geriatriske syndromer - dansk selskab for geriatri
TRANSCRIPT
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Geriatriske Syndromer
Solvejg Henneberg Pedersen marts 2013
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Indhold
• Geriatriens giganter
• Klassiske syndromer
• Geriatriske syndromer
• Hvad betyder det for praksis?
• Take Home messages
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Geriatriske giganter
• Et begreb udviklet af professor Bernard
Isaacs for at sammenfatte de store
sygdomme, der er associeret med aldring
• Selvom de hyppiggeste dødsårsager hos
ældre er cancer, hjertesygdom og
apopleksi, afspejler de geriatriske giganter
det store antal ældre, der er ramt af disse
sygdomsbilleder, og den store betydning
disse har for patienternes uafhængighed
Dr.P.SRINIVAS, ”Giants of Geriatrics-Current Issues and Challenges”, 1st world
congress on HEalthy aging, 2012
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Isaac´s Geriatriske giganter
1. Immobilitet
2. Instabilitet
3. Inkontinens
4. Impaired/nedsat intellekt/hukommelse
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Geriatriske giganter - Google
Geriatric Giants
• De tre D´er – kognition
– Delirium
– Demens
– Depression
• Dekonditionering
• Fald
• Ernæring
• Hydrering
• Inkontinens og obstipation
• Smerte
• Polyfarmaci
• Hud
Geriatric Giants
1. Frailty
2. Delirium and
Dementia
3. Falls
4. Medication Issues
5. Incontinence
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Geriatriske giganter i Danmark 2013
• Fald
• Infektion
• Demens
• Depression
• Funktionstab
• Cancer
• Hjertesygdom
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Syndromer
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Et klassisk syndrom er ?
“a group of signs and symptoms that occur together and characterize a particular abnormality” (Merriam-Webster Online Dictionary)
“the aggregate of symptoms and signs associated with any morbid process, and constituting together the picture of the disease” (Stedman’s Medical Dictionary)
“ a syndrome refers to a pattern of symptoms and signs with a single underlying cause that may not yet be known” (Olde Rikkert et al. Neth J Med 2003)
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Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003;51:574-76.
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Olde Rikkert et al: Geriatric syndromes: medical misnomer or progress in
geriatrics, Neth J Med 2003
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Traditionelle syndromer
Er klassiske eksempler på
Occam´s razor
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Hans filosofiske princip var at man skal ikke kigge efter flere årsager på en effekt/tilstand, hvis en enkelt årsag kan give en passende forklaring.
This is the “Law of Parsimony” also called “Occam’s Razor” because Occam wielded it sharply in his arguments.
Engelsk filosof og teolog
William of Ockham (Occam)
(°1285 - †1349)
Resnik NM: Principles of Internal medicine 14th Ed 1998
Drachman DA. Occam’s razor, geriatric syndromes, and the dizzy patient. Ann Int Med 2000;132:403-404.
“Plurality must not be posited without necessity”
“Do not multiply causes unnecessarily”
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Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003;51:574-76.
Apply occams razor
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Yngre patient
• Feber
• Kardiel mislyd
• anæmi
• Kan ikke gå – udviklet over få dage
• Embolus i retina
• Nyudviklet urininkontinens
• Diagnose?
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Yngre patient
• Feber
• Kardiel mislyd
• anæmi
• Kan ikke gå – udviklet over få dage
• Embolus i retina
• Nyudviklet urininkontinens
• Diagnose?
Endokardit med embolier
Klassisk Occam razor
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Ældre mand
• Feber
• Kardiel mislyd
• anæmi
• Kan ikke gå – udviklet over få dage
• Embolus i retina
• Nyudviklet urininkontinens
• Diagnose?
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Ældre mand
• Feber
• Kardiel mislyd
• anæmi
• Kan ikke gå – udviklet over få dage
• Embolus i retina
• Nyudviklet urininkontinens
• Diagnose?
Influenza
Aortastenose
Magnyl
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Et geriatrisk syndrom
derimod ….
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Er dette et syndrom?
Morley JE, Kim MJ, Haren MT, Kevorkian R, Banks WA. Frailty and the aging male. Aging Male. 2005;8:135-40.
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Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003;51:574-76.
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Olde Rikkert et al: Geriatric syndromes: medical misnomer or progress in
geriatrics, Neth J Med 2003
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GS eller
klassisk
syndrom
Flacker JM. What is a
geriatric syndrome
anyway? J Am Geriatr
Soc. 2003;51:574-76.
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Geriatrisk syndrom
Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research,
and policy implications of a core geriatric concept. J Am Geriatr Soc 2007
May;55(5):780-91.
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Definitioner og beskrivelser
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Definition på Geriatrisk Syndrom
• Multifactorial health conditions, that
occur, when the accumulated effects
of impairments in multiple systems
render (an older) person vulnerable to
situational challenges.
Tinetti et al. Shared risk factors for falls, incontinence, and functional dependence.
Unifying the approach to geriatric syndromes. JAMA 1995;273:1348-1353
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Hvad er et Geriatrisk Syndrom
• The term is used to capture those clinical
conditions in older persons that do not fit
into discrete disease categories. E.g. delirium, falls, frailty, dizziness, syncope, urinary incontinence.
– refers to the multiple causations of a unified
manifestation.
The conceptualisation of GS aligns itself with the
concept of “phenotype” Fried,L et al: Frailty in Older Adults: Evidence for a Phenotype, J Gerontol
2001;56A:M146-M156.
Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a
core geriatric concept. JAGS 2007;55:780-791.
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Kendetegn ved GS
• the outcome is a single phenomenology
rather than a spectrum of symptoms and
signs and results from numerous rather
than a single disruption. In geriatric
syndromes, it is multiple abnormalities that “run
together” to cause a single phenomenology.
• F.eks: in delirium, the cumulative effects of
multiple contributors (impaired cognition,
severe illness, old age, etc.) result in the
delirium phenomenology.
Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003;51:574-76.
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Kendetegn ved den geriatriske pt.
• Homeostatic strain caused by a new
disease often leads to symptoms
associated with a different organ
system, particular one compromised by
preexisting disease.
– the weakest link er ofte: hjerne, blærekontrol,
gangfunktion
• Infektion kan manifestere sig som fald
• Smerter kan manifestere sig som konfusion/ delir
• Urininkontinens skyldes immobilisation
Resnick,N : in Harrison´s Principles of Internal Medicine, 15th ed. 2001
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Kliniske overvejelser
• Multiple risk factors and organ systems are
often involved.
• Therapeutic management can be helpful
even in the absence of a firm diagnosis or
clarification of the underlying disease.
Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a
core geriatric concept. JAGS 2007;55:780-791.
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Many conditions have been called GS... Flacker et al JAGS 2003;51:574-576.
• delirium
• dementia
• depression
• dizziness
• emesis
• falls
• gait disorders
• hearing loss
• insomnia
• urinary incontinence
• language disorders
• functional dependency
• lower extremity problems
• oral and dental problems
• malnutrition
• osteoporosis
• pain
• pressure ulcers
• silent myocardial pectoris
• sexual dysfunction
• syncope
• vision loss
Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003;51:574-76.
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Klassisk syndrom eller
geriatrisk syndrom ?
Ligheder og forskelle
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Classical Syndrome vs. GS
• Geriatric interpretation of “syndrome”
– does not refer to the presenting
symptoms
– but to the multiple causations of a
unified manifestation.
Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a
core geriatric concept. JAGS 2007;55:780-791.
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• sjælden
• sygdom (gruppe af symptomer)
• Enkelt patogenese
• Intet overlap mellem etiologiske faktorer til forskellige syndromer
• Et syndrom pr. patient
• hyppig
• et symptom
• multifaktoriel oprindelse
• stort overlap mellem etiologiske faktorer til forskellige GS
• mere end et GS pr. patient
Classical Syndrome vs. GS
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Comparison of two approaches to Geriatric
Syndromes using falls as an example
Traditional Medical
Approach
(diagnosis and treatment)
• Search for cause of fall
Geriatric Approach
(risk factor assessment and
reduction)
• Search for cause of fall
• Risk factores and
intervention
– intrinsic (leg weakness)
– situational (cane)
– extrinsic (lights)
Phelan et al. Some considerations regarding GS. Ann Int Med 2001;135:1095.
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Fælles disponerende faktorer
Til geriatriske syndromer
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Shared Risk Factors for Falls, Incontinence,
and Functional Dependence.
Unifying the Approach to Geriatric Syndromes
• Udvalgte geriatriske syndromer:
– Fald
– Inkontinens
– Funktionel afhængighed
• Metode: populationsstudie 1 år
Tinetti et al. Shared risk factors for falls, incontinence, and functional dependence.
Unifying the approach to geriatric syndromes. JAMA 1995;273:1348-1353
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Fire uafhængige faktorer, der
predisponerer til inkontinens, fald og
funktionel afhængighed
– Langsom chair stands (lower extremity
impairment),
– Nedsat arm styrke (upper extremity
impairment),
– Nedsat syn og hørelse (sensory
impairment),
– Enten en høj angst eller depression score
(affective impairment).
Tinetti et al. Shared risk factors for falls, incontinence, and functional dependence.
Unifying the approach to geriatric syndromes. JAMA 1995;273:1348-1353
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Shared Risk og GS
• Fem geriatriske syndromer udvalgt:
tryksår,
incontinens,
fald,
funktionstab
delirium.
• Metode: litteraturstudie
Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a
core geriatric concept. JAGS 2007;55:780-791.
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Shared Risk og GS
Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a
core geriatric concept. JAGS 2007;55:780-791.
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Shared risk factors identified
consistently across all geriatric syndromes
• older age,
• functional impairment,
• cognitive impairment,
• and impaired mobility.
Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a
core geriatric concept. JAGS 2007;55:780-791.
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Shared risk factors identified
consistently across all geriatric syndromes
• older age,
• functional impairment,
• cognitive impairment,
• and impaired mobility.
Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a
core geriatric concept. JAGS 2007;55:780-791.
Isaacs geriatric giants
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Frailty – skrøbelighed og GS
Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a
core geriatric concept. JAGS 2007;55:780-791.
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Fald
Svimmelhed
ortostatisme
Anfaldsvis afli
Medicinbivirkninger
Dårligt syn
Dehydrering
Infektion
Ensartet
sygdomspræsentation
Variabel
sygdomforklaring
Modificeret efter Flacker
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Delir/konfusion
Svimmelhed
ortostatisme
Anfaldsvis afli
Medicinbivirkninger
Dårligt syn
Dehydrering
Infektion Ensartet
sygdomspræsentation
Variabel
sygdomforklaring
Modificeret efter Flacker
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Hvad giver begrebet
geriatrisk syndrom os ?
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Hvad kan vi bruge begrebet
Geriatrisk syndrom til ?.
• The power of the concept of the geriatric
syndrome is in abandonning Ockhams’s razor
when appropriate.
• By abandoning the search for a single culprit, we
can try to adress the multiple factors.
• To treat the complicated patient, we may have to return
to the individuality of the patient before us. Each one will
present a unique combination of medical, financial,
social, and psychological realities to be addressed within
the systematic framework of care that the team has
available.
Schwab, W.: Geriatric syndromes, JAGS 2008, 56(2), p 363-4.
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Hvad kan vi bruge begrebet
geriatrisk syndrom til
• Det fremhæver fænotypen eller End
Product
• Belyser forskellen mellem geriatrisk
approach og traditionelt approach til
udredning og behandling
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Hvad betyder alt dette i
praksis?
Hvilke patienter skal på geriatrisk
afdeling?
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Udfordringen ift funktionstab
For geriatere og andre læger:
• ”Endeproduktet” den tungt plejekrævende
patient, som ikke kan komme på benene
efter et sygdomstilfælde er ikke altid er
en geriatrisk patient
• Eks:
– Apopleksia cerebri
– End stage diabetes
– End stage KOL
– End stage hjerteinsufficens
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apopleksi Kan ikke mobiliseres
Pts. raske
ægtefælle indlagt
Patienten kan ikke
klare sig derhjemme
Pt har haft kompliceret
forløb med respirator beh.
og dialysebeh.
Patienten er langt fra
habitual tilstand
Eksempler
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K.Rockwood
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K.Rockwood, IAGG Paris 2008
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Take Home Message 1
Et geriatriske syndrom er kendetegnet ved:
• Et symptom, en fænotype
• Har en høj prævalens blandt ældre
• Den diagnostiske proces bør indeholde
både en udredning for en enkelt eller flere
sygdomme, der udløste symptomet
• Og en intervention overfor multiple
risikofaktorer.
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Take Home Message 2
• Geriatriske patienter skal undersøges
bredere.
• Symptomer ofte fra et andet organsystem
end der hvor den akutte årsag er
• Interventioner på mange punkter er
nødvendige – og effektive
• Det kan hjælpe at behandle fænotypen,
uanset at vi ikke har stillet diagnosen
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Take Home Message 3
• Det fremhæver fænotypen eller End
Product
• Og belyser fænotypens begrænsning i
visitationen
• Belyser forskellen mellem geriatrisk
approach og traditionelt approach til
udredning og behandling
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Tak til
Raf Van Hoeyweghen:
”The geriatric syndrome”,
8th Eama Course, Sion January 2009
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Tak for opmærksomheden