Adobe Systems The basic principles of gerontology dvojčata 005 Gerontology the body of knowledge on ageing, about the problems of aging people and life in old age KOLEČKOVÉ BRUSLE Gerontology subspecialties I experimental gerontology – causes and ways of ageing, actually at the cellular and molecular level, neuropsychology of ageing social gerontology – relationship between aging people and society, needs of elderly, demography, sociology, economy, law, urbanistics, architecture etc clinical gerontology - geriatrics Gerontology subspecialties II geriatrics - summarizes and generalizes across all disciplines main topics of senior´s health and fuctional status, specific needs, specificities of appearance, symptoms, therapy, prevention and social context of diseases of old age Expected changes of the population age-structure 2010-2050 Věková skladba obyvatelstva v roce 2050 *1990 *1990 *1975 *1975 *1960 *1960 Life expectancy and infant mortality rate Absolute numbers of live births and deaths 1785-2011 Specific features of diseases in elderly Risk of false diagnosis Oligosymptomatology expression of less typical symptoms peritonitis without defence musculaire Þpneumonia without fever Þcystitis with polakisuria, but without pain Þtachyfibrilation only in hyperthyreosis Microsymptomatology ouroinfection without fever ouncomplete inflammation symptomatology omyocardial infarction without typical stenocardia, but with chest tightness only oflorid ulcer disease with dyspepsia, but without typical pain oinflammation leucocytosis absent „Another organ cries“ current disease burden most frail organs Þcardiac failure because of pneumonia Þconfusion caused by sepsis, urosepsis Þstenocardia more expressed in anemia ÞTIA in anemia, cardiac failure, myocardial infarction Polymorbidity the number of chronic diseases increases with age 80% of patients above 80 years suffer from more than one chronic disease diseases influence each other – more frequently negatively polypragmasia, compliance, interaction long term recovery risk of imobilization Nejčastější "léky" nakoupené přes internet mají podpořit erekci. Glacier like symptom §apparent symptomatology is the little part of reality only §dyspnea in myocardial infarction only §confusion in cardiac failure §confusion in acute abdomen §dementia progression caused by chronic pain Interdisciplinary problems geriatric giants „4 I“ instability cognitive disturbances imobilization incontinentia, skin integrity disorders Adobe Systems Specificities and pecularities of pharmacotherapy in elderly Problem topics Farmacokinetics Compliance Problem topics qpharmacokinetics, pharmacodynamics qcompliance qpolymorbidity qpolypragmasia qmedications market qthe patient's wishes qtreatment coordination q„external“ influences Farmakokinetics I Ødecrease of gastric acidity Ødecrease of gastric motility Øreduced GIT blood flow Øslower resorption Farmacokinetics II Ødecreased distribution volume for hydrosolubile substantions Øincreased distribution volume for liposolubile substantions Ødecreased liver and kidney function Ødecreased albumin concentration Compliance and its changes in elderly I reciprocal association between compliance and number of medications used – 5 medications take exactly 33-44%, - 10 medications 10-20% only influence of relatives and caregivers dependence on specialised supervision Compliance and its changes in elderly II medicaton price influence user´s comfort medication shape and color content of package leaflet Polypragmasia? Polypharmacotherapy? tackle fundamental problems improve the quality of life profylactic medications number of medications limitation? respecting of guidelines unwanted symptoms induced by therapy express 24-28% patients, 90% of symptoms are predictable Therapy coordination problems v„gate keeping“x confidence in the knowledge of GP v„travelling“ around out-patient clinics vaddition of recommended treatments vlack of communication between GPs and specialists vfinancial limitations of GPs and specialists vdoubled generics Medication at the market many market names of the same generic substance the elderly patient remembers the medication according to shape and colour the influence of advertisement the influence of friends or neighbors „me too“ Seniors and medications consumption age group 60-75 years creates 15% of population Øconsums 33% prescription medications Øconsums 40% OTC medications Creating the medication schedule one coordinator specialist´s recommendations substantial medications or to know or to consult Ten rules for elderly prescription I »1. Define substantial problems to treat »2. Define treatment targets »3. Consider alternative methods including education and non pharmacologicla methods »4. Consider all risks and risk medications already taken »5. Optimal dosage “start low go slow” Ten rules for elderly prescription II »6. Select the simpliest schedule »7. Consider the risk of cumulation in retarded medications »8. Prepare the table containing redommended medications and ask the patient about understanding »9. Ask the use of OTC or other substances »10. Consider the possibility to stop the taking of some medication Non-pharmacological therapy positive alternative to polypragmasia regime measures – sleeping rhytm, to use the bed for sleeping only, regular day and week rhytm reduction of harmful habits change of eating habits – regular warm dishes, care for oral cavity and teeths Comprehensive geriatric assessment Comprehensive geriatric assessment (CGA) qpersonality qsomatic health qfunctional status qpsychical health qsocial context Personality ülife situations üpriorities and decisions – treat/not to treat, reanimate/not to reanimate, decisions in dementia üsubjective quality of life Somatic health üdiseases – main diseases, other diaseases üfunctional burden of diseases üsyndromological dg (imobilization, incontinentia …), hypotermie apod.) Functional efficiency üstability and walking üperformance and independence üphysical condition ünutrition KOLEČKOVÉ BRUSLE Mental health ücognitive and fatic disorders and deliria – active screening and evaluation üaffective disorders (depression) – active screening and evaluation ümental balance, maladaptation, the influence of psychosocial stressors Social context üsocial roles and relationships (social network) üoperation demands and safety of the home environment üsocial needs supplied or claimed služby Evaluation of stability and walking disorders vbasic neurological assessment vgetting up from lying to a sitting position and from sitting position to standing vspontaneous standing vmaneuvers in standing – Romberg, pull test, push test vspontaneous walking – 10m – base width, lenght of the step, fluidity of movement, start and stop, rotation, obstacles vmaneuvers in walking – on heels, on tiptoes, with closed eyes, backwords, tandem walking Possible pathologies üwalking of width base with unstable destination üpolyneuropathic walking – uncertainty, weakness of lower extremities ücerebellar walking – like ebrietas üchoreatic walking üshort step, stiffness üunability to start the step Evaluation of physical performance qanamnestic – comparison with contemporaries, with standards - ADL, IADL qstress tests – speed evaluation, observation of EKG, blood pressure, heart rate qselection of tests – izometric, izotonic, treadmill ADL IADL Cognitive performance evaluation MMSE -Mini Mental State Examination 30-27-23-18-13 -clock test -test connecting numbers and letters Connecting numbers and letters Clock test Depression evaluation – geriatric depression scale GDS Škála deprese podle Sheikha-Yesavage MNA I Poslední 3 měsíce ztráta chuti k jídlu, obtíže GIT, problémy se žvýkáním a polykáním 0 = těžké poruchy 1 = mírné 2 = bez potíží Ztráta tělesné hmotnosti v posledním měsíci 0 = více než 3 kg 1 = neví 2 = v rozmezí 1-3kg 3 = stabilní hmotnost Pohyblivost 0 = upoután na lůžko 1 = pohyb v okolí lůžka, po místnosti 3 = vychází ven Psychický stres v posledních 3 měsících 0 = ano 2 = ne Neuropsychické problémy 0 = těžká demence, deprese 1 = mírná demence 2 = žádné problémy Index tělesné hmotnosti BMI 0 = < 19 1 = 19 – 21 2 = 21 – 23 3 = > 23 maximum – 14 bodů norma - 12 bodů riziko malnutrice - < 11 bodů MNA II Žije v domácnosti 0 = ne 1 = ano Užívá více než 3 léky denně 0 = ne 1 = ano Dekubity 0 = ano 1 = ne Počet hlavních jídel denně 0 = 1 jídlo 1 = 2 jídla 2 = 3 jídla Příjem proteinů 1x a vícekrát denně mléčné výrobky ano ne 2x a vícekrát denně vejce a luštěniny ano ne maso, ryby denně ano ne 0 = 0-1x ano 0,5 = 2x ano 1 = 3x ano Ovoce a zelenina denně 0 = ne 1 = ano Příjem tekutin 0 = méně než 3 šálky 0,5 = 3-5 šálků 1 = 5 a více šálků MNA III Způsob příjmu potravy 0 = s dopomocí 1 = samostatně s obtížemi 2 = samostatně bez problémů Vlastní hodnocení stavu výživy 0 = podvyživený 1 = nehodnotí 2 = nemá nutriční problémy Hodnocení vlastního zdravotního stavu ve srovnání s vrstevníky 0 = nedobrý 0,5 = neví 1 = stejně dobrý 2 = lepší Střední obvod paže 0 = <21cm 0,5 = 21-22cm 1 = > 22cm Obvod lýtka 0 = < 31 cm 1 = 31 cm a více Zhodnocení – max. 14 bodů Celkové hodnocení z obou částí tabulky – 30 bodů - maximum 17-23,5 bodů – riziko malnutrice < 17 bodů - malnutrice Adobe Systems Klinika interní, geriatrie a praktického lékařství Fakultní nemocnice Brno a Lékařské fakulty Masarykovy univerzity Thank you for your attention 48