From Geriatric Diseases

Transcription

1 From Geriatric Diseases to Geriatric Syndromes Jean-Pierre MICHEL Department of Rehabilitation and Geriatrics Medical School and University Hospitals Geneva Switzerland

2 Geriatric diseases & syndromes «Index» disease Co- and multi-morbidity Syndrome: classical definition Geriatric syndrome: Current use of the term Towards an evidence based definition Needs of an operational definition Take home messages

3 Disease Entity Aetiology Pathogenesis Presenting symptoms Disease Known Known Known, but variable in presentation ti A disease is a clinical entity that t can be unequivocally defined d by its aetiology and pathogenesis and is presented as a single symptom or clinical sign or a well-known combination of clinical signs OLDE RIKKERT M et al Neth J Med 2003; 61: 83-7

4 Pathophysiology of disease Population ageing Shift in health Difficulty to focus on only one disease called PRIMARY or INDEX disease INOUYE SK et al J Am Geriatr Soc 2007; 55:

5 COMORBIDITY A PRIMARY or an INDEX disease + specific or multiple CONCURRENT conditions MULTIMORBIDITY SUM of CONDITIONS without a specific «INDEX» disease BOYD CM et al Aging Clin Exp Res 2008; 20: 181-8

6 COMORBIDITY CANCER + specific or multiple CONCURRENT conditions MULTIMORBIDITY SUM of CONDITIONS including CANCER BOYD CM et al Aging Clin Exp Res 2008; 20: 181-8

7 COMORBIDITY The complexity of patients is not captured by lists of diagnoses or biological burden ALONE MULTIMORBIDITY WALTER LC et al Jama 2001; 285: YANCIK R et al Jama 2001; 285: BYNUM JP et al Arch Intern Med 2005; 165:

8 COMORBIDITY 1. Changes the screening procedure 2. Affects ability to determine prognosis 3. Changes treatment options and 4. Increases risk of death MULTIMORBIDITY CGA WALTER LC et al Jama 2001; 285: YANCIK R et al Jama 2001; 285: BYNUM JP et al Arch Intern Med 2005; 165:

9 Geriatric diseases & syndromes «Index» disease Co- and multi-morbidity Syndrome: classical definition Geriatric syndrome: Current use of the term Towards an evidence based definition Needs of an operational definition Take home messages

10 Syndrome: Origins of the word First English translation from Greek in 1541, by Galen «Syn» Together «Dromos» A running In the current medical usage, a syndrome refers to a pattern of symptoms and signs with a single underlying cause that is or not yet known OLDE RIKKERT M et al Neth J Med 2003; 61: 83-7 DURHAM RH Eds. Encyclopedia of Medical Syndromes; New York: Harper & Brother 1960

11 Syndromes: examples Acute chest pain Hepato renal Acute coronary Irritable bowel Behcet Korsakoff Burning mouth Meinière* Carpal tunnel Nephrotic Cushing Patello femoral pain Dementia Ramsay hunt s Depression Restless legs Down s Temporo mandibular pain Fibromyalgia Wernicke Guillain Barre ( ) Cochrane library

12 Disease Syndromes vs. Entity Aetiology Pathogenesis Presenting symptoms Disease Known Known Known, but variable in presentation ti Syndrome 1 Unknown Unknown Defined, set of signs Chronic fatigue Syndrome 2 Unknown Known Defined, set of signs Marfan Syndrome 3 Known Unknown Defined, set of signs Cushing OLDE RIKKERT M et al Neth J Med 2003; 61: 83-7

13 Traditional Medical Syndrome: Cushing s Syndrome FLACKER JM J Am Geriatr Soc 2007; 51: 574-6

14 Geriatric diseases & syndromes «Index» disease Co- and multi-morbidity Syndrome: classical definition Geriatric syndrome: Current use of the term Towards an evidence based definition Needs of an operational definition Take home messages

15 «Geriatric Syndromes» Delirium, dementia, depression, dizziness, failure to thrive, falls, functional dependence, gait disorders, hearing loss, immobility, bl insomnia, incontinence, language disorders, lower extremity problems, oral & dental problems, malnutrition, osteoporosis, pain, pressure sores, self neglect, sexual dysfunction, syncope, vision loss ( ) Pubmed: papers 321 reviews

16 Disease Syndromes vs. Entity Aetiology Pathogenesis Presenting symptoms Disease Known Known Known, but variable in presentation ti Syndrome 1 Unknown Unknown Defined, set of signs Syndrome 2 Unknown Known Defined, set of signs Syndrome 3 Known Unknown Defined, set of signs Geriatric syndrome Mutiple factors Interacting pathways Single Symptom OLDE RIKKERT M et al Neth J Med 2003; 61: 83-7

17 Geriatric Syndrome: Delirium i yes yes yes FLACKER JM J Am Geriatr Soc 2007; 51: 574-6

18 Syndrome vs. Geriatric Syndrome Syndrome Geriatric syndrome Group of symptoms Symptom Single, Highly prevalent Single Aetiology Numerous (known or unknown) aetiologies and/or risk factors Unique Pathogenic pathways Overlaping Generally unique Clinical features Possible association in the same patient OLDE RIKKERT M et al Neth J Med 2003; 61: 83-7

19 «Geriatric Syndrome» Delirium, dementia, depression, dizziness, failure to thrive, falls, functional dependence, gait disorders, hearing loss, immobility, bl insomnia, incontinence, language disorders, lower extremity problems, oral & dental problems, malnutrition, osteoporosis, pain, pressure sores, self neglect, sexual dysfunction, syncope, vision loss ( ) Is it possible to call geriatric syndrome any commmonly encountered condition in older persons? FLACKER JM J Am Geriatr Soc 2007; 51: 574-6

20 «Geriatric Syndrome» Delirium, dementia, depression, dizziness, failure to thrive, falls, gait disorders, hearing loss, immobility, insomnia, The term incontinence, functional dependence, d «Geriatric syndrome» language g disorders, is lower extremity problems, oral a commonly & used, dental problems, malnutrition, but AN ILL-DEFINED osteoporosis, CONCEPT pain,! pressure sores, self neglect, sexual dysfunction, syncope, vision loss ( ) Is it possible to call geriatric syndrome any commmonly encountered condition in older persons? FLACKER JM J Am Geriatr Soc 2007; 51: 574-6

21 POSSIBLE SOLUTION? «Syn» Together «Dromos» A running EBM geriatric SYNDROME «Syn» Together «Koinoneo» To do in common To share To take part in a thing with another Geriatric SYNKOINON FLACKER JM J Am Geriatr Soc 2007; 51: 574-6

22 Geriatric diseases & syndromes «Index» disease Co- and multi-morbidity Syndrome: classical definition Geriatric syndrome: Current use of the term Towards an evidence based definition Needs of an operational definition Take home messages

23 «Geriatric Syndrome» This term is used to capture those clinical conditions in older persons that do not fit into «disease categories» Highly prevalent Associated with substantial ti co-morbidity Multifactorial Poor outcomes: disability & QoL Cross organ systems & discipline-based boundaries INOUYE SK et al J Am Geriatr Soc 2007; 55:

24 Risk factors (EBM) (at least twice) Delirium (N=36) Falls (N=12) Functional decline (N=12) Incontinence (N=9) Pressure ulcers (N=12) Age BMI BMI Cognition Diabetes Depression Falls Functioning Hospitalisation Incontinence Mobility Nutrition Psychoactive drugs Restraints Stroke Vision

25 Shared risks of 5 geriatric i syndromes Shared risks Older age Impaired: -Cognition Geriatric syndromes Delirium Falls Functional decline - Daily functioning Incontinence - Mobility Pressure ulcers INOUYE SK et al J Am Geriatr Soc 2007; 55:

26 Pathophysiology of geriatric syndrome INOUYE SK et al J Am Geriatr Soc 2007; 55:

27 Pathophysiology of geriatric syndrome INOUYE SK et al J Am Geriatr Soc 2007; 55:

28 «Geriatric Syndrome» This term is used to capture those clinical conditions in older persons that do not fit into «disease categories» Multiple risk factor assessment INOUYE SK et al J Am Geriatr Soc 2007; 55:

29 SHARED RISK FACTORS Geriatric syndromes Pressure ulcers Incontinence Poor Outcomes Disability Older Age Impaired: - Cognition - Functioning - Mobility Functional decline Falls FRAILTY Death Delirium INOUYE SK et al J Am Geriatr Soc 2007; 55:

30 Geriatric diseases & syndromes «Index» disease Co- and multi-morbidity Syndrome: classical definition Geriatric syndrome: Current use of the term Towards an evidence based definition Needs of an operational definition Take home messages

31 «Geriatric Syndrome» Why looking for a working definition? Clinics: Teaching: Research: Understand physio-pathological processes Facilitate diagnostic analysis Promote clinical guidelines Improve quality indicators (outcomes) Provide educational tools Allow web-based educational programmes Use the same evidence based criterias Compare results between studies Pool studies findings Public health: Pay for performance

32 Is sarcopenia a geriatric syndrome?

33 Sarcopenia is a geriatric syndrome Risk factors Constitutional factors Female gender Low birth rate Genetic susceptibility Ageing Increased muscle turnover Reduced number of muscle cells Hormonal deregulation Changes in nervous system Mitochondrial dysfunction Peripheral vascular flow Living habits Malnutrition Low protein intake Alcohol/ smoking Physical inactivity Chronic health conditions Cognitive impairment Mood disturbances Diabetes mellitus Heart / liver / lung / renal failure Osteoarthritis Chronic pain Drugs SARCOPENIA? Body protein content Thermo regulation Insulin resistance Immunity Infections Axial muscular tonus Falls Masticator force Venous flow Osteopenia / fractures Frailty Mobility Impaired gait Falls Low endurance Physical performance Physical Frailty Poor outcomes Disability Poor quality of life Nursing home admission Mortality Qualiy of Life Care costs Living conditions Starvation Bed rest /immobility /deconditioning Weightlessness CRUZ JENTOFT A et al Curr Opin Clin Nutr Metab Care 2010; 13: 1-7

34 YES, SARCOPENIA is a geriatric syndrome progressive and generalised loss of skeletal muscle mass, strength and/or function Highly prevalent Associated with substantial ti co-morbidity Multifactorial Poor outcomes: disability & death Cross organ systems & discipline-based boundaries CRUZ JENTOFT A et al Age Ageing 2010; May: 1-12

35 «Geriatric Syndrome» Why looking for a working definition? To improve the respect of Geriatric Medicine and ease communication BUT, before going ahead: NEED of IDENTIFYING EVIDENCE E E BASED CRITERIA Adapted from HAZZARD WR J Am Geriatr Soc 2007; 55: 794-6

36 Geriatric diseases & syndromes «Index» disease Co- and multi-morbidity Syndrome: classical definition Geriatric syndrome: Current use of the term Towards an evidence based definition Needs of an operational definition Take home messages

37 COMORBIDITY A PRIMARY or an INDEX disease + specific or multiple CONCURRENT conditions MULTIMORBIDITY SUM of CONDITIONS without a specific «INDEX» disease BOYD CM et al Aging Clin Exp Res 2008; 20: 181-8

38 Shared risks of 5 geriatric i syndromes Shared risks Geriatric syndromes Delirium Falls Functional decline Incontinence Pressure ulcers INOUYE SK et al J Am Geriatr Soc 2007; 55:

39 MUTIFACTORIAL GERIATRIC SYNDROMES Shared risks Older age Impaired: -Cognition Geriatric syndromes Delirium Falls Functional decline - Daily functioning Incontinence - Mobility Pressure ulcers Cross both organ systems & discipline-based INOUYE SK et al J Am Geriatr Soc boundaries 2007; 55:

40 SHARED RISK FACTORS Geriatric syndromes Pressure ulcers Incontinence Poor Outcomes Disability Older Age Impaired: - Cognition - Functioning - Mobility Functional decline Falls FRAILTY Death Delirium INOUYE SK et al J Am Geriatr Soc 2007; 55:

41 «Geriatric Syndrome» Evidence based data are urgently needed to elucidate complex medical problems as «Geriatric syndrome» To improve the respect of Geriatric Medicine and ease communication Adapted from HAZZARD WR J Am Geriatr Soc 2007; 55: 794-6

42 Thank you for your attention

43 Diagnosis of sarcopenia following the proposal of the European Working group CRUZ JENTOFT A et al Age Ageing 2010; May: 1-12