Gerontology is not only the treatment of the elderly
On an integrated approach to providing medical and social assistance to the elderly
A.S.Gracheva,
deputy. Head of the Department of organization of quality control of medical care to the population of Roszdravnadzor
Russian Pharmacies Magazine
Published on the website "Remedium"
The article is devoted to the urgent problem of the organization of medical and social assistance to elderly and senile people, contains examples of positive foreign and domestic experience in this field over the past 20 years. The features of the course of diseases in this category of patients and the principles of geriatric pharmacology are briefly described.
Quite drastic changes in the demographic structure of society in recent years, due to the aging process of the population, cause a natural interest in the social and medical problems of the elderly.
The UN Principles on the Elderly "Making the life of the Elderly full" define the role and place of elderly people in society, including ensuring independence, care, participation in social development, opportunities to realize their inner potential (UN General Assembly resolution 40/91).
Demographic aging of the population is an increase in the proportion of elderly and old people in the total population, which two decades ago was considered as a phenomenon related exclusively to developed countries, now covers almost the entire world. According to literature data, in 2000 the number of this part of the population reached 590 million people, and by 2025 the number of elderly people on the planet will reach 1 billion. man [3,4].
Due to the fact that the pace of aging has accelerated in Russia, there is a need for an in-depth study of various factors associated with this phenomenon, especially since the aging of the country's population is accompanied by dramatic changes in the state of health of citizens. The search for new ways of interdepartmental interaction and rational forms of organization of medical care for the elderly meets the principles of restructuring the healthcare system [1].
In the Russian Federation, almost a fifth (18%) of the total population of the country, about 30 million people, are people of retirement age, including about 11% (3.2 million) they are people over 80 years old.
It is expected that by 2015, one in three of the elderly will belong to the group of the oldest (over 75 years old). The aging of the population is most pronounced in the European part of Russia (North-Western, Central, Volga-Vyatka, Central Chernozem regions).
This trend will require further development of not only gerontology, but also geriatric services, in particular geriatric pharmacology. Gerontology and geriatrics is a field of medical and biological science that includes the study of aging processes, causes, mechanisms of development and features of the course of diseases in older age groups.
Considering the need to help the elderly, both domestic and foreign authors and organizations have begun to pay considerable attention to this problem. Shortly after the Second World War, national associations of gerontologists and geriatricians were established abroad, which formed in 1950. The International Association of Gerontologists (IAG).
At the UN World Assemblies on Aging (1982, 2002), complexes of measures for social protection and assistance to the elderly were approved. Gerontological care began to be considered as a medical and social problem. Large gerontological centers were established in a number of cities in Europe and North America [9].
In our country, the first urban society of gerontologists was established in 1957 in Leningrad. Later, the head Research Institute of Gerontology of the AMN was organized in Kiev and the All-Union Society of Gerontologists and Geriatricians was established. Work began on the creation of geriatric departments in order to train geriatric doctors, but it was not possible to create a coherent system of geriatric care at that time.
In the Russian Federation, the geriatric service began to be systematically created only from the late 80s - early 90s. The intensification of this work was facilitated by the association of domestic gerontologists and geriatricians in the Gerontological Society of the Russian Academy of Sciences (1994), which was subsequently accepted into the MAG.
Features of the course of diseases in elderly and senile people
The development of geriatrics (clinical gerontology) is aimed at studying the features of diagnosis, treatment and prevention of diseases in the elderly. The aging of the population makes urgent the problem of providing medical and social assistance to elderly and senile people, about 80% of whom suffer from multiple chronic pathology [2,6,8,10].
The course of many diseases in elderly and senile patients has its own characteristic features. Thus, in the structure of morbidity of elderly people, the main place is occupied by coronary heart disease, hypertension, diabetes mellitus, respiratory diseases, diseases of the musculoskeletal system. At the same time, only one disease is rarely detected in patients – a combination of three, four, and sometimes more diseases is found much more often, which creates additional difficulties in treatment and worsens the prognosis for recovery.
Many common diseases can occur in elderly patients covertly, without clear clinical symptoms, while simultaneously being accompanied by a tendency to develop serious complications.
Thus, infectious and inflammatory diseases in elderly patients are often not accompanied by an increase in body temperature, which is due to reduced reactivity of the body. One of the frequent concomitant manifestations of diseases in elderly and senile people is pain, the importance of which is often underestimated, is not diagnosed in a timely manner and, as a result, is not treated. Clinical symptoms of acute surgical diseases are sometimes erased, which leads to a late start of treatment. These difficulties are sometimes also connected with the fact that the elderly patient himself sometimes cannot clearly draw the line between health and illness, explaining the malaise that has arisen purely for "age-related" reasons. The combination of several diseases in the same elderly person that aggravate his condition often makes it impossible to conduct a full-fledged examination.
Principles of geriatric Pharmacology
It is believed that, on average, four to five different diseases are detected in one patient over the age of 60, which is naturally accompanied by an increase in the consumption of various medicines by such a patient. However, in the body of elderly people, the pharmacodynamics and pharmacokinetics of drugs most often change, there is a significantly higher frequency of their side effects. The doctor's ignorance of these features can worsen the course of the disease in elderly patients. Therefore, it is already a very urgent task for doctors of various specialties to master the basics of geriatric pharmacology.
The peculiarities of the action of drugs in the elderly also create difficulties in the treatment of these patients. The doctor should have a clear understanding of the principles of dosage of medicines in geriatrics, about the peculiarities of drug interaction, about ways to increase the resistance of the elderly to the undesirable effects of medications. The question of prescribing a particular drug should be decided only after a comprehensive analysis of its effects on the body of an elderly patient. One of the rules of geriatric pharmacotherapy is strict individualization of doses. At the very beginning of treatment, drugs are prescribed in doses reduced by about 2 times compared to those for middle-aged patients. And only gradually increasing the dose, individual drug tolerance is established. Upon reaching the therapeutic effect, the dose is reduced to a maintenance dose, which, as a rule, is also lower than the dose prescribed to middle-aged patients. The method of taking the medicine should be as simple and understandable as possible for the patient. If possible, the appointment of liquid dosage forms should be avoided, since due to impaired vision and tremor of the hands, elderly patients experience difficulties with their dosage. In addition, the lack of clear control over the tightness of the bottle can lead to a change in the concentration of the drug, its contamination or damage. In the hospital, medical staff should pay special attention to monitoring the timely intake of prescribed medications, since elderly and old people often forget to take the medicine on time or, conversely, take it again without waiting for the appointed time.
In elderly people, along with a decrease in the number of nerve tissue receptors, functional exhaustion and a decrease in its reactivity are simultaneously noted. This contributes to the development of difficult to predict, atypical, inadequate to the amount of the administered drug and even paradoxical reactions. As a result of structural age-related changes in the mucous membrane of the gastrointestinal tract, the absorption of drugs is disrupted, which reduces the therapeutic effect. In addition, age-related changes in the liver and kidneys contribute to the fact that drugs and their metabolic products are slowly excreted from the body. This contributes to the accumulation of the drug and the development of various side effects. In this regard, it is necessary to first prescribe small doses of the drug, followed by an individual dose increase depending on the tolerability [8].
According to medical statistics, the risk of side effects in patients older than 60 years is 1.5 times higher than in young people. And in patients aged 70-79 years, adverse reactions to the administration of drugs develop 7 times more often than in patients aged 20-29 years. Elderly and senile people are 2-3 times more likely than young and middle-aged people to be hospitalized for side effects of drugs. And the greatest number of deaths associated with irrational pharmacotherapy falls on the age group of 80-90 years.
It should be emphasized that medications prescribed to elderly people without taking into account the peculiarities of geriatric pharmacotherapy can cause much more harm than the disease itself, for the treatment of which they are used.
Due to the peculiarities of physiological and pathological processes in old age, the need for a specific approach to the management of patients of older age groups, attempts were made at the beginning of the last century to separate geriatrics and the corresponding specialty of a geriatrician into a separate clinical discipline. However, the specialty of a geriatrician was introduced only in 1994, and the place of this specialist in the primary health care system is not yet clearly defined, and therefore his functional responsibilities are not fully realized.
The possibilities of postgraduate education in gerontology and geriatrics are also limited. Therefore, most of the problems associated with the diagnosis, treatment and rehabilitation of elderly patients still have to be solved by a general practitioner, who requires general clinical training, the ability to solve related, interdisciplinary issues. Meanwhile, as experience shows, a general practitioner in the management of an elderly patient seeks help from doctors of narrow specialties. There is a kind of redistribution of medical duties, as a result of which an elderly patient, depending on the nature and number of diseases (or syndromes), becomes the object of attention of doctors of various specialties, each of whom, as a rule, treats "his" pathology, losing the vision of the elderly patient as a whole with his special geriatric problems.
Often, elderly and senile patients are prescribed uninformative, burdensome for their age and condition, and sometimes expensive diagnostic tests. At the same time, it turns out that the participation of related specialists in the diagnostic process and the conduct of special studies does not reduce the frequency of late diagnosis of diseases such as tuberculosis, sepsis, pulmonary embolisms, urinary tract infections, malignant tumors.
The need for an integral approach to an elderly patient based on extensive clinical training of a doctor can be most vividly illustrated by the example of managing a patient with diabetes mellitus. The nature of the course and the specifics of the complications of this disease, along with frequent concomitant pathology, require from the doctor appropriate knowledge and skills not only in endocrinology (timely diagnosis and selection of adequate therapy), but also in such clinical areas as cardiology (arterial hypertension, diabetic cardiomyopathy, heart failure), nephrology (diabetic nephropathy), urology (urinary tract infection, neurogenic bladder), neurology (polyneuropathy), ophthalmology (diabetic retinopathy, cataract), orthopedics and surgery (diabetic foot).
The reality of clinical interdisciplinarity of geriatrics is felt, in particular, in the management of elderly patients with various mental disorders, especially depression and "mild" dementia (initial manifestations), which are often not recognized.
The role of nursing staff in the prevention of aging is very limited, and in the hospital it is not traced at all. Family nurses are more clearly implementing the knowledge of aging prevention, but, unfortunately, they are clearly not enough to start solving this problem with the help of nursing staff. From the point of view of the effectiveness of the organization of outside care for elderly patients, the organizational and clinical potential of nursing staff is not used rationally enough.
Organization of medical and social assistance to the elderly
Healthcare for the elderly is a wide range of services and services, including the provision of care for acute and chronic conditions, care, outpatient care, short–term and long-term care, socially oriented personal care at the place of residence.
The following systems of services for the elderly are distinguished: information and educational, preventive, medical care for outpatient and hospital patients, long-term care, home care, social hospitals, general support services [5].
Geriatric care to the population is a system of measures to provide long–term medical and social services in order to preserve or restore the ability to self-care, partially or completely lost due to chronic diseases, facilitate the reintegration of elderly patients into society, as well as to ensure independent existence.
The projected changes in the size and structure of the population of elderly and old people show that the need for long-term forms of assistance will increase. Elderly people are 5 times more likely to need long-term care services (hereinafter DP) than patients of other age groups.
There are fundamental approaches to the development of various types of care for the elderly [1]:
– ensuring continuity of various services (inpatient, outpatient, home care);
– development of preventive and supportive services;
– development of integrative services at the local level;
– attracting public and private investments to provide a full range of services to the elderly;
– striving to create cost-effective systems of services, including disease prevention, compensation for impaired functions, support for independent living at home.
The analysis of the available literature devoted to the problems of gerontological PD allows us to distinguish three main types of services provided: medical, social and medico-social
Long-term care is defined as one or more services provided to maintain the functional abilities of a chronic patient until the maximum possible level of his physical, mental and social well-being is achieved. Such services are provided both at home and in a specialized institution [12].
One of the goals of DP is to strengthen the patient's ability to self–withdraw. Including medical and social services, this type of assistance also provides rehabilitation and support services for as long as possible. DP focuses its attention on the personality of a patient with functional disorders who needs strengthening of supporting systems to meet various types of daily activity – cooking, taking medications, housework, etc.
Abroad, there are three stages of DP: institutional, at the place of residence and at home. The first includes rehabilitation in the conditions of specialized departments of general hospitals, hospice, recovery care. The second is represented by day hospitals (hospitals) for rehabilitation and medical/social day care. Home care is represented by medical care (hospice), as well as monitoring the condition of patients.
The problems hindering the growth of DP in many countries, according to experts, include, in particular, insufficient funding, which leads to a decrease in the availability of this type of assistance. In Russia, the issues of care for elderly patients at home are becoming increasingly important due to various factors – the restructuring of the health care system and social services, the reorientation of primary medical and social care to the population towards outpatient care, the growing number of elderly people [13,15].
The most important type of long–term care for the elderly is the provision of services at home or home care (hereinafter referred to as PD), which is an integral part of the system of services for the elderly at the place of residence, including day care centers, mental health, hospices, etc.
These forms of gerontological care are widespread, for example, in the USA. In 1945, a home care department was established on the basis of Montefiore Hospital (New York State). His work is based on the concept of a team, which provided for the cooperation of doctors and social workers. In the 1950s and 60s, the number of PD programs for patients with functional disorders and mental patients increased. In 1958, PD standards were presented at a special conference. Since 1961, grants have been provided to projects for the development of services alternative to inpatient care, 15% of such projects provided for PD. Thanks to the movement to create mental health centers at the place of residence, the concept of social work outside hospitals was formulated. In 1964-65, the new Medicaid and Medicare health financing programs formed the concepts of long-term care for the elderly and people with disabilities. In the 1970s. PD is provided by the financing of these programs.
The main objectives of the PD:
– improvement of the functional status of the patient to achieve complete independence and the ability to self-care;
– improving and maintaining the functional status of the patient to ensure the ability to live with a family or receive assistance at the place of residence;
– to provide an opportunity for an elderly person to stay at home as long as possible.
Home care as an alternative to long-term institutional care is becoming a valuable resource in places where the elderly live, providing for their needs, especially for those with functional disabilities. Some of them receive psychological support from relatives or friends, but professional help and therapy are important elements in preventing hospitalization and, in many cases, institutionalization.
The organization of medical PD is the most effective and rational way to use the available resources of the healthcare system. The advantages of this type of care over other types and forms of gerontological care include:
– recovery at home occurs at an earlier time;
– the home environment is more comfortable, as patients feel more responsibility for their care from their loved ones than in care homes;
– hospital patients more often resort to taking sleeping pills due to sleep disorders in hospital wards;
– saving time due to the absence of the need to visit family members in hospitals;
– the cost of PD is lower than other types of treatment.
The positive impact of the family environment on the health of the elderly is well illustrated by the following data: the incidence of such elderly people is almost 2 times less than that of single people, mortality is more than 3 times lower, the average life expectancy is higher than that of those living alone.
A patient of the PD service is an elderly person who has a disease or a functional disorder that limits his ability to leave his home, except when using a cane, walker, crutches, wheelchair, special transport. According to experts, the elderly should not be sent to nursing homes while the ability to stay at home is preserved. The group of potential patients can include patients with developing functional disorders, the elderly after hospitalization, incapacitated and chronically ill, patients with mental disorders, terminal patients, people who abuse alcohol or psychotropic drugs.
Various disorders of the functional status of the elderly and old people are the reason for the need to provide comprehensive home care. Depending on the individual needs of the elderly, all services provided by PD services can be divided into two large groups of services:
1. Support of daily life activities.
2. Professional services.
Specialists also distinguish specialized PD programs, for example hospice.
To manage the disease in PD conditions , three main directions can be distinguished:
1. determination of the results of the care provided, including the patient and his satisfaction with the payment of services;
2. maintaining the quality of life as a feeling of the patient and his family;
3. determination of the amount of financial costs.
The results of disease management programs include:
– reducing the number of exacerbations of diseases;
– reduction of used health resources;
– patient satisfaction with the help received.
Quality of life criteria include:
– ability to do work;
– ability to maintain relationships;
– ability to carry out daily activities;
– the ability to realize various social roles.
A number of authors, speaking about various indicators reflecting the results of care, share those that affect the functioning of the patient and the degree of his autonomy. These include: physiological (pain syndrome), functional, cognitive, affective, social relationships, social participation, degree of satisfaction with help and satisfaction with the environment.
There are also criteria for the quality of care:
– the ability to assess the assistance provided;
– duration (duration) of the services provided from the point of view of the existence of the organization;
– the duration of the provision of services in terms of the needs of patients in cases where they need such assistance;
– effectiveness of assistance;
– safety for the environment.
To date, the development of geriatric centers, inpatient and day care units in multidisciplinary hospitals has not found proper development. In addition, there was a need for new principles of providing long-term medical and social care in the conditions of specialized geriatric departments.
The goals of gerontological care include:
1. Providing elderly people with appropriate indications of the availability of all forms of medical care, including outpatient, inpatient and emergency medical care, subject to constant monitoring of its volume and quality, medicines and medical products. Creation in the Russian Federation of an extensive system of gerontological assistance to the population, consisting of specialized offices and institutions and having the appropriate personnel potential.
2. Formation of a palliative care system, including special hospice institutions, palliative care departments in hospitals, palliative care offices in outpatient clinics.
3. Improving the system of gerontopsychiatric care through the development of a network of gerontopsychiatric offices in the structure of outpatient general institutions, units in neuropsychiatric dispensaries, gerontological departments in psychiatric hospitals, psychosomatic gerontological departments in general hospitals, as well as structures of socio–psychological care for the elderly.
4. Improvement of targeted rehabilitation and physical fitness work with the elderly, aimed at health promotion and disease prevention.
5. Ensuring the accessibility of hearing aids, prostheses, glasses, individual means of transportation and rehabilitation, exercise machines for physical therapy for the elderly.
However, despite some progress in the development of out-of-hospital care for the elderly in the country, the priority of outpatient services remains low. The development of the outpatient care system for the elderly population was facilitated by the order of the Ministry of Health of the Russian Federation No. 297 dated 28.07.1999 "On improving the organization of medical care for elderly and senile citizens in the Russian Federation", based on national and international experience in providing geriatric care. The annex to the order is the regulation on the organization of the geriatric center. Since the mid-90s of the last century, the system of personnel training also began to develop and improve, the development of educational standards for geriatrics began. The use of both international and domestic experience can contribute to solving urgent problems of outpatient care for the elderly population.
The first large territorial service system for the elderly in our country was established in 1989 in Nizhny Novgorod, where the regional gerontological center was founded. In 1994, the City Geriatric Center was established in St. Petersburg. In the future, similar large centers were established in Samara, Ulyanovsk, Yaroslavl and a number of other cities of the country. The most important link in the work of these centers was outpatient polyclinic care for the elderly and senile.
According to experts, in organizational terms, medical and social care for the elderly at home is one of the most difficult problems.
One of the reasons for the difficulties may be related to the fact that the provision of medical and social assistance to the elderly is entrusted to different departments - health authorities and social protection bodies of the population without proper relationship between these departments, which affects the quality of services in medical and social services at home [5].
To assess the possibilities and effectiveness of medical and social rehabilitation, an integral indicator was developed - the index of medical and social adaptation (hereinafter – MSA) of elderly and old people. The determination of the index revealed a decrease in MSA with age, the presence of various degrees of maladaptation in geriatric disabled people.
An example of a model of comprehensive care for the elderly at home can serve as a model developed in the Department of Social Protection of the population of Dubna and presented in the "Methodological material for employees of the medical and social service for home care for the elderly and disabled" (Dubna, 1996).
The model is based on the work of an interdisciplinary team, which includes the following specialists: a gerontologist, a nurse, a psychologist, a masseur, a social worker, a patronage worker, a hairdresser, a priest. In 1996, the model provided services to 369 elderly clients, the age structure was dominated by persons 70-80 years old. Analysis of the financial status of the clients served showed that almost a third of them had an income below the subsistence minimum.
The Department of Social Protection of the city's Population has established a department for home care for the elderly and disabled. The department consisted of three departments of medical and social care at home, a specialized department and a hospice at home. Each of the departments of medical and social care at home included a supervisor, social workers, nurses, sanitary workers, and a hairdresser.
The specialized department consisted of a supervisor, a nurse, junior nurses, social workers, volunteers, and a motor vehicle driver. The hospice at home included a medical director, nurses, junior nurses, social workers, and volunteers. The medical management of all three programs was carried out by a gerontologist, who coordinated his work with a psychologist and a massage therapist, as well as with the staff of the social ward of the city hospital. The general management was carried out by the head of the department.
The hospice program at home provided medical and social services to elderly patients with a life expectancy of no more than 6 months. A total of 87 people were served, most of them lived in families (63 people), 24 patients were single. The analysis of the causes of death showed that circulatory diseases, neoplasms, as well as injuries and poisoning prevailed. The hospice team interacted with the polyclinic and the hospital. During the initial home visit, a social worker filled out a questionnaire assessing the needs of a hospice patient and his family, which included 15 questions that reflected various parameters of the patient's status, including a scale of types of necessary care. The team also used questionnaires, the purpose of which was to identify the assessment of the nurse's work, the patient's assessment of pain syndrome, etc.
A similar model of hospice at home has been functioning in Krasnodar since 1998. The hospice department of the social service center was established in order to provide social, household, socio-medical, socio-psychological assistance to terminal patients. In the structure of the team there is a head, his deputy is a geriatrician (gerontologist), the staff of five visiting teams, including a doctor, a nurse, a social worker and a junior nurse. The full staff of this program is 25 employees providing assistance to 30 clients. Each of the visiting teams serves 3-5 patients per day. The department serves more than 100 clients a year. Two-thirds of them are elderly and senile (52% of them are elderly - 60-75 years old, 25% - over 75 years old). 86% of the elderly served had pensions below the subsistence level, every fourth is single or living alone. The duration of customer service was up to 3 months in almost half of the cases. Each client received daily from 2 to 5 medical and 2-3 social services. All hospice services at home were free for clients, the cost per day per patient was 38.2 rubles, whereas in the hospital they were 300 rubles. In the development of this model, a mobile emergency response team was created for patients living in remote areas of the city, and for urgent medical and social services at home, as well as a service of volunteers (volunteers).
Comparing this model of hospice at home with the model of Dubna, we can note the absence of a psychologist in its staff, whose role in hospice programs is important.
Analyzing their own experience of the model of comprehensive home care for the elderly, the specialists of Dubna made the following conclusions: the model of home care met the needs for medical and social care of almost 400 elderly residents of the city; a comparative analysis of the model of care at the polyclinic level and this model suggests a better quality of care and a wider range of services that provided a new model; the practical experience of the hospice program at home allowed to open a hospice school in the city as an educational and methodological center for training medical and social workers, as well as teaching nursing skills to family members of patients.
Conclusions Currently, in Russia as a whole, about 1.5 million older citizens need constant medical and social assistance.
Of particular relevance is the search, development and improvement of new forms of comprehensive care for the elderly and senile at home. In many countries of the world, home help services for the elderly and the elderly have become a phenomenally growing industry. Thus, in the USA from 1989 to 2004, the market for home care services grew from 9.4 billion to 30.3 billion dollars, i.e. more than 3 times. World experience shows that the efforts of state medical and social structures alone are not enough. In solving this urgent task, it is necessary to combine the joint efforts of state structures and interested public organizations.
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