Geriatriske Syndromer

Solvejg Henneberg Pedersen marts 2013

Indhold

• Geriatriens giganter

• Klassiske syndromer

• Geriatriske syndromer

• Hvad betyder det for praksis?

• Take Home messages

Geriatriske giganter

• Et begreb udviklet af professor Bernard

Isaacs for at sammenfatte de store

sygdomme, der er associeret med aldring

• Selvom de hyppiggeste dødsårsager hos

ældre er cancer, hjertesygdom og

apopleksi, afspejler de geriatriske giganter

det store antal ældre, der er ramt af disse

sygdomsbilleder, og den store betydning

disse har for patienternes uafhængighed

Dr.P.SRINIVAS, ”Giants of Geriatrics-Current Issues and Challenges”, 1st world

congress on HEalthy aging, 2012

Isaac´s Geriatriske giganter

1. Immobilitet

2. Instabilitet

3. Inkontinens

4. Impaired/nedsat intellekt/hukommelse

Geriatriske giganter - Google

Geriatric Giants

• De tre D´er – kognition

– Delirium

– Demens

– Depression

• Dekonditionering

• Fald

• Ernæring

• Hydrering

• Inkontinens og obstipation

• Smerte

• Polyfarmaci

• Hud

Geriatric Giants

1. Frailty

2. Delirium and

Dementia

3. Falls

4. Medication Issues

5. Incontinence

Geriatriske giganter i Danmark 2013

• Fald

• Infektion

• Demens

• Depression

• Funktionstab

• Cancer

• Hjertesygdom

Syndromer

Et klassisk syndrom er ?

“a group of signs and symptoms that occur together and characterize a particular abnormality” (Merriam-Webster Online Dictionary)

“the aggregate of symptoms and signs associated with any morbid process, and constituting together the picture of the disease” (Stedman’s Medical Dictionary)

“ a syndrome refers to a pattern of symptoms and signs with a single underlying cause that may not yet be known” (Olde Rikkert et al. Neth J Med 2003)

Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003;51:574-76.

Olde Rikkert et al: Geriatric syndromes: medical misnomer or progress in

geriatrics, Neth J Med 2003

Traditionelle syndromer

Er klassiske eksempler på

Occam´s razor

Hans filosofiske princip var at man skal ikke kigge efter flere årsager på en effekt/tilstand, hvis en enkelt årsag kan give en passende forklaring.

This is the “Law of Parsimony” also called “Occam’s Razor” because Occam wielded it sharply in his arguments.

Engelsk filosof og teolog

William of Ockham (Occam)

(°1285 - †1349)

Resnik NM: Principles of Internal medicine 14th Ed 1998

Drachman DA. Occam’s razor, geriatric syndromes, and the dizzy patient. Ann Int Med 2000;132:403-404.

“Plurality must not be posited without necessity”

“Do not multiply causes unnecessarily”

Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003;51:574-76.

Apply occams razor

Yngre patient

• Feber

• Kardiel mislyd

• anæmi

• Kan ikke gå – udviklet over få dage

• Embolus i retina

• Nyudviklet urininkontinens

• Diagnose?

Yngre patient

• Feber

• Kardiel mislyd

• anæmi

• Kan ikke gå – udviklet over få dage

• Embolus i retina

• Nyudviklet urininkontinens

• Diagnose?

Endokardit med embolier

Klassisk Occam razor

Ældre mand

• Feber

• Kardiel mislyd

• anæmi

• Kan ikke gå – udviklet over få dage

• Embolus i retina

• Nyudviklet urininkontinens

• Diagnose?

Ældre mand

• Feber

• Kardiel mislyd

• anæmi

• Kan ikke gå – udviklet over få dage

• Embolus i retina

• Nyudviklet urininkontinens

• Diagnose?

Influenza

Aortastenose

Magnyl

Et geriatrisk syndrom

derimod ….

Er dette et syndrom?

Morley JE, Kim MJ, Haren MT, Kevorkian R, Banks WA. Frailty and the aging male. Aging Male. 2005;8:135-40.

Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003;51:574-76.

Olde Rikkert et al: Geriatric syndromes: medical misnomer or progress in

geriatrics, Neth J Med 2003

GS eller

klassisk

syndrom

Flacker JM. What is a

geriatric syndrome

anyway? J Am Geriatr

Soc. 2003;51:574-76.

Geriatrisk syndrom

Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research,

and policy implications of a core geriatric concept. J Am Geriatr Soc 2007

May;55(5):780-91.

Definitioner og beskrivelser

Definition på Geriatrisk Syndrom

• Multifactorial health conditions, that

occur, when the accumulated effects

of impairments in multiple systems

render (an older) person vulnerable to

situational challenges.

Tinetti et al. Shared risk factors for falls, incontinence, and functional dependence.

Unifying the approach to geriatric syndromes. JAMA 1995;273:1348-1353

Hvad er et Geriatrisk Syndrom

• The term is used to capture those clinical

conditions in older persons that do not fit

into discrete disease categories. E.g. delirium, falls, frailty, dizziness, syncope, urinary incontinence.

– refers to the multiple causations of a unified

manifestation.

The conceptualisation of GS aligns itself with the

concept of “phenotype” Fried,L et al: Frailty in Older Adults: Evidence for a Phenotype, J Gerontol

2001;56A:M146-M156.

Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a

core geriatric concept. JAGS 2007;55:780-791.

Kendetegn ved GS

• the outcome is a single phenomenology

rather than a spectrum of symptoms and

signs and results from numerous rather

than a single disruption. In geriatric

syndromes, it is multiple abnormalities that “run

together” to cause a single phenomenology.

• F.eks: in delirium, the cumulative effects of

multiple contributors (impaired cognition,

severe illness, old age, etc.) result in the

delirium phenomenology.

Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003;51:574-76.

Kendetegn ved den geriatriske pt.

• Homeostatic strain caused by a new

disease often leads to symptoms

associated with a different organ

system, particular one compromised by

preexisting disease.

– the weakest link er ofte: hjerne, blærekontrol,

gangfunktion

• Infektion kan manifestere sig som fald

• Smerter kan manifestere sig som konfusion/ delir

• Urininkontinens skyldes immobilisation

Resnick,N : in Harrison´s Principles of Internal Medicine, 15th ed. 2001

Kliniske overvejelser

• Multiple risk factors and organ systems are

often involved.

• Therapeutic management can be helpful

even in the absence of a firm diagnosis or

clarification of the underlying disease.

Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a

core geriatric concept. JAGS 2007;55:780-791.

Many conditions have been called GS... Flacker et al JAGS 2003;51:574-576.

• delirium

• dementia

• depression

• dizziness

• emesis

• falls

• gait disorders

• hearing loss

• insomnia

• urinary incontinence

• language disorders

• functional dependency

• lower extremity problems

• oral and dental problems

• malnutrition

• osteoporosis

• pain

• pressure ulcers

• silent myocardial pectoris

• sexual dysfunction

• syncope

• vision loss

Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc. 2003;51:574-76.

Klassisk syndrom eller

geriatrisk syndrom ?

Ligheder og forskelle

Classical Syndrome vs. GS

• Geriatric interpretation of “syndrome”

– does not refer to the presenting

symptoms

– but to the multiple causations of a

unified manifestation.

Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a

core geriatric concept. JAGS 2007;55:780-791.

• sjælden

• sygdom (gruppe af symptomer)

• Enkelt patogenese

• Intet overlap mellem etiologiske faktorer til forskellige syndromer

• Et syndrom pr. patient

• hyppig

• et symptom

• multifaktoriel oprindelse

• stort overlap mellem etiologiske faktorer til forskellige GS

• mere end et GS pr. patient

Classical Syndrome vs. GS

Comparison of two approaches to Geriatric

Syndromes using falls as an example

Traditional Medical

Approach

(diagnosis and treatment)

• Search for cause of fall

Geriatric Approach

(risk factor assessment and

reduction)

• Search for cause of fall

• Risk factores and

intervention

– intrinsic (leg weakness)

– situational (cane)

– extrinsic (lights)

Phelan et al. Some considerations regarding GS. Ann Int Med 2001;135:1095.

Fælles disponerende faktorer

Til geriatriske syndromer

Shared Risk Factors for Falls, Incontinence,

and Functional Dependence.

Unifying the Approach to Geriatric Syndromes

• Udvalgte geriatriske syndromer:

– Fald

– Inkontinens

– Funktionel afhængighed

• Metode: populationsstudie 1 år

Tinetti et al. Shared risk factors for falls, incontinence, and functional dependence.

Unifying the approach to geriatric syndromes. JAMA 1995;273:1348-1353

Fire uafhængige faktorer, der

predisponerer til inkontinens, fald og

funktionel afhængighed

– Langsom chair stands (lower extremity

impairment),

– Nedsat arm styrke (upper extremity

impairment),

– Nedsat syn og hørelse (sensory

impairment),

– Enten en høj angst eller depression score

(affective impairment).

Tinetti et al. Shared risk factors for falls, incontinence, and functional dependence.

Unifying the approach to geriatric syndromes. JAMA 1995;273:1348-1353

Shared Risk og GS

• Fem geriatriske syndromer udvalgt:

tryksår,

incontinens,

fald,

funktionstab

delirium.

• Metode: litteraturstudie

Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a

core geriatric concept. JAGS 2007;55:780-791.

Shared Risk og GS

Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a

core geriatric concept. JAGS 2007;55:780-791.

Shared risk factors identified

consistently across all geriatric syndromes

• older age,

• functional impairment,

• cognitive impairment,

• and impaired mobility.

Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a

core geriatric concept. JAGS 2007;55:780-791.

Shared risk factors identified

consistently across all geriatric syndromes

• older age,

• functional impairment,

• cognitive impairment,

• and impaired mobility.

Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a

core geriatric concept. JAGS 2007;55:780-791.

Isaacs geriatric giants

Frailty – skrøbelighed og GS

Inouye et al: Geriatric syndromes: clinical, research, and policy implications of a

core geriatric concept. JAGS 2007;55:780-791.

Fald

Svimmelhed

ortostatisme

Anfaldsvis afli

Medicinbivirkninger

Dårligt syn

Dehydrering

Infektion

Ensartet

sygdomspræsentation

Variabel

sygdomforklaring

Modificeret efter Flacker

Delir/konfusion

Svimmelhed

ortostatisme

Anfaldsvis afli

Medicinbivirkninger

Dårligt syn

Dehydrering

Infektion Ensartet

sygdomspræsentation

Variabel

sygdomforklaring

Modificeret efter Flacker

Hvad giver begrebet

geriatrisk syndrom os ?

Hvad kan vi bruge begrebet

Geriatrisk syndrom til ?.

• The power of the concept of the geriatric

syndrome is in abandonning Ockhams’s razor

when appropriate.

• By abandoning the search for a single culprit, we

can try to adress the multiple factors.

• To treat the complicated patient, we may have to return

to the individuality of the patient before us. Each one will

present a unique combination of medical, financial,

social, and psychological realities to be addressed within

the systematic framework of care that the team has

available.

Schwab, W.: Geriatric syndromes, JAGS 2008, 56(2), p 363-4.

Hvad kan vi bruge begrebet

geriatrisk syndrom til

• Det fremhæver fænotypen eller End

Product

• Belyser forskellen mellem geriatrisk

approach og traditionelt approach til

udredning og behandling

Hvad betyder alt dette i

praksis?

Hvilke patienter skal på geriatrisk

afdeling?

Udfordringen ift funktionstab

For geriatere og andre læger:

• ”Endeproduktet” den tungt plejekrævende

patient, som ikke kan komme på benene

efter et sygdomstilfælde er ikke altid er

en geriatrisk patient

• Eks:

– Apopleksia cerebri

– End stage diabetes

– End stage KOL

– End stage hjerteinsufficens

apopleksi Kan ikke mobiliseres

Pts. raske

ægtefælle indlagt

Patienten kan ikke

klare sig derhjemme

Pt har haft kompliceret

forløb med respirator beh.

og dialysebeh.

Patienten er langt fra

habitual tilstand

Eksempler

K.Rockwood

K.Rockwood, IAGG Paris 2008

Take Home Message 1

Et geriatriske syndrom er kendetegnet ved:

• Et symptom, en fænotype

• Har en høj prævalens blandt ældre

• Den diagnostiske proces bør indeholde

både en udredning for en enkelt eller flere

sygdomme, der udløste symptomet

• Og en intervention overfor multiple

risikofaktorer.

Take Home Message 2

• Geriatriske patienter skal undersøges

bredere.

• Symptomer ofte fra et andet organsystem

end der hvor den akutte årsag er

• Interventioner på mange punkter er

nødvendige – og effektive

• Det kan hjælpe at behandle fænotypen,

uanset at vi ikke har stillet diagnosen

Take Home Message 3

• Det fremhæver fænotypen eller End

Product

• Og belyser fænotypens begrænsning i

visitationen

• Belyser forskellen mellem geriatrisk

approach og traditionelt approach til

udredning og behandling

Tak til

Raf Van Hoeyweghen:

”The geriatric syndrome”,

8th Eama Course, Sion January 2009

Tak for opmærksomheden