Continuità Assistenziale tra Ospedale e Territorio per l Anziano Fragile Alberto Pilotto Dipartimento OrtoGeriatria, Riabilitazione e Stabilizzazione - Livello 3: Area delle Fragilità E.O. Ospedali Galliera Ospedale di Rilievo Nazionale e Alta Specializzazione Genova, Italy Indici Demografici al 1 gennaio 2015 Popolazione 65 anni 75 anni Percentuale Donne Eu-28 Italia Liguria 21.4% 10.7% 28.0% 14.7% 742.067.000 60.782.668 51.1% 51.6% 52.7% 152.7 33.7 242.7 46.2 18.4% 7.6% Indice di Vecchiaia 117.7 Indice Dipendenza Anziani 1.583.263 Regione Liguria Speranza di Vita alla nascita 80.0 anni (M) Speranza di Vita a 65 anni 18.8 anni Speranza di Vita alla nascita Speranza di Vita a 65 anni 84.9 anni (F) 22.2 anni ISTAT, Annuario Statistico Italiano 1
Popolazione anziana anziana ee consumo didi farmaci farmaci DATI EPIDEMIOLOGICI Rapporto OsMed OsMed 2015 2015 AIFA ((Agenzia Agenzia Italiana Italiana del del Farmaco Farmaco) ) Farmaco )) Un soggetto di età 75 anni consuma una farmaci 17 volte superiore quantità di rispetto ad un soggetto adulto di 35-44 anni 2
Health Care Services for the Elderly in Liguria Region, Italy Aging Index 2015: Liguria=243 - Italy=153 - Europe 28=118 Genoa Nursing Home Dementia Care Units: Outpatients /day-care facilities Day-Care Facilities Home-Care Services (community-based) ASL: Azienda Sanitaria Locale (Local Health Agency) Acute Geriatrics Unit Intermediate Care Unit Home care services (hospital based) Dementia Care Units: Residential facilities PostGratuate School in Geriatrics Dpt. Geriatric Care, OrthoGeriatrics & Rehabilitation E.O. Galliera Hospital, Genoa, Italy Continuity of Care for Geriatric Patient Acute Care Geriatrics Unit: 42CGA beds OrthoGeriatric Unit: 9 beds Ambulatory Clinics 5000 outpatients/year - C. Cognitive Decline Dementia - Osteometabolic Center - Frailty Clinic - Geriatric Clinic - Genetic Disability: Down S. CGA Post-Acute Care (in hospital) Intermediate Care Unit : 22 beds OrthoGeriatric Rehab. Unit: 24 beds Day Hospital: 2+ 4 beds GEMU Geriatrician Trained Nurse Social Worker Home-care Services Home Care Services: patients in charge 45 Palliative Care Service: patients in charge 20 CGA Long-term Care Residential Services Nursing Home Rehab: subjects in charge 24 Alzheimer Unit: patients in charge 26 CGA 3
MULTIDIMENSIONAL ASSESSMENT (Comprehensive Geriatric Assessment - CGA) History,medical visit, Lab/Rx diagnostics Health Status Barthel, ADL IADL, Tinetti Cognitive, Functional, Mood, Motility Risk of pressure sores Exton-Smith Social Network - Cohabitation Nursing Homes - Income Biological Risk Social evaluation 1) Clinical profile 2) Pathological Risk 3) Residual skills Comorbidity Index (CIRS) Drug use SPMSQ, MMSE, GDS Mini Nutritional Assessment Private vs public: home-care, long-term care services Individual (personalized) Care Plan 22 RCT (1984-2010) evaluating 10,315 participants in six countries Geriatric Evaluation and Management Unit (GEMU) Ellis et al, The Cochrane Library 2011, Issue 7 4
CGA for older adults admitted to hospital: results 22 RCT (1984-2010) evaluating 10,315 participants in six countries Results Reference 1.25 Alive at home 6 months p=0.0002 1.16 Alive at home 1 year p=0.003 1.11 Cognition Institutionalized Mortality 1 year 0.5 p=0.02 0.79 p<0.0001 0.76 p=0.001 1 1.5 2.0 Ellis et al, The Cochrane Library 2011, Issue 7 Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials Conclusions Significantly more older patients are likely to survive admission to hospital and return home if they undergo CGA. Fewer will experience deterioration and more will have improved cognitive functioning. These benefits might be cost effective. Policy implications All frail elderly patients admitted to hospital should have access to CGA. The provision of geriatric services needs reviewed by healthcare providers Who should receive specialist services and which forms of CGA are most appropriate to which inpatient setting (acute or post-acute) are a priority of additional research. Ellis et al, BMJ 2011;343:d6553 doi: 10.1136/bmj.d6553 5
Ospedale-Territorio La continuità assistenziale per l anziano fragile ed il percorso di cura nella rete dei servizi Multidimensionale/Interdisciplinare/Multiprofessionale UVGO Dipartimento Cure Geriatriche, OrtoGeriatria e Riabilitazione Livello 3 Area delle Fragilità E.O. Ospedali Galliera Ospedale di Rilievo Nazionale e Alta Specializzazione Cartella VMD, informatizzata, «integrata» VMD MPI 6
The Multidimensional Approach to the Older Patient with Chronic Kidney Disease Alberto Pilotto, Daniele Sancarlo, Marilisa Franceschi, Massimiliano Copetti, Piero D Ambrosio, Carlo Scarcelli, Luigi Ferrucci A Multidimensional Prognostic Index (MPI) based on a comprehensive geriatric assessment predicts short- and long-term all-cause mortality in older hospitalized patients with transient ischemic attack Daniele Sancarlo Andrea Pilotto Francesco Panza Massimiliano Copetti Maria Grazia Longo Piero D Ambrosio Grazia D Onofrio Luigi Ferrucci Alberto Pilotto J Neurol 2012; 259 (4): 670-678 Multidimensional Prognostic Index Based on a Comprehensive Geriatric Assessment Predicts Short-Term Mortality in Older Patients With Heart Failure Alberto Pilotto, Filomena Addante, Marilisa Franceschi, Gioacchino Leandro, Giuseppe Rengo, Piero D Ambrosio, Maria Grazia Longo, Franco Rengo, Fabio Pellegrini, Bruno Dallapiccola and Luigi Ferrucci Circ Heart Fail 2010; 3: 14-20 Yourman et al, JAMA 2012, January 11, 2012 ; 307: 182-192 7
** Theoretical range 0-14. Higher scores indicate higher quality. Warnier et al, J Nutr Health Aging2016;20(2):218-30 Optimal setting and care organization in the management of older adults with hip fracture: a narrative review On the basis of available studies, it seems that services characterized by a multidisciplinary approach with a co-leadership (geriatrician and orthopedic surgeon) or a geriatrician leadership demonstrated to produce better outcomes compared to the traditional models. Giusti et al, Geriatric Care 2015,Vol 1: 5602:9-16 8
OrtoGeriatria Livello 2/3: Attività 2015 OTG Livello 2 OTG Livello 3 359 84,5 ± 7,6 9,4 ± 6,3 2,7 ± 2,6 6,9 ± 5,5 96% 4% 463 79,9± 10,3 16,46 ±8,7 Frattura Femore 62% Protesi anca/gin. 29% OTG Livello 3 80.8% - RSA 8.6% 28,3% Cure Domiciliari 1.4% 9.3% Domicilio 4.7% 55.5% Decesso 2.2% 1.3% Soggetti con frattura femore Età media (± SD) Degenza media (gg) (± SD) Degenza pre-operatoria (gg) (± SD) Degenza post -operatoria (gg) (± SD) Trattamento chirurgico (%) Trattamento conservativo (%) - Esito Dipartimento Cure Geriatriche, OrtoGeriatria & Riabilitazione Livello 3 Area delle Fragilità E.O. Ospedali Galliera, Genova, Italy Continuità delle Cure per l Anziano Fragile: 2015 Cure Domiciliari + Cure Palliative No. 75 Età media=87.1±5.8 No. 18 Età media=87.1±5.8 MPI 6.6% Domicilio 65.2% No. 739 19.6% VMD SC Geriatria 10.1% UVGO SSD Cure per Acuti Intermedie Geriatra No. 1134 dimessi Età media=86.1 ± 5.9 18.1% VMD No. 115 Assist. Sociale Età media=85.6 ± 5.1 Infermiere 6.0% No. 7 Domicilio 47.8% No. 44 32.6% MPI RSA (Residenze Sanitarie Assistenziali) No. 205 Età media=86.6±6.1 No. 30 Età media=87.1±5.6 9
Dipartimento Cure Geriatriche, OrtoGeriatria & Riabilitazione Livello 3 Area delle Fragilità E.O. Ospedali Galliera, Genova, Italy SC Geriatria Degenza media in rapporto all'esito: Anno 2015 Età Media±DS Degenza media (giorni) Domicilio, No. 739 86.0±6.0 10.2 ± 6.5 Cure Domiciliari, No. 75 87.1±5.8 11.3 ± 9.8 RSA, No. 205 86.6±6.1 15.2 ± 11.0 Cure Intermedie, No. 115 85.6±5.1 17.4 ± 11.3 P=0.2 (NS) P<0.0001 Esito, Numero casi Cure Intermedie totale = No. 448 (115/448 = 25.6%) MPI-TRIVENETO Project 22 Geriatrics Units, N patients=1178, F=59.4%, mean age=84.9±6.7 yrs MPI-1 23,6%, MPI-2 33,7%, MPI-3 42,6%, MPI medio=0,56±0,24 p<0.0001 500 400 300 200 100 0 N 321 N 413 N 226 14% 36% 47% 34% 38% 29% MPI 1 MPI 2 40% 41% 17% MPI 3 Peggiorato Invariato Migliorato Adjusted for baseline characteristics of patients (age,sex, MPI) and diagnosis at discharge: HF, pneumonia, dementia, respiratory failure, COPD, arrythmia, CKD Volpato et al, Rejuvenation Res 2016, in press 10
MOdello organizzativo, architettonico, tecnologico di DImissione PROtetta per soggetti anziani con dimissione difficile. Studio MoDiPro. Versione 1.0 del 22 ottobre 2015 HELP As Population Ages, Where Are the Geriatricians? By KATIE HAFNER, JAN. 25, 2016 One of the greatest stories of the 20th century was that we doubled the life expectancy, said T. Fulmer, president of the Hartford Foundation, which funds programs to improve the care of older adults. Now we need to have all the supports to assure not just a long life but a high quality of that long life. Phyllis Wolfe, 76, above, with her geriatrician, Dr. Elizabeth Eckstrom, in Portland, Ore., in November. Dr. Eckstrom was a general internist before completing a fellowship in geriatrics. I had no idea ALL what I didn t know, she said. Credit. Carl Kiilsgaard for The New York Times Recent evidence about care provided by geriatrics teams shows that with the care of such teams, the hospitalization of older adults runs shorter, costs less and results in fewer complications, including falls, pressure ulcers and urinary tract infections. There is an emerging emphasis on training many different health care professionals - nurses, pharmacists, family physicians, and physical and occupational therapists - to see older patients through a geriatrics lens. Mini-fellowships at teaching hospitals to train practicing physicians in geriatrics have sprung up around the country. Cardiology, urology, emergency medicine and other specialties are promoting geriatrics training within those disciplines. 11
Take Home Messages Continuità Assistenziale tra Ospedale e Territorio per l Anziano Fragile Background - invecchiamento demografico, fragilità e nuove necessità assistenziali Metodi - VMD e UVGO: multidimensionale e multiprofessionale Strumenti - Cartella Informatizzata-Integrata, VMD MPI Risultati - OrtoGeriatria Livello 2 /Livello 3, (Riabilitazione) - Geriatria, Cure Intermedie, Cure Domiciliari/ Palliative, RSA Conclusioni (The New York Times) - Modelli di Cure Geriatriche basati su evidenze; formazione; ricerca - Stakeholders: infermieri, medici specialisti, MMG, decisori Dipartimento Cure Geriatriche, OrtoGeriatria e Riabilitazione Livello 3 Area delle Fragilità E.O. Ospedali Galliera Ospedale di Rilievo Nazionale e Alta Specializzazione http://www.mpiage.eu Download MPI-calculate software impi application for iphone and ipad on AppStore available for free Grazie per l attenzione 12