Ateneo de actualizacioacuten en geriatriacutea
Valoracioacuten geriaacutetrica integral (VGI)
DRA LEMOS SOFIacuteA
Queacute evaluacutea la VGI
Deterioro cognitivo MMT-ACE
Declinacioacuten funcional AVD-AIVD
Riesgo de depresioacuten GDS
Riesgo caiacutedas Get up and go prueba alcance funcional
Riesgo nutricional MNA
Comorbilidades severas CIRS_G
Medicacioacuten BEERS
Incontinencia
Trastornos sensoriales
Sobrecarga del cuidador Zarit
VGI es un plan de gestioacuten 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 allaacute de la impresioacuten
Es una evaluacioacuten multi-disciplinaria donde los muacuteltiples problemas de las personas mayores son considerados descriptos y explicados
BMC Med 2012
Aust Fam Physician 2004
Valoracioacuten geriaacutetrica integral
Caiacutedas Disminucioacuten visioacutenMedicamentos
Perdida de pesohellip
Functional Decline in Older AdultsAm Fam Physician Sep 15 2013 88(6) 388ndash394
Cathleen S Coloacuten-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
Deterioro cognitivo
MMT
El MMSE continua siendo el instrumento mas utilizado 14 estudios (n=10185) 883 sensibilidad (95 CI 813 to 929) y 862 especificidad (95 CI 818 to 897) para un punto de corte de 2324 o 2425 en la deteccioacuten de demencia
Much more limited evidence exists for the following instruments to detect MCI MMSE (k=15 n=5758) IQCODE (k=4 n=975) CDT (k=4 n=4191) Mini-Cog (k=3 n=1092) TICS (k=3 n=568) and the Montreal Cognitive Assessment (MoCA) (k=2 n=251) The sensitivity andor 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 deacuteficits leves de memoria y de lenguaje como consecuencia del uso de tareas mneacutesicas y linguisticas muy simples 2) Su escasa sensibilidad para objetivar los deacuteficits ejecutivos observados en la demencia frontotemporal Existe consenso sobre la utilidad del MMSE para el seguimiento longitudinal del deterioro cognitivo
ACE
El ACE evaluacutea 6 dominios cognitivos El puntaje maacuteximo obtenible es 100 orientacioacuten atencioacuten memoria fluencia verbal lenguaje y habilidades visuoespaciales A su vez permite calcular los 30 puntos del MMSE ya que estaacuten incluidos en el cuestionario
El coeficiente VLOM del ACE en espantildeolpermite una orientacioacuten para el diagnoacutesticodiferencial entre DTA y DFT
Punto de corteAlta educacioacuten 86
Baja educacioacuten68
Clinical ReviewCognitive assessment of older peopleBMJ 2011343d5042bull Formal detection of these
syndromes may enable identification of treatable conditions is associated with better outcomes for patients and requires routine cognitive assessment
bull Cognitive assessment requires integration of information acquired from observing the patient and talking with carers and from the results of an assessment instrument
bull Cognitive assessment instruments are brief easy to use and sensitive to cognitive impairment
Observacioacuten del pacienteLa informacioacuten del convivienteY el resultado de los test
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Queacute evaluacutea la VGI
Deterioro cognitivo MMT-ACE
Declinacioacuten funcional AVD-AIVD
Riesgo de depresioacuten GDS
Riesgo caiacutedas Get up and go prueba alcance funcional
Riesgo nutricional MNA
Comorbilidades severas CIRS_G
Medicacioacuten BEERS
Incontinencia
Trastornos sensoriales
Sobrecarga del cuidador Zarit
VGI es un plan de gestioacuten 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 allaacute de la impresioacuten
Es una evaluacioacuten multi-disciplinaria donde los muacuteltiples problemas de las personas mayores son considerados descriptos y explicados
BMC Med 2012
Aust Fam Physician 2004
Valoracioacuten geriaacutetrica integral
Caiacutedas Disminucioacuten visioacutenMedicamentos
Perdida de pesohellip
Functional Decline in Older AdultsAm Fam Physician Sep 15 2013 88(6) 388ndash394
Cathleen S Coloacuten-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
Deterioro cognitivo
MMT
El MMSE continua siendo el instrumento mas utilizado 14 estudios (n=10185) 883 sensibilidad (95 CI 813 to 929) y 862 especificidad (95 CI 818 to 897) para un punto de corte de 2324 o 2425 en la deteccioacuten de demencia
Much more limited evidence exists for the following instruments to detect MCI MMSE (k=15 n=5758) IQCODE (k=4 n=975) CDT (k=4 n=4191) Mini-Cog (k=3 n=1092) TICS (k=3 n=568) and the Montreal Cognitive Assessment (MoCA) (k=2 n=251) The sensitivity andor 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 deacuteficits leves de memoria y de lenguaje como consecuencia del uso de tareas mneacutesicas y linguisticas muy simples 2) Su escasa sensibilidad para objetivar los deacuteficits ejecutivos observados en la demencia frontotemporal Existe consenso sobre la utilidad del MMSE para el seguimiento longitudinal del deterioro cognitivo
ACE
El ACE evaluacutea 6 dominios cognitivos El puntaje maacuteximo obtenible es 100 orientacioacuten atencioacuten memoria fluencia verbal lenguaje y habilidades visuoespaciales A su vez permite calcular los 30 puntos del MMSE ya que estaacuten incluidos en el cuestionario
El coeficiente VLOM del ACE en espantildeolpermite una orientacioacuten para el diagnoacutesticodiferencial entre DTA y DFT
Punto de corteAlta educacioacuten 86
Baja educacioacuten68
Clinical ReviewCognitive assessment of older peopleBMJ 2011343d5042bull Formal detection of these
syndromes may enable identification of treatable conditions is associated with better outcomes for patients and requires routine cognitive assessment
bull Cognitive assessment requires integration of information acquired from observing the patient and talking with carers and from the results of an assessment instrument
bull Cognitive assessment instruments are brief easy to use and sensitive to cognitive impairment
Observacioacuten del pacienteLa informacioacuten del convivienteY el resultado de los test
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
VGI es un plan de gestioacuten 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 allaacute de la impresioacuten
Es una evaluacioacuten multi-disciplinaria donde los muacuteltiples problemas de las personas mayores son considerados descriptos y explicados
BMC Med 2012
Aust Fam Physician 2004
Valoracioacuten geriaacutetrica integral
Caiacutedas Disminucioacuten visioacutenMedicamentos
Perdida de pesohellip
Functional Decline in Older AdultsAm Fam Physician Sep 15 2013 88(6) 388ndash394
Cathleen S Coloacuten-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
Deterioro cognitivo
MMT
El MMSE continua siendo el instrumento mas utilizado 14 estudios (n=10185) 883 sensibilidad (95 CI 813 to 929) y 862 especificidad (95 CI 818 to 897) para un punto de corte de 2324 o 2425 en la deteccioacuten de demencia
Much more limited evidence exists for the following instruments to detect MCI MMSE (k=15 n=5758) IQCODE (k=4 n=975) CDT (k=4 n=4191) Mini-Cog (k=3 n=1092) TICS (k=3 n=568) and the Montreal Cognitive Assessment (MoCA) (k=2 n=251) The sensitivity andor 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 deacuteficits leves de memoria y de lenguaje como consecuencia del uso de tareas mneacutesicas y linguisticas muy simples 2) Su escasa sensibilidad para objetivar los deacuteficits ejecutivos observados en la demencia frontotemporal Existe consenso sobre la utilidad del MMSE para el seguimiento longitudinal del deterioro cognitivo
ACE
El ACE evaluacutea 6 dominios cognitivos El puntaje maacuteximo obtenible es 100 orientacioacuten atencioacuten memoria fluencia verbal lenguaje y habilidades visuoespaciales A su vez permite calcular los 30 puntos del MMSE ya que estaacuten incluidos en el cuestionario
El coeficiente VLOM del ACE en espantildeolpermite una orientacioacuten para el diagnoacutesticodiferencial entre DTA y DFT
Punto de corteAlta educacioacuten 86
Baja educacioacuten68
Clinical ReviewCognitive assessment of older peopleBMJ 2011343d5042bull Formal detection of these
syndromes may enable identification of treatable conditions is associated with better outcomes for patients and requires routine cognitive assessment
bull Cognitive assessment requires integration of information acquired from observing the patient and talking with carers and from the results of an assessment instrument
bull Cognitive assessment instruments are brief easy to use and sensitive to cognitive impairment
Observacioacuten del pacienteLa informacioacuten del convivienteY el resultado de los test
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Valoracioacuten geriaacutetrica integral
Caiacutedas Disminucioacuten visioacutenMedicamentos
Perdida de pesohellip
Functional Decline in Older AdultsAm Fam Physician Sep 15 2013 88(6) 388ndash394
Cathleen S Coloacuten-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
Deterioro cognitivo
MMT
El MMSE continua siendo el instrumento mas utilizado 14 estudios (n=10185) 883 sensibilidad (95 CI 813 to 929) y 862 especificidad (95 CI 818 to 897) para un punto de corte de 2324 o 2425 en la deteccioacuten de demencia
Much more limited evidence exists for the following instruments to detect MCI MMSE (k=15 n=5758) IQCODE (k=4 n=975) CDT (k=4 n=4191) Mini-Cog (k=3 n=1092) TICS (k=3 n=568) and the Montreal Cognitive Assessment (MoCA) (k=2 n=251) The sensitivity andor 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 deacuteficits leves de memoria y de lenguaje como consecuencia del uso de tareas mneacutesicas y linguisticas muy simples 2) Su escasa sensibilidad para objetivar los deacuteficits ejecutivos observados en la demencia frontotemporal Existe consenso sobre la utilidad del MMSE para el seguimiento longitudinal del deterioro cognitivo
ACE
El ACE evaluacutea 6 dominios cognitivos El puntaje maacuteximo obtenible es 100 orientacioacuten atencioacuten memoria fluencia verbal lenguaje y habilidades visuoespaciales A su vez permite calcular los 30 puntos del MMSE ya que estaacuten incluidos en el cuestionario
El coeficiente VLOM del ACE en espantildeolpermite una orientacioacuten para el diagnoacutesticodiferencial entre DTA y DFT
Punto de corteAlta educacioacuten 86
Baja educacioacuten68
Clinical ReviewCognitive assessment of older peopleBMJ 2011343d5042bull Formal detection of these
syndromes may enable identification of treatable conditions is associated with better outcomes for patients and requires routine cognitive assessment
bull Cognitive assessment requires integration of information acquired from observing the patient and talking with carers and from the results of an assessment instrument
bull Cognitive assessment instruments are brief easy to use and sensitive to cognitive impairment
Observacioacuten del pacienteLa informacioacuten del convivienteY el resultado de los test
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Caiacutedas Disminucioacuten visioacutenMedicamentos
Perdida de pesohellip
Functional Decline in Older AdultsAm Fam Physician Sep 15 2013 88(6) 388ndash394
Cathleen S Coloacuten-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
Deterioro cognitivo
MMT
El MMSE continua siendo el instrumento mas utilizado 14 estudios (n=10185) 883 sensibilidad (95 CI 813 to 929) y 862 especificidad (95 CI 818 to 897) para un punto de corte de 2324 o 2425 en la deteccioacuten de demencia
Much more limited evidence exists for the following instruments to detect MCI MMSE (k=15 n=5758) IQCODE (k=4 n=975) CDT (k=4 n=4191) Mini-Cog (k=3 n=1092) TICS (k=3 n=568) and the Montreal Cognitive Assessment (MoCA) (k=2 n=251) The sensitivity andor 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 deacuteficits leves de memoria y de lenguaje como consecuencia del uso de tareas mneacutesicas y linguisticas muy simples 2) Su escasa sensibilidad para objetivar los deacuteficits ejecutivos observados en la demencia frontotemporal Existe consenso sobre la utilidad del MMSE para el seguimiento longitudinal del deterioro cognitivo
ACE
El ACE evaluacutea 6 dominios cognitivos El puntaje maacuteximo obtenible es 100 orientacioacuten atencioacuten memoria fluencia verbal lenguaje y habilidades visuoespaciales A su vez permite calcular los 30 puntos del MMSE ya que estaacuten incluidos en el cuestionario
El coeficiente VLOM del ACE en espantildeolpermite una orientacioacuten para el diagnoacutesticodiferencial entre DTA y DFT
Punto de corteAlta educacioacuten 86
Baja educacioacuten68
Clinical ReviewCognitive assessment of older peopleBMJ 2011343d5042bull Formal detection of these
syndromes may enable identification of treatable conditions is associated with better outcomes for patients and requires routine cognitive assessment
bull Cognitive assessment requires integration of information acquired from observing the patient and talking with carers and from the results of an assessment instrument
bull Cognitive assessment instruments are brief easy to use and sensitive to cognitive impairment
Observacioacuten del pacienteLa informacioacuten del convivienteY el resultado de los test
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Functional Decline in Older AdultsAm Fam Physician Sep 15 2013 88(6) 388ndash394
Cathleen S Coloacuten-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
Deterioro cognitivo
MMT
El MMSE continua siendo el instrumento mas utilizado 14 estudios (n=10185) 883 sensibilidad (95 CI 813 to 929) y 862 especificidad (95 CI 818 to 897) para un punto de corte de 2324 o 2425 en la deteccioacuten de demencia
Much more limited evidence exists for the following instruments to detect MCI MMSE (k=15 n=5758) IQCODE (k=4 n=975) CDT (k=4 n=4191) Mini-Cog (k=3 n=1092) TICS (k=3 n=568) and the Montreal Cognitive Assessment (MoCA) (k=2 n=251) The sensitivity andor 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 deacuteficits leves de memoria y de lenguaje como consecuencia del uso de tareas mneacutesicas y linguisticas muy simples 2) Su escasa sensibilidad para objetivar los deacuteficits ejecutivos observados en la demencia frontotemporal Existe consenso sobre la utilidad del MMSE para el seguimiento longitudinal del deterioro cognitivo
ACE
El ACE evaluacutea 6 dominios cognitivos El puntaje maacuteximo obtenible es 100 orientacioacuten atencioacuten memoria fluencia verbal lenguaje y habilidades visuoespaciales A su vez permite calcular los 30 puntos del MMSE ya que estaacuten incluidos en el cuestionario
El coeficiente VLOM del ACE en espantildeolpermite una orientacioacuten para el diagnoacutesticodiferencial entre DTA y DFT
Punto de corteAlta educacioacuten 86
Baja educacioacuten68
Clinical ReviewCognitive assessment of older peopleBMJ 2011343d5042bull Formal detection of these
syndromes may enable identification of treatable conditions is associated with better outcomes for patients and requires routine cognitive assessment
bull Cognitive assessment requires integration of information acquired from observing the patient and talking with carers and from the results of an assessment instrument
bull Cognitive assessment instruments are brief easy to use and sensitive to cognitive impairment
Observacioacuten del pacienteLa informacioacuten del convivienteY el resultado de los test
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Deterioro cognitivo
MMT
El MMSE continua siendo el instrumento mas utilizado 14 estudios (n=10185) 883 sensibilidad (95 CI 813 to 929) y 862 especificidad (95 CI 818 to 897) para un punto de corte de 2324 o 2425 en la deteccioacuten de demencia
Much more limited evidence exists for the following instruments to detect MCI MMSE (k=15 n=5758) IQCODE (k=4 n=975) CDT (k=4 n=4191) Mini-Cog (k=3 n=1092) TICS (k=3 n=568) and the Montreal Cognitive Assessment (MoCA) (k=2 n=251) The sensitivity andor 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 deacuteficits leves de memoria y de lenguaje como consecuencia del uso de tareas mneacutesicas y linguisticas muy simples 2) Su escasa sensibilidad para objetivar los deacuteficits ejecutivos observados en la demencia frontotemporal Existe consenso sobre la utilidad del MMSE para el seguimiento longitudinal del deterioro cognitivo
ACE
El ACE evaluacutea 6 dominios cognitivos El puntaje maacuteximo obtenible es 100 orientacioacuten atencioacuten memoria fluencia verbal lenguaje y habilidades visuoespaciales A su vez permite calcular los 30 puntos del MMSE ya que estaacuten incluidos en el cuestionario
El coeficiente VLOM del ACE en espantildeolpermite una orientacioacuten para el diagnoacutesticodiferencial entre DTA y DFT
Punto de corteAlta educacioacuten 86
Baja educacioacuten68
Clinical ReviewCognitive assessment of older peopleBMJ 2011343d5042bull Formal detection of these
syndromes may enable identification of treatable conditions is associated with better outcomes for patients and requires routine cognitive assessment
bull Cognitive assessment requires integration of information acquired from observing the patient and talking with carers and from the results of an assessment instrument
bull Cognitive assessment instruments are brief easy to use and sensitive to cognitive impairment
Observacioacuten del pacienteLa informacioacuten del convivienteY el resultado de los test
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
MMT
El MMSE continua siendo el instrumento mas utilizado 14 estudios (n=10185) 883 sensibilidad (95 CI 813 to 929) y 862 especificidad (95 CI 818 to 897) para un punto de corte de 2324 o 2425 en la deteccioacuten de demencia
Much more limited evidence exists for the following instruments to detect MCI MMSE (k=15 n=5758) IQCODE (k=4 n=975) CDT (k=4 n=4191) Mini-Cog (k=3 n=1092) TICS (k=3 n=568) and the Montreal Cognitive Assessment (MoCA) (k=2 n=251) The sensitivity andor 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 deacuteficits leves de memoria y de lenguaje como consecuencia del uso de tareas mneacutesicas y linguisticas muy simples 2) Su escasa sensibilidad para objetivar los deacuteficits ejecutivos observados en la demencia frontotemporal Existe consenso sobre la utilidad del MMSE para el seguimiento longitudinal del deterioro cognitivo
ACE
El ACE evaluacutea 6 dominios cognitivos El puntaje maacuteximo obtenible es 100 orientacioacuten atencioacuten memoria fluencia verbal lenguaje y habilidades visuoespaciales A su vez permite calcular los 30 puntos del MMSE ya que estaacuten incluidos en el cuestionario
El coeficiente VLOM del ACE en espantildeolpermite una orientacioacuten para el diagnoacutesticodiferencial entre DTA y DFT
Punto de corteAlta educacioacuten 86
Baja educacioacuten68
Clinical ReviewCognitive assessment of older peopleBMJ 2011343d5042bull Formal detection of these
syndromes may enable identification of treatable conditions is associated with better outcomes for patients and requires routine cognitive assessment
bull Cognitive assessment requires integration of information acquired from observing the patient and talking with carers and from the results of an assessment instrument
bull Cognitive assessment instruments are brief easy to use and sensitive to cognitive impairment
Observacioacuten del pacienteLa informacioacuten del convivienteY el resultado de los test
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
ACE
El ACE evaluacutea 6 dominios cognitivos El puntaje maacuteximo obtenible es 100 orientacioacuten atencioacuten memoria fluencia verbal lenguaje y habilidades visuoespaciales A su vez permite calcular los 30 puntos del MMSE ya que estaacuten incluidos en el cuestionario
El coeficiente VLOM del ACE en espantildeolpermite una orientacioacuten para el diagnoacutesticodiferencial entre DTA y DFT
Punto de corteAlta educacioacuten 86
Baja educacioacuten68
Clinical ReviewCognitive assessment of older peopleBMJ 2011343d5042bull Formal detection of these
syndromes may enable identification of treatable conditions is associated with better outcomes for patients and requires routine cognitive assessment
bull Cognitive assessment requires integration of information acquired from observing the patient and talking with carers and from the results of an assessment instrument
bull Cognitive assessment instruments are brief easy to use and sensitive to cognitive impairment
Observacioacuten del pacienteLa informacioacuten del convivienteY el resultado de los test
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
El ACE evaluacutea 6 dominios cognitivos El puntaje maacuteximo obtenible es 100 orientacioacuten atencioacuten memoria fluencia verbal lenguaje y habilidades visuoespaciales A su vez permite calcular los 30 puntos del MMSE ya que estaacuten incluidos en el cuestionario
El coeficiente VLOM del ACE en espantildeolpermite una orientacioacuten para el diagnoacutesticodiferencial entre DTA y DFT
Punto de corteAlta educacioacuten 86
Baja educacioacuten68
Clinical ReviewCognitive assessment of older peopleBMJ 2011343d5042bull Formal detection of these
syndromes may enable identification of treatable conditions is associated with better outcomes for patients and requires routine cognitive assessment
bull Cognitive assessment requires integration of information acquired from observing the patient and talking with carers and from the results of an assessment instrument
bull Cognitive assessment instruments are brief easy to use and sensitive to cognitive impairment
Observacioacuten del pacienteLa informacioacuten del convivienteY el resultado de los test
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Clinical ReviewCognitive assessment of older peopleBMJ 2011343d5042bull Formal detection of these
syndromes may enable identification of treatable conditions is associated with better outcomes for patients and requires routine cognitive assessment
bull Cognitive assessment requires integration of information acquired from observing the patient and talking with carers and from the results of an assessment instrument
bull Cognitive assessment instruments are brief easy to use and sensitive to cognitive impairment
Observacioacuten del pacienteLa informacioacuten del convivienteY el resultado de los test
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Escala cliacutenica de la demencia (CDR)
DCL
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Funcionalidad AVD_AIVD
AVD indice de Katz (bantildeo vestirse continencia alimentacioacuten transferencia movilidad aseo)
AIVD indice de Lawton y Brody (uso de teleacutefono compras cocinar transporte manejo de medicacioacuten y dinero)
La declinacioacuten funcional es frecuente en ancianos
Multicausal (sociales financieros comorbilidades severas etc)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Riesgo de Caiacutedas
Clin Cases Miner Bone Metab 2013
The prevalence of fall according to the increasing of age
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Time get up and go test
ldquolevantarse (sin usar apoyabrazos) camine 3 mts de la vuelta y vuelva a sentarserdquo
gt16seg riesgo de caiacutedas
Prueba de alcance funcional
ldquopararse con el brazo extendido Inclinarse para adelantar el puntildeo lo mas lejos posible sin dar un paso o perder la estabilidadrdquo
lt15cm riesgo de caiacutedas
TUG is not useful for discriminating fallers from non-fallers in healthy high-functioning older people but is of more value in less-healthy lower-functioning older people Multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls
Journal of the American Geriatrics SocietyVolume 61 Issue 2 pages 202ndash208
February 2013
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Riesgo de depresioacuten GDS
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Among multimorbid elderly patients depression was associated with
significantly higher health care utilization and costs
A number of empirical studies support for a bidirectional
association between depression and frailty in later life
PLoS One 2014
Int J Geriatr Psychiatry 2012
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Polifarmacia y medicacioacuten potencialmente inapropiada seguacuten criterios de BEERS
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsThe American Geriatrics Society 2012 Beers Criteria Update Expert Panel
Evitar uso de BDZ en ancianosMayor sensibilidad a las BDZ menor capacidad de metabolizar drogas de
accioacuten larga aumento en el riesgo de deterioro cognitivo delirium y caiacutedas
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
El objetivo del 2012 AGS Beers Criteria es mejorar el cuidado de los ancianos reduciendo la exposicioacuten a drogas
potencialmente inapropiadas
Adverse Drug Events in Older Patients Admitted as an EmergencyThe Role of Potentially Inappropriate Medication in Elderly People (PRISCUS) Dtsch Arztebl Int Mar 2013
EM+ medication errors leadingTo clinical events
Medication errors
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Riesgo nutricional El nivel nutricional es un
factor independiente de caiacutedas en ancianos de la comunidad PLoS One 2014
Hay una fuerte correlacioacuten entre deterioro cognitivo bajo nivel nutricional (Plt0005) declinacioacuten funcional (Plt005) y mortalidad (Plt001) Clin Interv Aging 2014
Existe una relacioacuten
directa entre nivel nutricional y declinacioacuten funcional Nutr J 2009
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Comorbilidades Escala CIRS_G Cumulative Illness Rating Scale for Geriatric
CARDIacuteACA 3-IAM 5 antildeos previos prueba de estreacutes anormal antec de angioplastiacutea o CRM derrame pericaacuterdico o pericarditis 4-Restriccioacuten marcada de la actividad secundaria a problema cardiacuteaco (por ej angina inestable o ICC intratable)VASCULAR3-2 o + siacutentomas de ateroesclerosis 2 o + drogas para HTA o HVI 2 o + siacutentomas de enfermedad vascular perifeacuterica 4-Cirugiacutea previa por problema vascular aneurisma aoacutertico gt4 cm
CAacuteNCER3-Requirioacute quimioterapia radioterapia terapia hormonal o procedimiento quiruacutergico para caacutencer en los uacuteltimos 5 antildeos 4-Malignidad recurrente con potencial de amenaza para la vida contencioacuten fallada de malignidad primaria tratamiento paliativo
PSIQUIAacuteTRICA3-Actualmente con depresioacuten mayor o 2 o + episodios de depresioacuten gt en los uacuteltimos 10 antildeos demencia moderada (MMT 15-20) uso actual de medicacioacuten ansioliacutetica actual abuso de sustancia o dependencia requiere medicacioacuten antipsicoacutetica diaria 4-Enfermedad mental actual requiriendo hospitalizacioacuten institucionalizacioacuten o manejo ambulatorio intensivo depresioacuten severa o suicida psicosis aguda o descompensacioacuten psicoacutetica agitacioacuten severa por demencia intoxicacioacuten por sustancias demencia severa (MMTlt15)
ENDOCRINO-METABOacuteLICA Y MAMA3-Cualquier alteracioacuten electroliacutetica que requiere tratamiento hospitalario BMIgt45 DBT regularmente controlada en valores de 300 mgdl con leve retinopatiacutea o neuropatiacutea perifeacuterica 4-DBT laacutebil o pobremente controlada o coma diabeacutetico en el uacuteltimo antildeo requiere terapia de reemplazo adrenal carcinoma adrenal tiroideo o de mama
NEUROLOacuteGICO3-ACV con disfuncioacuten residual leve cualquier procedimiento neurocx enf neurodegenerativa de severidad moderada 4-ACV con hemiparesia o afasia funcional residual enfermedad neurodegenerativa severa
MUSCULO-ESQUELEacuteTICO3- Limitacioacuten severa en AVD x artritis requiere corticoides para condicioacuten artriacutetica fracturas de compresioacuten vertebral por osteoporosis4-Limitado a silla de ruedas deformidad articular severa o uso severamente limitado osteomielitis cualquier carcinoma de hueso o muacutesculo melanoma metastaacutesico
GENITOURINARIO3- Caacutencer prostaacutetico in situ sangrado vaginal carcinoma cervical in situ hematuria urosepsis en el uacuteltimo antildeo incontinencia diaria requiriendo pantildeales o incontinencia nocturna regular ITUs a repeticioacuten en el varoacuten 4-Retencioacuten aguda de orina cualquier carcinoma genitourinario urosepsis actual
HEPATOBILIAR3-Bilirrubina (total gt2)elevacioacuten de transaminasas (gt150 de lo normal) requerimiento de enz pancreaacuteticas para la digestioacuten 4-Obstruccioacuten biliar cualquier carcinoma del aacuterbol biliar colecistitis pancreatitis hepatitis activa
RENAL3-Creatinina seacuterica gt3 o gt 15 en conjuncioacuten con diureacutetico antihipertensivo o tratamiento con bicarbonato pielonefritis actual 4-Requerimiento de diaacutelisis carcinoma renal
GASTRO-INTESTINAL INFERIOR3-Impactacioacuten fecal en el uacuteltimo antildeo uso diario de laxantes estimulantes o enemas4-Hematoquezia impactacioacuten fecal actual diverticulitis antecde obstruccioacuten intestinal caacutencer intestinal
OCULARES OTORRINOLA-RINGOLOacuteGICA3-Parcialmente ciego requiere un acompantildeante para salir incapaz de leer el diario no escucha bien a pesar de audiacutefono 4-Ceguera funcional incapacidad de leer reconocer una cara familiar o desenvolverse en un ambiente nuevo sordera funcional laringectomiacutea requerimiento de intervencioacuten quiruacutergica para veacutertigo
GASTRO-INTESTINAL SUPERIOR3-Ulcera activa SOMF + disglusia o disfagia 4-Cancer gaacutestrico historia de uacutelcera perforada melena o hematoquezia de origen GI superior
RESPIRATORIA3-Deambulacion limitada secundaria a capacidad respiratoria limitada requiere corticoides orales tbq gt40 py nac aguda 4-Requiere oxiacutegeno suplementario al menos un episodio de falla respiratoria requiriendo ARM caacutencer pulmonar
HEMATOPOYEacuteTICA3-Hb mujeres lt8 varones lt10 GBlt2000 4-Leucemia o linfoma
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
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
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Sobrecarga de cuidador
Factors associated with caregiver burden in patients with Alzheimers disease Psychiatry Investig 2014
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
47 a 55 sobrecarga leveSensibilidad 851 Especificidad 844
gt55 sobrecarga intensaSensibilidad 906 Especificidad 933
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Valoracioacuten social
OARS
CAGE (Alcoholismo)
Valoracioacuten de los cuidadores
Valoracioacuten semi-estructurada Soporte informal (amigos familia)
Soporte formal (bienestar social servicios de salud)
Soporte semiformal (Iglesia centros de jubilados sociedades de fomento)
Valoracioacuten estructurada por asistente social
Herramienta diagnoacutestica multidimensional adaptada
En espantildeol Proporciona informacioacutenacerca de cinco aacutereas estructura familiar y
recursos sociales recursos econoacutemicos
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Recomendaciones Sospecha de probable deterioro cognitivo
Estimulacioacuten cognitivaNonpharmacological therapies in Alzheimerrsquos 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 caregiversrsquo health-
BMC Geriatr 2014
Reevaluacioacuten en 6 meses ()
Manejo sobre riesgos de sobrecarga en cuidador
Eventual uso de anti-demenciales
Esfera cognitivaSiacutentomas
conductualesSobrecarga del
cuidador
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Recomendaciones Riesgo de caiacutedas
Recomendacioacuten de uso de bastoacuten
Recomendacioacuten de prevencioacuten de caiacutedas en domicilio
Eventual inicio de KNM para rehabilitacioacuten 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
Evaluacioacuten de medicacioacuten potencialmente inapropiada por riesgo alto de caiacutedas
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 lt 001) severe falls (p lt 001) and female sex (p = 003)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Pattern Screening and assessment
Intervention
Unstable health conditions Medical assessment Medical management may include geriatrician review medication reviewintervention to increase compliance referral for follow-up of medicalconditions
Under nutrition Setting appropriate screening
Mini Nutritional Assessment
Referral to a dietician for nutritional support educationabout foodsnutrition advice benefits of regular exercise and nutrition supportThe NICE clinical guideline lsquoNutrition Support in Adultsrsquo provides high qualityevidence for oral nutrition support in adults with malnutrition
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Pattern Screening and assessment
intervention
Psychological factors Geriatric Depression Scale (short form)
Frail older depressed patients are particularly susceptible to side effects ofantidepressant medication Antidepressant is effective inthe treatment of older peopleThe NICE clinical guideline lsquoOccupational therapy interventions and physicalactivity interventions to promote the mental wellbeing of older people inprimary care and residential carersquo
Impaired cognition Mini Mental Status Examination (MMSE)
Impaired visionhearing
Brief clinical assessment Referral for specialist Facilitate self-management of aids for visionhearing
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Patterns Screening and assessment
intervention
Decreased mobility Timed 4 m walkTimed Up and GoLower limb strength Timed sit to standBalance 4-point balance testFalls 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 andmultifactorial falls assess-ment and intervention are also effective
Problems withservices or supportsystems
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
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Queacute deberiacutea formar parte de la VGI
Calidad de vida Older Peoples 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 (institucionalizacioacuten y mortalidad) al antildeo 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 1003 95 [CI] 125-8054 P = 0030) and death (OR 423 95 CI 106-1681 P = 0041)
Top Related