I- Overview : definitions
Geriatrics is the medical specialty that takes care of elderly patients can be divided into two groups : elderly patients > 65 years (selon F WHO) and very elderly patients >75 years. The profile of these patients that the medical prescription must obey goals and special precautions.
Age alone is not enough to define a geriatric patient but the coexistence of certain characteristics that defines this profile.
There are also diseases related to age and physiological age to be taken into account and search, exp. cataract, prostate adenoma, osteoporosis….
The geriatric profile is characterized by :
- multiple disorders.
- Decreased homeostasis.
- Risk of poly medication.
- Risk of Disability.
- Changes in some cases the clinical picture and evolution of the pathology.
- Nesting somatic aspects, psychological and social.
"Fragility" of these patients depends on several factors : Age, sex, nutritional status, physical state, autonomy, entourage social.
The increase in life expectancy, leads us to support more often these patients.
II- Geriatric care goals :
The decision and prescription especially in geriatrics should be reflected, for :
- Preserve the best possible quality of life for older people.
- Preventing diseases and complications.
- Make every effort to limit the impact of iatrogenic.
- Improve adherence.
- Avoid diagnostic and therapeutic obstinacy.
- Do not refuse care on the grounds of age.
III- factors involved in the therapeutic decision :
When prescribing to consider several items related to patients :
- Decline in brain function secondary to the degeneration or cerebral hypoperfusion resulting in cognitive disorders, behavior and memory
- Decline in renal function : physiological decrease in glomerular filtration Who imposes the systematic assessment of renal function clearance (MDRD).
- Decline in liver function : if pre-existing liver disease
- Decline of myocardial function : heart failure, arrhythmias.
- Decline of digestive function : transit disorders or mucosal atrophy : hypo albumin where absorption or drug transportation anomalies.
- sensory disturbances : decreased hearing, the views…
To improve the therapeutic response we must ensure two conditions :
a / Adherence : which is defined by the compliance (membership) a patient taking prescription : tracking system, lifestyle change and respect for medical prescriptions or recommendations.
It depends on understanding the goals of treatment and cognitive faculties, the patient's functional status and his entourage.
This requires focus :
- treatments mono socket, simple presentations and dosages.
- consider chronic treatments (record all treatments on a medical form).
b/ L’iatrogénicité :
The iatrogenic drug is defined by the WHO as harmful and unintended response of a medicament for therapeutic or diagnostic doses, it is responsible for 15 at 20% hospitalizations. The elderly person is exposed to poor compliance. This iatrogenic is favored by certain drugs : IEC, diuretics, AINS, AVK, …
IV- Rules to follow :
In practice :
- Prescribe only what is necessary.
- Avoid poly medication as much as possible (Beyond 5 drugs some risk of drug interaction)
- Systematically self-medication or taking medicinal plants (appreciated by elderly patients).
- Reduce dosage anxiolytics, neuroleptics 20% (although the renal and hepatic function are conserved) because risk of side effects and drop.
- Dosage adjustments of medication to renal elimination.
- Adjust the dosage of medication hepatic metabolism.
- Search drug interactions, making plant,….
- etiological treatment preference.
- Do not try to treat everything.
V- Treatment imposing a monitoring :
A dosage adjustment is necessary in the elderly, WHO has also issued a recommendation that the dosage in the elderly is clearly established in the drug notices, surveillance should be even stricter for certain therapeutic classes
- diuretics : risk of dehydration and electrolyte disorders.
- oral antidiabetic : settle for a glucose comfort.
- antihypertensive : risk of hypotension and falls.
- Cardio in renal failure because of overdose risk.
- Digitaliques :
- Beta-blockers: Bradycardia can cause low cerebral blood flow.
- Anti-inflammatory NS : risque d'fonction rénale aigue association is at IEC and / or diurétiques, risk of gastrointestinal bleeding as delicate lining.
- Watch for dangerous interactions.
WE- Suggestive of possible side effects clinical signs :
- rehearsals to fall.
- Syndrome confusionnel.
- Renal failure.
- Fluid and electrolyte disturbances.
- Arrhythmias and conduction.
- hemorrhagic stroke.
- drug-induced hepatitis.
- allergic skin reaction.
- nausea, vomiting.
- Agitations, nightmares, visual disturbances.
- Cough, dyspnea.
WE- Conclusion :
The care of elderly patient based on a comprehensive approach that takes into account the peculiarities semiologic and risks of functional decompensation, from where 1 interest of diagnostic certainty and the anticipated therapeutic benefit.
Exclude often relied solely fatalism made of old age.
The prescription geriatric even more than for other patients must be attentive to the profile of the subject and its real needs.
Cours du Dr Touati. F. – Faculty of Constantine