- Email: [email protected]
Healthy aging and use of medicines
S26
8th Congress of the EUGMS / European Geriatric Medicine 3S (2012) S1–S32
introduce the relationship between strength of the muscles, sarcopenia and its influence on the quality of gait, in order to verify if the assessment and treatment of sarcopenia could influence the quality of the gait in older persons. Disclosure.– No significant relationships. http://dx.doi.org/10.1016/j.eurger.2012.07.433 O070
Improving functional status in rehabilitation F. Martin United Kingdom Improving functional status and quality of life are the key purposes of rehabilitation in clinical practice with older people. Rehabilitation implies that the individual has lost some function which may be recoverable. This may happen gradually and present as increased need for help in a community dwelling person. Or there may be a clear precipitating event such as an injury, acute illness or surgery. The precipitating event will influence the nature of the change in the individual. The impact on function is mediated through a variety of pathways. The WHO International Classification of Functioning, Disability and Health (ICF, http://www.who.int/classifications/icf/en/) provides a model. This clarifies that age-related frailty as well as specific diseases act to produce impairments in organs, systems or integration. These impact capacity, and the consequences of reduced capacity on social participation and quality of life depends upon psychosocial and environmental factors. For example, an acute stroke, causing a major neurologically based impairment may result in a sudden loss of function, causing reduced capacity. The extent of functional recovery is significantly affected by the spontaneous or induced reversal of neurological impairment. For survivors, it then becomes dependent on the amelioration of the slower additional impairments in nutrition, ventilatory capacity, aerobic capacity. And finally, fulfilling the functional recovery also depends on enhancement of psychosocial factors of mood, confidence and social engagement. In contrast, in a frail individual with a range of subcritical impairments, a relatively minor acute illness may precipitate functional loss and the recovery of this function is dependent upon a broader approach from the start. In people with chronic diseases, such as COPD, t he major obvious impairment only explains part of the variance in capacity. Frailty, deconditioning, mood, cognition, social support and other factors are also important. So in most clinical situations, rehabilitation requires a combination of approaches including those that may be specific to the condition, e.g. stroke, and non-specific approaches that address these other issues. So, rehabilitation after hip fracture needs good surgery but also management of delirium. Rehabilitation after stroke needs management of depression and support for carers at home. Planning a rehabilitation programme therefore requires recognition of frailty and diseases and their impact on impairment. But this is insufficient without understanding: which of the impairments are limiting capacity and; what are the psychosocial and environmental factors either enhancing or impeding the effects of this capacity loss on overall activity (social participation). The choice of skills needed depends on this analysis. Most patients will need a multidisciplinary approach but a holistic approach incorporates the right inputs at the right stage of the patients recovery. For some patients, an early medical diagnosis is crucial to plan rehabilitation, but for others, it is the general recognition of frailty impairments, which is needed. For some the physiotherapist is more important, but for others it is the adjustment of the environment or provision of new techniques by an occupational therapist, which makes the difference. Increasing self-efficacy and relationships is also important for a fuller recovery of the person.
I will review systematic reviews of the clinical trial evidence for specific examples of rehabilitation, and show example of the importance of a holistic approach. http://dx.doi.org/10.1016/j.eurger.2012.07.434 O071
Urinary and fecal incontinence in rehabilitation P. Chassagne Department of Geriatrics, Rouen University, Rouen, France Continence is one of the six basic activities of daily life, which is therefore systematically assessed to evaluate the geriatric profile of old people. Indeed, urinary and/or fecal incontinence are strong markers of disability. These two conditions should always be taken into consideration simultaneously for many reasons. First, epidemiologic data have strongly demonstrated the association between continence status and common geriatric syndromes or diseases such as mobility impairment, dementia or drug side effects. Second, some major mechanisms such as pelvic floor injuries or neurologic diseases (e.g.: Alzheimer disease, stroke, spinal cord impairment) may predispose to both conditions. Finally, the management of incontinence requires comprehensive assessment of patients in their usual environment. Geriatric rehabilitation, such as it is proposed in sub-acute care units, systematically includes specific programs to manage incontinence. Regarding both urinary and fecal incontinence, clinical approaches are much more efficient than realization of complementary explorations. Patient interview coupled with objective measurement of symptom frequency, using diaries and of course careful clinical examination enable diagnosis of urinary incontinence in up to 90% of cases. After this first clinical step, patients are classified in four groups according to their incontinence mechanisms: stress, urge, overflow and environment. As regards fecal incontinence, two groups of patients are defined according to the presence or absence of chronic constipation (especially rectal outlet delay). Caregivers then provide multi-component care techniques, which all contribute to impacting on continence recovery (from daily monitoring of voiding, to personalized physical exercise and finally to planning return home to an appropriate and adapted environment for the patient). The goal of this lecture is for geriatricians and caregivers to discuss that practical knowledge, relevant to the rehabilitation of incontinence in older adults. http://dx.doi.org/10.1016/j.eurger.2012.07.435 O072
Healthy aging and use of medicines A. Gudmundsson The relationship between use of medicines, well-being and function in older age remains complex. In the past century, vaccinations and antibiotics saved the lives of more children than any other medical product and may have ignited the demographic transition towards healthier aging and survival. Advancements in diagnostic technologies, drug treatments, interventional procedures and life style changes have delayed disability and improved life expectancy for older populations in recent decades. A major decrease in death rates from heart disease is a good example of this development. Older patients may benefit from preventive drug therapy to a greater extent than younger patients due to higher absolute risk of disease. However, functional geriatric outcomes are rarely included and “typical” users and the oldest old remain largely underrepresented in clinical trials. A continuous increase in drug use among older people has been noted and is in parallel with the number of new clinical guidelines.
8th Congress of the EUGMS / European Geriatric Medicine 3S (2012) S1–S32
Mistakes in drug administration, use of inappropriate medications and adverse drug reactions are a global phenomenon and a threat to healthy aging. Also, rapid emergence of antibiotic resistant bacteria and lack of adherence to life course vaccinations may jeopardize the health of geriatric populations. To maintain and improve the health and quality of life of older people, safe drugs and medication practices along with patient focused care are needed. Many geriatricians agree that non-pharmacologic and rehabilitative therapies are currently under-utilized and a collaborative approach with pharmacologic interventions is needed to ensure healthy aging. Numerous genes for aging and longevity have been identified in recent years. Many therapeutic targets specific to neurodegenerative diseases have been identified. These along with the discovery of cellular pathways mediating the longevity effects of caloric restriction are examples of promising leads for new drug developments that may support healthy aging by delaying age related diseases. http://dx.doi.org/10.1016/j.eurger.2012.07.436 O073
InterRAI assessment instruments: Basics, applications and research M. Ribbe a,∗ , P.V. Jónsson b,∗ , R. Bernabei c,∗ , G. Onder c,∗ , R.J. Van Marum d,∗ a Nursing Home Medicine, Amsterdam, Netherlands b Geriatrics, Landspítali University Hospital, Reykjavik, Iceland c Geriatrician, Università Cattolica del Sacro Cuore, Rome, Italy d Geriatrician And Clinical Pharmacologist, Jeroen Bosch Hospital, GZ Hertogenbosch, Netherlands ∗ Corresponding author. Session Description/Moderator Details.– interRAI Assessment Instruments: basics, applications and research Chair: Prof. Dr. M.W. Ribbe, nursing home physician, department of Nursing Home Medicine, VU University medical center, Amsterdam, the Netherlands Cochair: Prof. Dr. R. Bernabei, geriatrician, Università Cattolica del Sacro Cuore, Roma, Italia This symposium presents the basics of the interRAI assessment instruments, the potential and relevance of the interRAI Acute Care Instrument in the hospital setting, the results of a European Union research study on patients and care in nursing homes, and psychotropic drug use in nursing homes. Each presentation will take 18 minutes with 4 minutes discussion: – interRAI assessment instruments: essentials, facts and figures Prof. Dr. Miel W. Ribbe, nursing home medicine physician, VU University medical center, Amsterdam, the Netherlands The interRAI assessment instruments comprise a new technology for comprehensive geriatric assessment. Instrument related Client Assessment Protocols CAP’s assist the assessor to further analyse triggered health problems in the frail elderly and geriatric patient. The assessment data of individual patients allow for the development of a database that can be used for the construction of patient related quality indicators, research and health care management information. The use of interRAI data for research will be illustrated by a study in Finland, the Netherlands and Italy, which focuses on pain symptoms in nursing home patients in these countries; – interRAI Acute Care instrument: relevance for hospitals and results from the North European Acute Care study. Prof. Dr. Palmi V. Jónsson, geriatrician, Landspitali-University Hospital, Reykjavik, Iceland. InterRAI developed an assessment instrument for geriatric care in hospitals. With this instrument assessment of the prior and current diagnoses, health care problems, multi-morbidity, geriatric giants and effects of diseases on functioning of the patient can be assessed for proper care planning. The benefits and possible applications of this instrument will be presented by the results of an implementation study in the Northern European countries and implementation results in hospital settings in Austra; – SHELTER: design and results from the EU nursing home study Prof. Dr. Graziano Onder, geriatrician, Università Cattolica del Sacro Cuore, Roma, Italia SHELTER is an European study with the
S27
interRAI Long Term Care assessment instrument to study characteristics of European nursing home patients and to find the best nursing home care model by studying high quality patient outcomes in the participating facilities; – psychotropic Drug Use in nursing homes: combining interRAI research data and data from pharmacists Dr. Rob J. van Marum, geriatrician and clinical pharmacologist, Jeroen Bosch Hospital, Hertogenbosch, the Netherlands In this study data of Dutch nursing home patients assessed with the interRAI Long Term Care assessment instrument (VURAI database) were combined with the data of the pharmacists that collaborate with the participating nursing homes and their included patients in this study. From this database research results of psychotropic drug use (prescription of psychotropic drugs, side effects and–lack of–therapeutic effects) in nursing home patients will be presented. Correspondence: Prof. Dr. M.W. Ribbe, E: [email protected]. Abstract 1.– InterRAI Assessment Instruments: basics, applications and research 1. interRAI assessment instruments: essentials, facts and figures Prof. Dr. Miel W. Ribbe, nursing home medicine physician, VU University medical center, Amsterdam, the Netherlands The interRAI assessment instruments comprise a new technology for comprehensive geriatric assessment. Instrument related Client Assessment Protocols CAP’s assist the assessor to further analyse triggered health problems in the frail elderly and geriatric patient. The assessment data of individual patients allow for the development of a database that can be used for the construction of patient related quality indicators, research and health care management information. The use of interRAI data for research will be illustrated by a study in Finland, the Netherlands and Italy, which focuses on pain symptoms in nursing home patients in these countries. Abstract 2.– InterRAI Assessment Instruments: basics, applications and research 2. interRAI Acute Care instrument: relevance for hospitals and results from the North European Acute Care study. Prof. Dr. Palmi V. Jónsson, geriatrician, Landspitali-University Hospital, Reykjavik, Iceland. InterRAI developed an assessment instrument for geriatric care in hospitals. With this instrument assessment of the prior and current diagnoses, health care problems, multimorbidity, geriatric giants and effects of diseases on functioning of the patient can be assessed for proper care planning. The benefits and possible applications of this instrument will be presented by the results of an implementation study in the Northern European countries and implementation results in hospital settings in Australia. Abstract 3.– InterRAI Assessment Instruments: basics, applications and research 3. SHELTER: design and results from the EU nursing home study Prof. Dr. Graziano Onder, geriatrician, Università Cattolica del Sacro Cuore, Roma, Italia SHELTER is an European study with the interRAI Long Term Care assessment instrument to study characteristics of European nursing home patients and to find the best nursing home care model by studying high quality patient outcomes in the participating facilities. Abstract 4.– InterRAI Assessment Instruments: basics, applications and research 4. Psychotropic Drug Use in nursing homes: combining interRAI research data and data from pharmacists Dr. Rob J. van Marum, geriatrician and clinical pharmacologist, Jeroen Bosch Hospital, Hertogenbosch, the Netherlands In this study data of Dutch nursing home patients assessed with the interRAI Long Term Care assessment instrument (VURAI database) were combined with the data of the pharmacists that collaborate with the participating nursing homes and their included patients in this study. From this database research results of psychotropic drug use (prescription of psychotropic drugs, side effects and – lack of – therapeutic effects) in nursing home patients will be presented. Correspondence: Prof. Dr. M.W. Ribbe, E: [email protected]. Disclosure.– No significant relationships. http://dx.doi.org/10.1016/j.eurger.2012.07.437
8th Congress of the EUGMS / European Geriatric Medicine 3S (2012) S1–S32
introduce the relationship between strength of the muscles, sarcopenia and its influence on the quality of gait, in order to verify if the assessment and treatment of sarcopenia could influence the quality of the gait in older persons. Disclosure.– No significant relationships. http://dx.doi.org/10.1016/j.eurger.2012.07.433 O070
Improving functional status in rehabilitation F. Martin United Kingdom Improving functional status and quality of life are the key purposes of rehabilitation in clinical practice with older people. Rehabilitation implies that the individual has lost some function which may be recoverable. This may happen gradually and present as increased need for help in a community dwelling person. Or there may be a clear precipitating event such as an injury, acute illness or surgery. The precipitating event will influence the nature of the change in the individual. The impact on function is mediated through a variety of pathways. The WHO International Classification of Functioning, Disability and Health (ICF, http://www.who.int/classifications/icf/en/) provides a model. This clarifies that age-related frailty as well as specific diseases act to produce impairments in organs, systems or integration. These impact capacity, and the consequences of reduced capacity on social participation and quality of life depends upon psychosocial and environmental factors. For example, an acute stroke, causing a major neurologically based impairment may result in a sudden loss of function, causing reduced capacity. The extent of functional recovery is significantly affected by the spontaneous or induced reversal of neurological impairment. For survivors, it then becomes dependent on the amelioration of the slower additional impairments in nutrition, ventilatory capacity, aerobic capacity. And finally, fulfilling the functional recovery also depends on enhancement of psychosocial factors of mood, confidence and social engagement. In contrast, in a frail individual with a range of subcritical impairments, a relatively minor acute illness may precipitate functional loss and the recovery of this function is dependent upon a broader approach from the start. In people with chronic diseases, such as COPD, t he major obvious impairment only explains part of the variance in capacity. Frailty, deconditioning, mood, cognition, social support and other factors are also important. So in most clinical situations, rehabilitation requires a combination of approaches including those that may be specific to the condition, e.g. stroke, and non-specific approaches that address these other issues. So, rehabilitation after hip fracture needs good surgery but also management of delirium. Rehabilitation after stroke needs management of depression and support for carers at home. Planning a rehabilitation programme therefore requires recognition of frailty and diseases and their impact on impairment. But this is insufficient without understanding: which of the impairments are limiting capacity and; what are the psychosocial and environmental factors either enhancing or impeding the effects of this capacity loss on overall activity (social participation). The choice of skills needed depends on this analysis. Most patients will need a multidisciplinary approach but a holistic approach incorporates the right inputs at the right stage of the patients recovery. For some patients, an early medical diagnosis is crucial to plan rehabilitation, but for others, it is the general recognition of frailty impairments, which is needed. For some the physiotherapist is more important, but for others it is the adjustment of the environment or provision of new techniques by an occupational therapist, which makes the difference. Increasing self-efficacy and relationships is also important for a fuller recovery of the person.
I will review systematic reviews of the clinical trial evidence for specific examples of rehabilitation, and show example of the importance of a holistic approach. http://dx.doi.org/10.1016/j.eurger.2012.07.434 O071
Urinary and fecal incontinence in rehabilitation P. Chassagne Department of Geriatrics, Rouen University, Rouen, France Continence is one of the six basic activities of daily life, which is therefore systematically assessed to evaluate the geriatric profile of old people. Indeed, urinary and/or fecal incontinence are strong markers of disability. These two conditions should always be taken into consideration simultaneously for many reasons. First, epidemiologic data have strongly demonstrated the association between continence status and common geriatric syndromes or diseases such as mobility impairment, dementia or drug side effects. Second, some major mechanisms such as pelvic floor injuries or neurologic diseases (e.g.: Alzheimer disease, stroke, spinal cord impairment) may predispose to both conditions. Finally, the management of incontinence requires comprehensive assessment of patients in their usual environment. Geriatric rehabilitation, such as it is proposed in sub-acute care units, systematically includes specific programs to manage incontinence. Regarding both urinary and fecal incontinence, clinical approaches are much more efficient than realization of complementary explorations. Patient interview coupled with objective measurement of symptom frequency, using diaries and of course careful clinical examination enable diagnosis of urinary incontinence in up to 90% of cases. After this first clinical step, patients are classified in four groups according to their incontinence mechanisms: stress, urge, overflow and environment. As regards fecal incontinence, two groups of patients are defined according to the presence or absence of chronic constipation (especially rectal outlet delay). Caregivers then provide multi-component care techniques, which all contribute to impacting on continence recovery (from daily monitoring of voiding, to personalized physical exercise and finally to planning return home to an appropriate and adapted environment for the patient). The goal of this lecture is for geriatricians and caregivers to discuss that practical knowledge, relevant to the rehabilitation of incontinence in older adults. http://dx.doi.org/10.1016/j.eurger.2012.07.435 O072
Healthy aging and use of medicines A. Gudmundsson The relationship between use of medicines, well-being and function in older age remains complex. In the past century, vaccinations and antibiotics saved the lives of more children than any other medical product and may have ignited the demographic transition towards healthier aging and survival. Advancements in diagnostic technologies, drug treatments, interventional procedures and life style changes have delayed disability and improved life expectancy for older populations in recent decades. A major decrease in death rates from heart disease is a good example of this development. Older patients may benefit from preventive drug therapy to a greater extent than younger patients due to higher absolute risk of disease. However, functional geriatric outcomes are rarely included and “typical” users and the oldest old remain largely underrepresented in clinical trials. A continuous increase in drug use among older people has been noted and is in parallel with the number of new clinical guidelines.
8th Congress of the EUGMS / European Geriatric Medicine 3S (2012) S1–S32
Mistakes in drug administration, use of inappropriate medications and adverse drug reactions are a global phenomenon and a threat to healthy aging. Also, rapid emergence of antibiotic resistant bacteria and lack of adherence to life course vaccinations may jeopardize the health of geriatric populations. To maintain and improve the health and quality of life of older people, safe drugs and medication practices along with patient focused care are needed. Many geriatricians agree that non-pharmacologic and rehabilitative therapies are currently under-utilized and a collaborative approach with pharmacologic interventions is needed to ensure healthy aging. Numerous genes for aging and longevity have been identified in recent years. Many therapeutic targets specific to neurodegenerative diseases have been identified. These along with the discovery of cellular pathways mediating the longevity effects of caloric restriction are examples of promising leads for new drug developments that may support healthy aging by delaying age related diseases. http://dx.doi.org/10.1016/j.eurger.2012.07.436 O073
InterRAI assessment instruments: Basics, applications and research M. Ribbe a,∗ , P.V. Jónsson b,∗ , R. Bernabei c,∗ , G. Onder c,∗ , R.J. Van Marum d,∗ a Nursing Home Medicine, Amsterdam, Netherlands b Geriatrics, Landspítali University Hospital, Reykjavik, Iceland c Geriatrician, Università Cattolica del Sacro Cuore, Rome, Italy d Geriatrician And Clinical Pharmacologist, Jeroen Bosch Hospital, GZ Hertogenbosch, Netherlands ∗ Corresponding author. Session Description/Moderator Details.– interRAI Assessment Instruments: basics, applications and research Chair: Prof. Dr. M.W. Ribbe, nursing home physician, department of Nursing Home Medicine, VU University medical center, Amsterdam, the Netherlands Cochair: Prof. Dr. R. Bernabei, geriatrician, Università Cattolica del Sacro Cuore, Roma, Italia This symposium presents the basics of the interRAI assessment instruments, the potential and relevance of the interRAI Acute Care Instrument in the hospital setting, the results of a European Union research study on patients and care in nursing homes, and psychotropic drug use in nursing homes. Each presentation will take 18 minutes with 4 minutes discussion: – interRAI assessment instruments: essentials, facts and figures Prof. Dr. Miel W. Ribbe, nursing home medicine physician, VU University medical center, Amsterdam, the Netherlands The interRAI assessment instruments comprise a new technology for comprehensive geriatric assessment. Instrument related Client Assessment Protocols CAP’s assist the assessor to further analyse triggered health problems in the frail elderly and geriatric patient. The assessment data of individual patients allow for the development of a database that can be used for the construction of patient related quality indicators, research and health care management information. The use of interRAI data for research will be illustrated by a study in Finland, the Netherlands and Italy, which focuses on pain symptoms in nursing home patients in these countries; – interRAI Acute Care instrument: relevance for hospitals and results from the North European Acute Care study. Prof. Dr. Palmi V. Jónsson, geriatrician, Landspitali-University Hospital, Reykjavik, Iceland. InterRAI developed an assessment instrument for geriatric care in hospitals. With this instrument assessment of the prior and current diagnoses, health care problems, multi-morbidity, geriatric giants and effects of diseases on functioning of the patient can be assessed for proper care planning. The benefits and possible applications of this instrument will be presented by the results of an implementation study in the Northern European countries and implementation results in hospital settings in Austra; – SHELTER: design and results from the EU nursing home study Prof. Dr. Graziano Onder, geriatrician, Università Cattolica del Sacro Cuore, Roma, Italia SHELTER is an European study with the
S27
interRAI Long Term Care assessment instrument to study characteristics of European nursing home patients and to find the best nursing home care model by studying high quality patient outcomes in the participating facilities; – psychotropic Drug Use in nursing homes: combining interRAI research data and data from pharmacists Dr. Rob J. van Marum, geriatrician and clinical pharmacologist, Jeroen Bosch Hospital, Hertogenbosch, the Netherlands In this study data of Dutch nursing home patients assessed with the interRAI Long Term Care assessment instrument (VURAI database) were combined with the data of the pharmacists that collaborate with the participating nursing homes and their included patients in this study. From this database research results of psychotropic drug use (prescription of psychotropic drugs, side effects and–lack of–therapeutic effects) in nursing home patients will be presented. Correspondence: Prof. Dr. M.W. Ribbe, E: [email protected]. Abstract 1.– InterRAI Assessment Instruments: basics, applications and research 1. interRAI assessment instruments: essentials, facts and figures Prof. Dr. Miel W. Ribbe, nursing home medicine physician, VU University medical center, Amsterdam, the Netherlands The interRAI assessment instruments comprise a new technology for comprehensive geriatric assessment. Instrument related Client Assessment Protocols CAP’s assist the assessor to further analyse triggered health problems in the frail elderly and geriatric patient. The assessment data of individual patients allow for the development of a database that can be used for the construction of patient related quality indicators, research and health care management information. The use of interRAI data for research will be illustrated by a study in Finland, the Netherlands and Italy, which focuses on pain symptoms in nursing home patients in these countries. Abstract 2.– InterRAI Assessment Instruments: basics, applications and research 2. interRAI Acute Care instrument: relevance for hospitals and results from the North European Acute Care study. Prof. Dr. Palmi V. Jónsson, geriatrician, Landspitali-University Hospital, Reykjavik, Iceland. InterRAI developed an assessment instrument for geriatric care in hospitals. With this instrument assessment of the prior and current diagnoses, health care problems, multimorbidity, geriatric giants and effects of diseases on functioning of the patient can be assessed for proper care planning. The benefits and possible applications of this instrument will be presented by the results of an implementation study in the Northern European countries and implementation results in hospital settings in Australia. Abstract 3.– InterRAI Assessment Instruments: basics, applications and research 3. SHELTER: design and results from the EU nursing home study Prof. Dr. Graziano Onder, geriatrician, Università Cattolica del Sacro Cuore, Roma, Italia SHELTER is an European study with the interRAI Long Term Care assessment instrument to study characteristics of European nursing home patients and to find the best nursing home care model by studying high quality patient outcomes in the participating facilities. Abstract 4.– InterRAI Assessment Instruments: basics, applications and research 4. Psychotropic Drug Use in nursing homes: combining interRAI research data and data from pharmacists Dr. Rob J. van Marum, geriatrician and clinical pharmacologist, Jeroen Bosch Hospital, Hertogenbosch, the Netherlands In this study data of Dutch nursing home patients assessed with the interRAI Long Term Care assessment instrument (VURAI database) were combined with the data of the pharmacists that collaborate with the participating nursing homes and their included patients in this study. From this database research results of psychotropic drug use (prescription of psychotropic drugs, side effects and – lack of – therapeutic effects) in nursing home patients will be presented. Correspondence: Prof. Dr. M.W. Ribbe, E: [email protected]. Disclosure.– No significant relationships. http://dx.doi.org/10.1016/j.eurger.2012.07.437