Interdisciplinary care for frail elderly patients. A case report.
Global aging is a well-known phenomenon happening all over the world. This occurs mainly because the fertility rates are dropping and on the other hand life expectancy increase. Estimated reports say that between 2017 and 2050 the number of elderly people aged 80 or over is estimated to increase more than three times. In Europe and in Northern America more than one out of five persons was aged 60 or over in 2017.(25) According to a statistical survey conducted in Romania from 1950 to 2015 and further estimated for 2050 the average age of the population in Romania gradually increases from year to year. Same sourse says that life expectancy at birth in Romania has been continuously growing between 2005 and 2015 up to an average of 74.96 years in 2015 (Statistica--The Statistics Portal). "The health status of Romanians has improved, but life expectancy at birth remains among the lowest in the EU (nearly six years below the EU average)." (9)
The ageing process comes along with a progressively deterioration of various physiological systems associated with an increased risk of vulnerability. This pattern of elderly people is known as frailty (4), a concept that implies a series of very challenging dimensions of the ageing which frequently cause a poor quality of life and deeply affects the older people independence level. (14) The frailty concept is nowadays well-recognized as a geriatric syndrome as well as a predictor of disability, morbidity and mortality. (12,15,19) Frailty shouldn't be confused with comorbidity which is also an age-related common condition pottentialy with a negative influence on the physical and mental status of the elderly. The main distinction that separates the two concepts is huge, based on major differences in prognoses, outcome and therapy management. (7)
Literature acknowledges that frailty implies major effects both on the physical and mental status of the elderly and that's why has to be understood as a multidimensional syndrome. Even though there are some screening tools, unfortunately, there is still no consensus regarding frailty measurement in clinical settings. More than that, most of the frailty assessment tools are based on physical impairments and lately there's more and more evidence that mental deficits including both cognitive and mood dysfunctions should be taken into account when assessing frailty syndrome. A series of protective and risk factors are implied in the onset and later evolution of frailty and are fundamental for preventing and earlier detection of this syndrome. (16)
Basic factors considered in the frailty assessment tools are: shrinkage (weight loss), exhaustion, weaknesses, low gait speed and low physical activity, falls, abnormal laboratory values, changes in sleep, autonomy levels, cognitive deficit, mood impairment, memory changes, comorbidities, hospitalizations and many more depending on the purpose a specific tool was designed for. (6,8,16) Additionally there is some evidence for other variables (including musculoskeletal health, nutrition, biomarkers and other clinical conditions) for being associated with the frailty syndrome, some of them necessitating further information to be confirmed. (7,10,17, 18,23) "It seems thus essential for public health to implement the screening and multidisciplinary treatments of frailty." (6)
"The gold standard for the management of frailty in older people is the process of care known as Comprehensive Geriatric Assessment (CGA) also known in some countries as Geriatric Evaluation and Management (GEM). It involves an holistic, multidimensional, interdisciplinary assessment of an individual by a number of specialists of many disciplines in older people's health and has been demonstrated to be associated with improved outcomes in a variety of settings." (5) This type of assessment is designed not only for the diagnostic use of frailty syndrome but also to guide to an optimal treatment strategy based on patients needs. (11) Royal College of General Practitioners in collaboration with British Geriatrics Society made a case series report called "Integrated care for older people with frailty" aiming to improve the quality of life in frail elderly by using creative ideas and a specific good collaboration between GP and geriatricians. (21) Dementia is a term that includes a numerous set of syndromes which all have in common a gradual decrease of cognitive function. (13) Evidence from the English Longitudinal Study of Ageing showed "increased levels of frailty are independently associated with an increased risk of dementia, although this was not observed in adults who have a low global cognitive function at baseline." (20)
SA is an 89-year-old female patient hospitalized for decompensated heart failure most likely due to non-compliance with the recommended lifestyle behaviors including medications, diet, personal hygiene and regular medical visits. Living in a rural environment, she comes to admission accompanied by a niece, referred by a general practitioner. We evaluated the major components of comprehensive geriatric assessment (CGA) as follows:
Personal pathological and disease history
Medical history turns out to be difficult to obtain as long as the patient was slightly disoriented, with no other medical records and the impossibility of naming other pathologies previously diagnosed. More than that, interviewing the niece we faced the same lack of information.
Social support and financial concerns
Patient comes from rural environment, living alone (being a widow for many years) in a house with poor sanitary conditions. There is only this niece living next to her, helping her from time to time, as long as children visit here less often. She isn't an alcohol, tobacco or a coffee consumer.
When asked, patient knew she had chronic medication, but couldn't name the pills she's taking. She wasn't aware why she takes home medication or what kind of chronic diseases is she treating, and tells us she doesn't take it every day (depending on the niece's help to give her the meds). We found in her pill bag antihypertensive, digitalic and anti-aggregant medication (Enap 5mg/d, Digoxin 0,25 mg 1tb 5/7, Trombex 75mg/d).
Clinical examination reveals a slightly confused patient, with a Body Mass Index = 16,8 (underweight) in the absence of a sudden weight loss in the last 6 months, partially edentation, presenting dry skin (dehydration pinch test positive), bilateral lower extremity edema and swollen pelvic area. We noticed the presence of hearing and visual impairments (hypoacusia, decreased visual acuity).
Muscle atrophy and weakness suggesting for sarcopenia syndrome, hypotonia, hypokinesia, the patient being only able to move by using a support or assisted by medical staff. Cardiovascular evaluation shows a BP=180/100mmHg, HR=94bpm, arrhythmic heart sounds. We found an abdominal mass of 10/11/10 cm diameter, in the right flank, hard reducible in decubitus position (incisional abdominal wall hernia). Patient had also urinary incontinence. Functional capacity
We used the Basic Activities of Daily Living scale (BADLs) and Instrumental or Intermediate Activities of Daily Living scale (IADLs). We obtained significantly modified results (BADL score=3 out of 6, IADL score=2 out of 8) suggesting increased activity restriction and very limited autonomy of the patient.
Patient declares she uses a support to make walking around home possible and plus, it has vision impairment too. Conducting Tinetti Balance Assessment Tool we found a total score (balance + gait) = 8 meaning a high risk of falls. Psychological assessment (cognition, mood) Mini Mental State Examination score was 16 out of 30, suggesting mild cognitive impairment.
Yesavage Geriatric Depression Scale (GDS-15) was used for mood evaluation. Our patient scored 13 suggestive of severe depression.
Conducting Mini Nutritional Assessment scale our patient turned out to be malnourished (MNA score = 8,6).
Blood tests: cholesterol = 230mg/dl; LDL= 140mg/ dl; TG=170mg/dl; glucose=90mg/dl; serum electrolytes: Na = 143mEq/l; , K = 4,1mEq/l;
Creatinine = 0,90 mg/dlCreatinine Clearance (Cockcroft-Gault Equation) = 25 mL/min, TSH=3,8[micro]UI/MI; FT4=1,4ng/dl EKG: Atrial fibrillation 80/min. ChestXRay: Pulmonary vascular congestion (vascular redistribution, Kerley B lines), cardiomegaly, bilateral pleural effusion, cardiothoracic ratio > 0,5, aortic calcifications. Ecocardiography: aortic calcifications, left ventricular ejection fraction (LVEF<40%), left atrial enlargement and increased left atrial size; HF with reserved ejection fraction [HFrEF]
We requested some interdisciplinary consults as follows:
Ophtalmological and ENT examination showed Vission and Hearing losses MRI Brain image reveals hippocampal atrophy, especially on the right side.
After gathering all neccessary data we concluded on the following diagnoses: Permanent Atrial Fibrilation, Heart Failure NYHA III, grade 3 vascular hypertension with very high additional risk, Malnutrition, Incisional Abdominal Wall Hernia, Dementia. Treatment and evolution Treatment goals: recovering clinical and functional status as much as we can, preventing complications and to increase as much as possible patient's quality of life on long-term. In the attempt to achieve our aim, we followed the cardio guidelines 1,2,24 and we adjusted their recommendations according to the particular needs of our geriatric patient. 26
Non-pharmacological methods: family and patient education on disease and guidance for dietary and life style behaviors improvement (including also monitoring and continuum healhcare).
Pharmacological methods: calcium channel blockers: amlodipine + ACE Inhibitor: enalapril (Sevikar10/10mg), diuretic: Diurex 50/20 mg, digitalic: Digoxin 0,25 1tb/d, 5/7d, antiaggregation agent: aspenter 75mg/d, no anticoagulation. When evaluating the riskbenefit ratio of anticoagulation we considered the following factors: age > 85 years, [CHA.sub.2]-[DS.sub.2]-VASc Score (Stroke Risk) = 6, HASBLED Score (Major Bleeding Risk) = 3, high fall risk, age-related changes in pharmacokinetics and pharmacodynamics, nutritional status, comorbidities, thyroid status, possible medication interactions, monitoring and treatment adherence (including factors like education level, independence level, social support, financial concerns, pshycologic and psychiatric impairment). For dementia:antiplatelet drugs; treating the underlying disease; selective serotonin reuptake inhibitors (SSRIs) sertraline for agitation and psychosis.
Considering the advanced age, the important cardiovascular pathology associated with dementia, high probability of noncompliance to treatment, poor social and financial support as negative prognostic factors, our patient may be very exposed to rehospitalization in the shortest time or to an accelerated process of physical degradation.
* Our case report highlights the older frail patient, with both increased functional and mental impairments, who absolutely needs a multidisciplinary approach in order to cope with its age-related problems, our goal being to improve as much as possible his quality of life, not only during the hospitalization but most important in day-to-day life.
* Frailty syndrome as seen in our patient was identified in a quite advanced stage.
* Poor financial and social support may be a cause of insufficient monitoring and a factor of decreased quality of life.
* Multidimensional approach assessment is essential in the older patient.
* Vascular dementia diagnosis in our patient represents also a major predictor of critical health impairment in the later years of life and highlights the necessity of an improved gerotopshychiatric care.
* Remarkable multidisciplinary collaboration is vital in order to meet the health and social care needs of the frail elderly.
* We need geriatric healthcare programmes based on a sustainable development to provide our elderly patients best healthcare services according to their needs.
First of all, there is a fundamental need for interdisciplinary collaboration in the assessment of a geriatric frail patient. Second, this type of patient may be underdiagnosed and undertreated according to our demographic data and the current economic status of our country. This case report could be an invitation to further research to achieve more complex epidemiological data in order to start national health programmes and improve our healthcare services for the better of the elderly frail patients.
ACKNOWLEDGEMENTS AND DISCLOSURES
The authors state that they are no declared conflicts of interest regarding this paper.
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Irina Esanu--MD, PhD, senior internal medicine and geriatrics, lecturer "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
Diana Sotropa--Resident in geriatrics "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
Irina Dobrin--MD, PhD, senior psychiatrist, assistant of professor "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
Cringufa Paraschiv--MD, PhD, senior Internal Medicine and Geriatrics, lecturer "Gr. T. Popa" University of Medicine and Pharmacy, Iasi, Romania
Diana Sotropa, Resident in Geriatrics,"Gr. T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115, Iasi, Romania, E-mail: firstname.lastname@example.org, tel.0757121877
Submission: 01 mar 2018
Acceptance: 18 may 2018
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|Title Annotation:||Case Reports|
|Author:||Esanu, Irina; Sotropa, Diana; Dobrin, Irina; Paraschiv, Cringufa|
|Publication:||Bulletin of Integrative Psychiatry|
|Article Type:||Clinical report|
|Date:||Jun 1, 2018|
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