Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Features of patient care elderly in outpatient settings Agranovich NV MD, professor Head of Department outpatient therapy SGMU Age of human development is the interaction of two fundamental processes: aging and vitaukta. Aging - Universal endogenous destructive process, which manifests itself in increasing the probability of death. vitaukta (lat. vita- life, auctum- increase) process, the viability of stabilizing and increasing life expectancy. According to the reports of the UN in 2000, the number of people older than 60 years was 610 million. People, and in 2005 - has exceeded 1 billion., Representing 15% of the population. In Russia, the fifth of the population is elderly. In the next 10 years is expected to increase the number of senior citizens is about 2 times. 25-30% of the population will be in the category of elderly in 2020. The incidence in the elderly compared to younger persons above 2 times in old age - 6 times. The key and fundamental position in the problem of the "older generation" must be recognized first and foremost a social aspect, in the second - Medical. Last determines the need, first of all, the development of health and social services can adequately carry out medical and social expert assessment of the individual patient and not only outline the ways of his rehabilitation, and to implement it in practice. Although not a disease, aging creates prerequisites for the development of age pathology optimal state of health the presence of risk factors for disease death The aging process continuous gradual transition from stage to stage signs of pathology disability The rate of aging can be quantified using indicators reflecting the decrease in viability and increase of damage to the body. One such parameter is the age. Age - the duration of the existence of the body from birth to the present day. Performances to date modern age standards were adopted by the European a regional WHO office in 1963 Classification of age? (WHO, 1963) Young age 18-29 Adulthood 30-44 The average age of 45-59 Advanced age 60-74 Senile 75-89 Centenarians 90 and older Giorgione. Three ages of man. 1500-1510 years. Palazzo Pitti. Florence. Pathological changes characteristic of elderly and senile age, begin to appear since 40-50 years. Involutional associated with regression of functional and morphological changes lead to changes in the functioning of various organs and systems, which under certain conditions can lead to the development of the disease. For example, with age decrease of vital capacity of the lungs, bronchial obstruction, the value of the glomerular filtration in the kidneys, increased fat mass and decreased muscle mass, bone density. The main features of the sick elderly 1. The presence of two or more diseases in the same patient. On average, during the examination of the patient elderly reveal at least five diseases. In this regard, clinical disease "smeared" reduced diagnostic value of different symptoms. On the other hand, co-morbidities may potentiate each other's clinic. 2. Mainly chronic diseases. The progression of most chronic diseases contribute to age-related adverse endocrine-metabolic and immune changes. 3. Atypical clinical course of the disease. Often reveal more slowly and disguised the disease (pneumonia, myocardial infarction, pulmonary tuberculosis, neoplastic processes, diabetes, and others.). The main features of the sick elderly 4. The presence of "senile" diseases: osteoporosis, benign prostatic hyperplasia, Alzheimer's disease, senile amyloidosis, etc.). 5. Reducing protective primarily immune, responses.. 7. Changes in the social and psychological status. The main causes of social exclusion: retirement, loss of loved ones and friends, loneliness and limited communication difficulties self-deteriorating economic situation, the psychological perception of the age limit., Regardless of health status. These features suggest that the organization of health care for people elderly, special attention should be paid to the improvement of community-acquired forms of treatment, especially in clinics This is due to two main reasons The first - a steady increase in the need for the organization of outpatient care for these patients The second - the desire of the majority of elderly patients in the treatment process to be together with family, relatives, friends, do not change the habits of conditions of stay at home. In this connection takes on overriding importance using "Hospital at home" the need for the deployment of "hospital at home" on the type of patronage system for patients with chronic diseases, who can not attend the clinic and observed only at home. carrying out diagnostic and treatment procedures, coupled with the expansion of the motor mode and physical therapy. The level of organization and quality of active surveillance for them, especially on the part of the local therapist, largely depends on their overall health, frequency of exacerbations and the need for the provision of emergency assistance and emergency hospitalization From the observed home should highlight a group of patients at higher risk in relation to health and deaths: somatic caused serious condition, with age over 80 years, Living alone just discharged from the hospital, recent change of residence. The need to provide them with social-welfare assistance and the implementation of elements of personal hygiene In these issues can provide real assistance to the so-called social sister. Rational management of elderly patients involves compulsory mutual understanding and harmony in the triad "Sick - nurse - doctor" The correct approach provides "compliance" - the achievement of a high degree of implementation of patient medical recommendations. To do this: Use verbal and written instructions, reducing the number of appointed Pharmaceuticals, preference long-acting dosage forms and the combined drugs, etc.. Geriatric patients often "go into yourself", "listen" to his condition, they appear irritability, tearfulness. The ability to listen, empathize and give advice are important factors in successful treatment Nursing allowing for the elderly Preparing the patient for various medical manipulations The active work with patient, explaining to them the need for pest control habits of healthy lifestyle. In this effort the doctor and nursing staff must be directed to the study of the behavioral characteristics of elderly patients. Knowledge of these features will help to shape a more active attitude of the patient to his condition with an optimistic position, especially feeling "Satisfaction with life" required to improve the physical and mental health General principles of management of patients with elderly Control of reception of medicines Sick elderly should be provided with clear instructions given by the doctor not only verbally but also in writing. It is necessary to monitor the water balance as inadequate fluid intake can help improve concentration in the body-prescription drugs, side-effects and development of drug intoxication. Preference is given to a sustained dosage forms and a combination of drugs. General principles of management of patients with elderly Patients elderly observed frequent exacerbations chronicbronchitis, due to changes in age-related chest, restricting breathing movements, reducing drainage function due to the low efficiency of cough shock and atrophy of the ciliated epithelium, congestion in the pulmonary circulationreduction of anti-defense. Treatment of patients with chronic bronchitis in the elderly and old age should be implemented taking into account the characteristics of the pathological process, the presence of comorbidities, the individual patient. Increased incidence of geriatric patients with chronic bronchitis makes frequent use of antibacterial agents It is necessary to remember that in elderly patients were significantly more likely to develop the possibilities side effects antibacterial, e.g. hearing loss (streptomycin, gentamicin, etc.), toxic impact on kidneys (kanamycin), candidiasis, dysbiosis and atrophic glossitis (tetracycline combined antibiotics) and etc. Therefore it is necessary to teach the patient assigned to take the drug at the set time of the day, to comply with the recommended mode behaviour and conditions of taking the medicine. When monitoring patients with pneumonia particularly dangerous for the patient geriatric period Critical temperature reduction body when possible development of acute vascular insufficiency as vascular insufficiency have not seen the classic collapse, and worsening of coronary heart disease, stroke, increasing the degree of kidney failure and others. It should be used cautiously in the treatment of patients with elderly oxygen therapy. Excessive activity of oxygen therapy in the elderly may also lead to negative results - may appear dizziness, nausea, asthma, breathing, such as Cheyne-Stokes. Moreover, it may be hypercapnic inhibition of the respiratory center up to coma. Features of CVD in middle and old age caused as diseases of other organs and systems, involutive processes in the body, but primarily - sclerotic lesion as the vessels and the heart: reduced elasticity; seal the vascular wall leads to a permanent increase in peripheral resistance. There are crimped and aneurysmal dilation of capillaries and arterioles, develop fibrosis and hyaline degeneration that leads to the obliteration of the vascular capillary network, impairs transmembrane exchange. The blood supply to major organs becomes not quite adequate. As a result, failure of the coronary circulation develops degeneration of muscle fibers atrophy and their replacement by connective tissue, leading to heart failure and heart rhythm disturbances. Formed "Senile heart" In elderly and senile age formed a number of features of hemodynamics increased mainly systolic, reduce venous pressure, cardiac output, and later, minute volume, and others. and developed the so-called Isolation systolic hypertension. This reduces the brain, kidney and uterine blood flow. To date, no system of normative values of blood pressure according to age - increased blood pressure in elderly and senile some experts consider as normal compensatory phenomenon. So - reducing the pressure in the elderly only if the clinical symptoms associated with elevated blood pressure. BUT, clinical studies strongly suggest that the patient's age is not an obstacle to an active medical and surgical treatment of many cardiovascular diseases Regular long-term antihypertensive therapy significantly reduces the risk of major cardiovascular complications of hypertension - stroke, myocardial infarction and cardiovascular mortality in elderly patients in elderly patients with hypertension reduction of blood pressure medication for 3-5 years significantly reduces the incidence of heart failure by 48% Specifics of elderly patients with hypertension Older blood pressure should be measured carefully, because they are often found "psevdogipertoniya" (stiff arteries of the extremities). For elderly patients characterized by orthostatic reactions (due to violations pressosensitive unit), so it is strongly recommended that a comparison of blood pressure with the patient lying down and immediately after the transition to an upright position. Elderly people respond very well to a decrease in blood pressure by limiting salt intake and weight loss. It should seek to a gradual reduction in blood pressure before 140/90 mmHg. (with concomitant diabetes and renal failure, the target blood pressure - 130/80 mm Hg) Starting doses of antihypertensive drugs make up half the usual starting dose. Dose titration is slower than in other patients. In the treatment of hypertension in all age groups diuretics play a leading role both in monotherapy and in combination therapy AH (2003). Thiazide diuretics, b-blockers and combinations of the most effective in terms of reducing the risk of cardiovascular morbidity and mortality in elderly patients with hypertension. Older demonstrated the advantage of using amlodipine in reducing blood pressure compared to other calcium antagonist - diltiazem. Furthermore, the duration of amlodipine 24 hours, thereby to repeated admission to the day and provides ease of application. ACE inhibitors are the drugs of choice for the two categories of elderly patients with hypertension: 1) left ventricular dysfunction and / or congestive heart failure; 2) concomitant with diabetes. Elderly patients with CHF appointed ACE inhibitors, diuretics, b-blockers, spironolactone, both preparations have proved to improve survival and quality of life. If necessary, the treatment of ventricular arrhythmias on the background of chronic heart failure in the elderly and the elderly should be preferred amiodarone. Old age should not be an obstacle to direct the patient to coronary angiography. For successful treatment of cardiovascular diseases in the elderly is very important to the timely identification and elimination / correction accompanying diseases, often hidden and oligosymptomatic (wasting, anemia, thyroid dysfunction, liver and kidney disease, metabolic disorders, and others.). Particular attention doctors in geriatric patients draws Anemia The most common anemia in the elderly is not an independent nosological form, as a consequence of chronic diseases: kidney and liver (22% of the entire group of anemias) pulmonary processes and defeat of the gastrointestinal tract (GIT; by 19-18%), endocrine diseases (16%), cancer, hemorrhoids, and rheumatoid arthritis (by 6-5%). a combination of disease up to 6%. The prevalence of anemia in the elderly and old age varies from 2.9 to 61% in men and from 3.3 to 41% in women In all chronic diseases are the main factors of redistribution and metabolic iron, combined with its low entry and often - with increased costs or loss in elderly patients prevail hypochromic, iron anemia Long-term chronic blood loss account for nearly half of cases of anemia in older patients. More often - hidden bleeding erosive gastritis, gastric ulcer or duodenal ulcer, hemorrhoids. In the overwhelming majority of patients at the same time revealed a deep atrophic pangastritis often associated with H. pylori infection and gastric acid-oppressed. This and nutritional (medical and social) factors can cause iron deficiency, even without blood loss. Other causes of anemia elderly Chronic kidney disease, anemia develops gradually, with a decrease in generation erythropoietin. In addition to erythropoietin deficiency may have a value violation utilization of iron stores during prolonged chronic inflammation, strengthen its consumption, increased blood loss hemodialysis. Effects of excess production inflammatory cytokines such as necrosis factor tumours (ТNF), interleukin 1, interferon D Can cause depression have impaired secretion of erythropoietin, the deterioration of its regulatory functions in relation to erythropoiesis and suppression of erythroid progenitor cells. Often the clinical picture of anemia in elderly patients is masked by a variety of symptoms of the underlying disease, the prevalence of cardiovascular and cerebral manifestations Clinical manifestations of (chlorotica pica type, in the form of brittle nails, hair and trophic changes of the skin) erased and shaded age-related changes. Diagnostic criteria is to reduce the serum iron while maintaining its reserve as ferritin. If you experience problems in determining the level B12 used traditional morphological and reliable diagnostic test - study medullary hematopoiesis. Prevalence and B12 folic acid deficiency anemia in elderly persons 2%, but it often goes unrecognized. The need for timely and accurate diagnosis of anemia with the establishment of its shape and origin of adequate therapy in geriatric patients Development of anemia in the elderly accompanied by a significant deterioration in the quality of life (decrease in mental and physical activity, fatigue, depressed mood), aggravates the existing pathology and poses a threat to premature death. Treatment of anemia in the elderly require clinical supervision with regular (at least 1 time in 2-3 months.) Control of hematological parameters. In elderly and senile age significantly changing nature of the flow of digestive diseases due to age-related anatomical and physiological characteristics of the digestive tract Oral cavity : Developing an involution of mammary glands, changes masticatory apparatus. Esophagus: atrophied mucosa is reduced peristalsis, more likely to develop dyskinesia. stomach: reduced secretory and enzymatic Activity slows down physical activity. liver: reduces the number of hepatocytes, inhibits the regeneration, reduced functional activity of the liver: decrease of bilirubin, bile acids and phospholipids and high cholesterol, which contributes to a breach of digestion and is manifested dyspeptic disorders. Pancreas: age atrophy fabric reduces and exocrine function. Intestine: broken membrane digestion and absorption. Reduced physical activity small and large intestines, changes the composition of intestinal microflora, exacerbated by the phenomenon of intestinal dyspepsia. Blood supply and innervation of the digestive system are subjected to functional and structural changes involutive. According to statistics Chronic gastritis affects more than 50% of the working population, and in persons over 60 years the frequency of the disease is approaching to 100%. The prevalence of atrophic gastritis in the elderly due to prolonged course of bacterial chronic gastritis, often develops in elderly and senile age duodenogastric reflex. Clinical manifestations of chronic atrophic gastritis in elderly and senile patients are nonspecific and often masked by concomitant diseases (coronary heart disease, chronic pancreatitis, and others.). Under the guise of various diseases of the gastrointestinal tract often proceeds ischemic disease of the digestive system Chronic ischemia in this pathology is caused by lack of blood flow in the basins of the celiac, superior and inferior mesenteric arteries. reasons for violation of mesenteric circulation can be mesenteric artery atherosclerotic lesions and other conditions that reduce bloodstream. Clinical case Patient K. 70 years appealed to the gastroenterologist with complaints: Pronounced acute pain epigastric arising on an empty stomach, worse after eating, lasting from 30 minutes to 2 hours, stoped taking antacids. Dull, aching pain in the umbilical region, extending to the right and left upper quadrant, in the back that occur after a heavy meal, and physical or emotional surge, accompanied by bloating, sometimes combined with the pain in the hearts of anginal nature, lasting from several minutes to several hours or even days, not cropped antacids, somewhat reduced after taking muscle relaxants. General weakness, fatigue, poor appetite, alternating constipation and diarrhea. weight loss, clinical case From anamnesis: the patient considers himself over the past 5 7 years old when he first appeared pain in the umbilical region, gradually escalated symptoms appeared general weakness, fatigue, unstable chair. Around the same time, there were pains in the heart and after the examination was diagnosed with coronary artery disease. For 10 years, notes the increased blood pressure, a maximum of 180/100 mm Hg Epigastric pain appeared three years ago, and during endoscopy has been found associated with Helicobacter pylori stomach ulcer, which after adequate three or four-component therapy scar, but then reappeared, with obvious seasonality of exacerbations was not traced. As a working diagnosis at various stages of the survey appeared chronic cholecystitis without stones, chronic pancreatitis. Over the past 5 years I have grown thin about 10 kg. Results of the study EGDS Gastric ulcer. Moderately marked inflammation of the gastric mucosa. Urease test - weak positive. Changes in lipid profile total cholesterol - 6.7 mmol / L (3.5 - 5.2); triglycerides - 3.43 mmol / L (0.11 -2.17); high-density lipoprotein - 1.1 mmol / l (1.0 - 2.1); L ow-density lipoprotein - 5.3 mmol / l (3.5 - 7.5); atherogenic factor - 5.1 Prothrombin index - 107% Duplex scanning of the abdominal aorta and its visceral branches Colour inversion, and expressed local decrease of peak systolic flow velocity in the restriction zones P SStc - 340,9sm / sec, PSSams - 319.9 cm / sec Hemodynamically significant stenosis of the celiac trunk and the mouths of the superior mesenteric artery (70%). results of the survey Left ventricular hypertrophy and left atrial atherosclerotic lesions of the thoracic aorta and arteries brahiotsefalyh without hemodynamically significant restrictions; A common myocardial ischemia anteroseptal region of the left ventricle; US signs of sclerosis of the pancreas (reducing the size, heterogeneity of the structure with a predominance hyperechogenicity); Thickening of the walls of the gall bladder with symptoms gipomotornoy dyskinesia; clinical diagnose Atherosclerotic abdominal coronary artery disease, subcompensation stage. Atherosclerosis of the abdominal aorta, celiac artery stenosis hemodynamically significant stenosis of the superior mesenteric artery hemodynamically significant. Gastric ulcer. Atrophic gastritis. Coronary heart disease: stable angina FC II, NC - I st. Hypertensive heart disease II class. Terms elderly and power? senile -Sick elderly needed a little rest during the day and restful night's sleep. -Useful targeted exercises relaxation. -The patient needs a diet, in moderation rich in calories and rich in vitamins. -It should abandon the use of animal fats, sweets, "interception" between meals, since excess weight interferes with the heart. Hypocaloric and limited in terms of diet-as one of the most effective? methods to combat the aging process. In general, the diet sick elderly follows:: Limit: Products containing oxalic acid and cholesterol Sugar, flour, table salt. Provide: A sufficient amount of fruits, vegetables, salt containing K, Fe, Mg and vitamins. Variety and balance of food intake Antisclerotic thrust power Increase the share of vegetable oil (2 tbsp sunflower, olive or corn oil per day Inclusion in a diet of seaweed Bread wholemeal Easily digestible sources of calcium - milk, dairy products, cheese, sea fish, greens. For those elderly most rational 4-5 meals The diet of an elderly person The recommended ratio between proteins, fats and carbohydrates is 1 : 0,8 : 3,5