老年医学跨学科团队治疗多病共存高龄帕金森病患者1例

1例高龄女性帕金森病患者,出现进行性加重的吞咽障碍、消瘦及精神行为症状,患者同时合并多种慢性病及老年综合征。经过老年医学跨学科团队合作,采用肠内营养支持、吞咽康复、药物重整等措施,患者体重显著增加,恢复自主进食能力。基于老年综合评估的老年医学跨学科团队协作模式在老年患者多病共存管理、功能状态维护方面行之有效。     

Geriatric rehabilitation revisited

There is no gold standard for rehabilitation of geriatric patients. Although many studies indicate that a multifaceted team approach, such as seen with specialized stroke units, may enhance outcomes for many patients, how these units achieve this is still unclear. However, the evidence shows that a comprehensive program of both medical and psychosocial support tends to result in patients achieving and maintaining higher levels of function, with less need for readmission, and shorter hospital stays. In addition to interventions aimed at improving function, rehabilitation includes assessment, goal setting, and provision of care to maintain the patient's status. More randomized controlled studies of rehabilitation programs are needed so that we can identify which programs are best for which patients.     

The effect of geriatric rehabilitation on physical performance and pain in men and women

In the developed countries, people are living longer and the number of aged persons is growing. Knowledge on the effectiveness of rehabilitative procedures is needed and information in physical performance between men and women is scarce. An intervention study was carried out in two war veterans’ rehabilitation centers in Finland to examine the effects of geriatric inpatient rehabilitation on physical performance and pain in elderly men and women. The study included 441 community-dwelling persons with a mean age of 83 years. A clinical assessment and a structured interview were carried out. Cognitive capacity was evaluated with the mini-mental state examination (MMSE). Physical performance was measured through several validated tests. Pain was measured with the visual analogy scale (VAS). The rehabilitation was carried out with the standard rehabilitation protocol. Both men and women showed a statistically significant improvement in physical performance tests. The experience of pain and disease symptoms diminished significantly in both sexes (p < 0.001). The intervention showed that women improved more than men. It showed significant interactions of group by time in knee extension strength (p = 0.033), the experience of pain reduction (p = 0.002) and disease symptoms (p = 0.040). Inpatient geriatric rehabilitation appeared to have a positive effect on physical performance and the experience of pain in elderly people. The differences between the sexes in the experience of pain, disease symptoms and in the knee extension strength could provide a new perspective in the planning of more individual rehabilitation interventions.     

Family functioning and social support for older patients with depression in an urban area of Shanghai,China

PurposeGeriatric depression is now very common and leads to significant economic costs and family burden in China. Families with a depressed patient often report problematic family functioning in Western samples, and lack of social support is strongly associated with geriatric depression. However, the relationship between geriatric depression, family functioning and social support in mainland China has not been well studied.Materials and methodsThis study compared family functioning and social support in a Chinese sample of elderly patients with major depression and non-depressed elderly people, and evaluated the impact of family functioning, social support and socio-demographic factors on depression. A questionnaire was administered to 102 elderly patients with major depression and 107 non-depressed elderly people.ResultsThe elderly patients with major depression had worse family functioning and lower social support than elderly individuals without depression. Multivariate linear regression analysis showed associations between depressive symptoms and unhealthy family functioning, lower social support and single marital status.ConclusionsThe findings suggest that family interventions and improvement of social support are important in reducing depression among elderly patients. In addition, strategies to alleviate geriatric depression should be considered by the whole society, the community, family members and the depressed elderly patients themselves.     

Life-space mobility in older persons with cognitive impairment after discharge from geriatric rehabilitation

ObjectivesTo describe life-space mobility and identify its determinants in older persons with cognitive impairment after discharge from geriatric rehabilitation.MethodsA cross-sectional study in older community-dwelling persons with mild to moderate cognitive impairment (Mini-Mental State Examination, MMSE: 17–26) following geriatric rehabilitation was conducted. Life-space mobility (LSM) was evaluated by the Life-Space Assessment in Persons with Cognitive Impairment (LSA-CI). Bivariate analyses and multivariate regression analyses were used to investigate associations between LSM and physical, cognitive, psychosocial, environmental, financial and demographic characteristics, and physical activity behavior.ResultsLSM in 118 older, multimorbid participants (age: 82.3 ± 6.0 years) with cognitive impairment (MMSE score: 23.3 ± 2.4 points) was substantially limited, depending on availability of personal support and equipment. More than 30% of participants were confined to the neighborhood and half of all patients could not leave the bedroom without equipment or assistance. Motor performance, social activities, physical activity, and gender were identified as independent determinants of LSM and explained 42.4% (adjusted R²) of the LSA-CI variance in the regression model.ConclusionThe study documents the highly restricted LSM in older persons with CI following geriatric rehabilitation. The identified modifiable determinants of LSM show potential for future interventions to increase LSM in such a vulnerable population at high risk for restrictions in LSM by targeting motor performance, social activities, and physical activity. A gender-specific approach may help to address more advanced restrictions in women.     

A comparison of the quality of life reported by elderly whites and elderly blacks on dialysis

Objective: To compare indicators of quality of life reported by elderly whites and elderly blacks on chronic dialysis. Design: Survey of surviving patients from a previously identified prevalent cohort. Setting: 58 dialysis facilities located throughout the state of Georgia. Subjects: 46 whites (mean age = 72) and 85 blacks (mean age = 70) on chronic dialysis ≥3.5 years. Main outcome measures: Number of days in bed during past 3 months; number of nights hospitalized during past 6 months; score summarizing limitations in functional status; 10 dialysis symptoms/complaints; 9 indicators of subjective well-being. Results: Elderly whites, more than elderly blacks, complained of nausea, fatigue, and longer time to recover following a hemodialysis treatment. Whites also were more likely than blacks to perceive kidney failure/dialysis as intrusive for their health and for their diet, to report health dissatisfaction, and to report life dissatisfaction. Conclusions: Although blacks were more likely than whites to have diabetes as a primary diagnosis and blacks' educational level was lower than that of whites, all the statistically significant quality of life differences identified in this elderly cohort showed better quality of life among black patients than among white patients.     

Chronic kidney disease: psychosocial impact of chronic pain

Chronic kidney disease (CKD) affects more than 19 million people in the United States, and prevalance of CKD is expected to double within 10 years. Additionally, a significant number of predominantly elderly patients have end stage renal disease, necessitating dialysis or kidney transplant. Perception of chronic pain, especially in elderly dialysis patients, may be greatly underrecognized. As a result management of pain, as well as depression, and other physical and mental symptoms, may not be adequately addressed in the primary care setting. Clinical interventions such as psychiatric evaluation, pain management, and therapy to improve physical and mental symptoms, may markedly impact wellbeing for CKD patients. Constant reassessment is critical when treating CKD patients. Such an approach may significantly better elderly patients health-related quality of life.     

Interventions targeting geriatric frailty: A systemic review

Geriatric frailty has drawn growing interest in recent years for its associations with multiple adverse outcomes. Previous studies showed that interventions may improve some aspects of frailty such as physical function. However, interventions targeting the entire frailty construct have not been systemically reviewed. We conducted a comprehensive search for randomized controlled trials targeting geriatric frailty. Only trials that measured outcomes based on their predefined frailty indicators were included. Of 98 articles, 11 met the inclusion criteria. Eight studies were classified as high quality. Of the six exercise-based interventions, five showed significant improvements on at least two of their frailty indicators. Hormone replacement therapy was not effective. Two of the three multifactorial interventions have not published their results, and the third did not show significant improvements. More studies with standardized definitions and measurements of frailty are needed to determine the effectiveness of interventions on geriatric frailty.     

A co-twin control study of physical function in elderly African America women

Objective: This study investigated variables associated with physical functioning limitations among elderly African American women, controlling for genetics and common family environment. Method: Activities of daily living limitations (ADL) and instrumental activities of daily living limitations (IADL) are examined in 180 pairs of African American elderly twins using a co-twin control design. The association of chronic disease, other physical problems, lifestyle, and demographic factors with both measures are investigated. Results: Arthritis, hypertension, and more than 1 chronic disease are associated with ADL limitations and arthritis; diabetes, heart attack, and more than 1 chronic disease are associated with IADL limitations in univariate analyses. In multivariate analyses, a different set of additional variables is associated with the two measures. Discussion: Among elderly African American women, physical functioning limitations are influenced by the presence of chronic diseases, other physical problems, lifestyle, and demographics. These associations are not due to genetics or common family environment effects.     

Rehabilitation in der Geriatrie

Geriatric rehabilitation is a cornerstone of every treatment plan in elderly persons in the inpatient, day clinic and outpatient settings. Geriatric patients tend to be more in need of care and to have a loss of domestic independence due to multimorbidities. The goal of geriatric rehabilitation is to preserve and/or restore the disease-related functional deficits in order to guarantee mobility and activities of daily living (ADL) in addition to curative treatment. Structural prerequisites in all geriatric units are the comprehensive geriatric assessment (CGA) and the existence of an interdisciplinary geriatric team. Geriatric rehabilitative treatment is based on functionality (ICF) and is therefore indicated in a wide spectrum of diseases. The demographic shift necessitates an increase in geriatric treatment structures with innovative concepts such as geronto-traumatological interdisciplinary units or geriatric outpatient office groups with a better networking of different care structures.     

Home hospitalization service for acute uncomplicated first ischemic stroke in elderly patients: a randomized trial

OBJECTIVES: To evaluate whether home treatment of elderly patients with acute uncomplicated first ischemic stroke is associated with different mortality rates and clinical outcomes from those of patients treated on a general medical ward (GMW). DESIGN: Randomized, controlled, single-blind trial. SETTING: S. Giovanni Battista Hospital of Turin. PARTICIPANTS: One hundred twenty elderly patients admitted to the emergency department of the hospital with first acute ischemic stroke were randomized to home treatment from a geriatric home hospitalization service (GHHS) or to GMW treatment. MEASUREMENT: Main outcome was cumulative survival at 6 months in the two groups. Residual functional impairment, neurological deficit, depression, morbidity, and admission to rehabilitation and long-term care facilities were considered as secondary outcomes in survivors. RESULTS: One hundred twenty patients (mean age 82; 54 men and 66 women) were enrolled (60 in each study arm). The cumulative proportion of cases surviving at 6 months was 0.65 in the GHHS group and 0.60 in GMW group (log-rank test P=.53). Functional and neurological parameters were significantly improved in both GHHS and GMW patients, without significant differences between the two groups. Depression score was significantly better in home-treated patients (P<.001), who were more likely to remain at home at 6 months than hospital-treated patients and had a lower rate of select medical complications. CONCLUSION: Home-treated elderly patients with ischemic stroke have better depressive scores and lower rates of admission to nursing homes. These results should prompt further studies to evaluate home hospitalization for elderly stroke patients.     

Association of chronic non-steroidal anti-inflammatory drugs use and cognitive decline in non-demented elderly patients admitted to a geriatric evaluation and rehabilitation unit

In a geriatric evaluation and rehabilitation unit (GERU), 258 elderly patients (M: 71, F: 187; mean age 77.4 +/- 7.5) scoring 22 or more at Mini-Mental State Examination (MMSE) consecutively admitted were assessed in order to evaluate the effects of non-steroidal anti-inflammatory drugs (NSAID) chronic treatment on cognitive status in non-demented elderly patients. Sixty-six patients (25.6%) were considered chronic NSAID users. Patients chronically assuming NSAADs showed a significantly higher MMSE score than non-users (26.9+/-2.1 vs 25.7+/-2.5, P<0.0005 ). After controlling for potential confounders in a multivariate model, chronic NSAID use remained independently associated with MMSE score. The results support a positive association between chronic NSAID use and cognitive function in non-demented elderly patients. Randomized controlled trials will be needed to definitively prove this beneficial effect.     

Effects of Acute Phase Intensive Electrical Muscle Stimulation in Frail Elderly Patients With Acute Heart Failure (ACTIVE‐EMS): Rationale and protocol for a multicenter randomized controlled trial

In elderly patients with acute heart failure (AHF), clinical outcome is adversely affected by frailty. Although a number of potentially effective interventions for frailty have been reported, little is known about the effects of rehabilitation programs in frail elderly AHF patients. We postulated that addition of electrical muscle stimulation (EMS), which induces muscle contraction without requiring patient volition, to early rehabilitation would be efficacious in frail elderly AHF patients. The ACTIVE‐EMS (Effects of Acute Phase Intensive Electrical Muscle Stimulation in Frail Elderly Patients With AHF; UMIN000019551) trial is a multicenter, randomized controlled trial that will enroll 80 patients from 3 hospitals in Japan. AHF patients age ≥ 75 years positive for frailty, defined as Short Physical Performance Battery score 4 to 9, will be randomly assigned to receive early rehabilitation program only or EMS add‐on therapy for 2 weeks. The primary endpoint of the trial is the change in quadriceps isometric strength between baseline and 2 weeks, with changes in physical function and cognitive function, and clinical safety and feasibility of EMS therapy as secondary outcomes. ACTIVE‐EMS is the first randomized trial to evaluate the clinical effectiveness of adding EMS therapy to early rehabilitation in frail elderly AHF patients. The results of this study will provide insight for the development of appropriate rehabilitation programs for this high‐risk population.     

Performance indicators for hospital services for older people

BACKGROUND: standardised assessment is recommended in geriatric practice to improve patient care and generate quality data for audit and research. High level indicators used to measure performance of rehabilitation units suggested that more patients were discharged to long-term residential care from one of two hospitals in a Health Authority in South East England. OBJECTIVES: to test whether the information provided by standardised assessment could inform performance indicators used to compare outcomes between hospitals. DESIGN: prospective observational study. SUBJECTS: consecutive patients admitted for rehabilitation to two general geriatric rehabilitation wards in each of two nearby district general hospitals. METHODS: patients were assessed using standard tools (Barthel and Abbreviated Mental Test score) and various scales of the interRAI MDS assessment system (mental and physical functioning, pressure ulcers, continence, falls, mood), within a week of admission and up to one week before discharge. Place of residence prior to admission and discharge destination were determined. RESULTS: on bivariate analysis there was a significant difference in discharge to residential and nursing homes between hospitals. Results from multivariate logistic regression analysis showed an increased risk for institutionalisation at discharge for women [odds ratio 2.42 (95% CI 1.41-4.14)] and patients with impaired cognitive function [odds ratio 1.53 (95% CI 1.28-1.82) for each point increase in MDS cognitive performance scale] and physical function [odds ratio 1.15 (95% CI 1.08-1.22) for each point increase in MDS short ADL scale]. Barthel and Abbreviated Mental Test showed similar odds ratios. Hospital did not remain a significant predictor of discharge destination following adjustment for patients' physical and cognitive function. CONCLUSIONS: comparisons of outcomes between hospitals could be misleading unless informed by standardised data on physical and mental functioning of rehabilitation patients.     

Exercise rehabilitation of older patients with cardiovascular disease

As the population of elderly patients with cardiovascular disease continues to increase, much research needs to be done with the goal of maintaining physical functioning and personal independence in this population. It is of particular importance to determine whether training programs can improve physical functioning in the most severely disabled older coronary patients. Effects of cardiac rehabilitation programs on other outcome measures, including psychosocial outcomes, lipid levels, insulin levels, and body composition require better study. Finally, the economic benefits of cardiac rehabilitation in the older coronary patients has received little attention, although early reports are promising. In summary, the older population with coronary disease is characterized by high rates of disability. Exercise training has been demonstrated to be safe and to improve strength, aerobic fitness capacity, endurance and physical function. It remains to be seen whether exercise training can reverse or prevent disability in a broad population of older patients with cardiovascular disease. If successful, cardiac rehabilitation programs will pay great medical, social, and economic dividends in this population.     

Repercussions of early versus late initiation of dialysis

  Despite the widespread use of chronic dialysis, there remains a lack of consensus about the optimal time for initiation of renal replacement therapy. Recommendations from the National Kidney Foundation Kidney Disease Outcome Quality Initiative are generally used as the guideline. This has resulted in a trend in the past decade toward earlier initiation of dialysis, especially in the elderly. The associated burden of comorbidities in the elderly population has resulted in greatly reduced survival outcomes. Here, the data obtained from retrospective cohort studies have been corroborated with a recent randomized control trial conducted in Australia and New Zealand (IDEAL study). There are limitations to consider from the IDEAL study that originate from different confounding factors that intervene in the test population. The present paper is an evidence-based review of the literature, focusing on diminution of survival outcomes following the early initiation of dialysis.     

Is training for informal caregivers and their older persons helpful? A systematic review

BackgroundThe steady increase in the number of people suffering from chronic diseases and increasing life expectancy raises new demands on health care. At the same time, the need for informal caregivers is increasing. This study aims to perform a systematic review of the methodologies used to identify effect of different types of training on informal caregivers and their older persons.MethodsMEDLINE (PubMed), CINAHL and Ovid were searched from December 2016 and April 2017. The following keywords were used; "informal caregiver", "training" "elderly", older persons". Identified publications were screened by using the following inclusion criteria; systematic reviews, randomized controlled trials, prospective cohort and multicentre studies, English language full text journals, samples or interventions that included caregivers of older persons and published in last 10 years.ResultsTwenty four studies (12 randomised control trials, 8 intervention studies and 4 systematic reviews) were included. Most of the randomized controlled trials involved both caregivers and elderly. Pretests and post-tests were used in intervention studies (5 out of the 8 studies). ICT-based, psychosocial interventions on family caregivers' education program for caregivers were applied. Caregivers following a supportive educative learning had a significantly better quality of life.ConclusionsThe findings of this systematic review suggest that support interventions for caregivers can be effective in reducing caregivers' stress, with a consequent improvement of the quality of care. However, results are based on relatively small studies, reporting somewhat controversial findings supporting the need to perform further research in this field.     

Orthopaedic‐geriatric models of care and their effectiveness

Different types of orthopaedic geriatric units have been established. This review evaluates the effectiveness of this model of care. A computerised literature search was undertaken using Medline (January 1966–February 2009), Cochrane and CINAHL with the search terms orthopaedics, geriatrics, aged, orthopaedic procedures and fractures. Relevant articles were evaluated and appraised with particular focus on randomised controlled trials. Orthopaedic‐geriatric models can be divided according to the setting of care (i) acute inpatient orthopaedic‐geriatric care; (ii) subacute rehabilitation; and (iii) community‐based rehabilitation. Studies have been heterogenous in nature and outcomes measured have differed making pooled data analysis difficult. In general, there is a trend to effectiveness in outcomes such as functional recovery, length of stay, complications and mortality and importantly studies have not shown detrimental consequences. However, because of the varied types of interventions and models of care, it is difficult to draw firm conclusions about the effectiveness of these programs.     

Psychologic factors in scleroderma

CB interventions have been shown to reduce pain and improve psychosocial functioning in patients who have chronic illnesses, particularly chronically painful rheumatologic syndromes. These interventions are typically administered by specially trained professionals and are conducted during weekly individual or group sessions. When focused on pain and chronic illness, these interventions seem to have, at best, small effects on depression. Data from the headache literature and recent data about patients who have dental/facial pain indicate that minimal-contact CB therapy, the combination of some professional contact with audiotaped and written materials, may reduce pain in many patients, but the impact on functioning is less clear. Future studies should examine the impact of CB interventions on pain, depression, concerns about disfigurement, and physical and psychosocial functioning in scleroderma. Such knowledge is necessary for the optimal care of persons who have this debilitating illness. Although complicated, the advent of disease-specific interventions that are administered by way of the Internet may prove particularly useful in a rare illness, such as scleroderma. Psychologic factors with demonstrated relevance to scleroderma include pain, depression, and distress about disfigurement, physical function, and social function. Although these dimensions of quality of life are interrelated, pain, depression, and distress about disfigurement are common and may respond to psychologic interventions.