Personalised prevention in geriatrics. Gunnar Akner. Linnæus University Kalmar Sweden

Transcription

1 Personalised prevention in geriatrics Gunnar Akner Linnæus University Kalmar Sweden

2 CONFLICT OF INTEREST DISCLOSURE I have no potential conflict of interest to report

3 Disclosure

4 Professor in Geriatric Medicine Linnæus University, Kalmar Associate professor in Geriatric Medicine Disclosure Karolinska Institutet, Stockholm Physician, specialist in - Internal Medicine - Geriatric Medicine - Clinical Nutrition

5 Production Homepage Disclosure Scientific articles Books Reports Debate articles

6 Akner G. Multimorbidity in Elderly. Analysis, Management and Proposal of a Geriatric Care Center. VDM Press 2011

7 Akner G. Multimorbidity in Elderly. Analysis, Management and Proposal of a Geriatric Care Center. VDM Press

8 Ageing and multimorbidity

9 Ageing staircase Kurbitsmålning på väv Winter Carl Hansson, 1799 Danielsgården Bingsjö, Rättvik First age Second age Third age Fourth age

10 Ageing staircase First age Second age Third age Fourth age

11 Ageing staircase First age Second age Third age Fourth age

12 Ageing staircase First age Second age Third age Fourth age

13 Ageing staircase First age Second age Third age Fourth age

14 Ageing staircase First age Second age Third age Fourth age

15 Ageing staircase First age Second age Third age Fourth age

16 Ageing staircase First age Second age Third age Fourth age

17 Ageing staircase First age Second age Third age Fourth age

18 The trapezoid of aging Functional state steady state evolution involution Age

19 Prevention dream 1: The rectangle of aging Functional state steady state evolution Age

20 Prevention dream 2: The rectangle of aging Functional state steady state evolution involution Age

21 The trapezoid of aging Functional state steady state evolution involution Age

22 Aging the most important of all risk factors diseases injuries

23 Number of health problems Age (years) Age-related health problems exponential function

24 Tinetti et al JAMA 2012: 307:

25

26

27 Multimorbidity agnosia /Boyd et al 2013

28 Elderly people dominate in today s health care system Estimates from Sweden

29 Elderly people dominate in today s health care system Estimates from Sweden Primary care % (of physician time)

30 Elderly people dominate in today s health care system Estimates from Sweden Primary care % (of physician time) Hospital care Internal medicine General surgery Ortopaedic surgery Neurology Infectious diseases etc % (of in-patients)

31 Elderly people dominate in today s health care system Estimates from Sweden Primary care % (of physician time) Hospital care Internal medicine General surgery Ortopaedic surgery Neurology Infectious diseases etc % (of in-patients) Community elderly care 100 %

32 The trapezoid of aging Functional state steady state evolution involution Age

33 The trapezoid of aging Functional state Health promotion (prevention) steady state evolution involution Age

34 The trapezoid of aging Functional state Health promotion (prevention) steady state Management of manifest health problems (diseases and injuries) evolution involution Age

35 Prevention = risk factor management Primary prevention Secondary prevention Tertiary prevention

36 Prevention = risk factor management Primary prevention Prevent disease from occuring Secondary prevention Tertiary prevention

37 Prevention = risk factor management Primary prevention Prevent disease from occuring Screening and treatment of risk factors (hypertension, cholesterol) Vaccinations Secondary prevention Tertiary prevention

38 Prevention = risk factor management Primary prevention Prevent disease from occuring Screening and treatment of risk factors (hypertension, cholesterol) Vaccinations Early detection of asymtomatic disease Secondary prevention Tertiary prevention

39 Prevention = risk factor management Primary prevention Prevent disease from occuring Screening and treatment of risk factors (hypertension, cholesterol) Vaccinations Secondary prevention Early detection of asymtomatic disease Mammography (breast cancer) Dental control (cavities) Tertiary prevention

40 Prevention = risk factor management Primary prevention Prevent disease from occuring Screening and treatment of risk factors (hypertension, cholesterol) Vaccinations Secondary prevention Early detection of asymtomatic disease Mammography (breast cancer) Dental control (cavities) Tertiary prevention Treatment / management to prevent progress of chronic disease

41 Prevention = risk factor management Primary prevention Prevent disease from occuring Screening and treatment of risk factors (hypertension, cholesterol) Vaccinations Secondary prevention Early detection of asymtomatic disease Mammography (breast cancer) Dental control (cavities) Tertiary prevention Treatment / management to prevent progress of chronic disease Cardiac failiure Chronic obstructive pulmonary disease Diabetes mellitus

42 Individual analysis of multimorbidity (n=1)

43 Maria Johansson 86 y.o. (n=1)

44 Primary quality Health development for the individual person over time.

45 Maria Johansson 86 y.o.

46 Maria Johansson 86 y.o. Family 86-årig widow at 77 y.o. Two children: one daughter in southern Sweden, one son in USA

47 Maria Johansson 86 y.o. Family 86-årig widow at 77 y.o. Two children: one daughter in southern Sweden, one son in USA Living Handicap adjusted apartment, 2 rooms and kitchen

48 Maria Johansson 86 y.o. Family 86-årig widow at 77 y.o. Two children: one daughter in southern Sweden, one son in USA Living Handicap adjusted apartment, 2 rooms and kitchen Eating Home service delivers all meals Eats breakfast, one cooked meal and one in-between snack per day Eats almost always alone

49 Maria Johansson 86 y.o. Family 86-årig widow at 77 y.o. Two children: one daughter in southern Sweden, one son in USA Living Handicap adjusted apartment, 2 rooms and kitchen Eating Home service delivers all meals Eats breakfast, one cooked meal and one in-between snack per day Eats almost always alone Technical aids / support Hearing aid Cane and walker Grip forceps Low back girdle Increased shoe-height heel Urinary incontinence diaper Travel service Home service 2 hours / week (cleaning, buying groceries)

50 Maria Johansson 86 y.o. Family 86-årig widow at 77 y.o. Two children: one daughter in southern Sweden, one son in USA Living Handicap adjusted apartment, 2 rooms and kitchen Eating Home service delivers all meals Eats breakfast, one cooked meal and one in-between snack per day Eats almost always alone Technical aids / support Hearing aid Cane and walker Grip forceps Low back girdle Increased shoe-height heel Urinary incontinence diaper Travel service Home service 2 hours / week (cleaning, buying groceries) Social contacts Telephone contact with children and a female friend Daughter visits almost every week

51 Maria Johansson 86 y.o. Family 86-årig widow at 77 y.o. Two children: one daughter in southern Sweden, one son in USA Living Handicap adjusted apartment, 2 rooms and kitchen Eating Home service delivers all meals Eats breakfast, one cooked meal and one in-between snack per day Eats almost always alone Technical aids / support Hearing aid Cane and walker Grip forceps Low back girdle Increased shoe-height heel Urinary incontinence diaper Travel service Home service 2 hours / week (cleaning, buying groceries) Social contacts Telephone contact with children and a female friend Daughter visits almost every week Interests TV, radio, weekly magazine Takes walks twice a week during summer season

52 Diagnostics = health analysis Subjective Objective = symptoms = diagnoses

53 Maria Johansson 86 y.o. Subjective = symptoms

54 Maria Johansson 86 y.o. Subjective = symptoms Thirsty Day tiredness, fatigue Frequent urination Dry mouth Body weight reduction, non-voluntary Impaired memory Balance problem, falls x many Hearing problems Shortness of breath Tremor Difficulties swallowing Pain - right shoulder - hands, fingers Sleeping problems Palpitations Dry eyes with secretion Muscle weekness Cold hands and feet

55 Maria Johansson 86 y.o. Subjective = symptoms Thirsty Day tiredness, fatigue Frequent urination Dry mouth Body weight reduction, non-voluntary Impaired memory Balance problem, falls x many Hearing problems Shortness of breath Tremor Difficulties swallowing Pain - right shoulder - hands, fingers Sleeping problems Palpitations Dry eyes with secretion Muscle weekness Cold hands and feet 18 symptoms

56 Maria Johansson 86 y.o. Subjective = symptoms Thirsty Day tiredness, fatigue Frequent urination Dry mouth Body weight reduction, non-voluntary Impaired memory Balance problem, falls x many Hearing problems Shortness of breath Tremor Difficulties swallowing Pain - right shoulder - hands, fingers Sleeping problems Palpitations Dry eyes with secretion Muscle weekness Cold hands and feet 18 symptoms Suffering

57 Maria Johansson 86 y.o. Subjective = symptoms Thirsty Day tiredness, fatigue Frequent urination Dry mouth Body weight reduction, non-voluntary Impaired memory Balance problem, falls x many Hearing problems Shortness of breath Tremor Difficulties swallowing Pain - right shoulder - hands, fingers Sleeping problems Palpitations Dry eyes with secretion Muscle weekness Cold hands and feet 18 symptoms Suffering Frail?

58 Maria Johansson 86 y.o. Subjective = symptoms Thirsty Day tiredness, fatigue Frequent urination Dry mouth Body weight reduction, non-voluntary Impaired memory Balance problem, falls x many Hearing problems Shortness of breath Tremor Difficulties swallowing Pain - right shoulder - hands, fingers Sleeping problems Palpitations Dry eyes with secretion Muscle weekness Cold hands and feet 18 symptoms Suffering Frail?

59 Maria Johansson 86 y.o. ICD-10 Chronic diagnoses (WHO - International Classification of Disease)

60 Maria Johansson 86 y.o. ICD-10 Chronic diagnoses (WHO - International Classification of Disease) Chronic heart failure Parkinson s disease Hearing loss, sensory-neural Urininary incontinence Skin wound lower left leg Diabetes mellitus type 2 Depression Chronic pain syndrome Insomnia Vitamin B12 malabsorption (atrophic gastritis) Dysphagia Body weight reduction, non-voluntary Hypertension Status p. hip replacement right hip Pruritus NUD Osteoporosis with several fractures

61 Maria Johansson 86 y.o. ICD-10 Chronic diagnoses (WHO - International Classification of Disease) Chronic heart failure Parkinson s disease Hearing loss, sensory-neural Urininary incontinence Skin wound lower left leg Diabetes mellitus type 2 Depression Chronic pain syndrome Insomnia Vitamin B12 malabsorption (atrophic gastritis) Dysphagia Body weight reduction, non-voluntary Hypertension Status p. hip replacement right hip Pruritus NUD Osteoporosis with several fractures 16 diagnoses

62 Maria Johansson 86 y.o. ICD-10 Chronic diagnoses (WHO - International Classification of Disease) Chronic heart failure Parkinson s disease Hearing loss, sensory-neural Urininary incontinence Skin wound lower left leg Diabetes mellitus type 2 Depression Chronic pain syndrome Insomnia Vitamin B12 malabsorption (atrophic gastritis) Dysphagia Body weight reduction, non-voluntary Hypertension Status p. hip replacement right hip Pruritus NUD Osteoporosis with several fractures 16 diagnoses Frail?

63 Maria Johansson 86 y.o. ICD-10 Chronic diagnoses (WHO - International Classification of Disease) Chronic heart failure Parkinson s disease Hearing loss, sensory-neural Urininary incontinence Skin wound lower left leg Diabetes mellitus type 2 Depression Chronic pain syndrome Insomnia Vitamin B12 malabsorption (atrophic gastritis) Dysphagia Body weight reduction, non-voluntary Hypertension Status p. hip replacement right hip Pruritus NUD Osteoporosis with several fractures 16 diagnoses Frail?

64 Maria Johansson 86 y.o. Conclusion - Diagnostics 18 symptoms 16 diagnoses Multi-morbidity Difficult to overview in medical records Primary care Hospital care

65 Treatment

66 Maria Johansson 86 y.o. Treatment program

67 Maria Johansson 86 y.o. Treatment program Five treatment methods Medical drugs Nutrition Physical activity / exercise Technical aids ADL-support (food = energy, nutrients, water) (activities of daily living)

68 Maria Johansson 86 y.o. Treatment program Medical drugs

69 Maria Johansson 86 y.o. Treatment program Medical drugs 8 continuous, 1 when needed (9) every week Tabl Calcium/vitamin D3 500 mg/10 µg (CalcichewD3 ) 1x2 Powder Makrogol + KCl (Laxiriva ) 1x1 Tabl Acetylsalicylic acid 75 mg (Trombyl ) 1x1 Tavl Levothyroxin 0,125 µg (Levaxin ) 1x1 Tabl Ten vitamins + iron (Dulcicit comp) 1x1 Tabl Alendronate 70 mg (Alendronate Accord) 1 tabl Tabl Zopiclone 5 mg (Zopiklon ) 1x1 Inj Vitamin B12 1 mg/ml (Behepan ) 1 mg every 3rd month Tabl Paracetamol 500 mg (Alvedon ) 1 when needed

70 Maria Johansson 86 y.o. Treatment program Medical drugs 8 continuous, 1 when needed (9) every week Tabl Calcium/vitamin D3 500 mg/10 µg (CalcichewD3 ) 1x2 Powder Makrogol + KCl (Laxiriva ) 1x1 Tabl Acetylsalicylic acid 75 mg (Trombyl ) 1x1 Tavl Levothyroxin 0,125 µg (Levaxin ) 1x1 Tabl Ten vitamins + iron (Dulcicit comp) 1x1 Tabl Alendronate 70 mg (Alendronate Accord) 1 tabl Tabl Zopiclone 5 mg (Zopiklon ) 1x1 Inj Vitamin B12 1 mg/ml (Behepan ) 1 mg every 3rd month Tabl Paracetamol 500 mg (Alvedon ) 1 when needed Compliance: Does not take Calcium/D3 Forgets Alendronate often Avoids Paracetamol

71 Maria Johansson 86 y.o. Treatment program Nutrition

72 Maria Johansson 86 y.o. Treatment program Nutrition (2) Dietary advice Oral nutrition supplements (fluid) Fortimel compact (Nutricia ) 125 ml x 2 Contains: Energy: 600 kcal/d Protein: 24 g/d Water: 250 ml/d

73 Maria Johansson 86 y.o. Treatment program Physical activity / exercise

74 Maria Johansson 86 y.o. Treatment program Physical activity / exercise (2) Advice to increase physical actvity daily walks outside Home physical self-training while seated (muscle strength, mobility)

75 Maria Johansson 86 y.o. Treatment program Technical aids

76 Maria Johansson 86 y.o. Treatment program Technical aids (9) Cane Walker Permobile Grip device Urinary incontinence pads Toilet elevation Multiple handles in apartment Floor threshholds eliminated Safety larm

77 Maria Johansson 86 y.o. Treatment program ADL-support

78 Maria Johansson 86 y.o. Treatment program ADL-support (5) Instrumental ADL (= service) Shopping Cooking Making bed Cleaning Subsidized transportation service Personal ADL (body care) -

79 Maria Johansson 86 y.o. Conclusion Treatment (T) Prescription drugs 9 Nutrition 2 Physical activity / exercise 2 Technical aids 9 iadl-support 5 Sum 27 Multi-treatment Difficult to overview in medical records Primary care Hospital care

80 Maria Johansson 86 y.o. Diagnostics (D) Symptoms 18 Diagnoses 16 Treatment (T) Prescription drugs 9 Nutrition 2 Physical activity / exercise 2 Technical aids 9 iadl-support 5 27

81 Maria Johansson 86 y.o. Diagnostics (D) Symptoms 18 Diagnoses 16 Treatment (T) Prescription drugs 9 Nutrition 2 Physical activity / exercise 2 Technical aids 9 iadl-support 5 27 Multi-tasking = Geriatric Medicine

82

83

84 Preventive potential for an 86 year old woman

85 Risk factor analysis

86 Risk factors Heredity (genes) Living habits Living conditions Body factors

87 Risk factors Heredity (genes) 1st degree relatives Living habits Living conditions Body factors

88 Risk factors Heredity (genes) 1st degree relatives Living habits Food / meal situation Physical acticity Tobacco smoking Alcohol Living conditions Body factors

89 Risk factors Heredity (genes) 1st degree relatives Living habits Food / meal situation Physical acticity Tobacco smoking Alcohol Living conditions Family situation Housing Economy Social interaction Stress Body factors

90 Risk factors Heredity (genes) 1st degree relatives Living habits Food / meal situation Physical acticity Tobacco smoking Alcohol Living conditions Family situation Housing Economy Social interaction Stress Body factors Many established chronic conditions Non-voluntary body weight reduction Multimedication

91 Risk factors Heredity (genes) 1st degree relatives Living habits Food / meal situation Physical acticity Tobacco smoking Alcohol Living conditions Family situation Housing Economy Social interaction Stress Body factors Many established chronic conditions Non-voluntary body weight reduction Multimedication Frailty?

92 Risk factors Heredity (genes) 1st degree relatives Living habits Food / meal situation Physical acticity Tobacco smoking Alcohol Living conditions Family situation Housing Economy Social interaction Stress Body factors Many established chronic conditions Non-voluntary body weight reduction Multimedication Frailty?

93 Risk factors Heredity (genes) 1st degree relatives Living habits Food / meal situation Physical acticity Tobacco smoking Alcohol Living conditions Family situation Housing Economy Social interaction Stress Body factors Many established chronic conditions Non-voluntary body weight reduction Multimedication Frailty?

94 Risk factors Heredity (genes) 1st degree relatives Living habits Food / meal situation Physical acticity Tobacco smoking Alcohol Living conditions Family situation Housing Economy Social interaction Stress Body factors Many established chronic conditions Non-voluntary body weight reduction Multimedication Frailty?

95 Maria Johansson 86 y.o. Diagnose list Chronic heart failure Parkinson s disease Hearing loss, sensory-neural Urinary incontinence Skin wound lower left leg Diabetes mellitus type 2 Depression Chronic pain syndrome Insomnia B12-malabsorption (atrophic gastritis) Dysphagia Body weight reduction, non-voluntary Hypertension Status p. hip replacement right hip Pruritus NUD Osteoporosis with several fractures

96 Maria Johansson 86 y.o. Diagnose list Risk factors Chronic heart failure Parkinson s disease Hearing loss, sensory-neural Urinary incontinence Skin wound lower left leg Diabetes mellitus type 2 Depression Chronic pain syndrome Insomnia B12-malabsorption (atrophic gastritis) Dysphagia Body weight reduction, non-voluntary Hypertension Status p. hip replacement right hip Pruritus NUD Osteoporosis with several fractures

97 Maria Johansson 86 y.o. Diagnose list Chronic heart failure Parkinson s disease Hearing loss, sensory-neural Urinary incontinence Skin wound lower left leg Diabetes mellitus type 2 Depression Chronic pain syndrome Insomnia B12-malabsorption (atrophic gastritis) Dysphagia Body weight reduction, non-voluntary Hypertension Status p. hip replacement right hip Pruritus NUD Osteoporosis with several fractures Risk factors Diabetes mellitus type 2 Hypertension Osteoporosis with several fractures

98 Maria Johansson 86 y.o. Diagnose list Chronic heart failure Parkinson s disease Hearing loss, sensory-neural Urinary incontinence Skin wound lower left leg Diabetes mellitus type 2 Depression Chronic pain syndrome Insomnia B12-malabsorption (atrophic gastritis) Dysphagia Body weight reduction, non-voluntary Hypertension Status p. hip replacement right hip Pruritus NUD Osteoporosis with several fractures Risk factors Chronic heart failure Parkinson s disease Hearing loss, sensory-neural Urininary incontinence Skin wound lower left leg Diabetes mellitus type 2 Depression Chronic pain syndrome Insomnia B12-malabsorption (atrophic gastritis) Dysphagia Body weight reduction, non-voluntary Hypertension Status p. hip replacement right hip Pruritus NUD Osteoporosis with several fractures

99 Maria Johansson 86 y.o. Chronic diseases / conditions important risk factors?

100 Maria Johansson 86 y.o. Chronic diseases / conditions important risk factors? Depends on degree of health problem and/or progression rate

101 Maria Johansson 86 y.o. Chronic diseases / conditions important risk factors? Depends on degree of health problem and/or progression rate Chronic heart failure Parkinson s disease Hearing loss, sensory-neural Urinary incontinence Skin wound lower left leg Diabetes mellitus type 2 Depression Chronic pain syndrome Insomnia B12-malabsorption (atrophic gastritis) Dysphagia Body weight reduction, non-voluntary Hypertension Status p. hip replacement right hip Pruritus NUD Osteoporosis with several fractures

102 Risk factor management

103 Number of health problems Age (years) Age-related health problems exponential function

104 Barnett et al Lancet 2012; 380: 37-43

105 Worst socioeconomy Best socioeconomy Barnett et al Lancet 2012; 380: 37-43

106 Worst socioeconomy Potential for prevention Best socioeconomy Barnett et al Lancet 2012; 380: 37-43

107 Outcome risk reduction

108 Outcome risk reduction Research: Single outcomes

109 Outcome risk reduction Research: Single outcomes WHO Global health risks 2009

110 Outcome risk reduction Research: Single outcomes Baldwin et al Gerontol Nurs 1996; 22: 14-21

111 Outcome risk reduction Individual person Multiple outcomes

112 Outcome risk reduction Individual person Multiple outcomes Organ problems - Heart - Lungs - Kidneys - Liver - Skeleton - Skin Physical functions - Gait - Balance - Falls Mental functions - Cognition - BPSD - Mood Systemic functions - Bleeding - Lean body mass

113 Modifiable risk factors Outcome risk reduction

114 Modifiable risk factors Outcome risk reduction Heredity (genes) 1st degree relatives Living habits Food / meal situation Physical acticity Tobacco smoking Alcohol Living conditions Family situation Housing Economy Social interaction Stress Body factors Many established chronic conditions Non-voluntary body weight reduction Multimedication Frailty? Organ problems - Heart - Lungs - Kidneys - Liver - Skeleton - Skin Physical functions - Gait - Balance - Falls Mental functions - Cognition - BPSD - Mood Systemic functions - Bleeding - Lean body mass

115 Modifiable risk factors Outcome risk reduction Heredity (genes) 1st degree relatives Living habits Food / meal situation Physical acticity Tobacco smoking Alcohol Living conditions Family situation Housing Economy Social interaction Stress Body factors Many established chronic conditions Non-voluntary body weight reduction Multimedication Frailty? Organ problems - Heart - Lungs - Kidneys - Liver - Skeleton - Skin Physical functions - Gait - Balance - Falls Mental functions - Cognition - BPSD - Mood Systemic functions - Bleeding - Lean body mass

116 Modifiable risk factors Outcome risk reduction Heredity (genes) 1st degree relatives Living habits Food / meal situation Physical acticity Tobacco smoking Alcohol Living conditions Family situation Housing Economy Social interaction Stress Body factors Many established chronic conditions Non-voluntary body weight reduction Multimedication Frailty? Various relative importance Organ problems - Heart - Lungs - Kidneys - Liver - Skeleton - Skin Physical functions - Gait - Balance - Falls Risk factors have different weight Outcomes have various evidence Mental functions - Cognition - BPSD - Mood Systemic functions - Bleeding - Lean body mass

117 Subjective risk-score 0-3 Risk factor profile

118 Risk factor profile Subjective risk-score 0-3 Traffic light model

119 Risk factor profile Subjective risk-score 0-3 Traffic light model

120 The trapezoid of aging Functional state Health promotion (prevention) steady state Management of manifest health problems (diseases and injuries) evolution involution Age

121 The trapezoid of aging Functional state Health promotion (prevention) steady state Management of manifest health problems (diseases and injuries) evolution involution Primary prevention Secondary pevention Tertiary pevention Age

122 Guidelines Recommendations Guidelines / care programs

123 Guidelines / care programs Multiple manifest health problems Guidelines Recommendations

124 Guidelines / care programs Multiple manifest health problems Chronic heart failure COPD Diabetes mellitus Guidelines Recommendations

125 Guidelines / care programs Multiple manifest health problems Chronic heart failure COPD Diabetes mellitus Guidelines Recommendations

126 Guidelines / care programs Multiple manifest health problems Chronic heart failure COPD Diabetes mellitus Guidelines Recommendations Multiple risk management

127 Guidelines / care programs Multiple manifest health problems Chronic heart failure COPD Diabetes mellitus Guidelines Recommendations Multiple risk management Falls Malnutrition Skin pressure wounds

128 Guidelines / care programs Multiple manifest health problems Chronic heart failure COPD Diabetes mellitus Guidelines Recommendations Multiple risk management Falls Malnutrition Skin pressure wounds

129 Guidelines / care programs Multiple manifest health problems Chronic heart failure COPD Diabetes mellitus Guidelines Recommendations Multiple risk management Falls Malnutrition Skin pressure wounds

130 Guidelines 79-y.o. woman with five chronic health problems: Hypertension Diabetes mellitus Osteoporosis Ostheoarthritis COPD Boyd CM et al JAMA 2005; 294:

131 Guidelines 79-y.o. woman with five chronic health problems: Hypertension Diabetes mellitus Osteoporosis Ostheoarthritis COPD Boyd CM et al JAMA 2005; 294:

132 Guidelines 79-y.o. woman with five chronic health problems: Hypertension Diabetes mellitus Osteoporosis Ostheoarthritis COPD How can you follow this regimen? Boyd CM et al JAMA 2005; 294:

133 Health analysis in elderly multimorbid patients

134 CGA Comprehensive Geriatric Assessment National Institute of Health Consensus development conference statement Geriatric assessment methods for clinical desicion-making. J Am Geriatr Soc 1988; 36: 342-7

135 CGA Diagnosis: Integrated multi-domain analysis inter-disciplinary team-assessment

136 CGA Diagnosis: Integrated multi-domain analysis inter-disciplinary team-assessment

137 CGA Diagnosis: Integrated multi-domain analysis inter-disciplinary team-assessment Treatment: Integrated, targeted and coordinated plan for treatment

138 Problem: CGA is not operationalized as a working method

139 Possibilities

140 Health analysis in elderly multimorbid patients

141 Health analysis in elderly multimorbid patients Geriatric Medicine needs a scope

142 Microscope Gyroscope

143 Procedural disciplines Gastroscope Bronchoscope Laparoscope Colonoscope

144 Stetoscope

145 Scope Develop the electronic medical record Geroscope Interactive health analysis and management system

146 Proposal to operationalize CGA and to also include management 4-level health analysis

147 Proposal to operationalize CGA and to also include management 4-level health analysis Primary prevention Secondary pevention Tertiary pevention

148 4th level: Relations 3rd level: Domains 2nd level: Structure 1st level: Compilation

149 4th level: Relations 3rd level: Domains 2nd level: Structure 1st level: Compilation Compile Symptoms Diagnoses Risk factors - Treatment

150 Maria Johansson 86 y.o. Diagnostics (D) Symptoms 18 Diagnoses 16 Treatment (T) Prescription drugs 9 Nutrition 2 Physical activity / exercise 2 Technical aids 9 iadl-support 5 27

151 4th level: Relations 3rd level: Domains 2nd level: Structure Structure the results 1st level: Compilation Compile Symptoms Diagnoses Risk factors - Treatment

152 Multimorbidity matrix Akner G. Analysis of multimorbidity in individual elderly nursing home residents. Development of a multimorbidity matrix. Arch Gerontol Geriatr 2009; 49: 413-9

153 Diagnostics Treatment Multimorbidity matrix Akner G. Analysis of multimorbidity in individual elderly nursing home residents. Development of a multimorbidity matrix. Arch Gerontol Geriatr 2009; 49: 413-9

154 Diagnostics

155 Symptoms Diagnostics

156 Diagnostics Symptoms Problem-area

157 Diagnostics Symptoms Problem-area Organ

158 Symptoms Problem-area Organ System Diagnostics

159 Diagnostics Symptoms Problem-area Organ System Function

160 Diagnostics Symptoms Problem-area Organ System Function Symptom

161 Diagnostics Symptoms Problem-area Organ System Function Symptom Score

162 Treatment

163 Drugs Treatment

164 Nutrition Treatment

165 Treatment Physical activity / exercise

166 Treatment Technical aids

167 Treatment ADL

168 Treatment ADL Multimorbidity matrix Akner G. Analysis of multimorbidity in individual elderly nursing home residents. Development of a multimorbidity matrix. Arch Gerontol Geriatr 2009; 49: 413-9

169 4th level: Relations 3rd level: Domains Multidomain structure 2nd level: Structure Structure the results 1st level: Compilation Compile Symptoms Diagnoses Risk factors - Treatment

170 Multidomain structure

171 Multidomain structure

172 Symptoms Multidomain structure

173 Symptoms Diseases Injuries Multidomain structure

174 Symptoms Diseases Injuries Mental function Multidomain structure

175 Symptoms Diseases Injuries Mental function Sensoryorgan function Multidomain structure

176 Symptoms Diseases Injuries Mental function Sensoryorgan function Physical activity/ function Multidomain structure

177 Symptoms Diseases Injuries Mental function Sensoryorgan function Physical activity/ function Nutrition Multidomain structure

178 Symptoms Diseases Injuries Mental function Social function Sensoryorgan function Physical activity/ function Nutrition Multidomain structure

179 4th level: Relations Relations between findings 3rd level: Domains Multidomain structure 2nd level: Structure Structure the results 1st level: Compilation Compile Symptoms Diagnoses Risk factors - Treatment

180 Symptoms Diseases Injuries Relations Mental function Social function Sensoryorgan function Physical activity/ function Nutrition Integrated multidomain health analysis

181 Day fatigue Symptoms Diseases Injuries Relations Mental function Social function Sensoryorgan function Physical activity/ function Nutrition Integrated multidomain health analysis

182 Day fatigue Chronic cardiac failure COPD Diabetes mellitus Symptoms Diseases Injuries Relations Mental function Social function Sensoryorgan function Physical activity/ function Nutrition Integrated multidomain health analysis

183 Day fatigue Chronic cardiac failure COPD Diabetes mellitus Symptoms Diseases Injuries Relations Mental function Social function Cognitive dysfunction Sensoryorgan function Physical activity/ function Nutrition Integrated multidomain health analysis

184 Day fatigue Chronic cardiac failure COPD Diabetes mellitus Symptoms Diseases Injuries Relations Mental function Social function Cognitive dysfunction Sensoryorgan function Physical activity/ function Nutrition Visual impairment Hearing impairment Integrated multidomain health analysis

185 Day fatigue Chronic cardiac failure COPD Diabetes mellitus Symptoms Diseases Injuries Relations Mental function Social function Cognitive dysfunction Sensoryorgan function Physical activity/ function Nutrition Visual impairment Hearing impairment Low physical activity Integrated multidomain health analysis

186 Day fatigue Chronic cardiac failure COPD Diabetes mellitus Symptoms Diseases Injuries Relations Mental function Social function Cognitive dysfunction Sensoryorgan function Physical activity/ function Nutrition Low energy intake Visual impairment Hearing impairment Low physical activity Integrated multidomain health analysis

187 Day fatigue Chronic cardiac failure COPD Diabetes mellitus Symptoms Diseases Injuries Relations Mental function Social function Stress (e.g.worry for children Cognitive dysfunction Sensoryorgan function Physical activity/ function Nutrition Low energy intake Visual impairment Hearing impairment Low physical activity Integrated multidomain health analysis

188 Differential diagnosis day fatigue

189 Risk factor profile Subjective risk-score 0-3 Traffic light model

190 Prototype for Geroscope Interactive medical record focused on overview and relations

191 Concluding remark

192 Number of health problems Age (years) Exponential function of aging

193 Number of health problems Age (years) Exponential function of aging

194 Number of health problems Single-morbidity Multi-morbidity Age (years) Exponential function of aging

195 Number of health problems Single-morbidity Multi-morbidity Traditional Clinical work-methods Medical records Education / training Research methods (RCT) Management Age (years) Exponential function of aging

196 Number of health problems Single-morbidity Multi-morbidity Traditional Clinical work-methods Medical records Education / training Research methods (RCT) Management Traditional Clinical work-methods Medical records Education / training Research methods (RCT) Management Age (years) Exponential function of aging

197 Number of health problems Single multi switch (SMS) Single-morbidity Multi-morbidity Traditional Clinical work-methods Medical records Education / training Research methods (RCT) Management Traditional Clinical work-methods Medical records Education / training Research methods (RCT) Management Age (years) Exponential function of aging

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