Presentacin de PowerPoint

DISCAPACIDAD NOSOCOMIALNicols Martnez VelillaServicio de GeriatraComplejo Hospitalario de Navarra

Conflicto de interesesVegenat: Captulos de libros, charlasPfizer: Organizacin de Curso y charlaSanofi: Ayuda en congreso (viaje, inscripcin, hotel), captulo libroNovartis: CharlasNutricia: Charlas

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RESUMEN

Chile y EspaaFragilidad (predisponente de iatrogenia), discapacidad, multimorbilidad, cronicidadCambio paradigma en la atencin anciano hospitalizado Discapacidad nosocomialRevisin de bibliografa relevante Evidencia actual programas ejercicio fsico en hospitalizacin Nuestra experiencia. Ensayo clnico aleatorizado y Programa Europeo VivifrailConclusiones

PACIENTE CLASICO(siglo XX)

Una enfermedad

Sin impacto sobre la funcin

Sin secuelas funcionalesPACIENTE MODERNO(siglo XXI)

Varias enfermedades crnicas, con reagudizaciones frecuentes

Con impacto sobre la funcin

Con secuelas funcionalesCaractersticas del pacienteRodrguez-Maas; 2001

DEBEMOS CAMBIAR NUESTRO MODO DE PENSAR

9SmartArt custom animation effects: pictures peek-in(Basic)

To reproduce the SmartArt effects on this page, do the following:On the Home tab, in the Slides group, click Layout, and then click Blank. On the Insert tab, in the Illustrations group, click SmartArt.In the Choose a SmartArt Graphic dialog box, in the left pane, click Matrix. In the Matrix pane, double-click Titled Matrix (second option from the left) to insert the graphic into the slide. Select the graphic. Under SmartArt Tools, on the Format tab, click Size, and then do the following:In the Height box, enter 5.67.In the Width box, enter 8.5.Under SmartArt Tools, on the Format tab, click Arrange, click Align, and then do the following:Click Align to Slide.Click Align Middle. Click Align Center. Select the graphic, and then click one of the arrows on the left border. In the Type your text here dialog box, enter text in the top-level bullet only (text for the rounded rectangle at the center of the graphic). To remove the [Text] placeholder in the second-level bullets, select each bullet and press SPACE.On the slide, select the graphic. Under SmartArt Tools, on the Design tab, in the SmartArt Styles group, click More, and then under Best Match for Document click Moderate Effect.Select the rounded rectangle at the center of the graphic. On the Home tab, in the Font group, select 28 from the Font Size list, click the arrow next to Font Color, and then click White, Background 1 (first row, first option from the left).With the rounded rectangle selected, under SmartArt Tools, on the Format tab, in the bottom right corner of the Shape Styles group, click the Format Shape dialog box launcher. In the Format Shape dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Linear.In the Direction list, select Linear Up (second row, second option from the left).Under Gradient stops, click Add or Remove until three stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 0%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 35% (fifth row, first option from the left).Select Stop 2 from the list, and then do the following: In the Stop position box, enter 80%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 35% (fifth row, first option from the left).Select Stop 3 from the list, and then do the following: In the Stop position box, enter 100%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 15% (third row, first option from the left).Right-click the top left shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill, and then under Insert from, click File. In the Insert Picture dialog box, select a picture and then click Insert. Right-click the top right shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill, and then under Insert from, click File. In the Insert Picture dialog box, select a picture and then click Insert. Right-click the bottom left shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill, and then under Insert from, click File. In the Insert Picture dialog box, select a picture and then click Insert. Right-click the bottom right shape in the graphic, and then click Format Shape. In the Format Shape dialog box, in the left pane, click Fill. In the Fill pane, click Picture or texture fill, and then under Insert from, click File. In the Insert Picture dialog box, select a picture and then click Insert.

To reproduce the animation effects on this slide, do the following:On the Animations tab, in the Animations group, click Custom Animation.On the slide, select the graphic, and then do the following in the Custom Animation task pane: Click Add Effect, point to Entrance, and then click More Effects. In the Add Entrance Effect dialog box, under Subtle, click Expand. Under Modify: Expand, in the Speed list, select Fast.Under Modify: Expand, in the Start list, select After Previous.Also in the Custom Animation task pane, click the arrow to the right of the animation effect, and then click Effect Options. In the Expand dialog box, on the SmartArt Animation tab, in the Group Graphic list, select One by one.Also in the Custom Animation task pane, click the double-arrow below the animation effect to expand the list of effects, and then do the following:Press and hold CTRL, and then select all five animation effects in the Custom Animation task pane. Under Modify: Expand, in the Start list, select With Previous.Press and hold CTRL, select the second, third, fourth, and fifth animation effects (expand effects for the picture-filled rectangles), and then do the following:Click Change, point to Entrance, and then click More Effects. In the Change Entrance Effect dialog box, under Basic, click Peek In. Under Modify: Peek In, in the Speed list, select Fast.Select the second animation effect. Under Modify: Peek In, in the Start list, select After Previous.Select the third animation effect. Under Modify: Peek In, in the Direction list, select From Left.Select the fourth animation effect. Under Modify: Peek In, in the Direction list, select From Right.Select the fifth animation effect. Under Modify: Peek In, in the Direction list, select From Top.

To reproduce the background effects on this slide, do the following:Right-click the slide background area, and then click Format Background. In the Format Background dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Radial.Click the button next to Direction, and then click From Corner (fifth option from the left).Under Gradient stops, click Add or Remove until two stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 0%.Click the button next to Color, and then under Theme Colors click White, Background 1 (first row, first option from the left).Select Stop 2 from the list, and then do the following: In the Stop position box, enter 71%.Click the button next to Color, and then under Theme Colors click White, Background 1, Darker 15% (third row, first option from the left).

Robusto FrgilLimitacinfuncionalDiscapacidadDependenciaDefinicinIntervenciones para mejorar la calidad y los resultados, y prevenir o retrasar deterioro funcionalPrevencin fragilidadPrevencin fragilidadTratamientofragilidadPrevencin discapacidadTratamientoDeterioro funcionalPrevencin dependenciaTratamiento discapacidadManejode la dependencia

Posibilidad de reversibilidaddel deterioro funcional Fragilidad como un estado funcional dinmico

DISCIPLINAS QUE ESTN INCORPORANDO EL CONCEPTO DE FRAGILIDADGERIATRIAATENCIN PRIMARIACirugas CardiologaOncologaHematologaTraumatologaUrgenciasHospitalPaliativosPreoperatorios / anestesiaVIH

Enfermedad renal crnicaEPOCEnfermedad coronariaDiabetesHTADolorPolifarmaciaCalidad de vidaDiscapacidad nosocomialNutricinInsuficiencia cardacaEnfermedad de Alzheimer

En el hospital parece ms atractivo el IF por las variables disponibles. Mejor desempeo al alta y 6 meses. Dificil st en urgencias el fenotipoCiruga: ambos mejoran la estimacin convencional de riesgo quirrgico. Revisiones a favor. Mayor evidencia en ciruga cardaca; si bien no para seleccionar casos, s para refinar el apoyo perioperatorio13

Artculo 6 de el Clinical Trials Regulation ((EU No 536/2014): si un determinado gnero o grupo de edad es excluido o infrarrepresentado, hay que dar una explicacin. Evidende biased; bases legalesUna clasificacin estandarizada de la fragilidad es potencialmente til en la estratificacin del riesgo y para describir las carctersticas poblacionalesFragilidad fsica: SPPB (velocidad de marcha)Fragilidad y disfuncin cognitiva: MoCA (3MS, MMSE)Fragilidad y desnutricin: MNA-SFFragilidad y multimorbilidad: CIRS-G

MOMENTO HABITUALFragilidad: un Sndrome Complejo de Vulnerabilidad aumentada

FRAGILIDAD

Edad

Determinantes vitales: Biolgicos(incluyendo genticos)PsicolgicosSocialesMedio Ambientales

Enfermedad crnica

Disminucin reserva fisiolgica

Resultados adversosDiscapacdadMorbilidadHospitalizacionInstitutionalizacinMuerte

Posibles marcadoresNutricinMobilidadActividadFuerzaPotenciaCognicinAfectivo

REVERSIBILIDADPrevencin /Retraso FragilidadPromocin de la salud y Prevencin

Retrasar inicio

Retraso, prevencin de resultados adversos, cuidados

MOMENTO ADECUADOCHRONIC DISEASES

Lancet, November 2014

2121

Qu ocurre en nuestros hospitales?podemos cambiarlo / mejorarlo / empeorarlo?

La edad es algo que no importa, salvo que seas un quesoLuis Buuel

StatesWorse Than Death Among HospitalizedPatientsWith Serious IllnessesJAMA Intern Med, 2016

MANEJO HOSPITALARIOIntern Med J. 2011 Aug;41(8):610-7. doi: 10.1111/j.1445-5994.2010.02165.x. Acute gout management during hospitalization: a need for a protocol. Arch Intern Med. 2011Apr 11;171(7):630-4. Physicians recommend different treatments for patients than they would choose for themselves. Arch Intern Med. 2011 Oct 10;171(18):1646-53. Diagnosticblood lossfromphlebotomyand hospital-acquired anemia during acute myocardial infarction

Si un ciudadano es ingresado en un hospital de cualquier pas del mundo , tiene un 10% de probabilidades de sufrir algn evento en su cuidado, que en 1 de 300 casos puede llevarle a la muerte. El riesgo de morir en accidente areo es mucho menor. 1 / 10.000.000 (Liam Donaldson, Naciones Unidas)1- Acute gout episodes in hospital are variably investigated and treated with frequent suboptimal management. We recommend establishment of a hospital-wide protocol to support decision-making regarding investigations, treatment and follow up.2- The act of making a recommendation changes the ways that physicians think regarding medical choices. Better understanding of this thought process will help determine when or whether recommendations improve decision making.3- Blood loss from greater use of phlebotomy is independently associated with the development of HAA. These findings suggest that HAA may be preventable by implementing strategies to limit blood loss from laboratory testing. Blood loss from greater use of phlebotomy is independently associated with the development of HAA. These findings suggest that HAA may be preventable by implementing strategies to limit blood loss from laboratory testing.5- findings indicate that greater AEE may be protective against cognitive impairment in a dose-response manner. The significance of overall activity in contrast to vigorous or light activity should be determined.

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Factores deterioro funcional asociado a la hospitalizacin

Hasta el 80% de los casos de discapacidad iatrognica son prevenibles!!!

Discapacidad nosocomialHospitalizacin= acontecimiento centinela y causa habitual de discapacidad a largo plazo (duracin > 6 meses) (Gill TM, JAMA 2010)Incidencia: 5-60% (Boyd CM JAGS 2008; Sager MA, Arch Intern Med 1996) El Hospital Outcomes Project for the Elderly (HOPE): al alta 31% de los pacientes deterioro en al menos 1 ABVD, 40% perdan la habilidad de >2 ABVD. A los 3 meses, 19% deterioro en ABVD y 40% deterioro en AIVD.(Arora M, Med Care 2009)Institucionalizacin asociada (independiente de ABVD)(Portegijs E, JAMDA 2012), mortalidad (Buurman BM, PLoS One 2011), uso de recursos (Fried TR, Arch Intern Med 2011), deterioro cognitivo, sntomas depresivos y deterioro de calidad de vida (Helvik AS, Arch Gerontol Geriatr 2013)

31

a modo de ejemplo, la iatrogenia es la tercer causa de muerte en Estados Unidos

Si un ciudadano es ingresado en un hospital de cualquier pas del mundo , tiene un 10% de probabilidades de sufrir algn evento en su cuidado, que en 1 de 300 casos puede llevarle a la muerte. El riesgo de morir en accidente areo es mucho menor. 1 / 10.000.000 (Liam Donaldson, Naciones Unidas)

32

Is US Health really the best in the world? Starfield B. JAMA, 200012000 muertes / ao por cirugas innecesarias7000 muertes / ao por errores en medicacin20000 muertes / ao por otros errores hospitalarios80000 muertes/ ao por infecciones nosocomiales106.000 muertes / ao por ES (no errores)Discapacidad? desnutricin? sds geritricos?3 causa de muerte al ao tras enfermedad cardaca y cncer

DefinicionesEvento iatrognico adverso: Cualquier lesin no intencionada, dao o complicacin secundario ms a los cuidados que la enfermedad basal, teniendo en cuenta el estado del arte en un momento dado, sin implicar error o negligencia (NEJM 1991, National Conference on Health) Discapacidad: Limitacin funcional (habitualmente ADL) o restriccin de las actividades(WHO, 2001)Discapacidad iatrognica: deterioro funcional debido a 1 o varios eventos adversos durante la hospitalizacin. Incluye tres componente que interaccionan o tienen efecto acumulativo (Lafont C, J Nutr Health Aging 2011, MWG):Fragilidad previa del pacienteGravedad de la enfermedad que caus el ingresoEstructura del hospital y cuidados ofrecidos

De qu sirve que tengamos la mejor de las tecnologas o tratamientos hospitalarios si la discapacidad secundaria a dichos procedimientos condiciona una discapacidad a corto y largo plazo cuyas consecuencias pueden ser devastadoras?Nuestros ancianos hospitalizados sufren iatrogenia nosocomialINNECESARIAMENTE

Morton C. Hazards of Hospitalization of the Elderly. Annals of Internal Medicine. 1993;118:219-223.

37Respecto a los cuidados dispensados tenemos la interaccin entre cambios fisiolgicos del envejecimiento y riesgos de la hospitalizacin que llevan finalmente a outcomes.

DETERIORO FUNCIONAL EN RELACIN CON HORAS ENCAMADOSHORAS QUE PASAN ENCAMADOS ANCIANOS HOSPITALIZADOSMartinez-Velilla N, Urbistondo-Lasa G, Veintemilla-Erice E, Cambra-Contin K. [Determining the hours hospitalised patients are bedridden due to their medical condition and functional impairment and secondary mortality]. Rev Esp Geriatr Gerontol. 2013;48(2):96

Prevencin del deterioro funcional y cognitivo a travs de un programa de actividad fsica para pacientes geritricos hospitalizados: ensayo controlado aleatorio

Recruiting participants among patients admitted to the Geriatric Department (Aged 75 years)

Training group (n=185)

Usual care group (n=185)

Checking eligibility criteria

Orientation and informed consent

Baseline measurement

Randomisation (n=370)

Follow up at discharge (1 month)

Follow up at discharge (3 month)

Diagrama de flujon=81 n=83 Drop out n=29 n=193

MeasurementT1BaselineT2After training or control periodT31-monthT43-monthsCategorical scale of painXXXXBarthel IndexXXXXGeriatric depression Scale of Yasavage XXXXMini-Mental State Examination (MMSE)XXXXShort Physical Performance Battery (SPPB)XXXXGait velocity test (GVT)XXXXDual-task (verbal and counting GVT)XXXXMaximal isometric force of handgrip, knee extension and hip flexion XXXX1RM (Leg press, Chest press and Knee extension)XXXXMuscle power at 50% 1RM in Leg pressXXXXConfusion Assessment Method (CAM)XX Quality of Life (EQ-5D)XXXXGeriatrics syndromesXXXXIsaacs set testXXXXTrail Making Test (TMT)XXXXLaboratory parametersXDiseases considered grouped by ACG of Salisbury and CIE-10 codesXCumulative Illness Rating Scale for Geriatrics (CIRS-G)XZarit ScaleXMini Nutritional Assessment (MNA)X

ExerciseDay1Day2Day 3Day 4Day 5Day 6 *Day 7 *MORNINGRises from a chair1x52x103x103x103x83x83x8Leg press1RM + 1x10 (50%1RM)2x10 (30%1RM)3x10 (40%1RM)3x10 (50%1RM)3x8 (60%1RM)3x8 (60%1RM)3x8 (60%1RM)Chet press1RM + 1x10 (30%1RM) 2x10 (30%1RM)3x10 (40%1RM)3x10 (50%1RM)3x8 (60%1RM)3x8 (60%1RM)3x8 (60%1RM)Leg extension1RM + 1x10 (30%1RM)2x10 (30%1RM)3x10 (40%1RM)3x10 (50%1RM)3x8 (60%1RM)3x8 (60%1RM)3x8 (60%1RM)AFTERNOONLeg extension (0,5 - 1,0 Kg)2x102x102x102x102x102x10Leg flexion (0,5 - 1,0 Kg)2x102x102x102x102x102x10Hip abduction (0,5 - 1,0 Kg)2x102x102x102x102x102x10Hand grip ball2x102x102x102x102x102x10

* En el caso de que los pacientes sigan ingresados estos das.

Sesiones de entrenamiento

Escala Categrica de dolor

** p