update in geriatrics · stefania maggi president eugms «geriatric medicine is the specialty...

25/11/2016

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UPDATE IN GERIATRICS

Stefania Maggi

President EUGMS

«Geriatric medicine is the specialty concerned

with health related problems in older people,

including acute, chronic and rehabilitation

problems, in the community, long-stay and

hospital settings”

Duursma S et al. J Nutr Health Aging 2004;8(3):190-5

EUGMS position statement on geriatric medicine and the provision of health care services to older people.

ACUTE DISEASEEND OF LIFE

SUBACUTE CARE

CONVALESCENCE /RECOVERY

REHABILITATION

CHRONIC DISEASE(S)

DISABILITY

SOCIAL ENVIRONMENT

OLDER

PERSON FAMILY

» What elements are key to obtain improved

outcomes?

˃ Comprehensive Geriatric Assessment

˃ Team work

˃ Targeting

˃ Flexibility and adaptation to patients needs

˃ Integration of services

Figure 1. . (A) Phenotypic frailty. Phenotypic frailty is conceptualized as a clinical syndrome driven by age-related biologic changes that drive physical characteristics of frailty and eventually, adverse outcomes. (B) Deficit accumulation frailty.The deficit model of frailty proposes that frailty is driven by the accumulation of medical, functional, and social deficits, and that a high accumulation of deficits represents accelerated aging. An important distinction between these 2 conceptualizations of frailty is that biologic driven frailty causes the physical characteristics of frailty (arrows pointed outward). In contrast, deficit accumulation frailty is caused by accumulated abnormal clinical characteristics (arrows pointed inward). ..

Thomas N. Robinson, Jeremy D. Walston, Nathan E. Brummel, Stacie Deiner, Charles H. Brown IV, Maura Kennedy, Arti Hurria

Frailty for Surgeons: Review of a National Institute on Aging Conference on Frailty for Specialists

Journal of the American College of Surgeons, Volume 221, Issue 6, 2015, 1083–1092

Two conceptualizations of frailty

Figure 2. The concept of resilience. Resilience (a health-based, rather than disease-based, model) implies that disease is the consequence of inadequate reserve in the face of overwhelming stressors, which predispose to unstable and adverse health outcomes. St...




http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.428

25/11/2016

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Modified from Gill TM, Arch Intern Med 2006

N=754, followed for 18 Ms

51.5% 58.3% 63.9%

40.1% 24.9%Dead 4.2% Dead 4.9% Dead 13.1%

11.9% 23%

Robust Pre-Frail Frail

FRAILTY IS REVERSIBLE

Figure 3. The impact on health of social vulnerability.




http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.428

Young Adults

Symptoms

FrailtyFunctional Loss

Disabilities

Pathophysiology

Older Persons

MultiplePathologies

Pure Aging Syndrome

Socioeconomicsand Environment

Habits, Lifestyle,Behaviors

1 Disease

Interacting

cascadeof problems

Rx

Unità Geriatrica per Acuti

Baztàn et al., 2009,

Fox, JAGS, 2012

Ellis et al., 2011

0.5 1 1.5 2.0

Reference

Alive at home 6

months

Alive at home 1 year

Cognition

Institutionalized

1.25

1.16

1.11

0.79

Mortality 1 year0.76

CGA for older adults admitted to hospital: results

22 RCT (1984-2010) evaluating 10,315 participants in six countries

Results

Ellis et al, The Cochrane Library 2011, Issue 7

p=0.0002

p=0.003

p=0.02

p<0.0001

p=0.001

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2013; 381:752-62

Comprehensive Geriatric Assessment

(CGA) has become the

internationally established method to

assess elderly people in clinical

practice.

The CGA is sensitive to the

reliable detection of degrees of

frailty. This assessment is the

gold standard to detect frailty

and should be used more

widely.

Brunello et al. J Cancer Res Clin Oncol 2016N=658 new cancer pts =>70 yrs

ConclusionsAlthough there was a significant

reduction in mortality at 1 month

and 6 months after admission,

there were no effects on other

secondary outcomes.

A systematic CGA, followed by a

transitional care program, might

improve patient safety during the

vulnerable period that occurs

shortly after hospital discharge.

Buurman et al., JAMA Intern Med. 2016;176(3):302-309

Key points

• CGA has an evidence base that merits its implementation for

older people with frailty both in hospital and in other settings.

• The evidence base for how CGA can be implemented and its

effectiveness in modern and novel settings also needs to be

developed.

• Applied health research and service innovation and

development need to take place in parallel.

• This requires health researchers and those who might apply

research knowledge to work together to develop a better

evidence base. Gladman et al. Age and Ageing 2016; 45: 194–200

update in geriatrics · stefania maggi president eugms «geriatric medicine is the specialty...

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