xii congreso de la sociedad castellano-manchega de ... · people older than 65 años with...
TRANSCRIPT
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XII Congreso de la SociedadCastellano-Manchega deGeriatría y Gerontología
FRAGILIDAD Y DEMENCIA
Dr. Leocadio Rodríguez MañasJefe del Sº de Geriatría
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CONTENIDO DE LA CONFERENCIA A) Descripción del escenario. ¿Qué ha pasado? B) Envejecimiento y salud vs Envejecimiento y discapacidad
C) La fragilidad: ¿de qué estamos hablando? C) Enfermedad neurodegenerativa y dependencia: el caso de la demencia
D) Conclusiones-Propuestas
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Halley, first life table, 1693
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
10 20 30 40 50 60 70 80 90 100 110 120
Halley 1687-1691
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Japan 1980-1984
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
10 20 30 40 50 60 70 80 90 100 110 120
Halley 1687-1691
Sweden 1754-1756
Switzerland 1876-1880
Japan 1950-1954
Japan 1980-1984
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Las Pirámides de población en la España del siglo XX
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Evolución de la población alemana (Christensen et al., Lancet 2009)
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FOD-CC
HEALTHY LIFE YEARSAT AGE 65
MEN
WOMEN
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How many newborn are becoming adults?
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
1751 1776 1801 1826 1851 1876 1901 1926 1951 1976 2001
DenmarkEnglandFranceJapanNetherlandsNorwaySwedenSwitzerlandUSA
sex women
Somme de lx
Year
country
75000
80000
85000
90000
95000
100000
1920 1930 1940 1950 1960 1970 1980 1990 2000 2010
90000
92000
94000
96000
98000
100000
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
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Christensen et al. Lancet 2009
MUJERES HOMBRES
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0
1000
2000
3000
4000
5000
6000
7000
1946 1949 1952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006
100+
Female Male Total
Change in the number of centenarians in Spain
HMD data
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The centenarian rate in Europe
Robine and Saito, 2009
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Change in the number of centenarians in Europe vs Japan
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Number of centenarians (100+)
Japan
Females Males Total
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Number of centenarians (100+)
Fourteen European countries
Male Female Total
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More than 40,000 centenarians in Japan in 2009
14
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Number of centenarians
Total
Males
Females
Centenarians in Japan
August 14, 2010
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There is no evidence that the maximum human life span has
changed from what it was about a hundred thousand years
ago…
Hayflick, 1996
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How long are adult life durations?
0
1 000
2 000
3 000
4 000
5 000
6 000
20 40 60 80 100 120
1876-80
1929-32
1988-93
Modal length of life (M)
Maximum
life span Distribution of the ages at death in SwitzerlandDistribution of the ages at death in Switzerland
1876-1880, 1929-1932, 1988-19931876-1880, 1929-1932, 1988-1993
Maximum life expectancy
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CONTENIDO DE LA CONFERENCIA A) Descripción del escenario. ¿Qué ha pasado? B) Envejecimiento y salud vs Envejecimiento y discapacidad
C) La fragilidad: ¿de qué estamos hablando? D) Enfermedad neurodegenerativa y dependencia: el caso de la demencia
E) Conclusiones-Propuestas
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¿DE QUE ESTAMOS HABLANDO?
¿DE VIVIR MAS?
¿DE VIVIR MEJOR?
….QUE ES VIVIR SIN ENFERMEDAD
….QUE ES VIVIR SIN DISCAPACIDAD
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Frailty
Disability
“Failure to thrive”
Func
tiona
l Cap
acity
Death
Usual
Successful
Accelerated
DEATH
LONGEVIDAD
FRAGILIDAD/DISCAPACIDAD
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“He llegado a una conclusión totalmente errónea, lo que demuestra mi querido Watson, lo peligroso que es razonar a partir de datos insuficientes.”
Sherlock Holmes en“The speckled band”
‘Llegaremos a vivir 1000 años'
Aubrey de Grey• Aubrey de Grey: "The first person to live to 1,000 might be 60 already“
• Cambridge University geneticist Aubrey de Grey believes it will soon extend dramatically to 1,000. Here, he explains why.
• http://news.bbc.co.uk/1/hi/uk/4003063.stm
OBJETIVOS¿Moscas longevas sin
alas?Un biólogo presentó un trabajo sobre moscas longevas. Un demógrafo que estaba en la sala preguntó: ¿Qué aspecto tienen esas moscas? El biólogo contestó: “Oh, sus alas cayeron”
Las políticas sanitarias y los tratamientos centrados en la longevidad aun a costa de producir discapacidad (análogas a moscas sin alas) son inaceptables en las sociedades humanas. Verbrugge, 2005
HEALTHY AGING???
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People older than 65 años with disability1999 National Long-Term Care Survey.USA
PNAS, 2001
10121416182022242628
1982 1984 1989 1994 1999
25%
Decrease
(1.47%/y)
19.7%
26.2%24.2%
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Participantes 1986 (%) 1999 (%) Diferencia (%)
Hombres Total 65-69 70-74 75-79 80-84 ≥85
750.192 (39,88)25,7535,6345,3362,6676,85
524.830 (19,28)11,0715,3023,3330,8146,92
-51,64-57,02-57,07-48,54-50,83-38,94
Mujeres Total 65-69 70-74 75-79 80-84 ≥85
1.332.261 (48,98)31,0140,8451,0767,5486,41
1.068.302 (28,06)14,6624,1731,7740,1455,40
-42,70-52,71-47,42-37,80-40,56-35,88
Porcentaje de >65 años con discapacidad en España (1986-1999).Encuesta Nacional de Discapacidad.
Sagarduy-Villamor et al, J Gerontol Med Sci 2005; 60A: 1028-1034.
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Prev
alen
cia
%
Dependencia en AVD Instrumentales (Lawton)
ETES 2009 (AZUL) ETE 1994 (ROJO)
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Newcastle 85+ cohort studyBMJ, 2009
AutopercepciónEstado de Salud
Global(%)
Mujeres(%)
Hombres(%)
Excelente 10,3 9,5 11,7
Muy bueno 29,7 28,1 32,3
Bueno 37,6 38,2 36,7
Regular 18,9 20,2 16,8
Pobre 3,5 4,1 2,5
Percepción del estado de salud en mayores de 85 años
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PACIENTE CLASICO
Enfermedad aguda única
Sin repercusión funcional
Sin secuelas funcionales
PACIENTE CONTEMPORANEO
Enfermedades crónicas y múltiples
Con frecuentes reagudizaciones
Con repercusión funcional
Con secuelas funcionales
Características del Paciente del Siglo XXICaracterísticas del Paciente del Siglo XXI
Rodríguez-Mañas; 2001
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0
2
4
6
8
10
12
14
16
18
20
65 70 75 80 85
5%10%25%50%NORMAL
0
2
4
6
8
10
12
14
16
18
20
65 70 75 80 85
EX
PEC
TA
TIV
A D
E V
IDA
Edad al diagnóstico
Welch HG et al., Ann Intern Med 1996; 124: 577-584.
MUJERES HOMBRES
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29 JULY 2011 VOL 333 SCIENCE
Between 2008 and 2030 chronic diseases will maintain their leadership
in determining death…and disability
Causes of mortality (2008-2030)
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ENVEJECIMIENTO
ENF. CRONICA
DISCAPACIDAD
?
?
Solo una pequeña proporción de ancianos con 2 ó mas enfermedades crónicastienen fragilidad o discapacidad; algunas personas sin enfermedad (o muy leve)muestran los clásico signos de la fragilidad
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ETIOLOGY OF CATASTROPHYC*vs. PROGRESSIVE DISABILITY
(Ferrucci et al; JAMA 1997; 277: 728-734)
*(dependency in ≥ 3 BAVD in 1 yr.)
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Weiss, 2011
CHRONIC DISEASE AND TASKS ASRISK FACTORS FOR ADVERSE OUTCOMES
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Boyd CM, The American Journal of medicine (2005) 118:1225
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(JAGS 2008; 56: 2171-9)
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Situación funcional a los tres meses del alta
Declinan 41 9 23 19
Igual 49 87 16 70
Mejoran 10 4 61 11
declinan igual mejoran total (n=320) (n=656) (n=96) (n=1072)
Cambio en AVD básicas durante hospitalización (%)
Sager MA, Functional Outcomes of acute medical illnes andHospitalizatión in older person. Arch Intern Med 1996; 156: 645-52)
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Situación funcional a los tres meses del alta
Declinan 53 34 34 40
Igual 29 43 33 38
Mejoran 18 23 33 22
declinan igual mejoran total (n=320) (n=656) (n=96) (n=1072)
Cambio en AVD instrumentales durante hospitalización (%)
Sager MA, Functional Outcomes of acute medical illnes andHospitalizatión in older person. Arch Intern Med 1996; 156: 645-52)
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CONTENIDO DE LA CONFERENCIA A) Descripción del escenario. ¿Qué ha pasado? B) Envejecimiento y salud vs Envejecimiento y discapacidad
C) La fragilidad: ¿de qué estamos hablando? D) Enfermedad neurodegenerativa y dependencia: el caso de la demencia
E) Conclusiones-Propuestas
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Biological, Psychological,Social, societal modifiers/assets and deficits
Frailty: a Complex Syndrome of Increased Vulnerability
Prevent/Delay FrailtyHealth Promotion and Prevention
Delay Onset
Delay/Prevent adverse outcomes, care
FRAILTY
Age
Life-courseDeterminants: Biological (including genetic)PsychologicalSocial, SocietalEnvironment
Chronic Disease
Decline in physiologic reserve
Adverse outcomes•Disability•Morbidity•Hospitalization•Institutionalization•Death
Candidate markers
•Nutrition•Mobility•Activity•Strength•Endurance•Cognition•Mood
Modified from Bergman H, 2008
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Biological, Psychological,Social, societal modifiers/assets and deficits
Frailty: a Complex Syndrome of Increased Vulnerability
Prevent/Delay FrailtyHealth Promotion and Prevention
Delay Onset
Delay/Prevent adverse outcomes, care
FRAILTY
Age
Life-courseDeterminants: Biological (including genetic)PsychologicalSocial, SocietalEnvironment
Chronic Disease
Decline in physiologic reserve
Adverse outcomes•Disability•Morbidity•Hospitalization•Institutionalization•Death
Candidate markers
•Nutrition•Mobility•Activity•Strength•Endurance•Cognition•Mood
Modified from Bergman H, 2008
?
?
??
? ?
? ?
? ?
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We need to treat or to prevent disability in old people
…We do not know exactly its causes
nor what can prevent or improve it…but we are trying to
find it out!
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Hans Baldung Grien
[Las edades y la muerte.
Museo del Prado-Madrid]
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N= 2.494 participants
1965measurements
1752samples
InterviewPurpose
Determine frailty and disability models. Physiopathological basis
PhenotypeDetermine predicting factorsfor disability over time. Determine precipitant factors of events. Determine aging models.
40 ml(4 tubos)
10 ml (sin EDTA)
20 ml(EDTA)
10 ml(EDTA)
SERUM1º Coagular (15 min)
2º Centrifugar3º Congelar
CELLS1º Lavar en suero frío x 22º Centrifugar (3.000 rpm)
PLASMA
Sevilla (4 Tubos)
- 2 tubos de 2,5 ml suero- 1 ml sangre+1ml agua destilada- 1 ml plasma
Dario (6 Tubos)
-5 tubos 1 ml células- 1 ml plasma
Mónica (3 Tubos)
- 1 ml células.- 2 tubos 1 ml plasma.
Pepe Viña (1 Tubo)
- 1 ml sangre (con EDTA)
Franjo (1 Tubo)
- 1 ml células
LAB SAMPLES
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Sarcopenia
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RATIONALE
• There is a necessity to identify old people at high risk for developing some outcomes
• There are many definitions.• With different conceptual frameworks and domains.• The criteria are not universally applicable. Depending
upon the used definition, the prevalence comes from <5% to >80%
• The definitions have been validated in epidemiological settings, but not in clinical ones
FOD-CC
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Biological, Psychological,Social, societal modifiers/assets and deficits
Frailty: a Complex Syndrome of Increased VulnerabilityComplex problems require complex solutions
Prevent/Delay FrailtyHealth Promotion and Prevention
Delay Onset Delay/Prevent adverse outcomes, care
FRAILTY
Age
Life-courseDeterminants: Biological (including genetic)PsychologicalSocial, SocietalEnvironment
Chronic Disease
Decline in physiologic reserve
Adverse outcomes• Disability• Morbidity
• Hospitalization• Institutionalization• Death
Candidate markers• Nutrition
• Mobility• Activity
• Strength• Endurance
• Cognition• Mood
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PREVENTION OF IMPAIRMENT
INJURY DISABILITY DEPENDENCY
USUAL TIME OFDIAGNOSIS
APPROPRIATE TIME FOR INTERVENTION
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Why do we need an operational definition of frailty?FOD-CC
Vigoroso Frágil Dependiente
ROBUST FRAIL DISABLED
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Why do we need an operational definition of frailty?FOD-CC
To identify old people at risk of Disability Adverse Health outcomes
MortalityMorbidityHospitalizationPermanent institutionalization
To manage them in a different way
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FOD-CC
Sternberg SA et al., JAGS 2011
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RATIONALE
• There is a necessity to identify old people at high risk for developing some outcomes
There are many definitions.• With different conceptual frameworks and domains.• The criteria are not universally applicable. Depending
upon the used definition, the prevalence comes from <5% to >80%
• The definitions have been validated in epidemiological settings, but not in clinical ones
FOD-CC
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Definition AuthorFrailty is a loss of resources in several domains of functioning, which leads to a declining reserve capacity for dealing with stressors.
Schuurmans et al. (2004)
A syndrome involving grouping of problems and losses of capacities in multiple domains, which make the individual vulnerable to environmental challenge
Strawbridge et al. (1998)
A syndrome of multisystem reduction in reserve capacity as a result of which an older person’s function may be severely compromised by minor environmental stresses, giving rise to the condition of ‘‘unstable disability.’’
Campbell et al. (1997)
A biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, causing vulnerability to adverse outcomes.
Fried et al. (2001)
A combination of biological, physiological, social, and environmental changes that occur with advancing age and increase vulnerability to changes in the surroundings and to stress.
Nourhashémi et al. (2001)
A vulnerability state resulting from a precarious balance between the assets maintaining health and the deficits threatening it.
Rockwood et al. (1994)
A state of reduced physiological reserve associated with increased susceptibility to disability. Buchner et al. (1992)
A combination of aging, disease, and other factors that make some people vulnerable. Rockwood et al. (1999)
Complex and cumulative expression of altered homeostatic responses to multiple stresses resulting in metabolic imbalance.
Hamerman et al. (1999)
Frailty is diminished ability to carry out important practical and social activities of daily living. Brown et al. (1995)
A state of being neither ’’too independent’’ nor ‘‘too impaired’’ that puts the person at risk for adverse health outcomes.
Winograd et al. (1988)
Ranking of conceptual definitions of frailty definition according to a consensus of experts
Table from Gobbens et al., J Am Med Dir Assoc 2010; 11:338-343
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RATIONALE
• There is a necessity to identify old people at high risk for developing some outcomes
• There are many definitions.With different conceptual frameworks and domains.• The criteria are not universally applicable. Depending
upon the used definition, the prevalence comes from <5% to >80%
• The definitions have been validated in epidemiological settings, but not in clinical ones
FOD-CC
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Instrument/studyNutritional
statusPhysical activity
Mobility Strength Energy Cognition MoodSocial
relations/social support
Modified Functional + - + - - - - -IndependenceMeasure(FIM)/Carlson et al.(1998)
Instrument - - + - - - - -‘Gealey’/Gealey (1997)
Frail Elderly Functional - - + - - - - -AssessmentQuestionnaire/Gloth et al. (1995, 1999)
Instrument ‘Chin A + + - - - - - -Paw’/Chin A Paw et al. (1999)
Instrument + + + - - - + +‘Winograd’/Winograd et al. (1991)
Self-report Screening - - + - - - - -Instrument/Brody (1997)
Table from de Vries et al. Ageing Research Reviews 10 (2011) 104-114
Frailty instruments assessed on frailty factors, publications before 2000FOD-CC
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Frailty instruments assessed on frailty factors, publications since 2000 - A
Instrument/studyNutritional
statusPhysical activity
Mobility Strength Energy Cognition MoodSocial
relations/social support
Frailty Phenotype/Fried et al. (2001) + + + + + - - -, Cigolle et al. (2009), Kiely et al. (2009), and Rockwood et al.(2007)
Frailty Index, + + + + + + + +accumulation ofdeficits/Mitnitski et al. (2001), Cigolle et al. (2009), Rockwood et al. (2007, 2006)
Instrument + + + + - - - -‘Carriere’/Carriere et al. (2005)
Groningen Frailty + - + - - + + +Indicator(GFI)/Schuurmans et al. (2004)
Instrument - - + - + + - -‘Guilley’/Guilley et al. (2008)
Instrument ‘Rothman’ + + + - - + - -/Rothman et al. (2008)
Clinical Global + + + + + - + +Impression ofChange in PhysicalFrailty (CGIC-PF)/Studenski et al. (2004)
The Vulnerable Elders - - + + - - - -Survey (VES)/Salibaet al. (2001) and McGee (2008)
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Frailty instruments assessed on frailty factors, publications since 2000 - B
Instrument/studyNutritional
statusPhysical activity
Mobility Strength Energy Cognition MoodSocial
relations/social support
Study of Osteoporotic + - + + + - - -Fractures (SOF)instrument/Kiely et al. (2009)
Instrument ‘Puts’/Puts et al. (2005) + + - - + + -
Instrument ‘Ravaglia’ - + + - - - + -/Ravaglia et al. (2008)
Grip strength as a single marker - - - + - - - -/Syddall et al. (2003)
1994 Frailty Measure + - - + - + - -Strawbridge/Cigolle et al. (2009) and Matthews et al. (2004)
Geriatric Functional + - + - + + - +Evaluation(GFE)/Scarcella et al. (2005)
Frailty Index- + - + - - + + +ComprehensiveGeriatric Assessment(FI-CGA)/Jones et al. (2004, 2005)
Table from de Vries et al. Ageing Research Reviews 10 (2011) 104-114
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Proportion of definitions including each frailty domainper
centa
ge
de Vries et al. Ageing Research Reviews, 2011
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FOD-CC
Sternberg SA et al., JAGS 2011
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RATIONALE
• There is a necessity to identify old people at high risk for developing some outcomes
• There are many definitions.• With different conceptual frameworks and domains.The criteria are not universally applicable. Depending
upon the used definition, the prevalence comes from <5% to >80%
The definitions have been validated in epidemiological settings, but not in clinical ones
FOD-CC
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Song et al., 2010
Garcia et al., 2011
Global prevalence: 8.4%
Global prevalence: 22.7%
FOD-CC
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PREVALENCE OF FRAILTY IN EUROPE (SHARE STUDY)
Santos-Eggimann y cols, J Gerontol 2009
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Same criteria?
In TSHA, we used the lowest percentil 20 in our population meeting the frailty criteria 4 and 5Prevalence: 8.7%
CRITERIA DEFINITION
1. Weight loss Unintentional weight loss of 4.5 Kg during the last year
2. Exhaustion Using the responses (YES/NO) to two statements of the CES-DDepression Scale (Orme J et al., 1986)
3. Physicalactivity
Assessed by the short version of the Minnesota Leisure TimeActivity questionnaire (Taylor HL et al., 1978)
4. Slowness Assessed by walk time and stratified by gender and height
5. Weakness Assessed by grip strength and stratified by gender and BodyMass Index
• Frailty will be identified by the presence of three or more of the criteria.
• Pre-frailty will be identified by the presence of one or two of the criteria
In FRADEA, we used the Fried´s criteria “comme il faut”, as they were validated.Prevalence: 13.7%
FOD-CC
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BA=64.19 + (.18 x frailty score)
FOD-CC
García-García FJ, Larrión JL & Rodríguez-Mañas L., Gac Sanit 2011
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RATIONALE
• There is a necessity to identify old people at high risk for developing some outcomes
• There are many definitions.• With different conceptual frameworks and domains.• The criteria are not universally applicable. Depending
upon the used definition, the prevalence comes from <5% to >80%
The definitions have been validated in epidemiological settings, but not in clinical ones
FOD-CC
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With permission from H. Bergmann
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RATIONALE (2)
We do have several definitions, but we do not have an operative definition for the
daily practice
FOD-CC
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FOD-CC
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FOD-CC
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FOD-CC THE AIM
At the projectProviding a definition of frailty,the selected biomarker(s) identified and aguideline to allow early diagnosis of frailtyto be used in clinical practice
Kick-off meeting reportClinical definition of frailty (useful for clinicians)with a sub-aim of definition of ‘frailty’for research (animal models).
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5 Focus Groups
• Geriatricians
• Basic scientists
• Non geriatricians, clinicians
• Non clinical health workers
• Social and non governmental workers
FOD-CC
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THE QUESTIONNAIRE
• The conceptual framework• Proposed definition• Setting where applying the definition
(clinical settings and research settings)• Biomarkers• Biomarkers/criteria/parameter directly
relevant to the definition
FOD-CC
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FOD-CC
Construction of the 2nd Round questionnaire
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FOD-CC
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Table 5: Rate of Accepted and Excluded Statements According to theAlternative Classification. Final Analysis
Table 4: Rate of Accepted and Excluded Statements According to EachBlock of Questions, Final Analysis
FOD-CC
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CONCLUSIONS• Frailty is a dynamic, non linear process 24 that involves
alterations in multiple domains of functioning 29, impacts multiple body systems 28, 50 and may be considered a clinical syndrome4.
• It is different from vulnerability and disability 26, 96, 97 and is often modulated by disease 102 to the extent that the presence of co-morbidities tends to exacerbate the consequences of frailty 104.
• Definitions of frailty are frequently multidimensional involving a variety of psychological, social, emotional, and spiritual elements in addition to physical components 13. Definitions of frailty should be applicable across different clinical settings 7.
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CONCLUSIONS• Frailty is characterized by a decreased reserve and
diminished resistance to stressors 6. No single biomarker is adequate for the prediction and/or diagnosis of frailty 60.
• Numerous variables have been proposed for use in the diagnosis of frailty including nutritional status n8
and physical performance n14, gait speed n16 and mobility n17. In addition, mental health assessments and cognitive status evaluations are highly recommended as part of the assessment of frailty n9,
64.
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CONCLUSIONS• The consequences of frailty include an increased
vulnerability to stress in which minimal levels of stress can cause functional impairments 27, 21. Although disability can occur without prior frailty, frailty is a risk factor for disability 99.
• A major purpose of diagnosing frailty is to identify and stratify older persons at high risk for disability and/or other adverse outcomes 12, 45.
• A diagnosis of frailty is of importance because can help to predict a variety of different health outcomes including disability, falls, hospitalization, permanent institutionalization, and death 100, 59. The predictive value of frailty depends on its severity and will vary from person to person 101.
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CONCLUSIONS• The diagnosis of frailty is of importance in numerous
clinical and non-clinical settings 43 in addition to geriatric medicine 48. Frailty diagnosis is useful in both primary care and community care 46 and is of value in managing older people with chronic diseases 47. Because frailty is a condition in which prevention may still be possible it is mandatory for clinicians and health workers to identify those at risk for frailty as early as possible 23. Among the interventions that show promise for the management or attenuation of frailty include a variety of healthy lifestyles n7, including physical activity n6, 22.
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FOD-CC
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FOD-CC
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FOD-CC
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MID-FRAIL STUDYFP7-HEALTH
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CONTENIDO DE LA CONFERENCIA A) Descripción del escenario. ¿Qué ha pasado? B) Envejecimiento y salud vs Envejecimiento y discapacidad
C) La fragilidad: ¿de qué estamos hablando? D) Enfermedad neurodegenerativa y dependencia: el caso de la demencia
E) Conclusiones-Propuestas
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A los viejos les enseñaría que la muerte no llega con la vejez, sino
con el olvido
Gabriel García Márquez
A A los viejos les enseñaría que la muerte no llega con la vejez, sino con
el olvido
Gabriel García Márquez
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A los viejos les enseñaría que la muerte no llega con la vejez, sino
con el olvidoA A los viejos les enseñaría que la
muerte no llega con la vejez, sino con la pérdida de autonomía.
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Théodore Géricault (1791-1824)Óleo sobre lienzo. 1822Musée du Louvre. París
DEMENCIAS , FUNCIONY FRAGILIDAD
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EVOLUCIÓN
Progresivamente el paciente va perdiendo
su capacidad funcional, primero para aquellas
actividades más avanzadas y
paulatinamente para las más básicas, como la
capacidad del autogobierno y del
autocuidado.
AVANZADAS
INSTRUMENTALES
BÁSICAS
Tiempo medio de supervivencia 3-20 años
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Demencia y declinar funcional
• EA: más años con discapacidad en valor absoluto y en % sobre expectativa de vida– Est epidemiológico 15 años: EA más años y
más proporción de vida con dep 6 o 7 AIVD*– Riesgo atribuible poblacional de discapacidad
incidente en ABVD/AIVD entre 11% y 36% según actividad analizada**
* Dodge HH et al. Arch Neurol 2003; 60: 253-259.** Dodge HH et al. Gerontologist 2005; 45: 222-230.
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Demencia y dependencia incidente (Wolff JL et al. J Am Geriatr Soc 2005)
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Ancianos complejos: reto para el sistema y para el clínico
• Patología múltiple crónica
• Problemas funcionales y mentales
• Entorno social insuficiente o débil
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Enfermedad y carga de salud pública
• Nº de personas que la padecen (incidencia y prevalencia)
• Mortalidad que provoca• Costes derivados tanto directos como
indirectos
Doody et al. Dement Geriatr Cogn Disord 2005, 20: 198-208.
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100
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Niv
el
cogn
itivo
Tiempo
S.depresivo
diagnóstico
tnos.conducta
SCA
enf.intercurrentes
déficits funcionales
Sobrecargafamiliar
institucionalización
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Age
Func
tion
Mild cognitive impairment
Alzheimer’s disease
Death
Pathology begins
757055
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Enfermedad de Alzheimer y sarcopenia
• La EA se asocia con pérdida de peso (previo a su diagnóstico)
• La pérdida de peso severidad y progresión de EA• Composición corporal a lo largo de la vida y riesgo de EA
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LABORATORIO DEEVALUACIONMULTIFUNCIONAL DELANCIANO
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Demencia
DCND EA Cualquier tipo
OR (IC 95%) OR (IC 95%) OR (IC 95%)
Actividad física
Ninguna 1 1 1
Baja 0.66 (0.46-0.96) 0.67 (0.39-1.14) 0.64 (0.41-1.02)
Moderada 0.67 (0.52-0.87) 0.67 (0.48-0.98) 0.69 (0.50-0.95)
Alta 0.58 (0.41-0.83) 0.50(0.28-0.90) 0.63 (0.40-0.98)
Test de tendendencia
P<0.01 P=0.02 P=0.04
Actividad física y riesgo de deterioro cognitivo y demencia en > 65 años. Seguimiento a cinco años. CSHA.
Laurin D, Arch Neurol 2001; 58:498-504
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CONTENIDO DE LA CONFERENCIA A) Descripción del escenario. ¿Qué ha pasado? B) Envejecimiento y salud vs Envejecimiento y discapacidad C) Enfermedad neurodegenerativa y dependencia: el caso de la demencia
D) Conclusiones-Propuestas
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Eubie Blake(vivió hasta los 96)
“Si hubiera sabido cuánto iba a vivir, me hubiera cuidado más.”
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THANKS FOR YOUR ATTENTION!!!
IT´S THE TIME FOR QUESTIONS
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MEDICINA GERIATRICA
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¿Preguntas?¿Preguntas?