrome
- tuberous sclerosis
121
what are some common physical health problems with people with LD?
- epilepsy
- hypothyroidiism
- constipation
- obesity / underweight
- early dementia
- poor vision
- heart defects
122
ame some common (mental health) comorbidities of patients with autism?
- anxiety (very common!)
- depression
- psychotic disorder s
- ADHD
-
123
why is mortality so high in patients with learning disabilites?
- attitude and prejudice
- knowlegde and confidence in treating a patient with learnign disabilities
- increased co morbidites
124
barriers to healthcare for patients with learnign disabilites
- clinicasn lack of knowledge and understanding
- communication difficulties
- pts may need carer/gaurdian to taek them to appts
- inability t udnerstadn clinician
- pts may find it harder to locate and describe pain
125
what is diagnostic overshadowing
pt comes in with health problem separate to their learnign disability but clinician misses the important features as not tryign to find underlying cause due to pts LD overshadowing
126
who is part fo the LD MDT TEAM?
- LD community nurse
- therapists SALT, OTs, PTs,
- psychologists
- nursing assisants
- consultant psychiatrist
- social worker
127
what does STOMP and STAMP mean in LD?
Stopping Overmedication in People With LD
- lots of antipsychotics prescribed innaproprately without diagnosis and leads to lots fo SE: e.g. constipation, weight gain
128
average life expectancy after entering a residential home or nursing home?
residential home - 24 months
nursing home - 12 months
129
definition of frailty
state of increased vulnerability to poor resolution of homeostasis after a stressor event as a consequence of ageing-related cumulative decline across multiple physiological systems
130
what clinical features in frailty associated with
Low grip strength
*Low energy
*Slowed waking speed
*Low physical activity
*Unintentional weight loss
131
definition of multimorbities?
cooexistion of two or more long term medical conditions
