Transcript Features of patient care elderly in outpatient settings Agranovich NV

Features of patient care elderly
in outpatient settings
Agranovich NV
MD, professor
Head of Department
outpatient therapy SGMU
 Age of human development is the interaction of
two fundamental processes: aging and
vitaukta.
 Aging - Universal endogenous destructive
process, which manifests itself in increasing the
probability of death.
 vitaukta (lat. vita- life, auctum- increase)
process, the viability of stabilizing and increasing
life expectancy.
 According to the reports of the UN in 2000, the number of
people older than 60 years was 610 million. People, and in
2005 - has exceeded 1 billion., Representing 15% of the
population.
 In Russia, the fifth of the population is elderly. In the next
10 years is expected to increase the number of senior
citizens is about 2 times.
 25-30% of the population will be in the category of elderly
in 2020.
 The incidence in the elderly compared to younger persons
above 2 times in old age - 6 times.
 The key and fundamental position in the problem of
the "older generation" must be recognized first and
foremost a social aspect, in the second - Medical.
 Last determines the need, first of all, the
development of health and social services can
adequately carry out medical and social expert
assessment of the individual patient and not only
outline the ways of his rehabilitation, and to
implement it in practice.
Although not a disease, aging creates
prerequisites for the development of age
pathology
optimal state of
health
the presence of risk
factors for disease
death
The aging process continuous gradual
transition
from stage to stage
signs of pathology
disability
The rate of aging can be quantified using indicators
reflecting the decrease in viability and increase of
damage to the body.

One such parameter is the age.
Age - the duration of the existence of the body from birth to the
present day.
Performances to date modern age standards were adopted by the
European a regional WHO office in 1963
Classification of age? (WHO, 1963)

Young age
18-29
Adulthood
30-44
The average age of 45-59
Advanced age
60-74
Senile
75-89
Centenarians 90 and older
Giorgione.
Three ages of man.
1500-1510 years. Palazzo Pitti.
Florence.
Pathological changes characteristic of elderly
and senile age, begin to appear since 40-50
years.
 Involutional associated with regression of functional and morphological
changes lead to changes in the functioning of various organs and
systems, which under certain conditions can lead to the development
of the disease.
 For example, with age decrease of vital capacity of the lungs, bronchial
obstruction, the value of the glomerular filtration in the kidneys,
increased fat mass and decreased muscle mass, bone density.
The main features of the sick
elderly
 1. The presence of two or more diseases in the same patient.
On average, during the examination of the patient elderly reveal at least
five diseases. In this regard, clinical disease "smeared" reduced diagnostic
value of different symptoms. On the other hand, co-morbidities may
potentiate each other's clinic.
 2. Mainly chronic diseases.
The progression of most chronic diseases contribute to age-related
adverse endocrine-metabolic and immune changes.
 3. Atypical clinical course of the disease.
Often reveal more slowly and disguised the disease (pneumonia,
myocardial infarction, pulmonary tuberculosis, neoplastic processes,
diabetes, and others.).
The main features of the sick
elderly
 4. The presence of "senile" diseases:
osteoporosis, benign prostatic hyperplasia, Alzheimer's disease, senile
amyloidosis, etc.).
 5. Reducing protective primarily immune, responses..
 7. Changes in the social and psychological status.
The main causes of social exclusion: retirement, loss of loved ones and
friends, loneliness and limited communication difficulties self-deteriorating
economic situation, the psychological perception of the age limit.,
Regardless of health status.
These features suggest that the organization of health care for people
elderly, special attention should be paid to the improvement of
community-acquired forms of treatment, especially in clinics
This is due to two main reasons
 The first - a steady increase in the need for the organization of
outpatient care for these patients
 The second - the desire of the majority of elderly patients in the
treatment process to be together with family, relatives, friends, do not
change the habits of conditions of stay at home.
In this connection takes on overriding importance using
"Hospital at home"
 the need for the deployment of "hospital at home"
on the type of patronage system for patients with
chronic diseases, who can not attend the clinic
and observed only at home.
 carrying out diagnostic and treatment
procedures, coupled with the expansion of the
motor mode and physical therapy.
The level of organization and quality of active surveillance for them,
especially on the part of the local therapist, largely depends on their overall
health, frequency of exacerbations and the need for the provision of
emergency assistance and emergency hospitalization
 From the observed home should highlight a group of
patients at higher risk in relation to health and deaths:
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somatic caused serious condition,
with age over 80 years,
Living alone
just discharged from the hospital,
recent change of residence.
 The need to provide them with social-welfare assistance
and the implementation of elements of personal hygiene
 In these issues can provide real assistance to the so-called
social sister.
Rational management of elderly patients involves
compulsory mutual understanding and harmony in the
triad
"Sick - nurse - doctor"
 The correct approach provides "compliance" - the achievement of
a high degree of implementation of patient medical
recommendations.
 To do this:
Use verbal and written
instructions, reducing the number of appointed
Pharmaceuticals, preference
long-acting dosage forms
and the combined drugs, etc..
Geriatric patients often "go into yourself",
"listen" to his condition, they appear
irritability, tearfulness.
 The ability to listen, empathize and give advice are
important factors in successful treatment
 Nursing allowing for the elderly
 Preparing the patient for various medical
manipulations
 The active work with patient, explaining
to them the need for pest control habits
of healthy lifestyle.
 In this effort the doctor and nursing staff must be directed
to the study of the behavioral characteristics of elderly
patients.
 Knowledge of these features will help to shape a more
active attitude of the patient to his condition with an
optimistic position, especially feeling
 "Satisfaction with life"
required to improve the
physical and mental health
General principles of management of
patients with elderly
Control of reception of medicines
 Sick elderly should be provided with clear instructions given by the doctor not
only verbally but also in writing.
 It is necessary to monitor the water balance as inadequate fluid intake can help
improve concentration in the body-prescription drugs, side-effects and
development of drug intoxication.
 Preference is given to a sustained dosage forms
and a combination of drugs.
General principles of management of
patients with elderly
Patients elderly observed frequent exacerbations
chronicbronchitis, due to changes in age-related
chest, restricting breathing movements, reducing drainage
function due to the low efficiency of cough shock and atrophy of
the ciliated epithelium, congestion in the pulmonary
circulationreduction of anti-defense.
 Treatment of patients with chronic bronchitis in the elderly and
old age should be implemented taking into account the
characteristics of the pathological process, the presence of
comorbidities, the individual patient.
Increased incidence of geriatric patients with chronic
bronchitis makes frequent use of antibacterial agents

It is necessary to remember that in elderly patients were significantly more likely to
develop the possibilities side effects antibacterial, e.g. hearing loss (streptomycin,
gentamicin, etc.), toxic impact on kidneys (kanamycin), candidiasis, dysbiosis and
atrophic glossitis (tetracycline combined antibiotics) and etc.
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Therefore it is necessary to teach the patient
assigned to take the drug
at the set time of the day,
to comply with the recommended mode
behaviour and conditions of taking the medicine.
When monitoring patients with pneumonia
 particularly dangerous for the patient geriatric period Critical
temperature reduction body when possible development of acute
vascular insufficiency as vascular insufficiency have not seen the
classic collapse, and worsening of coronary heart disease, stroke,
increasing the degree of kidney failure and others.
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It should be used cautiously in the treatment of patients with
elderly oxygen therapy. Excessive activity of oxygen therapy in
the elderly may also lead to negative results - may appear
dizziness, nausea, asthma, breathing, such as Cheyne-Stokes.
Moreover, it may be hypercapnic inhibition of the respiratory center
up to coma.
Features of CVD in middle and old age
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caused as diseases of other organs and systems, involutive processes in the
body, but primarily - sclerotic lesion as the vessels and the heart:
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reduced elasticity; seal the vascular wall leads to a permanent increase in
peripheral resistance.
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There are crimped and aneurysmal dilation of capillaries and arterioles,
develop fibrosis and hyaline degeneration that leads to the obliteration of the
vascular capillary network, impairs transmembrane exchange.
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The blood supply to major organs becomes not quite adequate.
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As a result, failure of the coronary circulation develops degeneration of
muscle fibers atrophy and their replacement by connective tissue, leading to
heart failure and heart rhythm disturbances.
Formed "Senile heart"
In elderly and senile age formed a number of
features of hemodynamics
increased mainly systolic, reduce venous pressure,
cardiac output, and later, minute volume, and others. and
developed the so-called Isolation systolic hypertension.
This reduces the brain, kidney and uterine blood flow.
To date, no system of normative values of blood
pressure according to age - increased blood pressure in elderly and
senile some experts consider as normal compensatory phenomenon.
So - reducing the pressure in the elderly only if the clinical
symptoms associated with elevated blood pressure.
BUT,
 clinical studies strongly suggest that the patient's age is
not an obstacle to an active medical and surgical treatment
of many cardiovascular diseases
 Regular long-term antihypertensive therapy significantly
reduces the risk of major cardiovascular complications of
hypertension - stroke, myocardial infarction and
cardiovascular mortality in elderly patients
 in elderly patients with hypertension reduction of blood
pressure medication for 3-5 years significantly reduces the
incidence of heart failure by 48%
Specifics of elderly patients with
hypertension
 Older blood pressure should be measured carefully, because
they are often found "psevdogipertoniya" (stiff arteries of the
extremities).
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For elderly patients characterized by orthostatic reactions
(due to violations pressosensitive unit), so it is strongly
recommended that a comparison of blood pressure with the
patient lying down and immediately after the transition to an
upright position.
 Elderly people respond very well to a decrease in blood
pressure by limiting salt intake and weight loss.
It should seek to a gradual reduction in blood pressure before
140/90 mmHg. (with concomitant diabetes and renal failure,
the target blood pressure - 130/80 mm Hg)
 Starting doses of antihypertensive drugs make up half the
usual starting dose. Dose titration is slower than in other
patients.
 In the treatment of hypertension in all age groups diuretics
play a leading role both in monotherapy and in combination
therapy AH (2003).
 Thiazide diuretics, b-blockers and combinations of the most
effective in terms of reducing the risk of cardiovascular
morbidity and mortality in elderly patients with hypertension.
 Older demonstrated the advantage of using amlodipine in
reducing blood pressure compared to other calcium
antagonist - diltiazem.
 Furthermore, the duration of amlodipine 24 hours, thereby to
repeated admission to the day and provides ease of
application.
 ACE inhibitors are the drugs of choice for the two categories
of elderly patients with hypertension:
 1) left ventricular dysfunction and / or congestive heart
failure;
 2) concomitant with diabetes.
 Elderly patients with CHF appointed ACE inhibitors,
diuretics, b-blockers, spironolactone, both preparations
have proved to improve survival and quality of life.
 If necessary, the treatment of ventricular arrhythmias on the
background of chronic heart failure in the elderly and the
elderly should be preferred amiodarone.
 Old age should not be an obstacle to direct the patient to
coronary angiography.
For
successful
treatment
of
cardiovascular diseases in the elderly
is very important to the timely
identification
and
elimination
/
correction accompanying diseases,
often hidden and oligosymptomatic
(wasting, anemia, thyroid dysfunction,
liver and kidney disease, metabolic
disorders, and others.).
Particular attention doctors in geriatric patients
draws Anemia
 The most common anemia in the elderly is not an independent
nosological form, as a consequence of chronic diseases:
 kidney and liver (22% of the entire group of anemias)
 pulmonary processes and defeat of the gastrointestinal tract (GIT;
by 19-18%),
 endocrine diseases (16%),
 cancer, hemorrhoids, and rheumatoid arthritis (by 6-5%).
 a combination of disease up to 6%.
 The prevalence of anemia in the elderly
and old age varies
from 2.9 to 61% in men and
from 3.3 to 41% in women
In all chronic diseases are the main factors of redistribution and
metabolic iron, combined with its low entry and often - with
increased costs or loss
in elderly patients prevail
hypochromic, iron
anemia
 Long-term chronic blood loss account for nearly half of cases of
anemia in older patients.
 More often - hidden bleeding erosive gastritis, gastric ulcer or
duodenal ulcer, hemorrhoids.
 In the overwhelming majority of patients at the same time
revealed a deep atrophic pangastritis often associated with H.
pylori infection and gastric acid-oppressed. This and nutritional
(medical and social) factors can cause iron deficiency, even
without blood loss.
Other causes of anemia elderly
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Chronic kidney disease, anemia develops gradually, with a
decrease in generation erythropoietin.
 In addition to erythropoietin deficiency may have a value
violation utilization of iron stores during prolonged chronic
inflammation, strengthen its consumption, increased blood loss
hemodialysis.
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Effects of excess production inflammatory cytokines such as
necrosis factor tumours (ТNF), interleukin 1, interferon D Can
cause depression have impaired secretion of erythropoietin, the
deterioration of its regulatory functions in relation to
erythropoiesis
and suppression of erythroid
progenitor cells.
Often the clinical picture of anemia in elderly patients is
masked by a variety of symptoms of the underlying disease, the
prevalence of cardiovascular and cerebral manifestations

Clinical manifestations of (chlorotica pica type, in the form of
brittle nails, hair and trophic changes of the skin)
erased and
shaded age-related changes.
 Diagnostic criteria is to reduce the serum iron while maintaining
its reserve as ferritin.
 If you experience problems in determining the level
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B12 used traditional
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morphological and reliable
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diagnostic test - study
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medullary hematopoiesis.
Prevalence and B12 folic acid deficiency
anemia in elderly persons 2%,
but it often goes unrecognized.
The need for timely and accurate diagnosis of anemia with the
establishment of its shape and origin of adequate therapy in
geriatric patients
 Development of anemia in the elderly accompanied by a
significant deterioration in the quality of life (decrease in
mental and physical activity, fatigue, depressed mood),
aggravates the existing pathology and poses a threat to
premature death.
 Treatment of anemia in the elderly require clinical supervision
with regular (at least 1 time in 2-3 months.) Control of
hematological parameters.
In elderly and senile age significantly changing nature of the
flow of digestive diseases due to age-related anatomical and
physiological characteristics of the digestive tract
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Oral cavity : Developing an involution of mammary glands, changes masticatory
apparatus.
Esophagus: atrophied mucosa is reduced
peristalsis, more likely to develop dyskinesia.
stomach: reduced secretory and enzymatic
Activity slows down physical activity.
liver: reduces the number of hepatocytes, inhibits the regeneration, reduced functional
activity of the liver: decrease of bilirubin, bile acids and phospholipids and high
cholesterol, which contributes to a breach of digestion and is manifested dyspeptic
disorders.
Pancreas: age atrophy fabric reduces and exocrine function.
Intestine: broken membrane digestion and absorption. Reduced physical activity small
and large intestines, changes the composition of intestinal microflora, exacerbated by the
phenomenon of intestinal dyspepsia.
Blood supply and innervation of the digestive system are subjected to functional and
structural changes involutive.
According to statistics
 Chronic gastritis affects more than 50% of the working
population, and in persons over 60 years the frequency
of the disease is approaching to 100%.
 The prevalence of atrophic gastritis in the elderly due to
prolonged course of bacterial chronic gastritis, often
develops in elderly and senile age duodenogastric reflex.
 Clinical manifestations of chronic atrophic gastritis in
elderly and senile patients are nonspecific and often
masked by concomitant diseases (coronary heart disease,
chronic pancreatitis, and others.).
Under the guise of various diseases of the
gastrointestinal tract often proceeds ischemic
disease of the digestive system
 Chronic ischemia in this pathology is caused by lack of blood
flow in the basins of the celiac, superior and inferior mesenteric
arteries.
 reasons for violation of mesenteric circulation can be
mesenteric artery atherosclerotic lesions and other
conditions that reduce
bloodstream.
Clinical case
Patient K. 70 years appealed to the gastroenterologist with
complaints:
Pronounced acute pain epigastric arising on an empty stomach,
worse after eating, lasting from 30 minutes to 2 hours, stoped
taking antacids.
Dull, aching pain in the umbilical region, extending to the
right and left upper quadrant, in the back that occur after a
heavy meal, and physical or emotional surge, accompanied by
bloating, sometimes combined with the pain in the hearts of
anginal nature, lasting from several minutes to several hours or
even days, not cropped antacids, somewhat reduced after
taking muscle relaxants.
General weakness, fatigue, poor appetite,
alternating constipation and diarrhea.
weight
loss,
clinical case
From anamnesis: the patient considers himself over the past 5 7 years old when he first appeared pain in the umbilical region,
gradually escalated symptoms appeared general weakness, fatigue,
unstable chair. Around the same time, there were pains in the heart
and after the examination was diagnosed with coronary artery
disease. For 10 years, notes the increased blood pressure, a
maximum of 180/100 mm Hg
Epigastric pain appeared three years ago, and during
endoscopy has been found associated with Helicobacter pylori
stomach ulcer, which after adequate three or four-component therapy
scar, but then reappeared, with obvious seasonality of exacerbations
was not traced.
As a working diagnosis at various stages of the survey
appeared chronic cholecystitis without stones, chronic pancreatitis.
Over the past 5 years I have grown thin about 10 kg.
Results of the study
 EGDS
Gastric ulcer. Moderately
marked inflammation of
the gastric mucosa.
Urease test - weak positive.
Changes in lipid profile
 total cholesterol - 6.7 mmol / L (3.5 - 5.2);
 triglycerides - 3.43 mmol / L (0.11 -2.17);
 high-density lipoprotein - 1.1 mmol / l (1.0
- 2.1);
L ow-density lipoprotein - 5.3 mmol / l (3.5
- 7.5);
 atherogenic factor - 5.1
 Prothrombin index - 107%
Duplex scanning of the abdominal aorta and its visceral
branches
Colour inversion, and
expressed local decrease of
peak systolic flow velocity in
the restriction zones
P SStc - 340,9sm / sec,
PSSams - 319.9 cm / sec
Hemodynamically significant stenosis of the celiac trunk and the mouths
of the superior mesenteric artery (70%).
results of the survey
 Left ventricular hypertrophy and left atrial atherosclerotic lesions of
the thoracic aorta and arteries brahiotsefalyh without
hemodynamically significant restrictions;
 A common myocardial ischemia anteroseptal region of the left
ventricle;
 US signs of sclerosis of the pancreas (reducing the size,
heterogeneity of the structure with a predominance
hyperechogenicity);
 Thickening of the walls of the gall bladder with symptoms
gipomotornoy dyskinesia;
clinical diagnose
 Atherosclerotic abdominal coronary artery disease,
subcompensation stage. Atherosclerosis of the
abdominal aorta, celiac artery stenosis
hemodynamically significant stenosis of the superior
mesenteric artery hemodynamically significant. Gastric
ulcer. Atrophic gastritis.
 Coronary heart disease: stable angina FC II, NC - I st.
 Hypertensive heart disease II class.
Terms elderly and power? senile

-Sick elderly
needed a little rest during the day
and restful night's sleep.
-Useful targeted exercises
relaxation.
-The patient needs a diet, in moderation
rich in calories and rich in vitamins.
-It should abandon the use of animal fats,
sweets, "interception" between meals,
since excess weight interferes with the heart.
Hypocaloric and limited in terms of diet-as one of
the most effective? methods to combat the aging
process.
In general, the diet
sick elderly
follows::
Limit:
 Products containing oxalic acid and cholesterol
 Sugar, flour, table salt.
Provide:
 A sufficient amount of fruits, vegetables, salt containing K, Fe,
Mg and vitamins.
 Variety and balance of food intake
Antisclerotic thrust power
 Increase the share of vegetable oil (2 tbsp sunflower, olive or
corn oil per day
 Inclusion in a diet of seaweed
 Bread wholemeal
 Easily digestible sources of calcium - milk, dairy products,
cheese, sea fish, greens.
For those elderly
most rational 4-5 meals
The diet of an elderly person
The recommended ratio
between proteins, fats and carbohydrates is
1 : 0,8 : 3,5