Transcript CURS1 - UMF IASI 2015

GERIATRY AND
GERONTOLOGY
DR. IOANA ALEXA
THE MAJORITY OF ELDERLY PATIENTS
WOULD HAVE MULTIPLE HEALTH
PROBLEMS
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heart insuficiency class
II NYHA
paroxystic AF
chronic myocardial
ischemia
atherosclerotic
hypertension
hypercholesterolemia
diabetes mellitus
chronic kidney disease,
possibly secondary to
ischemic nephropathy
urinary infection
prostate adenoma
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varicosis
cerebral circulatory
insuficiency
chronic degenerative
rheumatism
systemic osteoporosis
gallbladder stones
early stage cataract
both eyes
minor cognitive
impairment
anxiety
THE FINAL PRESCRIPTION WOULD
LOOK LIKE THAT:
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Amiodarone, od
Acenocumarole, od
indapamide, od
nitrate, twice a day
Ca channel blocker, od
ACE inhibitor, od
statine, od
fibrate, od
dyosminum twice a day
Hepatrombine, ointment, twice a
day
Metformine, 2-3 times a day
Hypoglicemic sulfonamide, od
Antibiotic, twice a day
± urinary antiseptic pills, 2-3 times
a day
alpha adrenergic blocker, od
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Pentoxifilin, 400 mg x 3/zi
Derivaţi de gingko biloba, 1 tb x 3/zi
Stugeron, în 2-3 prize/zi
Milgama (dată fiind şi prezenţa
diabetului),în 2 prize/zi
Inhibitor de COX-2 (Arcoxia, 60
mg/zi)
Diclofenac 5%, ung local x 3/zi
Mydocalm, 150 mg x 3/zi, 10 zile
Tramadol/Zaldiar, 50 mg x 3/zi
Myacalcic (Calcitonină) spray, 1 puff
x 3/zi
CalDevit, 1 tb x 2/zi
Rubjovit, sol. oftalmică, 1-2 pic
instilaţii oculare
Lorazepam, 0.5 mg/zi
Buspironă, 5 mg x 3/zi
Piracetam,1 tb x 2/zi
Pronoran, 1 tb x 2/zi
This will sum up to:
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an impressive diet, as our patient should have
restriction on glucose, lipids, proteins, salt,
smoking, drinking, too much exercise, too little
exercise....
29 drugs
48 administrations as:
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tablets
 ointment
 spray
ophthalmic drops
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Our goal: the right medication,
the right dose, the right time
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POLIMEDICINE
POLIPHARMACY
IATROGENY
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WHO TAKES CARE OF SUCH PATIENTS?
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GERIATRICS AND
GERONTOLOGY
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The branch of medicine that focuses on
health care of the elderly
It aims to promote health and to
prevent and treat diseases and
disabilities in elderly patients
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Geriatrics differs from adult medicine in many
respects. The body of an elderly person is
substantially different physiologically from
that of an adult. Old age is the period of
manifestation of decline of the various organ
systems in the body. This varies according to
various reserves in the organs, as smokers,
for example, consume their respiratory
system reserve early and rapidly.
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Geriatricians aim to treat the disease
and to decrease the effects of aging on
the body
Years of training and experience, above
and beyond basic medical training, go
into recognizing the difference between
what is normal aging and what is in fact
pathological.
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The decline in physiological reserve in organs
makes the elderly develop diseases (such as
dehydration from a mild gastroenteritis) and
be liable to complications from mild problems
Fever in elderly persons may cause confusion
leading to a fall and to a fracture of the neck
of the femur ("breaking her/his hip").
Functional ability, independence and quality
of life issues are of greater concern to
geriatricians, perhaps, than to adult
physicians.
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Treating an elderly person is not like treating an
adult. A major difference between geriatrics and
adult medicine is that elderly persons sometimes
cannot make decisions for themselves.
The issues of power of attorney, privacy, legal
responsibility, advance directives and informed
consent must always be considered in geriatric
procedure.
Elder abuse is also a major concern in this age group.
In a sense, geriatricians often have to "treat" the
caregivers and sometimes, the family, rather than
just the elder.
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The so-called 'Geriatric giants' are:
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Immobility
Instability
Incontinence
Impaired intellect/memory
Health issues in older adults may also include
elderly care, delirium, use of multiple
medications, impaired vision and hearing.
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In the United States, geriatricians are primary care
physicians who are board-certified in either family
medicine or internal medicine and who have also
acquired the additional training necessary to obtain
the Certificate of Added Qualifications (CAQ) in
geriatric medicine.
In the United Kingdom, most geriatricians are
hospital physicians, while some focus on community
geriatrics.
In contrast to the United States, geriatric medicine is
a major specialty in the United Kingdom; geriatricians
are the single most numerous internal medicine
specialists.
HISTORY
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Bible: Matusalem = 969 years old,
Moses = 120 years old
Ancient Egypt: Ebers papyrus (1550
b.c.): “The weakness of the old ones is
due to dilatation of the heart”
India: “life can be prolonged by a
healthy way of living”
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China (sec VI b.c.): old age is the highlight of
life as we gain wisdom and knowledge
Confucius: elderly deserve the higher respect
Grece: Sophocles = 91 years old, Socrates =
98 years old
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Aristote: the first Textbook of Geriatry (7 pages)
WORLD POPULATION
LIFE EXPECTANCY
Source: United Nations Department of Economic and Social Affairs, Population Division. World Population
Prospects. The 2004 Revision. New York : United Nations, 2005.
Number of Americans >65 (Millions)
70
69
U.S. Bureau of Census
60
53
50
39
40
35
26
30
17
20
10
9
3
5
0
1900
1920
1940
1960
1980
2000
2010
2020
2030
Total U.S. Market for Elderly Drugs ($ Billion)
EVALUATION OF AN
ELDERLY PERSON
HISTORY
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Physicians often need to spend more time
interviewing and evaluating elderly:
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Many non-specific symptoms, making difficult to
focus
Sensory deficits (hearing or vision impairment)
Underreport symptoms which they consider part
of normal aging
NO SYMPTOMS SHOULD BE ATTRIBUTED TO
NORMAL AGEING!
HISTORY
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Clinical features of diseases may differ from
those in younger patients: dyspnea may be
absent in a patient with HF and arthritis
Because of cognitive dysfunction they may
have difficulties recalling all past illnesses and
drugs
Patient’s chief complaint may differ from what
the family considers the main problem
APPROACH TO THE INTERVIEW
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Ask the patient about everyday concerns, social
circumstances and find out information about
one’s psychology; it will help orient and guide the
interview
Ask him to describe a typical day: it may reveal
more than focusing only on the main complaint
and it will give information about quality of life,
liveliness of thought, and physical independence
This approach is very important especially during
the first meeting!
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It is important to establish a good
relationship with the patient: it will help
you to communicate with him and the
family members and to obtain
adherence with treatment
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Patient should be fully clothed during the
interview and should wear dentures,
eyeglasses or hearing aid if necessary so
communication can be facilitated
The interviewer should stay close to the
patient, facing him directly, speaking clearly
and slowly (to allow lip-reading) and looking
directly in his eyes
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Some patients prefer to have a relative
present but, unless mental status is
impaired, the patient should be
interviewed alone to encourage the
discussion of personal matters
PAST MEDICAL HISTORY
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The physician should record the drug
history, topical drugs must be included
It could be better if the patient could bring
all the pills, ointments or liquids the patient
uses
The patient should be tested if capable to
take the medication recommended
(recognize drugs, read labels, open vials)
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The physician should know nutritional
habits, alcohol intake, dietary fiber, and
the amount of money the patient can
spent on food and if he has suitable
kitchen facilities
We should assess the patient’s ability to
eat: decreased vision, arthritis,
immobility, tremors, urinary
incontinence
FAMILY AND SOCIAL
HISTORY
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Family history should focus on:
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Alzheimer’s disease
Diabetes
cancer
Social history includes assessment of patient’s
living arrangements, best achieved by a home
visit (home features that can lead to fall
should be identified and solved)
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Let the patient describe a typical day
Marital status, economic difficulties, tobacco and
alcohol use
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Don’t forget to ask:
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What are your wishes regarding measures
for prolonging life
Who is taking surrogate decisions in case
of incapacity
PHYSICAL EXAMINATION
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May require additional time to undress
and transfer to the examining table:
they should not be rushed!
Preliminary assessment: observe
personal hygiene
VITAL SIGNS
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During measurement of height and
weight: patients with balance problems
should be helped
Temperature recording (the absence of
fever does not exclude infection)
Pulse (taken for more than 30 sec) and
blood pressure
Respiratory rate
BLOOD PRESSURE
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BP might be overestimated because of
arterial stiffness: there should be several
measurements under resting conditions
Orthostatic hypotension is quite common: all
patients should be checked for it (BP in
supine position, than observed more than 3
min in standing position)
SKIN
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Search for pre-malignant and malignant
lesions and tissue ischemia
! Pressure sores: the ulceration of the
skin surface is smaller than the
underlying soft tissue lesion
Unexplained bruises may indicate abuse
EYES
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Loss of orbital fat enophthalmos (not
necessarily a sign of dehydration)
Test visual acuity
Screen for glaucoma and cataract
CARDIOVASCULAR SYSTEM
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The size of the heart: one can find
displacements of the apex due to
kyphoscoliosis, not to HF
Systolic murmur: aortic valve sclerosis
(it may not be hemodynamically
significant)
Bradycardia may be normal but should
be investigated anyway
GASTROINTESTINAL AND
GENITO-URINARY SYSTEMS
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Weak abdominal muscles: it may result
hernias
Look for abdominal aortic aneurysm
Examine ano-rectal area + perform a
digital examination (examine the
prostate as well)
Regular pelvic examination
MUSCULOSKELETAL
SYSTEM
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Examine carefully joints: tenderness,
swelling, subluxation, crepitus, redness,
etc
Determine active and passive range of
motion
Identify and treat any foot problems: it
will maintain elderly’s independence
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SARCOPENIA is the degenerative loss of
skeletal muscle mass and strength
associated with aging.
NEUROLOGIC STATUS
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The neurologic examination is similar to
that for any adult = assess cranial
nerves, motor function, sensory
function and mental status
Non-neurologi disorders common in
elderly may complicate the
examination:
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Diminished sight and hearing may impair
cranial examination
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Homeostenosis = the characteristic,
progressive constriction of homeostatic
reserve that occurs with aging in every
organ system.
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Parameters that don’t change with
aging:
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RBC, WBC, PLT
Electrolytes
Ureea
Liver tests
Thyroid tests
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Parameters that change with aging:
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Blood glucose
ESR
Creatinine
Serum albumine
asymptomatic bacteriuria
X-ray
ECG
COMPREHENSIVE
GERIATRIC ASSESSMENT
COMPREHENSIVE
GERIATRIC ASSESSMENT
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The cornerstone of the practice of geriatric medicine is the
multidimensional assessment of the elderly
The term comprehensive geriatric assessment (CGA)
refers to this process of evaluation and management of older
patients
The 1987 National Institutes of Health (NIH) consensus
conference defined CGA as “a multidisciplinary evaluation in
which the multiple problems of older patients are uncovered,
described, and explained, if possible, and in which the
resources and strengths of the person are catalogued, need
for services assessed, and a coordinated care plan developed
to focus interventions on the person's problems”
This approach is useful in all settings in which we encounter
older patients, whether in the home, office, hospital, day
facility, or institutional setting.
DIFFERENTIATE
COMPREHENSIVE
GERIATRIC ASSESSMENT
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Evaluation of functional status includes
information on the patient's ability to perform
basic and complex activities of daily living.
Gait, balance, and risk of falls should also be
assessed. The findings on functional
assessment are often linked to the basic
physical health assessment.
BASIC ADL
Consist of self-care tasks, including:
 Personal hygiene and grooming
 Dressing and undressing
 Self feeding
 Functional transfers (getting into and out of bed or
wheelchair, getting onto or off toilet, etc.)
 Bowel and bladder management
 Ambulation (walking with or without use of an
assistive device (walker, cane, or crutches) or using a
wheelchair)
A useful mnemonic is DEATH: dressing, eating,
ambulating, toileting, hygiene.
FUNCTIONAL ASSESSMENT
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Typically ADL performance is lost in a predictable sequence.
Skills for bathing and dressing are diminished before
transferring, toileting, grooming, and eating. An atypical
pattern of loss may have diagnostic significance. For
example, early loss of continence may reflect a more
localized problem with the genitourinary system.
ADL deficits often indicate a need for in-home assistance in
the community setting. The number and type of deficits
suggest the amount of assistance needed. Problems with
bathing alone may indicate a need for a home health aide 2
to 3 times per week, whereas dependence in more areas
may require daily or 24-hour care.
INSTRUMENTAL ACTIVITIES
OF DAILY LIVING (IADLs)
They let an individual live independently in a
community:
 Housework
 Taking medications as prescribed
 Managing money
 Shopping for groceries or clothing
 Use of telephone or other form of communication
 Using technology (as applicable)
 Transportation within the community
A useful mnemonic is SHAFT: shopping, housekeeping,
accounting, food preparation/meds,
telephone/transportation.
Occupational therapists often evaluate IADLs when
completing patient assessments. Assessments may
include 9 types of IADLs that are generally optional in
nature and can be delegated to others:
 Care of others (including selecting and supervising
caregivers)
 Care of pets
 Child rearing
 Use of communication devices
 Community mobility
 Financial management
 Health management and maintenance
 Meal preparation and cleanup
 Safety procedures and emergency responses
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Mental health evaluation should
include the use of standardized
cognitive screens (MMSE) and more
thorough testing when indicated.
Because of the atypical presentation of
depression in this age group, screening
for depression should also be included.
COMPREHENSIVE
GERIATRIC ASSESSMENT
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The social assessment should identify support
network strengths and weaknesses. Some
determination of the patient's values and the
presence or absence of formal advance directives
should be determined. Caregiver burden should be
evaluated. Financial resources to meet current and
future needs should also be assessed.
Environmental issues should be evaluated through
patient and/or family reports or direct observation of
the living situation. Accurate information allows for
recommendations that may maximize functional
independence in the individual's environment and
address basic safety issues.
IATROGENY AND THE
ELDERLY
INTRODUCTION
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The etymology of iatrogeny is from Greek:
iatros = physician; gennon = induce
Iatrogeny refers to any unwanted event
induced by an intervention belonging to
health system either ambulatory or during
hospitalization … by any person involved in
medical gestures: doctors, nurses, persons
performing kinesitherapy or physiotherapy,
psychotherapists and the patient himself (lack
of proper surveillance)
Soubrié et Lebrun-Vigne
DEFINITION
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Iatrogeny should include any
unwanted effect induced by any
diagnostic, therapeutic or prophylactic
gesture performed in the health system.
CAUSES OF INCREASED
VULNERABILITY OF ELDERLY
DECREASE OF FUNCTIONAL
RESERVOIR OF ORGANS AND
SYSTEMS
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Aging is always associated with a
progressive decline in all functions which
favors drugs’ side effects and iatrogenic
complications of interventional medicine
Multiple hospitalization favor nosocomial
infections with multiple resistant germs
ALTERATIONS OF MUSCLES,
JOINTS AND BONES
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Parkinson
Rheumathoid arthritis
Arthrosis
Stroke
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FDA Warning July 2009:
Tablet splitting: a risky
practice
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24.1 % of recommended tablets are
capable of splitting
8.7 % are not made for splitting
3.8 % should not be splitted
VISUAL ALTERATIONS
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Catharact/glaucoma
Do not identify tablets by
their color!
Be able to identify the
tubes with adequate
tablets!
PHYSIOLOGICAL CHANGES THAT INFLUENCE
PHARMACOKINETICS AND
PHARMACODYNAMICS IN ELDERLY
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decrease of absorption
decrement of hepatic functions will induce
decrease of liver’ capacities of metabolizing drugs
decrease of renal function
SLEEP DISTURBANCES
INSOMNIA
DEPRESSION
DEMENTIA
MCI (Mild Cognitive Impairment)
Normal
Mild cognitive impairment)
Cognitive
function
Mild Dementia uşoară
Severe Dementia
Age
ELDERLY AND
VULNERABILITY
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Numerous comorbidities need numerous medical
services, which expose elderly people to the risk
of aggressive investigations (contrast
investigations, endoscopy, catheterism) and to
polimedication, usually prescribed by different
specialists
Medical non-compliance is much more severe in
elderly usually due to polimedication associated
with difficult medical schemes recommended in
patients with cognitive disorders, sensory and
motor deficiencies and lack of a familial or social
support for the possible handicap
Drug posology is usually inappropriate
CONCLUSION
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Elderly patients need a careful monitorization
and a refined therapeutical individualization
because they are difficult to include in the
standardized medical procedures due to
comorbidities with functional deficits, which
may need polipharmaceutical approach with
possible medical interferences
Therapeutical individualization must take care
of the patient’s and his family’s needs,
respecting the rules of informed consent;
these patients should have a multidisciplinary
approach without excessive hospitalization
CONCLUSION
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The demographic trend of the aging of
population with an increment of the old and very
old persons suggest the imperious need of a
geriatric education for all doctors, no matter the
specialty, which should be acquired during
studenthood and afterwards
Geriatry, until recently still in the process of
defining itself, begins to surface in the first line of
medical assistance (in hospitals and out-patient
system) as every specialist would have to treat
elderly persons
CONCLUSION
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Iatrogenic pathology, extremely frequent in
elderly, should be introduced in every
specialty’s curricula because avoiding drugs’
side effects is as important as insuring
therapeutical efficacy; iatrogeny can spoil the
results of any good treatment and can
increase greatly patients’ suffering and
medical costs.
GUIDELINES FOR EFFECTIVE
PRESCRIBING
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Obtain a complete drug history. Have patients
bring all drugs to the office visit for review.
Ask about allergies, adverse reactions, use of
tobacco, alcohol, caffeine, and recreational
drugs and any other health care providers.
Use no drugs before its time. Avoid
prescribing when no diagnosis has been
established, when symptoms are minor or
nonspecific, or when the benefit of drugs is
questionable
GUIDELINES FOR EFFECTIVE
PRESCRIBING
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Use no drug beyond its time. Review drug
lists at each visit and update them.
Discontinue any drugs that are no longer
indicated. Monitor the use of as-needed and
over-the-counter drugs.
Know the drugs you use. Know the
pharmacologic profile of the drugs you
prescribe and the potential adverse effects
and toxicities. Monitor patients closely for
deterioration in functional parameters that
could be drug related
GUIDELINES FOR EFFECTIVE
PRESCRIBING
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Start low, go slow. Always use the
minimum dose necessary for efficacy.
Use drug levels when available and
appropriate.
Treat adequately. Use dosages sufficient
to achieve the therapeutic goals, as
tolerated. Do not withhold therapy for
treatable diseases.
GUIDELINES FOR EFFECTIVE
PRESCRIBING
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Encourage treatment adherence. Clearly
communicate with patients about therapeutic
goals and methods to achieve them. Give legible
written instructions. Consider complexity of
dosing schedules, expense, and potential adverse
effects when choosing a drug.
Use new drugs with particular caution. Most new
compounds have not been thoroughly evaluated
in the elderly, and the risk/benefit ratio is often
unknown.
The Merk Manual of Geriatrics
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Polymedication Electronic
Monitoring System
(POEMS), Isabell Arnet,
Philipp Walter and Kurt
Hersberger, Pharmaceutical
Care Research Group,
Department of Pharmaceutical
Sciences, University of Basel,
Basel, Switzerland, 2013
GERONTECHNOLOGY AND
THE QUALITY OF LIFE
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Role of technology as a means of maintaining and
continually improving the functional independence and
quality of life in aging individuals through
gerontechnological solutions in the home, community,
and institutional environments of elderly
IF AGING ISN'T YOUR CONCERN
NOW,
WAIT AWHILE, IT WILL BE!
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ROBOTS
ASSISTIVE ROBOTIC WALKER
THE FITNESS INSTRUCTOR
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Taizo is aprox. 70 cm
high, weights aprox. 7
kg and has 20
functional “joints”
He can do 30 types of
physical exercises
implemented by a
fitness expert and he
can say “Hello” and
“Let’s do another
exercise.”
ASSITIVE ROBOTIC DEVICES
DOMO – the housekeeper robot
It helps the elderly in daily elementary activities:
preparing the meals, bathing, dressing
It provides several domestic tasks: cleaning,
monitoring health parameters, security
WAKAMARU – LIVES WITH
PEOPLE
It is 1 m high and
has a nice,
human-like
expression
It offers company (it
is connected to
Internet and has
an extended
vocabulary)
ASSISTIVE SOCIAL ROBOTS
Increase the quality of life
by escaping loneliness
AIBO (Artificial Inteligence roBOt)
1999 - 2006
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It has a 1000 words
vocabulary, so he can ask
his master about simple
things
THE EMOTIONAL ROBOT CAT
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iCat has 13 servers that control
different parts of the face so it can
express joy, surprise, sadness
Hasbro White Cat – music loving cat
THE HUGGABLE
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Pets diminish stress,
decrease hearts rate and
increase optimism
Pet therapy is often used for
children/elderly hospitalized
patients with
depression/dementia
If the patient is not capable
to take care of a real pet, we
can turn to the robots
PARO – THE CUDDLY
ROBOT