Valoreación geriátrica integral

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Ateneo de actualización en geriatría: Valoración geriátrica integral (VGI) DRA. LEMOS SOFÍA

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  • 1. Ateneo de actualizacin en geriatra: Valoracin geritrica integral (VGI) DRA. LEMOS SOFA

2. Qu evala la VGI: Deterioro cognitivo: MMT-ACE Declinacin funcional: AVD-AIVD Riesgo de depresin: GDS Riesgo cadas: Get up and go, prueba alcance funcional. Riesgo nutricional: MNA Comorbilidades severas: CIRS_G Medicacin: BEERS Incontinencia Trastornos sensoriales Sobrecarga del cuidador: Zarit 3. VGI: es un plan de gestin para hacer frente a los problemas del adulto mayor VGI: identifica problemas como la funcionalidad y problemas psicosociales en el adulto mayor que generalmente son subdiagnosticados Objetivar mas all de la impresin Es una evaluacin multi-disciplinaria donde los mltiples problemas de las personas mayores son considerados, descriptos y explicados BMC Med. 2012 Aust Fam Physician. 2004 4. Valoracin geritrica integral 5. CadasDisminucin visin Medicamentos Perdida de peso 6. Functional Decline in Older Adults Am Fam Physician. Sep 15, 2013; 88(6): 388394. Cathleen S. Coln-Emeric, MD, MHS, Heather E. Whitson, MD, MHS, Juliessa Pavon, MD, and Helen Hoenig, MD SORT: KEY RECOMMENDATIONS FOR PRACTICE Comprehensive geriatric evaluation and treatment programs conducted by an interdisciplinary team should be considered for patients with unexplained or progressive disability. A 41, 42 Randomized trial and meta- analysis of randomized trials of geriatric evaluation and management Comprehensive geriatric assessment for older adults admitted to hospital: meta- analysis of randomised controlled trials A controlled trial of inpatient and outpatient geriatric evaluation and management. 7. Deterioro cognitivo 8. MMT El MMSE continua siendo el instrumento mas utilizado. 14 estudios (n=10,185) 88.3% sensibilidad (95% CI, 81.3 to 92.9) y 86.2% especificidad (95% CI, 81.8 to 89.7) para un punto de corte de 23/24 o 24/25 en la deteccin de demencia. Much more limited evidence exists for the following instruments to detect MCI: MMSE (k=15; n=5,758), IQCODE (k=4; n=975), CDT (k=4; n=4,191), Mini-Cog (k=3; n=1,092), TICS (k=3; n=568), and the Montreal Cognitive Assessment (MoCA) (k=2; n=251). The sensitivity and/or specificity of these instruments is generally worse for the detection of MCI compared with dementia. MMSE falla en detectar demencia en los estadios iniciales. Esto se debe a dos razones: 1) Su escasa sensibilidad para objetivar dficits leves de memoria y de lenguaje como consecuencia del uso de tareas mnsicas y lingu isticas muy simples. 2) Su escasa sensibilidad para objetivar los dficits ejecutivos observados en la demencia frontotemporal. Existe consenso sobre la utilidad del MMSE para el seguimiento longitudinal del deterioro cognitivo 9. ACE 10. El ACE evala 6 dominios cognitivos. El puntaje mximo obtenible es 100: orientacin, atencin, memoria, fluencia verbal, lenguaje y habilidades visuoespaciales. A su vez, permite calcular los 30 puntos del MMSE, ya que estn incluidos en el cuestionario. El coeficiente VLOM del ACE en espaol permite una orientacin para el diagnstico diferencial entre DTA y DFT Punto de corte: Alta educacin: 86 Baja educacin: 68 11. Clinical Review Cognitive assessment of older people BMJ 2011;343:d5042 Formal detection of these syndromes may enable identification of treatable conditions, is associated with better outcomes for patients, and requires routine cognitive assessment Cognitive assessment requires integration of information acquired from observing the patient and talking with carers, and from the results of an assessment instrument Cognitive assessment instruments are brief, easy to use, and sensitive to cognitive impairment. Observacin del paciente, La informacin del conviviente Y el resultado de los test 12. Escala clnica de la demencia (CDR) DCL 13. Funcionalidad: AVD_AIVD AVD: indice de Katz (bao, vestirse, continencia, alimentacin, transferencia, movilidad, aseo). AIVD: indice de Lawton y Brody (uso de telfono, compras, cocinar, transporte, manejo de medicacin y dinero) La declinacin funcional es frecuente en ancianos Multicausal (sociales, financieros, comorbilidades severas, etc) 14. Riesgo de Cadas Clin Cases Miner Bone Metab. 2013 The prevalence of fall according to the increasing of age 15. Time get up and go test levantarse (sin usar apoyabrazos); camine 3 mts, de la vuelta y vuelva a sentarse >16seg: riesgo de cadas Prueba de alcance funcional pararse con el brazo extendido. Inclinarse para adelantar el puo lo mas lejos posible sin dar un paso o perder la estabilidad 150% de lo normal); requerimiento de enz. pancreticas para la digestin. 4-Obstruccin biliar; cualquier carcinoma del rbol biliar; colecistitis; pancreatitis; hepatitis activa. RENAL 3-Creatinina srica >3 o > 1.5 en conjuncin con diurtico, antihipertensivo o tratamiento con bicarbonato; pielonefritis actual. 4-Requerimiento de dilisis; carcinoma renal. GASTRO-INTESTINAL INFERIOR 3-Impactacin fecal en el ltimo ao; uso diario de laxantes estimulantes o enemas. 22. The measures that have been most widely used and for which there is greatest evidence of validity are the Charlson index, disease counts, and the ACG System. Other measures such as the CIRS are more complex to administer, and their advantages over easier methods have not been well established. Ann Fam Med. Mar 2012 The assessment of CIRS-G requires a health professional more skilled on clinical examination, all of these indexes have been shown to have a good predictive value about functional impairment and mortality. Rev Med Inst Mex Seguro Soc. 2011 23. Sobrecarga de cuidador Factors associated with caregiver burden in patients with Alzheimer's disease. Psychiatry Investig. 2014 24. 47 a 55 sobrecarga leve Sensibilidad: 85,1%; Especificidad: 84,4%. >55 sobrecarga intensa Sensibilidad: 90,6%; Especificidad: 93,3% 25. Valoracin social OARS CAGE (Alcoholismo) Valoracin de los cuidadores Valoracin semi-estructurada: Soporte informal (amigos, familia) Soporte formal (bienestar social, servicios de salud) Soporte semiformal (Iglesia, centros de jubilados, sociedades de fomento) Valoracin estructurada por asistente social Herramienta diagnstica multidimensional adaptada En espaol. Proporciona informacin acerca de cinco reas: estructura familiar y recursos sociales, recursos econmicos. 26. Recomendaciones: Sospecha de probable deterioro cognitivo Estimulacin cognitiva Nonpharmacological therapies in Alzheimers disease: a systematic review of efficacy. Dement Geriatr Cogn Disord. 2010 The effects of a Cognitive Stimulation Therapy [CST] programme for people with dementia on family caregivers health- BMC Geriatr. 2014 Reevaluacin en 6 meses (*) Manejo sobre riesgos de sobrecarga en cuidador Eventual uso de anti-demenciales Esfera cognitiva Sntomas conductuales Sobrecarga del cuidador 27. Recomendaciones: Riesgo de cadas Recomendacin de uso de bastn Recomendacin de prevencin de cadas en domicilio Eventual inicio de KNM para rehabilitacin de la marcha Falls prevention for the elderly. GMS Health Technol Assess. 2012 Effectiveness of a multifactorial falls prevention program in community-dwelling older people when compared to usual care: study protocol for a randomised controlled trial (Prevquedas Brazil). BMC Geriatr. 2013 Mar Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial. BMJ. 2012 Aug Evaluacin de medicacin potencialmente inapropiada por riesgo alto de cadas Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care. BMC Geriatr. 2014 Positive associations between fall risk and the total number of drugs (p < 0.01), severe falls (p < 0.01) and female sex (p = 0.03) 28. Pattern Screening and assessment Intervention Unstable health conditions Medical assessment Medical management may include geriatrician review, medication review, intervention to increase compliance, referral for follow- up of medical conditions. Under nutrition Setting appropriate screening, Mini Nutritional Assessment Referral to a dietician for nutritional support: education about foods,nutrition advice, benefits of regular exercise, and nutrition support. The NICE clinical guideline Nutrition Support in Adults provides high quality evidence for oral nutrition support in adults with malnutrition 29. Pattern Screening and assessment intervention Psychological factors Geriatric Depression Scale (short form) Frail older depressed patients are particularly susceptible to side effects of antidepressant medication. Antidepressant is effective in the treatment of older people. The NICE clinical guideline Occupational therapy interventions and physical activity interventions to promote the mental wellbeing of older people in primary care and residential care Impaired cognition Mini Mental Status Examination (MMSE) Impaired vision/ hearing Brief clinical assessment Referral for specialist. Facilitate self-management of aids for vision/hearing 30. Patterns Screening and assessment intervention Decreased mobility Timed 4 m walk Timed Up and Go Lower limb strength: Timed sit to stand Balance: 4-point balance test Falls risk: Physiological Profile Assessment Appropriately designed exercise interventions are effective in preventing falls in older people living in both the community and nursing care settings. Exercise should be under-taken at least two hours per week. Home safety inter- ventions reduce falls rate in this high-risk frail group, and multifactorial falls assess-ment and intervention are also effective. Problems with services or support systems Clinical assessment Support and education of formal and informal carers. Caregivers and family should be taught about frailty, interventions to optimize function, and be involved in planning and development of manage-ment plans. 31. Qu debera formar parte de la VGI: Calidad de vida Older People's Quality of Life (OPQOL) scores and adverse health outcomes at a one-year follow-up. A prospective cohort study on older outpatients living in the community in Italy. Health and Quality of Life Outcomes 2011 Baja calidad de vida referida por los ancianos como factor predictor independiente del desarrollo de eventos adversos (institucionalizacin y mortalidad) al ao de seguimiento. The lowest score-based quartile of the health-related OPQOL sub-score was associated with a greater risk of any fall as well as of nursing home placement (OR 10.03, 95% [CI] 1.25-80.54, P = 0.030) and death (OR 4.23, 95% CI 1.06-16.81, P = 0.041).